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RHO archives : Topics : Family Planning Program Issues

Annotated Bibliography

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General

Centers for Disease Control and Prevention (CDC). "Providing Family Planning Services." In: Family Planning Methods and Practice: Africa, 2nd edition. Atlanta, Georgia: United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, 547-672 (2000). Available at: www.dec.org/pdf_docs/PNACH981.pdf.
The final section of this comprehensive manual offers a practical discussion of the management challenges facing family planning programs. Topics covered include: principles of family planning education, counseling, and behavior change; the impact of service delivery policies and administrative decisions on clients; advantages and disadvantages of clinic-based, community-based, and commercial retail service delivery systems; financing family planning services; obstacles to service delivery; selecting, training, and supervising staff; managing contraceptive supplies; collecting, analyzing, and reporting information; and assuring the quality of services.

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Increasing access to family planning

Ali, M.H. Quality of care and contraceptive pill discontinuation in rural Egypt. Journal of Biosocial Science 33:161-172 (2001).
Using data from the 1988 Demographic and Health Survey and 1989 Service Availability Survey in Egypt, indicators of access to and the quality of family planning services were linked with the use of oral contraceptives. Controlling for womens socioeconomic, demographic, and motivational characteristics, discontinuation of pill use (except for discontinuation in order to become pregnant) was associated with three factors in the general service environment: smaller numbers of health personnel trained in family planning, lack of access to facilities with female doctors, and limited range of available contraceptive methods.

Bertrand, J.T. et al. Access, quality of care, and medical barriers in family planning programs.International Family Planning Perspectives 21(2):64-74 (June 1995). Available at: www.agi-usa.org/pubs/journals/2106495.html.
This article defines the concepts of access, quality of care, and medical barriers and synthesizes them into a consistent framework. Access determines whether interested individuals make contact with a family planning provider; quality and medical barriers come into play afterward, affecting the decision to adopt a method and the motivation to continue. Access issues include the difficulty of getting to a service point, the cost of services and commodities, clinic hours, knowing where to seek services, and factors like social stigma that discourage people from seeking services. Quality of care can be measured at the policy, service delivery, or client levels. The client's perspective is useful but insufficient as a measure of quality; objective measures are also important. Medical barriers are practices that impede contraceptive use based on some unjustified medical rationale such as outdated contraindications and requiring unnecessary physical exams and lab tests. Some argue that reducing medical barriers does not serve women's best interests in the long term, because it shifts the debate away from quality back to quantity. All three concepts are linked: quality of care and medical barriers affect access, and reducing unnecessary medical policies and practices may improve quality of care. The authors conclude that programs can and must work to improve both the quality and quantity of services at the same time. Quality should be promoted both as a woman's right and because it increases contraceptive use. Managers also must be aware that integrating services may have negative effects on family planning. For example, bundling lab tests with family planning to improve overall health care may erect medical barriers, and additional demands on providers may lower the quality of care.

Best, K. et al. Community-based distribution.Network 19(3) (Spring 1999). Available at: www.fhi.org/en/fp/fppubs/network/v19-3/index.html.
This special issue of Network is devoted to community-based distribution (CBD) programs. A series of seven articles describes how CBD programs work; discusses which contraceptive methods they can safely offer; examines how residence and salary affect the job performance of CBD workers; compares the cost of CBD services with other delivery approaches; discusses combining community-based family planning services with other health services; profiles four CBD programs in Peru, Bangladesh, and Zimbabwe; and discusses how CBD services can enhance women's autonomy and self-esteem.

Bratt, J.H. et al. Three strategies to promote sustainability of CEMOPLAF clinics in Ecuador. Studies in Family Planning 29(1):58-68 (1998).
Separate studies were conducted to analyze the impact of three strategies to increase the sustainability of a private organization operating 20 reproductive health clinics in Ecuador. Reducing the number of follow-up visits for IUD users during the first year from four to one liberated provider time for gynecological consultations and saved money for IUD users with little impact on quality of care. A survey of clients found that CEMOPLAF fees are low relative to clients' income and could be increased, although measures should be taken to protect truly need clients. A cost projection determined that ultrasound machines would be a profitable investment of scarce resources at only three of 19 potential sites. The authors conclude that no one of the interventions would make a large impact on CEMOPLAF's cost-recovery ratio, but together they could improve the agency's financial situation.

Debpuur, C. et al. The impact of the Navrongo Project on contraceptive knowledge and use, reproductive preferences, and fertility. Studies in Family Planning 33(2):141-164 (June 2002).
An experimental study conducted in rural northern Ghana tested the impact of two types of community health and family planning outreach programs on reproductive preferences and behavior. One intervention stationed nurses in villages and gave them motorbikes to visit clients in local communities, thus improving access to contraception. The other intervention mobilized traditional leaders and networks in support of family planning and also recruited community health volunteers to improve access to services. Each intervention increased contraceptive knowledge, but only nurse-outreach affected reproductive preferences. Fielding both interventions together had the greatest impact on contraceptive use and fertility. Continuing support is needed to sustain the beginnings of ideational and behavioral changes observed.

Green, C.P. et al. Using men as community-based distributors of condoms. FRONTIERS Program Brief No. 2 (January 2002). Available at: www.popcouncil.org/pdfs/frontiers/pbriefs/male_CBDs_brf.pdf.
This paper reviews research in 13 countries to determine whether recruiting men as community-based distribution (CBD) workers increases the use of male condoms. Studies shows that male CBD workers are acceptable to communities, distribute more condoms than women do, serve more male clients, and distribute as many years of contraceptive protection as women. Male CBD agents may encourage men to share responsibility for contraception more equally with women and may increase the acceptability and use of male condoms. However, managers and supervisors may find it harder to recruit men and may need to overcome staff prejudices against male distributors. Once recruited, men and women can be trained together.

Hanifi, S.M.A. and Bhuiya, A. Family-planning services in a low-performing rural area of Bangladesh: insights from field observations. Journal of Health, Population, and Nutrition 19(3):209-214 (2001). Available at: www.icddrb.org/pub/publication.jsp?classificationID=30&pubID=330.
To examine why family planning programs in some administrative divisions in Bangladesh have been far less successful than others, this article presents an 18-month observational study of an under-performing rural area in Chittagong. Low contraceptive prevalence in the area has been blamed on social and religious obstacles. Although the study confirmed the existence of these barriers, it also points to poor provider performance as a key factor. Field workers did little to motivate potential clients, ignored clients needs, did not counsel or help manage contraceptive side effects, and visited homes and satellite clinics irregularly. Supervision and monitoring of field workers was extremely poor. Clients did not list poor service quality as a reason not to adopt a method, however, because they had low expectations and because they did not want to complain about field workers, who came from influential local families.

Hossain, M.B. and Phillips, J.F. The impact of outreach on the continuity of contraceptive use in rural Bangladesh. Studies in Family Planning 27(2):98-106 (1996).
Eight years of longitudinal data from two rural districts in Bangladesh are analyzed to assess the impact of a household visitation program on the continuity of contraceptive use. Discontinuation rates were high: one-third of users discontinue use with the first six months and one-half within a year. Continuation rates were highest for IUD users. A multivariate analysis found that client characteristics had significant, but relatively weak effects on continuation. In contrast, contact by family welfare assistants had a strong influence on the continuity of use. Overall odds of discontinuation are reduced by 65 percent if women are contacted at home at least once in a 90-day period. The importance of home visits increased over the duration of the program, because the proportion of highly motivated and committed users swindled. The authors conclude that scaling back household service delivery may undermine the sustainability of contraceptive practice.

Katz, K.R. et al. Increasing access to family planning services in rural Mali through community-based distribution. International Family Planning Perspectives 24(3):104-110 (August 1998). Available at: www.agi-usa.org/pubs/journals/2410498.html.
This study employed a rigorous experimental design to evaluate the effectiveness of a family planning CBD program integrated into a primary health care system in rural Mali. Pre- and post-test surveys were conducted to compare family planning and knowledge in three areas: two sub-districts in which a CBD program was introduced, two sub-districts in which primary health care workers offered family planning education but not supplies in villages, and one sub-district that served as a control group. Women's knowledge of at least one contraceptive increased more in the CBD group (10%-99%) than in the education-only (10%-71%) or control (10%-53%) groups. Women's current use of a method also increased further in the CBD group (1%-31%) than in the education-only (1% to 10%) or control (2% to 14%) groups. Men's ever-use of condoms also increased more in the CBD group (9% to 35%) than in the education-only (7% to 16%) or control (6%t to 10%) groups. The CBD program had a greater impact on knowledge and attitudes among men than women.

Ketende, C. et al. Facility-level reproductive health interventions and contraceptive use in Uganda. International Family Planning Perspectives 29(3):130-137 (2003). Available at: www.agi-usa.org/pubs/journals/2913003.html.
This article examines the effect of service environment factors on contraceptive use by analyzing data from a household questionnaire and a facility survey fielded by the Delivery of Improved Services for Health (DISH) program in Uganda. Five variables were considered: geographic accessibility of health facilities, range of method choice, dissemination of information on the availability of family planning services, staff training, and follow-up mechanisms. A multivariate analysis controlling for women’s socio-demographic characteristics found that none of these variables was associated with contraceptive use in rural areas. In urban areas, the proximity of a private health facility and the presence of at least three DISH-trained service providers significantly increased the likelihood of contraceptive use (odds ratios of 2.1 and 1.7, respectively).

Magniani, R.J. et al. The impact of the family planning supply environment on contraceptive intentions and use in Morocco. Studies in Family Planning 30(2):120-132 (1999).
This study examined the relationship between the supply of family planning, family planning intentions, and contraceptive use by analyzing the 1992 Morocco Demographic and Health Survey together with the 1995 Morocco Panel Survey, which revisited and reinterviewed DHS participants. Both sociodemographic factors (women's age, literacy, rural-urban residence, and cement floors at home) and supply factors (method availability, number of nurses, number of staff members trained to provide family planning services, and infrastructure at the nearest facilities) were independently related to contraceptive use. Surprisingly, a multivariate analysis found that, when all other factors are held constant, contraceptive intention was not a significant predictor of contraceptive use. In contrast, method availability at the nearest public clinic did predict contraceptive use, but only among women who reported not intending to use a method in 1992. Simulations found that the percentage of women who intended to use a method would increase from 29 percent under minimal supply condition to 52 percent under actual conditions to 63 percent under optimal supply conditions. Among women who did not intend to use a method, the proportion who adopted a method would increase from 13 percent under minimal supply conditions to 35 percent under actual conditions to 45 percent under optimal conditions. The authors conclude that supply factors are more likely to be related to intention than to actual use, at least in Morocco, where family planning is socially accepted and services are fairly widely available.

Phillips, J.F. et al. Lessons from Community-Based Distribution of Family Planning in Africa. New York: Population Council, Policy Research Division Working Paper No. 121 (1999). Available at: http://www.popcouncil.org/pdfs/wp/121.pdf.
This review of CBD programs in sub-Saharan Africa found that it was difficult to make generalizations because most research was site-specific. Three types of CBD programs were identified: those distributing contraceptives from fixed delivery points, home-outreach programs, and complete community mobilization efforts. No single type of CBD is appropriate everywhere, but successful programs share some common elements, including community involvement in strategic planning, the selection of CBD workers based on community opinion, and the use of paid workers. The authors conclude that CBD is administratively feasible in Africa, that it is more critical to overcome social barriers to access than geographic ones, that CBD generates contraceptive use that would not otherwise occur, and that CBD programs should be designed to fit the setting and based on scientific evidence.

Ross, J. et al. Contraceptive method choice in developing countries. International Family Planning Perspectives 28(1):32-40 (2002). Available at: www.guttmacher.org/pubs/journals/2803202.html.
To examine the relationship between access and contraceptive use, the authors analyze studies of family program effort undertaken in 1982, 1989, 1994, and 1999, along with national surveys on contraceptive use. Prevalence of the four methods examined (female sterilization, IUD, pill, and condom) increases with access. In 1999, for example, contraceptive prevalence was 12 percent in countries with very low access, compared with 44 percent where access was highest. Contraceptive prevalence also is higher where access is uniform, that is, where all couples have equal access to all methods. Over time the number of countries with uniformly high access to contraceptives has increased from 9 to 23. Where access is low, the pill and condom contribute disproportionately both to access and prevalence. The authors argue that programs should pay more attention to offering ready access to a full range of methods.

Routh, S. et al. Consequences of the shift from domiciliary distribution to site-based family planning services in Bangladesh. International Family Planning Perspectives 27(2):82-89 (2001). Available at: www.agi-usa.org/pubs/journals/2708201.html.
The Bangladesh family planning program is shifting from door-to-door distribution of contraceptives to clinic-based delivery of integrated health and family planning services, both to reduce costs and broaden services. Data from urban and rural longitudinal surveillance systems were used to assess the impact of this change on program performance. In urban areas, contraceptive prevalence increased slightly, but there was no change in method mix, the proportion of new acceptors, or the contraceptive dropout rate. In rural areas, contraceptive prevalence increased, the method mix shifted toward injectables and away from traditional methods, new acceptors increased, and dropouts declined. The authors conclude that, contrary to the norms of purdah, women are willing to venture outside their homes to obtain contraceptives and thus site-based services are a viable strategy in Bangladesh.

Schuler, S.R. et al. Barriers to effective family planning in Nepal. Studies in Family Planning 16(5):260-270 (1985).
To investigate how providers may contribute to underutilization of contraception in Nepal, simulated clients were sent to request information and advice at 16 family planning clinics in Kathmandu. They came from different caste, class, and educational backgrounds and were trained to ask for as much information as possible about contraceptive methods. Even after intensive training and encouragement, it was difficult to persuade simulated clients recruited from the lower class to visit the clinics or, once inside, to ask questions. The accuracy and completeness of the information provided and the staff's attitude and bias toward the client was positively related to the socioeconomic status of the client. Inside the clinics, traditional hierarchical patterns of behavior rule, with the result that clinics only provide satisfactory services to higher-class clients. Much incorrect and inadequate information is provided to all clients. When interviewed, providers said that it was difficult to deal with uneducated clients because they cannot understand information about contraceptives; the providers also believed that it was their job to choose which method was best for the client.

Seiber, E.S. and Bertrand, J.T. Access as a factor in differential contraceptive use between Mayans and ladinos in Guatemala. Health Policy and Planning 17(2):167-177 (2002).
To explore whether differential access to services explains lower contraceptive use among Mayan than ladino women in Guatemala, this study links household data from the 1995-1996 Demographic and Health Survey with facility-level data from the 1997 Providers Census in highland areas. Access to family planning services, as measured by distance to facilities, varied little between Mayans and ladinos. Quality may be more important than access in determining contraceptive use: only 8 percent of users got their last contraceptive from the nearest facility, and 48 percent got their supplies from APROFAM clinics, which are known for high quality but are the nearest clinic for only 7 percent of respondents.

Shelton, J.D. et al. Putting unmet need to the test: community-based distribution of family planning in Pakistan. International Family Planning Perspectives 25(4):191-195 (1999). Available at: www.agi-usa.org/pubs/journals/2519199.html..
This study analyzed records from six household contraceptive distribution projects in Pakistan, and researchers also interviewed supervisors, fieldworkers, and clients. Contraceptive use rose substantially in all six projects, from an average of 12 percent to 39 percent in less than two years. However, researchers noted weaknesses in field-worker performance, referrals, and transport to clinical services. The authors conclude that the CBD projects clearly demonstrate that unmet need exists in Pakistan, but they speculate that unmet need is greater than that measured by traditional surveys. People's actions may be so strongly influenced by the practical opportunities available that demand for family planning may be not even be felt on a conscious basis in the absence of services. Improving access thus may reveal—and satisfy—substantial need for family planning.

Steele, F. and Geel, F. The impact of family planning supply factors on unmet need in rural Egypt, 1988-1989. Journal of Biosocial Science 31:311-26 (1999).
Results from the 1988-1989 Egypt Demographic and Health Survey were analyzed to determine the impact of two factors on levels of unmet need: women's characteristics (including age, parity, and education) and characteristics of the service environment (including the distance to a clinic, the presence of community workers, and doctors' sex). Most of the variation in unmet need was regional; there was little difference by women's demographic or socioeconomic characteristics. Two service factors reduced levels of unmet need: doorstep delivery services (significant in Upper Egypt only) and the presence of a female doctor at a clinic within 5 km of the village.

Steele, F. et al. The impact of family planning service provision on contraceptive-use dynamics in Morocco. Studies in Family Planning 30(1):28-42 (1999).
This study analyzes linked data from the 1992 and 1995 Morocco Demographic and Health Surveys, including the service-availability module, to evaluate the impact of the service environment on contraceptive discontinuation, switching, and adoption of a modern method following a birth. According to a multivariate analysis, (1) the presence of a nearby public health center was associated with a greater likelihood of adopting a modern method after giving birth and with lower method-failure rates; (2) the presence of a nearby pharmacy was associated with lower discontinuation because of side effects or health concerns; (3) the availability of at least three modern methods was not associated with discontinuation, but did heighten the likelihood of switching to another modern method after quitting the pill and also the likelihood of adopting a method after a birth.

Stephenson, R. and Tsui, A.O. Contextual influences on reproductive health service use in Uttar Pradesh, India. Studies in Family Planning 33(4):309-320 (2002).
An analysis of the 1995-1996 PERFORM Systems of Indicators Survey in Uttar Pradesh examined the impact of individual, household, and community factors on the likelihood of women using four different health services: family planning, STI treatment, antenatal care, and childbirth. Results differed for the four services, but contraceptive use was associated with a woman’s parity, education, experience of a child’s death, exposure to family planning messages in the media, household assets, the number of family planning methods available in the community, and the operation of a health campaign. The use of all four services was strongly influenced by economic factors, with cost posing a barrier to care, and by the availability of services in the community.

Sultan, M. et al. Assessment of a new approach to family planning services in rural Pakistan. American Journal of Public Health 92(7):1168-1172 (2002).
This article assesses the impact of a community-based delivery system on contraceptive use in Pakistan. Beginning in 1993, literate married women in rural areas were trained to distribute contraceptive information and basic services during home visits to women living in their own and neighboring communities. This system overcame the limited mobility of Pakistani women, which prevents them from traveling to health centers. Data from a nationally representative household survey show that married women were 1.7 times more likely to be using a modern, reversible contraceptive method if they lived within 5 kilometers of two community-based workers. The authors recommend that the community-based delivery system be expanded.

Thang, N.M. and Anh, D.N. Accessibility and use of contraceptives in Vietnam. International Family Planning Perspectives 28(4):214-219 (2002). Available at: www.guttmacher.org/pubs/journals/2821402.html.
This analysis of the 1997 Vietnam Demographic and Health Survey found that 80 percent of women in rural areas and 100 percent in urban areas lived within one kilometer of at least one source of family planning services, most often a communal health clinic or drugstore. Ready access to any source of family planning significantly increased the likelihood that women aged 25 to 34 and those with more education were currently using a modern method. Access to a greater number of sources further increased the likelihood of using a modern method. The authors conclude that increasing the availability of contraceptive methods and information could increase use of family planning in Vietnam.

Tuoane M, Madise NJ, Diamond I. Provision of family planning services in Lesotho. International Family Planning Perspectives. 2004;30(2):77-86. Available at: www.agi-usa.org/pubs/journals/3007704.html.
This situation analysis used surveys and focus group discussions to assess providers’ readiness to provide family planning services in Lesotho and women’s perceptions of service delivery. Because most facilities were only open five days a week during working hours, access was restricted for employed people. In the absence of clear guidelines, providers imposed their own rules and restrictions on the use of certain contraceptive methods. Some women were discouraged from using contraception by provider bias, lack of privacy, and recurrent shortages of pills. Contraceptive costs varied and were generally higher in rural areas, where transportation costs also increased the overall cost of using family planning methods. The authors recommend that the government expand women’s access to service sites, develop guidelines for family planning providers, adopt standard prices, and ensure the availability of a wide range of methods.

Vernon, R. and Foreit, V. How to help clients obtain more preventive reproductive health care. International Family Planning Perspectives 25(4):200-202 (1999). Available at: www.agi-usa.org/pubs/journals/2520099.html.
In Latin America, reproductive health services are often underutilized because clients are not aware of their availability at the hospitals, clinics, and health posts they attend for curative care. Screening clients for preventive health needs and offering them additional services during the same visit would reduce unmet need for preventive services in an efficient and cost-effective manner. To accomplish this, clients must be made aware of the full range of services available at a facility and their own need for preventive health care, while providers must be taught to screen clients for unmet needs with simple instruments.

World Health Organization (WHO). Contraceptive Method Mix: Guidelines for Policy and Service Delivery. Geneva: WHO (1994).
Increasing the range of contraceptive methods offered by a family planning program can improve user satisfaction, enhance a program's reputation, and increase contraceptive prevalence, thus contributing to the ultimate goal of reducing unwanted fertility. This book provides a comprehensive guide to the factors that must be considered when planning to expand the range of contraceptive methods offered by family planning programs. General policy issues are covered which describe how an appropriate mix of contraceptive methods contributes to both overall reproductive health and increased prevalence of contraceptives. Detailed information regarding the advantages and disadvantages of all currently available methods are provided. Factors affecting a client's choice of method throughout the reproductive life cycle are discussed. The importance of helping couples make informed choices is emphasized.

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Overcoming medical barriers

Bossyns, P. et al. Supply-level measures to increase uptake of family planning services in Niger: the effectiveness of improving responsiveness. Tropical Medicine and International Health 7(4):383-390 (2002).
In 1999, a package of new operational instructions was formulated to improve the responsiveness of family planning services in Niger and eliminate some medical barriers. Procedures were made more flexible so that non-menstruating women could be offered contraceptives, women could receive six months' supply at a time, and women did not have to follow a strict schedule for repeat visits. In addition, family planning services were made available at all times, and providers were instructed to offer family planning to all eligible women no matter what the reason for their visit. These low-cost interventions had a big impact on family planning uptake. After the intervention, new acceptors, oral contraceptives, injections, and couple-years of protection all increased two- to threefold. The percentage of eligible women presenting for non-family planning reasons who received contraceptives also increased from less than 1 percent to 29 percent.

Brown, L.F. and Morgan, G.T. Tests and procedures required of clients in three countries of West Africa. In: Miller, K. et al., eds., Clinic-Based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. New York: Population Council, 181-196 (1998). Available at: www.popcouncil.org/pdfs/cbfp.pdf.
This study compares findings from Situation Analyses in Burkina Faso, Senegal, and Ghana with international standards on laboratory tests and medical procedures required for family planing clients. Providers in all three countries commonly overapplied the pelvic exam for the pill and injectable, blood pressure readings for the IUD and injectable, and breast exams and weight taking for all methods. In contrast, they underapply screening for STIs by medical history when providing the IUD. The authors express the most concern about excess pelvic and breast exams, which may discourage women from using family planning, occupy a substantial amount of providers' time, and are of limited usefulness in the absence of locally available treatments for breast and cervical cancer. There also is a discrepancy between the tests providers say they require and the tests they are observed to require; this suggests providers may not always agree with the program guidelines.

Cottingham, J. and Mehta, S. Medical barriers to contraceptive use. Reproductive Health Matters 1:97-100 (May 1993).
After defining each of the six types of medical barriers to contraceptive use and providing examples, this article reports on a WHO survey of more than 50 collaborating centers around the world. The survey found wide variation in routine exams and tests performed before providing contraceptives and in follow-up schedules. It concluded that there were no norms, no consensus, and little standardized information regarding the minimum but necessary elements of care for family planning. There also is a long delay before new research findings are translated into national and local practice. Althugh there is some concern that removing medical barriers is tantamount to decreasing the quality of care provided, "de-medicalizing" contraceptive services need not mean less service or less information. Removing medical barriers may increase the cost-effectiveness of services while decreasing burdens on women.

Hardee, K. et al. Assessing family planning service-delivery practices: the case of private physicians in Jamaica. Studies in Family Planning 26(6):338-349 (November-December 1995).
Some 367 private physicians in Jamaica were surveyed to determine the consistency of care given to family planning clients and to see whether service delivery practices were based on current scientific information. There was considerable inconsistency between providers in the care they offered, including the eligibility requirements, medical and laboratory tests, and follow-up schedules they required. Many impose unnecessary barriers on access to contraceptive methods, such as eligibility requirements based on age and parity, conservative criteria for blood pressure, asking women to return when menstruating, and mandatory rest periods during the use of a method. At the same time, many physicians do not screen for medical conditions that should preclude use of some methods, such as anemia, abnormal bleeding, or breast lumps. Physicians had a strong preference for the pill and female sterilization. The authors conclude that updated service guidelines should be made available to private physicians.

Katz, K.R. et al. Reasons for the low level of IUD use in El Salvador. International Family Planning Perspectives 28(1):26-31 (March 2002). Available online in html at www.guttmacher.org/pubs/journals/2802602.html and in PDF at www.guttmacher.org/pubs/journals/2802602.pdf.
In-depth interviews with 30 providers, 40 clinic visits by simulated clients, and 10 focus groups with family planning users were conducted to explore why the IUD is so little used in El Salvador. Results found that three main barriers to IUD use. First, widespread rumors and myths give women a negative impression of the method, but providers spontaneously try to dispel those myths in only about half of visits. Second, providers spontaneously mention pills and injectables far more often than IUDs or other family planning methods. Third, even those providers who have been trained in IUD insertion feel they lack sufficient experience with it. The authors conclude that providers need to be proactive in discussing the IUD and clarifying misconceptions. Providers also need opportunities to improve their counseling and insertion skills.

Mendez M, Lopez F, Brambila C, Burkhart M. Screening family planning needs: an operations research project in Guatemala. BMC International Health and Human Rights. 2004;4(1):2. Available at: www.biomedcentral.com/1472-698X/4/2.
In the Guatemalan highlands, providers do not readily offer family planning services and women are reluctant to request them. To overcome medical barriers to family planning in this conservative environment, researchers designed a job aid with three simple screening questions about women’s reproductive intentions, a checklist to rule out pregnancy, commonly asked questions and answers about various methods, and a decision tree. After the job aid was fielded, there were significant increases in the proportion of women who were: asked about their reproductive intentions during routine visits (from 7% to 37%), informed about methods (from 8% to 42%), and given a method (from less than 1% to 17%). The authors conclude that, because the job aid prompts women to ask questions about contraceptives, it empowers clients and helps break down cultural barriers to family planning.

Miller, K. et al. How providers restrict access to family planning methods: results from five African countries. In: Miller, K. et al., eds., Clinic-Based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. New York: Population Council, 159-180 (1998). Available at: www.popcouncil.org/pdfs/cbfp.pdf)
Service protocols and staff-imposed restrictions on access to family planning methods were analyzed in Botswana, Burkina Faso, Kenya, Senegal, and Zanzibar, based on recent and comparable Situation Analyses. Marital status restrictions were imposed most commonly on IUDs and female sterilization and least commonly on condoms in all five countries. Unmarried women in Botswana, Burkina Faso, and Senegal may have an easier time obtaining contraception than a married woman without her husband's consent—although none of the countries imposes consent restrictions on methods other than female sterilization. A considerable proportion of providers impose parity requirements on IUDs and injectables, and Burkina Faso, Kenya, and Zanzibar impose these restrictions as a matter of policy. Although service protocols and international guidelines place no or few strict age requirements on methods, providers generally consider different methods appropriate for different age groups. On average, providers in each country average impose twice as many eligibility requirements as required or encouraged by national guidelines. The authors conclude that providers' attitudes and behavior play a significant role in method restrictions, so that programs must address broader social concerns in addition to revising service protocols.

Shelton, J.D. et al. Medical barriers to access to family planning. Lancet 340:1334-1335 (November 28, 1992).
This landmark article outlines six kinds of practices that result in scientifically unjustifiable impediments to contraception: inappropriate and outdated contraindications; eligibility barriers based on age, parity, and spousal consent; process hurdles such as unnecessary physical exams or delaying the start of a methods until the menstrual period begins; limits on what types of health workers can provide contraceptives; provider bias for and against specific methods; and regulatory restrictions on the availability and advertising of contraceptives. Medical barriers are due to ignorance about the safety and benefits of contraception, reliance on a clinic-based and curative medical model, and economic and political interests. To overcome needless medical barriers, the authors recommend assessing medical obstacles; improving knowledge and training of policy makers, providers, the media and the public; mobilizing medical opinion leadership; fostering a public health rather than a medical mentality about contraception; and conducting further research. While the authors agree that some clinical practices have secondary health benefits, eliminating those that pose unnecessary medical barriers to family planning is not an attack on the quality of care.

Speizer, I.S. et al. Do service providers in Tanzania unnecessarily restrict clients' access to contraceptive methods? International Family Planning Perspectives 26(1):13-20 (March 2000). Available at: www.agi-usa.org/pubs/journals/2601300.html.
This article analyzes data on 123 urban and 238 rural government service delivery points collected in the 1996 Tanzania Service Availability Survey. Despite government efforts to provide universal access to family planning by introducing new guidelines, improving the commodities and logistical systems, and training service providers, some barriers to care persist. They are imposed by individual service providers without government policy endorsement or medical justification. For example, 53 percent of doctors, 71 percent of nurses, and about 80 percent of lower-level providers report imposing age restrictions on OCs that limits use by adolescents and older women. While age restrictions are most common, a substantial minority of providers also use parity and marital status to restrict methods. These eligibility barriers are not related to whether the provider has recently received training. Many providers also impose process barriers to contraceptive use by asking non-menstruating women to return at their next menses before supplying a hormonal method or IUD, rather than testing for pregnancy or ruling it out with a history. Overall, an unmarried 15-year-old girl who wants OCs would encounter provider barriers at 57 percent of government facilities. Although continued in-service training and supervisory reinforcement of official guidelines is the logical response to these finding, such a response will not address the cultural norms and attitudes which shape providers' environment and lead them to resist change.

Stanback, J. et al. Menstruation requirements: a significant barrier to contraceptive access in developing countries. Studies in Family Planning 28(3):245- 250 (September 1997).
Evidence from Ghana, Kenya, Cameroon, Jamaica, and Senegal indicates that non-menstruating women are commonly told they must return at a later date, when they are menstruating, in order to receive a hormonal contraceptive method or IUD. One rationale offered to justify menstruation requirements is that they are cheap, effective proxies for pregnancy tests. However, checklists may be used to reliably rule out pregnancy in the absence of a lab test, and the impact of hormonal methods on birth defects is overstated. A second rationale is that hormonal methods reduce menstrual disturbances when initiated during menstruation, and the IUD is easier to insert at this time. However, the former is irrelevant for many women, and inserting IUDs in non-menstruating women offers other benefits, including better diagnosis of STIs and lower rates of infections and expulsion. A third rationale is that pregnant women may seek contraception in order to induce abortion. However, hormonal methods do not induce abortion, and refusing to provide contraception on these grounds denies women their right to contraception. A fourth rationale is that few women are affected because they know to come for services when they are menstruating. However, data from Africa found that about half of new clients arrive when they are not menstruating. The authors conclude that menstrual requirements pose a serious, but under-recognized, barrier to family planning.

Stanback, J. et al. Checklist for ruling out pregnancy among family-planning clients in primary care. Lancet 354:566-567 (1999).
This study tested a simple, six-item checklist that allows providers to determine whether family planning clients are pregnant without a lab test. It includes questions on most recent birth, duration and frequency of breastfeeding, last menstrual period, miscarriage or abortion, sexual relations, and current contraception. The checklist was administered to 1,852 new, non-menstruating family planning clients in Kenya, followed by a commercial pregnancy test. The checklist ruled out pregnancy for 88 percent of the women (according to the lab test, 99 percent were not pregnant); its sensitivity was 64 percent and its specificity 89 percent. The checklist only mistakenly ruled out pregnancy in 8 women, or 0.4 percent of the sample. The author concludes that the checklist is a good way to lessen restriction to contraceptives, especially in countries where hormonal methods of contraception (which have few risks for pregnancies) dominate.

Stanback, J. and Twum-Baah, K.A. Why do family planning providers restrict access to services? An examination in Ghana. International Family Planning Perspectives 27(1):37-41 (2001). Available at: www.agi-usa.org/pubs/journals/2703701.html.
Using situation analysis data, researchers identified facilities where clients were at high risk of facing medical barriers and other obstacles to family planning services. Individual interviews with 97 providers identified restrictive practices and the reasons behind them. Providers restricted services according to age and parity because of moral concerns and concerns about client safety, especially that contraceptives might limit future fertility. Providers also enforced strict resupply and revisit schedules and routinely conducted laboratory tests because of concerns about potential health risks; their lack of technical knowledge exaggerates the potential dangers of contraceptives.

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Guidelines and indicators

Bertrand, J.T. et al. Handbook of Indicators for Family Planning Program Evaluation. Chapel Hill, North Carolina: EVALUATION Project (December 1994). Available at: www.cpc.unc.edu/measure/publications/manuals/manuals.html.
This handbook presents a comprehensive listing of the most widely used indicators for monitoring and evaluating family planning programs in developing countries, organized according to the conceptual framework developed by the EVALUATION Project. It defines indicators to measure the policy environment, service delivery operations, family planning service outputs, demand for children, demand for family planning, service utilization, contraceptive practice, and fertility impact. The introduction also describes different types of indicators (input, process, output, and outcome) and their various uses.

Bertrand, J.T. et al. Evaluating Family Planning Programs, with Adaptations for Reproductive Health. Chapel Hill, North Carolina: EVALUATION Project (September 1996). Available at: www.cpc.unc.edu/measure/publications/manuals/manuals.html.
This exhaustive manual offers guidance on every aspect of the program monitoring and impact evaluation process, from clarifying its purposes, selecting and defining relevant indicators, and developing an implementation plan, to disseminating and utilizing the results. The authors critically assess different approaches to monitoring and evaluation in order to help program personnel design appropriate and effective evaluation plans. This manual is designed to be used along with the Handbook of Indicators for Family Planning Program Evaluation, also published by the EVALUATION Project.

Bessinger, R.E. and Bertrand, J.T. Monitoring quality of care in family planning programs: a comparison of observations and client exit interviews. International Family Planning Perspectives 27(2):63-70 (2001). Available at: www.agi-usa.org/pubs/journals/2706301.html.)
The Quick Investigation of Quality (QIQ) monitors the quality of care with data on 25 indicators collected in a facility audit, observations of client-provider interactions, and client exit interviews. Using linked data from QIQ field tests in Ecuador, Uganda, and Zimbabwe, this study analyzes whether the observations and exit interviews yield consistent results. Within each country, results were consistent between instruments. For all three countries combined, observations and exit interviews had consistent responses in 63-99 percent of cases. Agreement was highest on indicators measuring interpersonal relations. Most discrepancies arose when clients received information outside of the observed client-provider interaction. Despite high levels of agreement, the authors conclude that using both instruments provides a fuller assessment of quality of care than either one alone.

Fort, A.L. More evils of CYP. Studies in Family Planning 27(4):228-231 (1996).
Because community-based distribution (CBD) programs rely on short-term contraceptive methods, they produce lower CYP (couple-years of protection) than clinic-based programs. This disparity is especially wide at the start of a program, since new acceptors of short-term methods generate less than a year of CYP, while new acceptors of long-term and permanent methods are immediately credited with many years of CYP. The bias of CYP—and the cost-effectiveness calculations to which it contributes—against community-based programs may lead policy makers and managers to overly rely on clinical programs and to inappropriately promote long-term and permanent methods. The author concludes, instead, that programs should reduce the weight assigned to quantitative targets, acknowledge the full range of benefits associated with interventions, give more credit to serving hard-to-reach populations, and promote the use of new indicators to assess program effectiveness.

Hardee, K. et al. What have we learned from studying changes in service guidelines and practices? International Family Planning Perspectives 24(2):84-90 (June 1998). Available at: www.agi-usa.org/pubs/journals/2408498.html.
This review article examines the spate of research on service delivery guidelines and service practices sparked by the medical barriers initiative and the development of consensus eligibility guidelines. The author examines the tension between eliminating medical barriers while maintaining high quality of care. While many countries have revised their guidelines based on legal and regulatory analyses, a review of current guidelines, and expert discussions, they have overlooked the sometimes substantial gap between the ideal practices specified by guidelines and providers' actual practices. The author recommends collecting data on service practices with provider and client surveys, observation, and simulated clients. When changing practices, one should assess the impact on safety as well as access and quality; people may disagree over whether a proposed change is removing a medical barrier or eliminating a needed service. Sometimes increased risks must be balanced against savings to the clinics and the women themselves. Since changing guidelines is not sufficient to ensure that service practices actually change, the author recommends greater understanding of how laws, regulations, and resource availability constrain provider practices; disseminating new guidelines in basic and refresher training; and addressing providers' personal preferences and biases.

Horstman, R.G. et al. Monitoring and Evaluation of Sexual and Reproductive Health Interventions: A Manual for the EC/UNFPA Initiative for Reproductive Health in Asia. London: London School of Hygiene and Tropical Medicine and Netherlands Interdisciplinary Demographic Institute(April 2002). Available at: www.asia-initiative.org/pdfs/m_and_e_manual.pdf.
This manual provides the practical information and instructions needed for organizations to monitor and evaluate sexual and reproductive health interventions. It discusses the concepts and terminology underlying the monitoring and evaluation process as well as the practical issues surrounding the formulation and selection of appropriate indicators, the sources and methods of data collection, the monitoring and evaluation plan, and the dissemination and use of the findings for planning and policy formulation.

Ippolito, L. et al. SEATS II Clinical Protocols for Family Planning Programs: A Resource Book, Volumes I and II. New York: AVSC International and JSI (October 1995). Portions available at: www.seats.jsi.com/publications/27Quality/clinicprot.pdf.
This two-volume set compiles the instructions and reference materials that family planning programs need to develop up-to-date clinical protocols that can help improve the quality of FP services. It describes a six-part process to develop protocols: identifying need for standardized clinical practices and the target audience, assigning management responsibility for the project and assembling a team, developing or revising the protocols, disseminating protocols, implementing protocols, and evaluating how well they are working in the clinical setting. A lengthy case study of national clinical protocols development in Turkey illustrates how this process works. The remainder of the volumes are devoted to international consensus documents on medical eligibility criteria, method-specific information, and prototypes of protocols.

Jain, A. Implications for evaluating the impact of family planning programs with a reproductive health orientation. Studies in Family Planning 32(3): 220-229 (2001).
In order to assess and encourage family planning programs with a reproductive health orientation, an index called HARI (Helping individuals Achieve their Reproductive Intentions) has been proposed. It measures the extent to which individuals achieve their own reproductive intentions without suffering any severe reproductive health problems. This study examines the methodological challenges of applying HARI, using data from a Peruvian panel study covering a 29-month period. About 25 percent of the women did not achieve their reproductive intentions (including unintended and mistimed pregnancies, regrets over sterilization, and potential infertility problems), and 5 percent experienced a severe reproductive health problem associated with pregnancy or contraceptive use. Although HARI does not cover the full set of reproductive health problems set out in the ICPD Programme of Action, it may be useful for traditional family planning programs taking the first steps toward extending their services.

Jain, A. Should eliminating unmet need for contraception continue to be a program priority? International Family Planning Perspectives 25 (Suppl.):S39-S49 (1999). Available at: www.agi-usa.org/pubs/journals/25s3999.html.
To examine whether unmet need is an accurate measure of program performance, this study analyzed data on 1,093 Peruvian women who participated both in the 1991-1992 Demographic and Health Survey and a 1994 follow-up survey. Although there was little change in the overall level of unmet need, individual data revealed substantial changes: 72 percent of women with an unmet need in 1991-1992 no longer had an unmet need in 1994, whereas 12 percent of the sample went from not having an unmet need to having an unmet need. A further analysis of those women who had an unintended pregnancy between surveys (20% overall) found that a program strategy focusing on eliminating pregnancies among women already practicing contraception would have a greater impact on the rate of unintended pregnancy (reducing it to 6%) than a strategy focusing on persuading nonusers to adopt a method (reducing it to 17%). The author concludes that a reduction in unintended pregnancies at the individual level is a better indicator of the success of a family planning program than unmet need. The article also proposes a algorithm to help providers determine which services should be offered to individual clients, based on their desire for children and contraceptive use.

Lea, J. and Knauff, L. Best and better practice in the development, dissemination, promotion, application and impact of guidelines on service access and quality. Background paper for the USAID Conference on MAQ: Guidelines to Action. Chapel Hill, North Carolina: INTRAH (April 1998).
This paper summarizes the views of USAID Cooperating Agencies with field experience in the development and dissemination of service guidelines. It offers a practical body of advice on strengthening host country commitment to guidelines, the development and pretesting process, disseminating and promoting adherence to guidelines, making sure that guidelines stay up to date, and evaluating guidelines' impact on service delivery.

Ravindran, T.K.S. and Mishra, U.S. Unmet need for reproductive health in India. Reproductive Health Matters9(18):105-113 (2001).
Using data from the 1992-1993 National Family Health Survey and the reproductive histories of a cross-section of 70 women from rural Tamil Nadu, this article uses the HARI index approach to examine how well women in India have been able to achieve their reproductive intentions. Only one of these 70 women achieved her reproductive intentions in a healthy manner; the remainder were unable to prevent unwanted pregnancies, could not achieve desired pregnancies, and/or suffered from serious reproductive health problems. The authors conclude that measuring unmet need for reproductive health services according to the HARI index is feasible and could provide important insights for planning reproductive health programs in India and elsewhere.

Reproductive Health Affinity Group (RHAG) Indicators Committee. Critical Areas, Issues, and Topics in Sexual and Reproductive Health Indicator Development: An Annotated Bibliography. New York: IPPF/Western Hemisphere Region (October 2002). Available in English and Spanish at: www.ippfwhr.org/publications/publication_detail_e.asp?PubID=40.
This annotated bibliography lists resources for the development and use of indicators that can measure improvements in reproductive and sexual health. The inventory includes indicator sets from both international and local initiatives and from a number of different fields of study. In addition to narrower measures of health and family planning, the inventory also includes measures of closely related areas in women’s empowerment and socioeconomic development.

Shelton, J.D. What's wrong with CYP? Studies in Family Planning 22(5):332-335 (1991).
This commentary analyzes multiple weaknesses in the use of couple-years of protection (CYP) to assess family planning programs. One problem is that conventional CYP calculations do not accurately reflect fertility because they do not take account of contraceptive failure rates, sporadic use of methods, wastage of contraceptives by clients, differences in women's fecundity, local variations in contraceptive use (such as the average age at sterilization), and differences in whether births are being averted now or in the future. Another problem is that CYP's narrow focus on the quantity of services devalues important program priorities, such as reaching underserved clients, improving health (for example, by preventing AIDS and other STIs), and improving the quality of care. The author concludes that the calculation of CYP should be adjusted to correct for the first problem and that CYP should be supplemented with other indicators to solve the second problem.

Sullivan, T.M and Bertrand, J.M., eds. Monitoring Quality of Care in Family Planning by the Quick Investigation of Quality (QIQ): Country Reports. MEASURE Evaluation Technical Report Series No. 5. Chapel Hill, NC: Carolina Population Center, University of North Carolina (July 2000). Available at: www.cpc.unc.edu/measure/publications/techreports/qiq.pdf.
The Quick Investigation of Quality (QIQ) initiative has developed a low-cost, practical method to routinely measure quality of care in family planning programs using a short list of quality of care indicators and three methods of data collection (facility audits, observations of consultations, and client exit interviews). Results of field tests of QIQ in five countries (Ecuador, Morocco, Turkey, Uganda, and Zimbabwe) are reported here. Based on these experiences, the editors consider how practical the QIQ methodology is for reproductive health programs, how it can be adapted to programmatic needs, and how it can best be applied.

United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). Handbook on Reproductive Health Indicators. New York: United Nations; 2003. Available at: www.unescap.org/esid/psis/publications/handbookhealth/handbook.pdf.
This handbook lists input, process, output, and impact indicators that are essential to assess, monitor, and evaluate reproductive health programs. The indicators selected are useful, scientifically robust, representative, understandable, accessible, and ethical. Listings for each indicator include its definition, data requirements, data sources, usefulness, and limitations.

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