The strategic approach to contraceptive introduction.

The introduction of new contraceptive technologies has great potential for expanding contraceptive choice, but in practice, benefits have not always materialized as new methods have been added to public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP) has taken major steps to develop a new approach and to support governments interested in its implementation. After reviewing previous experience with contraceptive introduction, the article outlines the strategic approach and discusses lessons from eight countries. This new approach shifts attention from promotion of a particular technology to an emphasis on the method mix, the capacity to provide services with quality of care, reproductive choice, and users' perspectives and needs. It also suggests that technology choice should be undertaken through a participatory process that begins with an assessment of the need for contraceptive introduction and is followed by research and policy and program development. Initial results from Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, and Zambia confirm the value of the new approach.

PIP: In response to difficulties associated with the introduction of new contraceptive technologies to public sector service systems, the UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction has formulated a new model. The strategic approach to contraceptive introduction shifts the emphasis from the promotion of a particular technology to quality of care issues, a reproductive health focus, and users' perspectives and needs. It further entails a participatory approach with collaboration among governments, women's health groups, community groups, nongovernmental providers, researchers, international donors, and technical assistance agencies. The underlying philosophy is that method introduction should proceed only when a system's ability to provide high-quality services exists or can be generated. Since 1993, WHO has provided support for the implementation of this perspective in public sector programs in Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Viet Nam, and Zambia. Preliminary assessments in these countries revealed major structural, managerial, and philosophical barriers to high-quality family planning services. In cases where assessments have indicated the feasibility of new method introduction, this has been implemented through a carefully phased, research-based process intended to encourage the development of appropriate managerial capacity and to promote a humanistic philosophy of care.

Indigenous concepts useful in programs. Experiences in the Bolivian highlands.

PIP: Culturally appropriate health messages can make a huge difference in conveying health information on, for instance, acute respiratory diseases (ARI). In Bolivia, PLAN health projects are devoted to developing and implementing effective strategies to reduce infant and child morbidity and mortality. Acute respiratory disease are a major contributory cause. Health messages emphasize recognition by mothers of symptoms, such as prolonged coughing and fever and rapid breathing. The usual strategy promoted by the World Health Organization is to translate the messages into Spanish and print posters and training manuals. However, ARI has not been affected by such efforts. In Altiplano, a rural Aymara community, the community health workers receive this training in Spanish, but the Aymara idiom is used in this rural area. PLAN conducted an ethnographic study which revealed that pneumonia does not translate well into Aymara, and other less serious folk illnesses have similar symptoms. The solution was to promote the notion that rapid breathing was a serious problem, a solution not possible without linking indigenous and biomedical perspectives.^ieng

Significant improvements in children's health.

PIP: The field report from PLAN field offices in Sucre and Altiplano in Bolivia, Santo Domingo in the Dominican Republic, and Amatitlan in Guatemala provides a summary of survey results pertaining to diarrheal disease control, immunizations, and nutrition. The PLAN sites are rural with the exception of the periurban slum surrounding Santo Domingo, which has better access to health services. Interviews were conducted among mothers with children aged 0-23 months in project areas, with the exception of Altiplano and Santo Domingo which included nonproject areas for comparative purposes. The results for diarrhea disease control are that an estimated 90% of episodes can be successfully treated at home. Evaluation is made of the timeliness and coverage of immunizations, the degree of management of diarrhea at home and at the health facility, and the extent of exclusive breast feeding in the first 4 months, and total breast feeding with food supplementation in the first year of life. The conclusion is that the four field offices make a significant and positive impact on children aged 0-23 months.^ieng

Analysis of maternal mortality in Nicaragua.

PIP: The Women's Collective in Matagalpa, Nicaragua, Sanitaria VI region estimated maternal mortality rates for 1989 and 1990 to be 309 and 239/100,000 live births, respectively. The majority of births took place at home, assisted by untrained midwives, and in 68% of cases the place and attendant(s) were not listed. National figures for maternal mortality are 49.4 and 159/per 100,000 in 1989. Thus the proportion of unreported maternal mortality is probably high in Nicaragua. The Collective believers that health workers give substandard prenatal care and fail to refer high risk cases to higher levels of care. They recommend that women mount a permanent campaign, insist on training programs for health workers that focus on women's situation, that more data be collected, and that women themselves take action.^ieng

Lactation, nutrition and fertility and the secretion of prolactin and gonadotrophins in Mopan Mayan women.

The effect of lactation on menstrual cycles, ovulation and conception was studied in a group of non-contracepting Amerindian Mopan Mayan women. Anthropological observations of relevant events were made over a 21-month period. Blood samples were assayed to determine the plasma concentrations of prolactin, luteinising hormone, follicle stimulating hormone, human chorionic gonadotrophin, placental lactogen, oestrogen, progesterone and cortisol. The data show that: frequent and prolonged breast-feeding was associated with a marked increase in plasma prolactin concentrations to levels similar to those in lactating Gaing but higher than those in lactating Scottish women; ovulatory menstrual cycles and pregnancy occurred during frequent lactation; in lactating menstruating women there was an inverse correlation between fat weight and months post-partum. These data suggest that other factors as well as suckling account for the effects of lactation on fecundity.

PIP: Lactation, ovulation and conception were observed as part of an anthropological study of Amerindian Mopan Mayan women from the village of San Jose Hawaii in western Belize from March 1985-January 1987. Single blood samples from each subject were immunoassayed for prolactin, LH, FSH, hCG, placental lactogen, estrogen, progesterone and cortisol. Anthropomorphic data analyzed were body mass index (BMI), fat/weight percentage, total body water and lean body weight. 117 women had at least 1 child during the study; 91 were lactating; 51 reported no menstrual cycles. 50 submitted to blood testing. Almost all infants were breast fed for 18 months or longer, up to 3 years, typically at least 6 times per day and 3 times per night. Women averaged 9 live births and 8 surviving children, with a mean birth interval of 28 months. 25 of the 29 women known to be pregnant conceived while lactating. 16 lactating women were pregnant. Their culture requires them to have 3 menses before conception to nourish the fetus, yet forbids speaking about menstrual blood: women fabricated menstrual dates, but in confidence 51 of 81 stated that they did not menstruate before the last conception. Most often menses began 12 months postpartum. Lactating women had heightened prolactin levels even if supplementing their children's diet. Thus frequent lactation delayed onset of menses, but supplementation had no effect. Most of the women were within the normal range of BMI, but 13% were below normal. In lactating menstruating women there was a significant negative correlation between fat weight and postpartum month. The data suggest that the interval to conception or menstruation was inversely correlated with fat weight. Here suckling frequency rather than prolactin levels seems to postpone fertility. In this society, with 10-12 births and 9-10 children in the completed family, the largest in the world, prolonged frequent lactation has little effect on fertility. Instead, birth trauma, maternal mortality, fetal and infant mortality, and perhaps nutrition, have more effect on completed family size.

Underutilization of health centers in rural Mexico: a qualitative approach to evaluation and planning.

PIP: A short field study of Durango, Mexico, is reported as a case study of a qualitative approach to evaluation. This approach uses a combination of methods, including in depth interviews, questionnaires, and participant/observation, to achieve a deeper understanding of program functioning and to provide a perspective unavailable from traditional quantitative measures. Recommendations for additional training for auxiliary nurses are offered.^ieng