Showing papers in "Studies in Family Planning in 1994"

Credit programs, women's empowerment, and contraceptive use in rural Bangladesh.

Abstract: This article presents findings of research addressing the question of how women's status affects fertility. The effects on contraceptive use of women's participation in rural credit programs and on their status or level of empowerment were examined. A woman's level of empowerment is defined here as a function of her relative physical mobility, economic security, ability to make various purchases on her own, freedom from domination and violence within her family, political and legal awareness, and participation in public protests and political campaigning. The main finding is that participation in both of the credit programs studied, those of Grameen Bank and Bangladesh Rural Advancement Committee (BRAC), is positively associated with women's level of empowerment. A positive effect on contraceptive use is discernible among both participants and nonparticipants in Grameen Bank villages. Participation in BRAC does not appear to affect contraceptive use.

Reproductive motivation and family-size preferences among Nigerian men.

Abstract: Data collected from 3,073 couples in four Nigerian cities and one semi-urban settlement were used to examine reproductive decision-making and male motivation for large family size. The report concludes that the characteristic male-dominant and patrilineal traditions support large family size and that men's reproductive motivation, to a large extent, affects the reproductive behavior of their wives. Therefore, the factors influencing men's reproductive outcomes and intentions are considered important for fertility transition in Nigeria. Male education, age at marriage, monogamy, interspousal communication, and intention not to rely on children for old-age support are significantly related to smaller actual family size and preferences for smaller families, while being in a male-dominant family setting has a strong relation with large family size and preferences for larger families. The policy implication of this study is the need for programs targeted at men and designed to change their attitudes about population matters and motivate them, and hence their wives, to produce smaller families.

The study of client-provider interactions: a review of methodological issues.

Abstract: In recent years, increased focus on the quality of family planning and other reproductive health services has led to a better understanding of women's reproductive health needs and has drawn attention to program-client interactions as a critical and neglected dimension of program effort. In this article, the relevant methods and experience related to studying client-provider interactions within family planning programs in southern countries are reviewed. The policy relevance of this work is highlighted first by stressing the operational usefulness of examining what happens when people engage with service-delivery systems that offer family planning or reproductive health services. Subsequently, the content areas encompassed by program-client interactions are clarified by identifying manifest and latent dimensions and by distinguishing the variables that define these interactions from variables related to their determinants and consequences. Finally, a critical review of existing methods is presented, with examples of research and a discussion of ethical issues.

The impact of women's employment and education on contraceptive use and abortion in Kinshasa, Zaire

Abstract: This report examines contraceptive behavior and abortion among women residing in Kinshasa, Zaire's capital city, with particular emphasis on women's employment and education. A data set collected in 1990 covering 2,399 women of reproductive age was used. While the practice of contraception is a common event in Kinshasa, dominated by the rhythm method, the use of modern contraceptives remains limited, but is on the rise. Induced abortion is reported by 15 percent of the ever-pregnant women in the survey. Women's employment and education are strongly linked to contraceptive use and abortion, and differences in the incidence of abortion by schooling and employment status appear to play an important role in contributing to corresponding observed differences in fertility. Modern contraceptives and induced abortion appear to be used as complementary fertility-control strategies in Kinshasa, and analyses of the findings suggest that better-educated women employed in the modern sector are most likely to be in the forefront of the contraceptive revolution.

The Estimated Effect of Oral Contraceptive Use on the Cumulative Risk of Epithelial Ovarian Cancer.

Abstract: This study sought to determine the effect of oral contraceptive (OC) use on the cumulative incidence of epithelial ovarian cancer from ages 20 to 40 20 to 50m and 20 to 55 years among 4 groups of women: positive family history negative family history parous and nulliparous. Cancer and Steroid Hormone Study data were combined with data from the Surveillance Epidemiology and End Results Network to provide estimates of the age-specific incidence rates of epithelial ovarian cancer among never-users of OCs in the 4 specified groups of women. These rates provided the basis for calculating cumulative incidences. The rates in women using OCs were estimated from meta-analysis of the epidemiologic literature using regression equations expressing the log-relative rate of epithelial ovarian cancer as a function of duration of use and recency. In all 4 groups the cumulative number of epithelial ovarian cancer cases estimated to occur per 100000 OC users compared to never-users decreased with increasing duration of OC use. The authors results suggest that 5 years of OC use by nulliparous women can reduce their ovarian cancer risk to the level seen in parous women who never use OCs and that 10 years of OC use by women with a positive family history can reduce their risk to a level below that for women whose family history is negative and who never use OCs. These data represent the first published estimates of the effect of OC use on the cumulative incidence of epithelial ovarian cancer by family history and by parity. The demonstrated substantial noncontraceptive benefit from OCs justifies their judicious use as a potentially powerful resource for primary prevention in women at high risk of ovarian cancer. (authors)

Population Policies Reconsidered: Health, Empowerment, and Rights.

Abstract: In this volume, scholars, policy-makers and women's health advocates suggest a new consensus on population policy directions for the 21st century, centred on health, women's empowerment, and human rights. They argue that public policy should assure the rights and well-being of people, rather than simply attempting to limit the ultimate size of the world's population.

Women's and Health-Care Providers' Views of Maternal Practices and Services in Rural Nigeria

Abstract: Maternal mortality and morbidity estimates in Nigeria continue to be dramatically high largely because maternal services, especially in rural areas, are often deficient and inappropriate to women's situations. The Safe Motherhood Project in Zone A examined the pregnancy-related knowledge, attitudes, and practices of community members, and women's use of community maternal health services. Focus-group discussions and interviews confirmed a number of recent findings by other studies; they also documented extensive hostility between the two most commonly used health-care providers: traditional birth attendants and midwives. The hostility resulted in rumors, deliberate attempts to discourage women from seeking higher levels of care, and refusals to accept referrals or treat patients, which were found to be serious constraints to good maternal care in the targeted rural area.

Reproductive choice in Islam: gender and state in Iran and Tunisia.

Abstract: This report examines the extent to which reproductive choice is compatible with Islamic principles. It presents the argument that the impact of Islam on reproductive choice is largely a function of the political context in which gender issues are defined. Indicators of reproductive health in countries of the Middle East are reviewed and the way these relate to constraints on reproductive choice is assessed. The examples of Tunisia and Iran are used to illustrate the way in which Islam is invoked to legitimate conflicting positions concerning women and their reproductive options.

Abortion in Vietnam: measurements, puzzles, and concerns.

Abstract: This report summarizes current knowledge about abortion in Vietnam, drawing upon government statistics, survey data, and fieldwork undertaken by the author in Vietnam throughout 1993 and part of 1994. The official total abortion rate in Vietnam in 1992 was about 2.5 per woman, the highest in Asia and worrisome for a country with a still-high total fertility rate of 3.7 children per woman. Vietnamese provinces exhibited substantial variation in both the rate of abortion and the type of procedures performed. Among the hypotheses explored to explain Vietnam's high rate of abortion are the borrowing of family planning strategies from other poor socialist states where abortion is common; current antinatal population policies that interact with a lack of contraceptive alternatives; and a rise in pregnancies among young and unmarried women in the wake of recent free-market reforms. Because family-size preferences are still declining, abortion rates may continue to increase unless the incidence of unwanted pregnancy can be reduced, a goal that Vietnamese population specialists are seeking to achieve.

Sex preference and fertility in Peninsular Malaysia.

Abstract: This study uses data from the Second Malaysian Family Life Survey, conducted in 1988, to examine parents' preferences for the sex of their children within each of Malaysia's three ethnic groups. While Malay and Indian parents do not show a consistent sex preference, Chinese parents prefer to have all sons, or a combination of sons and daughters, with more sons than daughters, or at least an equal number of them. Son preference among the Chinese does not seem to be a constraint to fertility decline among that population. Since 1970, Chinese fertility has dropped rapidly; at the same time, Chinese son preference has become more pronounced. Evidence indicates that further reductions in Chinese fertility, through the reduction in sex preference, would be small.

Indicators for measuring the quality of family planning services in Nigeria.

Abstract: This article presents the Situation Analysis approach as a means of collecting data that can be used to assess the quality of care provided by family planning service-delivery points (SDPs), and describes the quality of services offered in Nigeria Elements of the quality of services provided at 181 clinical service-delivery points in six states of Nigeria are described The substantive results from the study suggest that although most of the 181 service points sampled are functional, the quality of care being provided could be improved Illustrative scores for these indicators and elements of the Bruce-Jain framework are given By comparison with contraceptive prevalence surveys, the Situation Analysis approach is still in its early stages Some methodological issues are raised here and future directions for strengthening the validity and applicability of the approach are discussed

Do fertility intentions predict subsequent behavior? Evidence from Peninsular Malaysia.

Abstract: Data from the 1984 Malaysian Population and Family Survey were matched with birth registration records for 1985-87 to determine the accuracy of statements regarding desired family size that were reported in a household survey in predicting subsequent reproductive behavior. The findings of this study were that stated fertility intention provides fairly accurate forecasts of fertility behavior in the subsequent period. In other words, whether a woman has another child is predicted closely by whether she wanted an additional child. Informational, educational, and motivational activities of family planning programs would, therefore, have greater success in reducing family size if fertility intentions were taken into account.

The integration of family planning and childhood immunization services in Togo.

Abstract: Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration, which can be achieved through improved referral across categories of health programs. The use of an unobtrusive referral message that linked family planning and the Expanded Program of Immunizations (EPI) services was tested in an operations research study in Togo. The introduction of the referral message was accompanied by an 18-percent increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54 percent. These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time. In Togo, no evidence existed of a negative impact on EPI services, and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study.

Misinformation, mistrust, and mistreatment: family planning among Bolivian market women.

Abstract: Ethnographic data were used to examine fertility control in 1993 among Aymara urban women in Bolivia. Data were gathered from in-depth interviews on family planning (FP) with 30 women from similar interviews with eight men from 38 other household interviews and from FP service clients. Most of the Bolivian population is composed of members of the Aymara or Quechua indigenous groups. About 50% of total population is urban. Interview responses indicated that most women wanted to control their fertility so that they could improve their economic situation by selling items in the market. Cultural norms and beliefs were compatible with fertility control and womens work. Women were expected to control reproduction through rhythm or a form of abstinence. Barriers to fertility control included a lack of communication about sexual and contraceptive matters with friends family or spouses. This pattern of silence was handed down from their mothers. Almost 66% of the 30 women had never received information on menstruation or reproduction when growing up. The message was that sexuality was dangerous and shameful. Almost 33% engaged in a living arrangement with a sexual partner at the age of 14-16 years and the remaining had done so by 17-20 years. Marriage occurred accidentally or by force (25%). Voluntary cohabitation occurred in about 50% of cases. After sexual contact occurred parents strongly urged marriage. Women eventually learned about contraception through womens clubs clinics church groups husbands or friends. When fertility control failed women resorted to extreme abstinence abortion infanticide or modern methods. Modern methods were viewed as dangerous and with harmful side effects; modern medicine was viewed similarly. Contraceptive use could be associated with promiscuity. Women feared being touched by health personnel. Although abortion was illegal women conveyed a desire to end an unwanted pregnancy or acted with systematic neglect to end an unwanted birth. Recommendations were made for providing culturally sensitive services which involved men.

The impact of condom prices on sales in social marketing programs.

Abstract: The issue of pricing contraceptives in family planning programs is becoming more and more important. What is the relationship between consumer prices and demand, and how can we strike the correct balance between the two? This report examines the correlation between consumer prices for condoms, expressed as a percentage of per-capita gross national product, and per-capita sales of condoms in 24 social marketing programs. The correlation that emerges is strong and negative: Even when the data are controlled for age of program and other independent variables, there is a clear negative correlation between prices and contraceptive sales in these programs. The conclusion is clear that condom prices must be set very low--well below the equivalent of 1 percent of per-capita gross national product for a year's supply--in order to achieve satisfactory prevalence for condoms in either a family-planning or an AIDS-prevention context.

Taiwan's transition from high fertility to below-replacement levels.

Abstract: This article compares the fertility experience of Taiwanese in the eight years since the total fertility rate reached 2.1 with that before fertility reached replacement levels. During the earlier period, two-thirds of the fertility decline resulted from falling marital fertility and one-third from higher age at marriage. The changing age distribution retarded this decline. Since 1983, the further decline to 1.7-1.8 has been entirely the result of the trend toward later marriage. Older age distributions now facilitate the decline. Births postponed by those marrying later make the conventional TFR misleading. Computation based on parity-progression ratios raise TFRs from 1.7 to 2.0, a number less alarming to policymakers. Contraceptive prevalence is at saturation levels in all major populations strata. The "KAP-GAP" has disappeared. What would have happened without Taiwan's effective family planning program is impossible to determine, but clearly, contraceptive services supplied by the program were the major proximate cause of Taiwan's fertility decline.

The use of traditional methods of contraception among Turkish couples.

Abstract: About half the users of contraceptives in Turkey employ traditional methods of family planning, particularly withdrawal. This report presents data from a 1988 national survey to examine Turkish couples' use of and opinions about these methods. Use of traditional methods is widespread across all geographic, demographic, and socioeconomic groups. The principal reasons reported for not using methods generally considered to be highly reliable were fear of health problems and side effects and the opposition of husbands to such methods. Most couples who practice withdrawal also feel that it is as effective as modern methods. These findings imply that a major focus of family planning efforts should be the education of women, of their partners, and of health-care and family planning providers concerning the benefits, risks, and failure rates of both traditional and modern contraceptive methods.

Using situation analysis data to assess the functioning of family planning clinics in Nigeria, Tanzania, and Zimbabwe.

Abstract: Situation analyses conducted in Nigeria. Tanzania, and Zimbabwe have revealed problems in the functioning of many of the subsystems of family planning service delivery, namely in supplies of commodities; in facilities and equipment; in staffing and training; in information, education, and communication; and in record keeping. Although a clear pattern of clinic use exists, in that only a few service-delivery points provide contraceptive services to the majority of new family planning acceptors in the three countries, an attempt to explain how clinics with more clients differ from those that are visited less frequently revealed only a weak association between subsystem functioning and use.

Factors inhibiting the use of reversible contraceptive methods in rural south India.

Abstract: In 1990 in south India a study in 45 villages in Belgium and Gulbarga districts of Karnataka state aimed to identify the perceptions and experiences of 35 program personnel about promoting reversible methods of family planning. It also aimed to determine the degree of knowledge about these methods and couples acceptance of them among 60 community leaders and the knowledge and attitudes of couples (815 married women and 136 of their husbands) towards reversible methods. The contraceptive prevalence rate for all modern family planning methods was 41% but the rate for all reversible methods was around 2%. The leading modern method was female sterilization. Mean family size was 3.9. Even though district and primary health center program managers approved of promoting reversible methods they did not do anything to ensure better performance in providing reversible methods in the villages. Their superiors did not provide them any clear direction on how to improve performance of these methods. Health workers and health supervisors were concerned that reversible methods did not receive more emphasis in the program and that couples were not enthusiastic about using them. Superiors used sterilization methods rather than reversible methods to evaluate subordinates performance. Most family planning personnel believed that women wanted to achieve their desired family size as soon as possible rather than spacing births. They thought side effects linked to reversible methods and opposition from elders accounted for low use of these methods. The low emphasis on promotion of reversible methods left the couples uninformed about their benefits. These findings showed that demand for reversible methods and the supply of services were low. The researchers recommend a strong commitment to promotion of reversible methods by program managers at all levels appropriate direction and training for field workers and supervisors to educate and motivate couples to use reversible methods and adequate services at clinics and in villages.

The Bali Indirect Maternal Mortality Study

Abstract: The Bali Indirect Maternal Mortality Study (BIMMS) was conducted in Bali Province, Indonesia in 1991. The objective of the study was to evaluate the indirect sisterhood method for estimating maternal mortality, using a prospective (direct) community-based survey undertaken from 1980 to 1982 among women of reproductive age (Reproductive Age Mortality Survey, or RAMOS) as a comparison. The BIMMS maternal mortality ratio was 331 per 100,000 live births adjusted for 1982. This ratio is similar to the RAMOS one prior to its adjustment, of 359 per 100,000 live births. The sisterhood method was faster, cheaper, and appears to be as accurate as direct methods.

The reliability of simulated clients quality-of-care ratings.

Abstract: Program feedback from the field must be had to verify attainment of quality goals to make changes and to reinforce good practices. Feedback may be for programs overall or for specific staff therein. Instruments must be developed for this purpose. To that end this study examines the reliability of quality-of-care ratings in a Peruvian community-based distribution (CBD) program using pairs of concealed observers consisting of a simulated client and a companion. 18 women aged 18-45 years were trained as simulated clients. Each investigating pair rated 10-20 female CBD promoters working in metropolitan Lima. A total 84 promoters were ultimately rated. Average interrater agreement measured by intraclass correlation was .50 indicating that ratings are not reliable enough to permit the evaluation of a single provider by a single rater. Study findings therefore would suggest that checklist-item scores referring to specific provider behaviors are more reliable and useful than ratings.

Prospects and programs for fertility reduction, 1990-2015.

Abstract: What is the likelihood of 37 countries with population of 15 million or greater reaching replacement fertility by 2015? The 37 countries had in 1990 a combined population of 3.9 billion 91% of total developing country population. Bernard Berelson in 1978 assessed the likelihood of reaching a crude birth rate (CBR) of 20 births per year per 1000 population by the year 2000 for 4 groups of countries: 1) The Certain: Taiwan South Korea and Chile; 2) The Probable: China Brazil Mexico Philippines Thailand Turkey Colombia Sri Lanka Venezuela and Malaysia; 3) The Possible: India Indonesia Egypt and Peru; and 4) The Unlikely: Bangladesh Pakistan Nigeria Iran Zaire Afghanistan Sudan Morocco Algeria Tanzania Kenya and Nepal. Those countries which by 1994 have already or almost reached replacement level include: Taiwan South Korea China Thailand Chile and Sri Lanka. What accounts for the miscalculation is the slow growth between 1965-85 in gross national product the smaller decline in total fertility rate [TFR] the smaller decrease in infant mortality and life expectancy insufficient increases in literacy and larger increase in males in nonagricultural labor. Contraceptive prevalence has increased and family planning efforts have improved. World TFRs declined by 33% between the 1960s and 1980s. Socioeconomic improvements are needed worldwide. Likelihood projections were based on socioeconomic setting total fertility rate total fertility rate decline contraceptive prevalence program effort score and composite index. The certain group now includes China both Koreas Sri Lanka Taiwan and Thailand. The probable group includes India Indonesia Malaysia Philippines Vietnam Argentina Venezuela Brazil Peru Egypt Morocco Turkey and South Africa. The possible group includes Bangladesh Myanmar Algeria Iran and Kenya. The unlikely group is comprised of Afghanistan Nepal Pakistan Iraq Sudan Ethiopia Ghana Nigeria Tanzania Uganda and Zaire. When proximate determinants (marriage contraceptive use induced abortion and breast feeding) are considered the groups of countries change. TFR projections extrapolating from past trends compared to UN projections showed all the certain countries the same 4 of the probable countries reaching a TFR of 2.3 and none of the possible or unlikely countries reaching replacement fertility.

Program- and method-related determinants of first DMPA use duration in rural Bangladesh.

Abstract: This article examines the determinants of first-time use durations of the injectable contraceptive Depo Medroxy Progesterone Acetate (DMPA) for rural Bangladeshi women. The method's side effects were defined by 200 first-time users in Matlab district during lengthy, open-ended interviews. Women with many children used the method longer than did women of low parity. Those who experienced side effects had shorter use durations than those who did not, and those who cited heavy bleeding as their main problem discontinued use soonest. Women whose husbands approved of family planning had significantly longer use durations than those whose husbands disapproved. Respondents who adopted DMPA because of perceived positive aspects of the drug used it longer than those who chose it for other reasons. Results of the study underscore the importance of viewing side effects in a specific social and cultural context. Expanded side-effects counseling for women and their husbands is needed.

Integrating the lactational amenorrhea method into a family planning program in Ecuador.

Abstract: The aim of this inquiry was to describe the planning and process of integration of the Lactational Amenorrhea Method (LAM) as a viable contraceptive option into an existing family planning service network. LAM was introduced as a demonstration project in 1991 in 4 out of 20 available clinics nationwide operated by the private nonprofit Centro Medico de Orientacio y Planificacion. Study sites included Quito in an urban mountainous area Latacunga in a mixed urban/rural mountainous area Cajabamba in an isolated area with indigenous populations and Santo Domingo in a mixed urban/rural coastal area. A needs assessment of clients staff and organizational information system factors was conducted 4 months prior to introducing LAM into the pilot clinics. Organizational materials were prepared for clients and a staff training program was implemented. Baseline information was obtained from 58 clients and 24 staff on the prevailing knowledge attitudes and practices of breast feeding and contraception. The educational materials included a wall chart on breast feeding promotion a wall poster on contraception including LAM a 12 page booklet for LAM clients and a desk-size flip chart for one-to-one instruction. Record keeping was improved. LAM was introduced to all mothers with infants <6 months old who were fully or nearly fully breast feeding and were amenorrheic and identified by intake staff. Follow-up was after 3 months unless there was a change in desires or a change in the LAM requirements. After 6 months of implementation a qualitative evaluation was made. 50% of acceptors were interviewed (67 of which 23 were still using LAM). The results showed that 73% used LAM as their first ever contraceptive method. Compliance with follow-up and LAM instructions varied with each clinic. 87% of users and 67% of Quechua users expressed satisfaction with LAM. A number of observations were made about clinic operations. A refined training model was developed and there was consensus that the 12-page booklet was the most useful. A well child program was integrated into the LAM program. A surprise finding was the low use among rural traditional ethnic groups. LAM is being included in outreach efforts and the expertise passed along to other health programs. The Pearl pregnancy index was 6.8% which was comparable to other temporary methods in Andean countries.

Should the recommended number of IUD revisits be reduced

Abstract: This study uses data from clinical trials of intrauterine devices to examine the effect of reducing the recommended number of IUD follow-up visits. Over 11,000 follow-up forms were analyzed to estimate the number of health problems that would have escaped detection if women with no or mild symptoms had not made recommended revisits. Less than one percent of woman-visits with no or only mild symptoms had an underlying health risk that could have gone undetected if the follow-up visits that were made in the clinic trial setting had not been made. The results from this analysis suggest that a reduction in the number of recommended follow-up visits is safe, when measured according to selected conditions. Additional research is necessary to determine whether any revisits should be recommended in the absence of signs or symptoms.

Use of traditional medical practitioners to delivery family planning services in Uttar Pradesh.

Abstract: This pilot study conducted in Muzaffarnagar district in the state of Uttar Pradesh, India, demonstrates the potential for using traditional medical practitioners in the delivery of family planning services after a brief training period. Practitioners participated continuously in the program for an intervention period of two years during which their services were accepted by the community. The impact of their involvement was reflected in increased knowledge of permanent as well as reversible contraceptive methods and in higher contraceptive use rates, especially of reversible methods adopted by women younger than 25 years (from 8 percent to 37 percent), in the intervention villages, as compared with increased knowledge and use (from 13 percent to 25 percent) of permanent methods alone in the control villages.

User characteristics and oral contraceptive compliance in Egypt.

Abstract: The results of the 1988 Egypt Demographic and Health Survey showed that misuse of oral contraceptives was higher by four times when the source was the government. Users took pills out of sequence. Further follow-up is needed because of the small sample sizes and lack of information on differences in packaging counseling knowledge or other psychosocial factors. Results also indicated that women who were uneducated were more likely than educated women to take pills out of sequence. Confounding beliefs that the pill need only be used when sperm were present may have been responsible. Support was given to prior findings that there was a strong association between occurrence of side effects and discontinuation of use. This practice was explained as possibly related to the belief that the body needed a "rest" and the misunderstanding that breakthrough bleeding was a resumption of menses which would necessitate stopping pill taking. Women reported having missed taking pills without becoming pregnant which reinforced the idea that pills need not be taken sequentially. Findings also indicated that pills were taken more consistently and correctly when husbands or some else secured the product for the client. An important finding was that almost all had poor knowledge of the correct interval to wait before resuming pill use between cycles. A study by Abou-Bakr found that family planning training was variable and counseling was not directed to the level of knowledge understanding or concerns of clients. Clients also relied heavily on the printed instructions/inserts provided with the supplies. The sample included 8911 ever married women aged 15-49 years and a subsample of 1258 current oral contraceptive users. Oral contraceptive users were 59% urban and had a mean number of 4 children. 44% had no education. 28% of husbands had no education. Pill use averaged 2 years and ranged from 2 months to 22 years. 91% used 21 day cycle pills. Logistic regression models were used to analyze incorrect pill use.

A Test of Alternative Supervision Strategies for Family Planning Services in Guatemala

Abstract: This report presents results of an operations research project that tested the impact and cost-effectiveness of alternative supervision schemes of reproductive health services in Guatemala. The strategies tested were (1) indirect supervision, in which one of the two annual supervised visits to each health unit was replaced by a one-day meeting at the district level with the supervisor; and (2) self-assessment, in which one supervised visit was replaced by a two-day workshop where participants filled out self-assessment checklists identifying quality of care problems and made a plan to solve identified problems during the following months. Health units in the two experimental groups showed greater increases in productivity than units receiving traditional supervision. In both alternative strategies, supervisors were able to reach a larger proportion of health units and service providers than through the traditional supervision system. The supervised cost per unit was also lower in the two experimental groups than in the control group. Few differences were observed between the experimental and control groups in terms of the satisfaction of service providers with their jobs and of clients with services received.