Assessing the acceptability, service delivery requirements, and use-effectiveness of the diaphragm in Colombia, Philippines, and Turkey.

The diaphragm is not available in many countries, despite the recommendations of numerous authors that it has important advantages as a woman-controlled method that offers some protection against sexually transmitted diseases, and one that is safe and free of side effects. An interagency team collaborated to introduce the diaphragm in Colombia, the Philippines, and Turkey, using the same protocol to assess the acceptability, service delivery requirements and use-effectiveness of the method. Eighteen public and private sector service delivery sites were involved and a total of 550 women were enrolled in the study. Provider training aimed to improve the quality of care with which all methods were delivered and included counseling about sexuality and reproductive health risks. The cumulative 12-month pregnancy rate of 10.1 (SE 1.7) per 100 woman-years is on the low end of previous studies of the diaphragm, and the 12-month continuation rate (57.2 [SE 2.4] per 100) compares favorably with that for oral contraceptives and the intrauterine device. Focus group discussions conducted with clients and providers indicated that the method was an important alternative for some women, particularly those who had experienced health problems with other methods or were unable to negotiate condom use with their partners. Provider biases diminished as they observed the strategic niche that the diaphragm filled for their clients. While providing the diaphragm requires training and good client-provider interaction, the requirements are consistent with those called for in the Programme of Action of the International Conference on Population and Development (ICPD, 1994). With proper attention to quality of care, the diaphragm can be successfully offered in resource-poor settings.

Factors affecting contraceptive use in Pakistan.

PIP: This study postulates that contraceptive use in Pakistan is affected by the usual demographic factors as well as husband-wife communication, female autonomy, son preference, religious beliefs, and family planning service supply. Analysis is based on data obtained from the Pakistan Demographic and Health Survey of 1990-91. Findings indicate that 74% of women never talked in the past year with their husbands about family planning. Almost 60% believed that family size was "up to God." About 47% knew where to obtain contraception; only 20.4% had easy access to a source of supplies. Current use was 14% and ever use was 22.4%. Analysis is based on three basic models. Model 1 includes the control variables and son preference. Model 2 includes husband-wife communication, religious attitudes, and female autonomy. Model 3 includes the addition of family planning to model 2 variables. Urban residence increases the odds of contraceptive use considerably only in Model 1. The influence of urban residence in the other models is reduced. Husband's education is significant only in Models 1 and 2 and insignificant in Model 3 when the family planning variable is included. Increased women's age is also insignificant in Model 3. Of the supply factors in Model 3, knowledge of a source and easy access to a source were highly significant, while mass media exposure was not important. Knowledge of a source was the most important predictor. Model 3 explained 90% of use. Among urban women, lack of husband-wife communication and fatalistic beliefs reduce the log-odds of contraceptive use. For rural women, age and women's secondary education were key predictors. Findings confirm that demographic and socio-cultural factors affect contraceptive use in Pakistan. All the theorized variables exerted a strong influence on contraceptive use, which can be counteracted by improved supply and service strategies.^ieng