Family planning in poverty-ridden Nicaragua.

PIP: The percentage of people living in poverty in Nicaragua's cities has increased significantly in recent years and reflects an increase in the number of households headed by women. Among the nongovernmental organizations created to help meet the needs of Nicaragua's population is Profamilia, the International Planned Parenthood Federation affiliate founded in 1971. Profamilia offers high quality sexual and reproductive health services at regional clinics operating in 9 out of 16 political subdivisions and manages a nationwide network of over 1000 community-based contraceptive distribution posts. Knowledge of modern contraception is almost universal in Nicaragua, and a 1992-93 health survey revealed that almost half of women of reproductive age were using contraception. Profamilia uses the mass media and other means to advertise its services, which are preferred by many over the free government services. In the communities, trained volunteer promoters distribute contraceptives and provide counseling. Because adolescent pregnancy and fertility rates are high, Profamilia has developed services, including educational workshops, that target youth. These workshops offer information on responsible sex behavior and ways to reduce the risk of pregnancy or infection. In addition, Profamilia offers training courses for teachers and educational sessions for parents, pregnant adolescents, and adolescent parents.^ieng

For men only.

PIP: In 1985 the Colombian Family Planning Association PROFAMILIA realized that men did not want to come to its family planning centers simply because they felt intimidated by the feminine atmosphere there. Nor did they dare disclose their problems and sexual questions even to a female professional. The solution was to establish a family planning center, La Clinica del Hombre (Men's Clinic), providing services exclusively for men and staffed with men to provide the necessary privacy. Latin American men's attitudes are changing. In 1985 in Bogota, the majority of men were convinced that a vasectomy was equivalent to castration. In 1993, 300 vasectomies were performed in the clinic each month. The Colombian Family Planning Association is not only providing contraception, but also information on sexual and reproductive education to avoid misunderstanding of the available methods. PROFAMILIA has incorporated a sexuality consultation into its services, so they can deal with husbands and wives separately, without spoiling the couple's relationship. PROFAMILIA now has 7 family planning clinics for men and 48 for women, thanks to the contribution of international donors. The Challenge Grant for Men's Programs, given by an anonymous donor from the United States, helped with the fund-raising to open 3 clinics in the Atlantic Coast Region where needs were vital. The Clinica del Hombre will incorporate a program to treat infertility, in addition to the department of urology, general medicine, ambulatory surgery, and treatment of sexually transmitted diseases. In January, 1994, they will begin offering dental and plastic surgery services because, owing to the violence that exists in the country, there are many men whose faces are disfigured and who need to have corrective plastic surgery.^ieng

Measuring university student satisfaction with a campus family planning clinic in Costa Rica.

Family planning clinics for university students play a valuable role in promoting health. This research project, a pilot study among women students who sought family planning services through a Costa Rican university clinic, introduced student evaluation of the family planning clinic, documented services provided in family planning visits, and identified issues for further study. Aged 18-33 years, the 53 respondents (a convenient sample) who completed a self-administered questionnaire were mostly (64%) single; all were sexually active; and 78% wished to have children (or more children) some day. Though all were sexually active at the time of their visit, only 62% were currently using contraception, and fewer than half of these were using effective methods. Nearly all students (96%) reported they learned new information during their appointment, and many received screening tests and examinations. Respondents rated their satisfaction with aspects of clinic service as high, citing the clinic's low visibility on campus as the most important area for improvement. All of the students said they would definitely return (85%) or would consider returning (15%). The results support the continuance of such a clinic on the campus, as well as of the practice of student evaluation. This collaborative study demonstrated areas for future research and stimulated interest in the university clinic as a research setting.

PIP: In Costa Rica, a nurse researcher or a nurse clinician interviewed 53 female students aged 18-33 at the family planning clinic at the Universidad Nacional Heredia. This 6-month, descriptive pilot study aimed to learn what services are covered during family planning visits, the students' evaluation of the clinic, and their demographic characteristics. 36% of the students were either married or in a consensual union. Just 25% of the women had children. 78% of the students wanted to be mothers (mean ideal family size = 1.8). All the women were sexually active, yet only 26% had previously sought family planning advice. 62% currently used birth control. 62% of family planning users used natural family planning methods or barrier methods. Referral by a health provider was more common than referral by a friend (17% vs. 7.3%). 34% of all students had used other services in the student health department. The most common services covered during family planning visits were pelvic exam (59%) and contraceptive information (51%). Other relatively common services were sexuality counseling (26%), breast exam (24%), and blood pressure check (23%). 96% of the students received new information mainly on contraceptive methods (65%), breast self-examination (39%), and sexuality education (35%). The students were satisfied with all clinic services (3.9-4.9, with 5 equaling very satisfied), especially, with the opportunity to ask questions, counseling provided, and advice given by clinicians. 22% of the students wanted greater clinic outreach, especially about family planning. 85% said that they would definitely return to the university clinic. 91% would recommend it to a friend wanting family planning advice. The field of family planning needs of and services to university students is an open field for nurse researchers.

The client's view of high-quality care in Santiago, Chile.

The meaning of quality of care for the women who receive reproductive health services at a family planning and maternal and infant care clinic in Santiago, Chile, was examined to describe the clinic's service from the women's point of view. A participatory research project with the staff of the clinic was conducted. The central part of that study, reported here, consisted of interviews with 60 of the 330 women who came to the clinic during two weeks in June 1991. The women defined high quality of care as "being treated like a human being." Among specific elements of care they identified were cleanliness, promptness and availability of service, time made available for consultation, learning opportunities for themselves and their partners, and cordial treatment. Clients' view of quality of care must be supplemented by professional judgments about how well services meet clients' needs. But the client's view is determinant if improvements are to result in greater acceptance and sustained use of the services offered. The issues identified by the clients involve only minor costs for the clinic.

Family planning goes public.

PIP: The Center for Family Orientation (COF), a private family planning agency with clinics in 8 provinces of Bolivia, initiated a bold, scientifically planned, and successful mass media campaign in 1986. As late as 1978 the Bolivian government had been hostile to COF. The Johns Hopkins University/Population Communication Services helped COF determine that the Bolivian public and its leaders were open to more information about family planning. Bolivia, the poorest Latin American country, then had 7 million people, expected to double in 27 years. There are 2 distinct indigenous groups, the Aymara and the Quechua, and Spanish-speaking people, centered in the cities of La Paz, Cochabamba, and Santa Cruz, respectively. Only 4% of couples use modern family planning methods. Initial surveys of 522 opinion leaders, 300 family planning users, focus groups of users, and a population survey of 1300 people in 8 provinces showed that 90% wanted modern family planning services. Radio was chosen to inform potential users about COF's services, to increase clinic attendance, and to involve men. To obtain support from public leaders, 10 conferences were held. The 1st series of radio messages focused on health benefits of family planning and responsible parenthood; the 2nd series gave specific benefits, information on child spacing, breast feeding, and optimal ages for childbearing. Besides 36,800 radio spots broadcast on 17 stations, booklets, posters, calendars, promotional items, and audiotapes to be played in public busses, were all designed, pretested, and revised. New acceptors increased 71% during the 11-month campaign. Success of the project influenced the start of the National Reproductive Health Project and new IEC efforts planned through cooperation of public and private institutions.^ieng

Country watch: Brazil.

PIP: Young girls and female adolescents living on the streets of Rio de Janeiro are often open to discrimination, abuse, violence, and exploitation from society and male peers. They are ignorant of and misinformed about bodily functions, lack access to and information on health services and family planning, and run a high risk of pregnancy, unsafe abortions, HIV/sexually transmitted disease (STD) infections, drug abuse, and other health problems. This paper describes the work of the Centre for the Defense of the Rights of Children and Adolescents in combating these problems since 1988. Center workers first met the girls on the street, and began informal conversations. Gradually, trust was gained, and staff were able to determine some of the girls' needs. Help was provided to the girls in securing identification papers. Workers eventually offered to accompany girls to health clinics. Successful experiences at the clinics yielded the establishment of reference services where girls could go for physical exams, prenatal car, births, and the treatment of STDs. Through focus groups, the girls have helped develop a video on AIDS, printed educational materials, memory and board games, and most recently t-shirts with an education theme. Girls, however, did get bored viewing the video, and had limited ability to maintain and carry printed materials in their street existence. The program has proved successful with girls ultimately seeking clinic help on their own. A special ID card testifies to their rights to receive services. Center staff support the slow development of the program and their relationships with the girls as important in gaining trust.^ieng

Mexican doctors serve rural areas.

PIP: The Mexican Foundation for Family Planning (MEXFAM) worked to solve the unemployment problems of physicians and to increase health services to underserved rural areas. In Mexico, 75% of practicing physicians were located in 16 urban areas. Mexico had a large population of 83 million, of whom many in rural areas have been deprived of family planning and medical services. MEXFAM initiated the Community Doctors Project in 1986. The aim was to help Mexican doctors set up a medical practice in marginal urban towns and small towns with low income residents. Funding to physicians was provided for conducting a market survey of the proposed region and for advertising the new medical services. Loans of furniture and medical supplies were provided, and options were provided for purchase of equipment at a later date. During the promotion, services for maternal and child health care were provided for a small fee, while family planning was provided for free. Doctors usually become self-sufficient after about two years. The MEXFAM project established 170 community doctor's offices in 30 out of 32 states. Services were provided for at least 2500 families per office. In 1990, 13 offices were opened to serve an estimated 182,000 clients. A new effort is being directed to owners of Mexican factories. MEXFAM will set up a medical and family planning clinic very close to factories for a company contribution of only $12,000. The clinic promotion is being marketed through videos. MEXFAM found two companies that agreed to support a clinic.^ieng

[Profamilia: immense unknown contribution]. / Profamilia: inmenso aporte desconocido.

PIP: In late 1965, when he presented himself to the International Planned Parenthood Federation headquarters in London weeks after founding the Profamilia Foundation, Dr. Fernando Tamayo was an unknown Colombian physician with a mission to modify Colombia's very rapid rate of population growth. Colombia in 1964 has a population of 17.5 million growing at an annual rate of 3.4%. By 1973, the population was 22.9 million and growing at 2.7%. Cultural, religious, and moral obstacles precluded an aggressive family planning campaign, which would have aroused violent resistance. Profamilia personnel worked discreetly but persistently, convinced that they would see few short term results but that their effect would be immense in the long run. Family planning is partly a process of educating families in the health, socioeconomic, and psychological benefits of smaller families. Profamilia has a centralized organization which administers 3 main programs, the clinical program with 40 traditional clinics in major cities and 8 well-accepted male clinics, the sterilization program in clinics and mobile units, and the community-based distribution program which distributes pills, condoms, and IUDs through 3000 community posts under the direction of 120 instructors. Between 1964-90, Colombia's total fertility rate declined from 9.2 to 4.4 in rural areas, from 5.2 to 2.2 in urban areas, and from 7.0 to 2.8 overall. The rate of population growth declined from 3.4 to 1.8%. It has been estimated that over half the decline is due to Profamilia services. The total investment by Profamilia during its history was US $100 million. The average cost of protecting a couple against unwanted pregnancy is US $5.26 per year. Colombia's population is projected to increase from 30 to 54 million between 1985 and 2025 even if the growth rate declines from 1.8% in 1990 to 1.3% in 2025. The most worrisome aspect of the projected growth is its concentration in urban areas, which are already beset by poverty, inadequate basic services, and a limited potential water supply already threatened by deforestation. It is clear that the work of family planning in Colombia is not done and that much remains to be accomplished.^ieng

Decree No. 157 of 8 December 1986 revising the Family Code of the State of Hidalgo.

PIP: Among other things, this Decree eliminates from the Family Code of Hidalgo, Mexico provisions enacted in 1983 relating to family planning and fertility control. The provisions promoted the establishment of family planning centers, called for doctors in these centers to furnish their patients with information on contraception, instituted obligatory sex education, and endorsed a wide variety of methods of birth control, including sterilization (Decree No. 129 containing the Family Code for the state of Hidalgo appeared in [Periodico Oficial, No. 45, 8 November 1983, pp. 3-35]).^ieng

New clinical services in Argentina.

PIP: Recent activities of the Asociation Argentina de Proteccion Familiar or Argentinian Family Protection Association reflect the return of democratic rule there. In December 1986, the law was changed to permit family planning. In response, the Association switched its focus from information and education to influencing government policy markers and providing clinical services. In 1986 the organization opened 6 new clinics in different regions, the only subsidized services available. 2 more clinics are planned in Rosario and San Martin, funded by a grant by the Public Welfare Foundation. The Association also operates a profitable fee-for-service clinic in Buenos Aires. In 1986 20,774 visits were logged by 6075 clients. The majority were single, educated and employed, were referred by another client, and chose the IUD. The Association is also working on university curricula in reproductive health training. The government is moving toward of family planning into its health system, according to the new law, so the Argentinian Family Protection Association will undoubtedly continue to adapt to the country's needs.^ieng

Male-only clinics: a success story in Colombia.

PIP: 2 male-only reproductive health clinics in Colombia are refuting the stereotype that Latin American men reject vasectomy as a threat to their machismo image and consider birth control to be a woman's responsibility. Over 1000 vasectomies were performed in the 2 clinics in Bogota and Medellin in 1986. The clinics are operated by PROFAMILIA and supported by the Association for Voluntary Surgical Contraception. Information about these male-only clinics is dispersed through radio announcements, magazine advertisements, and newspaper articles. The cost of services at these clinics is 50% less than services provided at other family facilities. These clinics demonstrate that Colombian men are willing to share family planning responsibilities if services are offered in a manner respectful of their needs. 3 additional male-only clinics are scheduled to open in Colombia in 1987.^ieng

Family planning practices among Anglo and Hispanic women in U.S. counties bordering Mexico.

PIP: The US Center for Disease Control surveyed women of reproductive age living on the US side of the Mexican border as to contraceptive use and source of care. It found that overall contraceptive practice is quite similar among married Hispanic and Anglo (white, non-Hispanic) women: 75% of Anglo and 66% of Hispanics use some method. Among never marrieds however, Anglos are twice as likely as Hispanics to use a method. About 22% of Anglo and 12% of Hispanic women are protected from pregnancy by contraceptive sterilization of themselves or partners, the difference almost entirely attributable to a very low incidence of vasectomy among Hispanic males. The pill is the most popular reversible method among both groups. Hispanic women are more likely to go to Planned Parenthood or health department clinics, Anglo women to go to private physicians or clinics. Unmet need is much higher among Hispanics: about 4 times the proportion of married Hispanic women as comparable Anglo women were at risk of unintended pregnancy and were using no method.^ieng

[Prevalence of anemia in women attending family planning clinic in Durango (author's transl)]. / La prevalencia de anemia en mujeres asistentes a servicios de planificación familiar en la Ciudad de Durango.

PIP: This study investigates the prevalence of anemia in a group of 500 women requesting contraception for the first time at the Health Center in Durango, Mexico. 92% of women were between 15-34, with the majority in the age group 20-24; most had parity 1-4. The average hemoglobin level was 13.04 g/dl, with SE of 0.08. There were 70 anemic women with hemoglobin level below 12 g/dl, which gave a percentage of 14%. 90% of anemic women presented iron deficiency. 16.8% of the total number of women were within the 1st 6 weeks postpartum or postabortion; of these 32% were anemic. Of the 82.4% of women beyond this period of time only 10.4% were anemic. There was no increase in the prevalence of anemia in women with higher parity; among the 174 obese women the percentage of anemia was 86%. The relatively high prevalence of anemia in women seeking contraception compels the doctor to consider very seriously the type of contraception to be prescribed. In Mexico there is an important difference in the geographic distribution of anemia, which seems to be most common in the province of Yucatan, and which is probably caused by alimentary iron deficiency.^ieng

[Family planning counseling centers in Brazil]. / Consultori per la pianificazione familiare in Brasile

PIP: The authors describe conditions in Brazil that led to the establishment of family planning centers in 1965 and their institutionalization in 1971. Their organization is described, and a table showing attendance at family planning clinics is presented. Family planning is discussed in relation to social conditions in Brazil, and the results of an empirical study of population growth and family planning are introduced. The study includes tabulated results of a survey undertaken in Sao Paulo and Rio de Janeiro in 1967-1977 to examine attitudes toward contraception, use of the pill, and government policy on birth control.^ieng

[Organization of Maternity Hospitals]. / Organisacao de Maternidades.

PIP: In a lecture given in Rio de Janeiro in 1919, the author praises the efforts made to establish a maternity clinic at the School of Medicine of that city, but deplores the insufficient facilities, which prevent the staff from providing proper care to the patients and from successfully using the clinic as a teaching hospital for gynecology and obstetrics. The text of the lecture is followed by a letter in which a professor working at the clinic denies this statement, which is regarded as derogatory.^ieng

On the spatial diffusion of fertility decline: the distance-to-clinic variable in a Chilean community.

PIP: Survey data collected in San Gregorio, Chile during 1967 were selected for an investigation of the importance of residence distance-from-clinic in the pattern of contraceptive acceptance. Data were obtained through interviews conducted with women of fertile age who resided in every 4th house in the community. 1163 household reports could be employed. This number included a total of 1612 women in their fertile years. The 1612 women could be divided into users of some means of contraception and non-users. Once the basic binary classification procedure has been applied, each available socioeconomic variable for users and non-users may then be compared to determine if a significant difference exists among the distribution of the variables for each group. The variables of abortions, recent births, and aspiration level were the most potent discriminators between users and non-users of birth control. The more conventional socioeconomic variables showed little discriminatory power. Distance was found to be a fairly powerful discriminator between the group of users and non-users. Several variables other than distance are correlated with birth control practice, but once the influence of the spatial variation of these correlates has been extracted, distance emerges as the single most powerful discriminator between users and non-users of contraceptive techniques. There thus appears to be a need to emphasize the distribution of contraceptive supply in order to reduce the distance which women must travel to obtain birth control information or devices.^ieng

Psychocultural aspects of contraceptive behavior in Jamaica. Individual fertility control in a developing country.

PIP: Variables which influence the decision among primarily lower-class J amaican women to use or not to use contraception are discussed. The material is based on interviews with 20 women, 14 of whom are clients at a family planning clinic. Additional data is derived from shorter interviews with 80 family planning clients. Case histories highlight the material. The following psychocultural variables were considered significant. 1) Poor communication between sexual partners. 2) Strictness in child rearing, shielding the child from any knowledge of sexual relations and its possible outcome in the hope of keeping her chaste but in fact often leading to early sexual relations. 3) High value attached to the status and role of mother. To many women, their mother is more important than their mate. 4) Negative perceptions of Ja maican men and of potential roles for women other than motherhood. 5) Socially permissible loose conjugal and household arrangements with little pressure on the men to assume responsibility for their children and much pressure on the woman to bear a child for each new mate. 6) Anxiety about contraception through ignorance and lack of communication with an informed, authoritative person. The force of these factors is apparent in the fact that fertility patterns have changed little in the 7 years since the government mounted a massive family planning campaign. However, the coming to a family planning clinic, especially early in a woman's reproductive period, represented a move in the direction of autonomy and self-determination for women.^ieng

[Factors of high fetal risk in a peripheral clinic]. / Factores de alto riesgo fetal en un consultorio periférico

PIP: The health risks of pregnancy to mother and fetus can be represented schematically by the diagram of an iceberg. Its tip represents the level of risk encountered at the hospital level which has obviously been conditioned by biological, socioeconomic, and psychological factors at a lower level. This lower level of factors that determine risk can only be understood if specifically investigated at the level of the consulting clinic, prior to any hospitalization. 2 groups of patients attending such a clinic in Chile were studied: 1 with pregnancy complications and 1 characterized by normal pregnancy. The purposes were to determine the prevalence of pathology at the clinic livel, to relate the biological factors that condition risk and the pathology of the particular gestational period, and to relate pregnancy complications, the characteristics of labor, the puerperium, and the newborn. 6 factors were traced that condition risk at pregnancy: age, place of residence, abortion history, parity, height, and control of pregnancy. In turn, these were related to each specific period of gestation and birth. The data collected and tabulated show that the different factors analyzed exercise a differential effect on the various periods of pregnancy and labor. The greatest risk factors are those of maternal age, parity, abortion history, height, and pregnancy complications such as urinary infection, toxemia, and anemia.^ieng