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E/CN.14/POP/128 1 November 1974 ORIGINAL: ENGLISH OUT

ECONOMIC COMMISSION FOR AFRICA Expert Group on National Population

Policies and Programmes in Africa

Addis Ababa, Ethio~ia, 11-15 November 1974

HEALTH AND FAMILY PLANNING Prepared by

WORLD HEALTH ORGANIZATION

CONTENTS

I. FM4ILY PLANNING AS A HEALTH PRIORITY 1. Maternal Health

1.1 Mortality 1. 2 Morbi\lity . 1.3 Abortion

2. Fetal and Neonatal Health 2.1 Mortality . . .

2.2.Fetal malnutrition 3. Child Health

.

1 1 1 2 3 3 3 4 4

3.1 Postneonatal mortality 5

3.2 Maternal care . . 5

3.3 Infectious disease 5

3.4 Height and weight. . 5

3.5 Intellectual development 5

4. Family Health . . . 6

5. Infertility and Sub-Fertility 6

II. CHARACTERISTICS OF MATERNITY WITH RESPECT TO HEALTH 7 ASPECTS OF REPRODUCTION . . . .

1. Maternal Health and Fertility. . . 7 M74-2146

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E/CN.14/POP/128

CONTENTS (Continued)

2. Postpartum Ame~o~h~ea, Practices . . ; • • .

Breast Feeding and Weaning

Page 7 3. Hormonal Contraceptives and Breast Feeding

4. Socio-Cultural Determinants . . • . . . . •

8 8

III. THE RATIONALE fu~D ftDVANTAGES OF INTEGRATING FAMILY

PLANNING WITH !,L,\TERNAL AND CHIlli HEALTH AND OTHER FAMILY AND CONMUNITY HEALTH' ,ffiASURES . . . . • . . . .

1. Maternity-Centred Family Planning (integrated MCH/FP care) . . • .

9 11

2. Other Activities in Health Services and Family Planning . . . • . .

13 IV. REVIEW OF THE STATUS OF DEVELOPMENT OF FAMILY PLANNING

AS !1. PART OF HEALT'ri SERVICES . . • . . .

1. Variations in Planning and Evaluation . . . • . . 2. Current Status of Maternity-Centred Family Planning

13 13 14 V. PLANNING' ADI~INISTRATION AND IMPLEMENTATION OF FAMILY

PUURIING IN THE CONTEXT OF HEALTH SERVICES . . . . • 1. Problems of Organization, Administration and Service

1.1 Central level . . . 1.2 Intermediate level 1.3 Peripheral level

2. Education of Families and the Community

3. Collaboration and Cooperation between Integrated .Health Programmes and Other Community Programmes or

Family Planning Activities Outside the Health Sector

17 18 19

20 20

23 24

27 28

26 26 27 24

28 IN HEALTH SERVICES 29 31 35 EVALUATION OF FAMILY PLANNING PROGRAMMES

SUMMARY AND CONCLUSIONS REFERENCES . . . • . .

VI. EDUCATION AND TRAINING OF HEALTH AND OTHER WORKERS FOR THEIR ROLES IN HEALTH·ASPECTS OF F~IILY PLAN}IING

1. Medical Education • • 2. Nursing and Midwifery

3. Training of Administrators, Managers and Manpower

Specialists .

4. Training in Health Education 5. Health Auxiliaries

6. Workers in Other Sectors VII.

VIII.

- i i -

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n/CN.14/POP/128

HEi,LiH AIiJ ,,;I,ilLY PLANNING

I. FAldLY PLANNING AS A HEALTH PRIORITY

The principal theme of this document is to discuss the inter-relationship of health and family planning and its implication for health service delivery systems.

Family planning can favourably influence the health, development and well-being of the family and particularly has an effect on tlv, health measures fl'r health, thus family planning care is an integral part of the health care of the family.

The health impact of family planning could be considered within the framework of the following influences:

(a) Avoidance of unwanted pregnancies and the occurrence of wanted births that might oth€rwi5e not have taken place.

(b) A change in the total number of children born to a mother.

(c) Allowing a natural interval between pregnancies.

(d) Changes in the time at which births occur, particularly the first and last, in relation to the age of the parents, especially the mother (WHO Technical Report Series 422, 1970; QT-~an 1971a) Social, economic and cultural factors impinge on all aspects of human reproduction. For example, high parity (a large number of births) or short pregnancy 'ntervals are commonly acsociated with low socia-economic status, poor nutrition, p00r hygiene, over-crowding, poor education and poor health practices. These inter-related factors in turn tend to be linked with unfavourable outcomes of pregnancy such as premature or difficult labour,

1011 birth weight babies, birth trauma and infection, in which it becomes difficult to establish clear causal relations. But at the same time, there is little doubt that selected interactiuns of factors, including high numbers and short intervals of pregnancies, increase the risk of

unfavourable outcomes. It is on the basis of this evidence that the health benefits of family planning are founded. As will be seen, the benefits are most striking in relation to the health of mothers and children.

1. Materdal Health 1.1 Mortalitx.

While maternal mortality is slightly less with the second and third pregnancies than with the first, it rises with each pregnancy beyond the third and increases significantly with each pregnancy beyond the fifth.

It is at times possible to dissociate the effects of parity from those of the mother's age, but usually the two factors are inter-linked. Excess female mortality at childbearing ages over male mortality at equivalent

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E/CN.l4/lPOP/123 Pagc 2

ages further quant1fies the loss in such situations. The tragic implica- tions of mat erna l death in relation to health and welfare of t~'i0 f'ami Iy cer-t ai.aIy ...·cq:..:d.:..',: ~lO et aborriti,)Tl.

1.2 ,.fcTb::'di<:y

Th'2 long·tel't!l effects of pr-egnancy and its compi icat i.ons have not been fu l Iy asc es s ed , but it is evident that reneated inadequately spaced pregnancies deplete a woman's store of nutrients, including protein, calcium and iron. 1r0n deficiency anaemia and folic "cid def_cie~cy

are common jn developing countries and not uncommon in some ~ec'eloped

countries. In South Ameri.ca , iron def i.ciency anaemia has been found to affect about 5-15 per cent of men and 10-35 per cent of ~·ICj'.8nt in Asia

abc~t 10 per ceat of men and 20 per cent of women, risi~g to 40 per ce~t

in pregnancy; and in the Middle East approximately 20-25 pel' cent of pregnant women, In Europe, it is estimated that 10-25 per 'on.: cf wouen

suffer fror.;.iron deficiency anaemia and in the USA the c:Jrr~:pGr;ding level has been determined, mainly amongst the poorest sections of t~~ population, at about 20 per cent. (il"'-j() Technical Report Series 1~52, 1970) In ymO- sponsored s tud ics in diff'cr-errt parts of the world, t~·:} perccnt ag e of women with anaemi a ranged from 21 per cent tv 80 per cent C'EO Technical Report Series 405, 1968). Pregnancy predisposes wo,:,e'l to the '"anifesta- t i.c.is of m.aemia because folic ad" and iron needs ir.creasc sharply during this period, especially wnere malabsorption or poor diet "0'0 invc Ivcd . In devel opi ng countries therefore there tends to be a widesi','ead prevalence of matnut.rition and anaomi a , scmet imes labelled "mat.erna l dcp Ietior;", due to superimpos atIon of an almost: continuous sequence of pregnancy and breast feeding der-nnds on poor maternal diet and heavy physical work . I t has been suggested ·.~_tat if the" number of prcgnancie s were limi_oo to thr eo or less the incidence of severe 01' mooerate anaemia might be r-educed by as much as two-thirds. The incidence might be further reduced by he~t:er pTegnancy spac in« (~~0 :11"(1 GopalanJ 1971. ) .

Mato,n"l malnutrition and anaemia are a3g,avated by infection and chronic i,lness, which further increase the risks associat:ec with repeated p·regnancy. In some developing countries, malaria and parasi. tic infcst.at Ion contribute to the severity of maternal anaemia connected with malnutrition.

Such hazards of infection are ~reater where there is restricted access to antiseptic conditions, inadequate drugs and health care facilities.

The pregna~cy risks &ssociated wit~ obsterical complications such as placenta .pi'evia, .abruptic placenta and rupture of the ut.erus ; a hbtory of

medic~l ~onditjons of che mother, including toxaemia of pregnancy, hereditary disorders; cid.b::::·~GS uel Litu s a::::! c crt.ain phycb lat r ic sn.I neurclcgical

conditions, arc aggrav<'.ted by high parity, particularly grand multiparity (Omran 1971b),' Fhere health and socio-economic cond i.t.f.ons axe mavgi na l , many of these problems become especially prevalent and m:Jre m2cked as

parit-: 2.:1d age of the mother rncrease.

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1.3 ~tion .,

Intervention to interrupt pregnancy wOuld appear to provide the' clearest indication that a pregnancy is unwanted for personal, social or medical reasons. Family planning can help the mother to prevent unwanted pregnancies which might result in unqualified termination of pregnancy with known health hazards for the mother.

In an increasine number of countries, pregn~,cy may be legally

interrupted for ,social or personal reasons, as well as on medical grounds.

In many aparts of the world, however, women choose hazardous, unqualified and illegal abortions rather than accept the burdens of additional unwanted pregnancies, resulting in serious risk to their life and health (~old, 1966).

The common practice of· abortion is shown in figures from studies in South America: it was found that one of every four pregnancies among married women and one of every three in broken and common-law homes ended in abortion (Tabah and Samuel, 1962). In a random sample of 3,776 women

(20-45 years of age) liVing in 3 cities of Chile, 41 per cent gave a positive history of abortions, and 75.1 of this group admitted to having had up to three induced abortions (~ijo and Monrreal, 1965). For a random sample of 1,662 Peruvian women between 20 and 30 years of age living in the area of the capital (Lima), abortion rate of 20 per 100 pregnancies in the upper

socio-economic level, 18 in the middle and 12 in the lower bracket were found (Hall; 1965). The particular complications of unquo.lified and illegal-abortion include infection, haemorrhage and mechanical injury, and, at times acute renal failure and thromboembolism.

2. Fetal and Neonatal Health 2.1 Mortality

Perinatal mortality (a sum of late fetal and early neonatal mortality) is closely related to maternal age at pregnancy and parity - two variables which can readily be altered by family planning. A highly significant correlation has been noted between increasing perinatal death rates and mUltiparity, although the incidence is also high among pri~igravida

(first pregnancies).

Studies show that perinatal mortality is elevated among young mothers under 17 years of age, is at its lowest level between 20 and 29, and rises sharply thereafter. Among ,"others over 40, the rate of perinatal mortality is several times that among those under 20. The exeess rates among young girls are accentuated when associated with higher birth orders. Older mothers of birth order one are at 'high risk of perinatal loss, but for all of the younger age categories there is a direct relationship with parity. Perinatal mortality rates have been reported to be lowest when the interval from the end of one pregnancy t~ the beginning of the next is between two and three years (WHO Technical Report Series, 442, 1970).

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E/Q,-14/POP/128

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2.2 Fetal malnutrition

In recent years, fetal malnutrition has received more attention.

It has been discussed as the end result of two rather different patholo- gical phenow~na•. In one, maternal, vascular disease may restrict blood flow to the placenta, while in the other, maternal malnutrition is believed to reduce the quantity of essential nutrients reaching the fetus (Winick, 1970). ~aternal malnutrition and anaemia have been

described above in relation to their seriolls effects on maternal health, but where nutritional resel~es are depleted an~ food intake during

pregnancy is poor, the toll on the developing fetus may also be substantial, adversely af:::ecting birth weight, perinatal mortality, and· brain development. Even in developed socia-economic conditions maternal nutrition is felt tb playa role, since pre-pregnancy weight of the mother and weight gain during pregnancy have been shown to be positively associated with birth weight of the infant (Committee on Maternal Nutrition and Food and NutritiG.1 Board, 1970). In developing countries, the widespread prevalence of chronic malnutrition among women of childbearing age leads to a high incidence of low birth weight infants.

A large proportion of perinatal deaths and perinatal morbidity occurs among the low birth weight babies, who thus represent a high risk group in general. Hence, the control of birth weight is considered a prime means of reducing perinatal mortality and immediate and long-term morbidity.

Birth spacing is similarly associated with birth weight and therefore is another important factor .in infant survival and health. It has been shown that spacing of at least two years between pregnancies has helped to improve birth weights (Douglas and Blomfield, 1954; Yerushalmy, et al., 1956; ~on and Gordon, 1962; ~ishop, 1964). Short intervals between

pregnancies have been shown to ;)0 associated with low birth weight, early neurological retardation, as well as lower mean IQ scores at four years of age, even when controlled ror socio-economic status and other factors (Holley et al., 1969). Fetal mal-nutrition also has been

demonstrated to have a definite retarding effect on brain growth during the critical period before hirth (Winick, 1970). The results of a well- controlled experiment in four Guatemelan villages are of interest since they showed that by supplementary feeding of the pregnant women who are chronically malnourished, the birth weight of their babies is improved

(~abicht, et al., 1972).

3. Child Health

Many studies have documented significant relationships between the health of children, family size and spacing .. Only some selected

representative reports can ~e cited here. .

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3.1 Postneonata. mortality (n.ortal ity of infants after first month

of

age, 1-12 months)

Infants of the youngest mothers with the hi ghest parity are at greatest risk, with maternal age being the more important of these two factors. Deaths during this period are associated with such environmental factors as housing, sanitation, nutrition and exposure to infectious diseases. !1any studies support the stroY':; associations between high postneonatal mort ali ty, pregnancy at an early age, and high parity (Morrison et al., 1959; Heady et al., 1955;

~on and Gordon, 1962; ~iegel et aT., 1966). The timing and spa~ing and control of the number of births as a means of achieving lower postneonatal mortality is highly relevant to family planning practice.

- ?

.>.- Haternal care

Care provided by the mother for her infant, and her interests and attitudes towards her children in relation to family size, were analyzed as a part of longitudinal studies of pregnancy and childhood in Great Britain

(Nesbit and Entwistle, 1967). The adverse effects of increasing family size on infant care, use of medical services, interest in school progress and desire for hatter schooling were consistent.

3.3 Infe~tious disease

It has been shown through detailed longitudinal family studies that the prevalence of infectious gastro-enteritis and respiratory disease were directly related to family size (~inglc et al., 1964).

3.4 Heig.t and weight

Child growth has also been found to be associated with family size.

Data indicate quite clearly that children in large families are smaller, and that firsc-born children with one or more siblings do not reach the height and weight obtained by those who remain only children (Grant, 1964).

A stuJy of preschool malnutrition in Candelaria, Colombia, showed a

significantly higher prevalence of growth retardation among children from families with five Or more living children than a matched group of families with four or fewer children (~ray and Aguirre, 1969).

3.5 Intellectual development

Few studies dealing \"ith the relationship between family size and intellectual development have used acceptable methods and they are confined to western cu l tures , However, these show It definite adverse effect of family size on intelligence. One of the most adequately controlled

investigations is the long-term fOllow-up of the large sample of children in Britain (refer to 3.2 above). At eight years, the children completed four tests - non-verbal intelligence, sentence completion, reading and vocabUlary; at eleven years the reading and vocabulary tests were repeated.

For all socio-economic groups, there was a consistent decline in the scores with larger family size (Nesbit and Entwistle, 1967). The longitudinal studies indicate that earTy childhood influences, before 'ge seven, produce the greatest ef~ects.

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E/CJ:.lt:./?GP/I~S

Page 6

As noted earlier, chi Idr-en from larp;e families are more likely to suffer from def ic i.encies of parental care. Thus, it "'ight be inferred that the qual it)' and quantity of auu lt contact (that of parents and, in

extended Fam'iLi es, other adults) may l e the most Inf Iuerrt Lal factor

determining achievenent, notivation and perhaps ability. It is clear that the more children a mother has, the less attention she can provide

for anyone of them. However, other environmental faccors such as crowded livinG status, reduced income and lower per capita spending for food, all associated wit~ large families, also must deter the full intellectual development of such children.

4. Family Health

The relationship between family size and selected measures for maternal and child health have been reviewed. In many instances, they reflect the effects of fro"ily overcrowding and its correlates. TI,US, it might be postulayed·that tho larger the family, the higher the probability of poor adult health - unrelated to their immediate effects of reproduction or growth and development. However, methodologically sound studies to support such a hypotheis are scarce and oyiginate largely from western countries. Therefore, associations of adult health with family size will be alluded to only briefly. For example; the developwent of rheumatoid arthritis has becn shown to be more frequent in individualS from larger sibships and peptic ulcer among fathers increased with the ~~ber of children in the family (Chon and Cobb, 1960). It has also been suggested that marital adjustment may be associated with family size.

Effective famjly planning can favour~hle influenc0 the health, development .md \wll-being of family members and the f"mily unit as a whole, and is therefore considered as an important preventive measure in the health care of the family. It may also improve the quality of life through its imract on f~ily health. For example, when children are born at optimum times and are wanted, it is more likely that they will be "ell cared for and that their environment will be conducive to normal growth and development, while family members can more easily share

an emotionally satisfyinr, relationship that will rrornote family health (UNICEF/WHO Review of FcmiIy Planning Aspects of Family Health, 1972).

5. Infertility and Sub-fertility

Although major emphasis has been placed upon the health benefits of pregnancy, spacing and family size limitation, family planning properly encompasses also a concern with infertility and sub-fertility from the

physical and psychological viewpoints. In some social and cultural milieux, a woman's status and happiness as well as a man's are related to his or her fertility or sub-fertility. Hence, ideally, family planning as a component of he a lt h services should seek to determine the specific cause of sub-fertility, begin the appropriate treatment, and continue care until a child is born to the couple.

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rr.:

CHARAC'tERIST~CS ::~ :':T:,ryJJEY \,:~'~E !{ESPECT TO HEALTH

ASPECTS OF REPRODUCTION 1. Maternal Health and Fertility

Maternal health and nutritional status as they relate to fertility have been discussed. Although acute catastrophic starvation such as was experienced during World War II results in sub-fertility, it is not shown that chr0nic malnutrition has a major influence. However, among pregnant women rood infants, improved nutrition might indirectly affect fertility. For example, reducing infant mortality might lengchen the duration of lactation which would tend to increase the intervals between births and thus reduce fertility. This is however a w.~tter of great dispute and, if lactation affects the interpregnancy interval, its effect per ~ is small. (Ihompson et al., 1972). On the other hand, socio- economic and cultural changes associated with improved nutrition and falling infant mortality may result in a conco~itant decrease in breast feeding and/or a relaxation in the taboos on coitus during lactation

which would have a reverse effect and tend to raise fertility. Infections, especially venereal diseases rold genetic disorders, and age at menarche are among the additional biological factors which affect fertility.

2. Postpartum Amenorrhoea, Breast Feeding and Weaning Practices.

Postpartum amenorrhoea and breast feeding and weaning ?ractices as they relate to fertility, merit consideration. Although postpartum amenorrhoea reduces fertility for a total population, there are,

unfortunately, limited data regarding postpartum amenorrhoea variations between and within populations. There is evidence thot the duration of postpartum amenorrhoea is related t~ the duratio~ of lactation and to the outcome of previous pregnancy - it being shortest following abortions, slightly longer following stillbirths and neonatal deaths and longer

still if the infant survives th3 first month (\~10 Technical Peport Series 435, 1969).

Breast feeding appears to prolong postpartum amenorrhoea and conse- quently to delay ovulation and pregnancy; however, the duration of

protection against conception provided by lactation varies considerably between different population groups (Thompson et al., 1977). On the other hand, socio-economic and cultural changes associated with improved nutrition and falling infant mortality may result in a concomitant decrease in breast feeding and/or a relaxation in the taboos on coitus during lactation.which would have a reverse effect and tend to raise fertility. Infections,

especially venereal diseases and genetic disorders, and age at menarche are among the additional biological factors which affect fertility.

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B/CN.14/POIil28

Page 8

- -~ ~--~-. --_.

!n devc Ior.Ing count r-i.es , weani.ng practices playa major role in relation to child sUTvival as well a~ f0~tility. Therefore, mothers shoulo bs encouraged to breast feed and additional supplementary foods should 'Je added as the child grows. f:egrettably, as societies become modernized, preference for artificial feeding ha5 proceeded at an alarmin~

pace. V~en mothers i~ impoverished communities with low levels of educatiun canoge not to or are unable to brsast feed, their infants may develop f'at at f,astre>-ente"itis and nutritionl or other diseases that could have been p.ceventcd, The death of the infant is often foLlowed closely by another pregnancy. Conversely a new pregnancy may lead to death of tho preceding child - the "last but one" - possibly as a result of early weaning (~~O Technical Report Series 435, 1969).

3. Hormonal Con~raceptives and Breast Feeding

Considerable interest and concern has focussed on the effects of hormonal contraceptives on LactatLon , Although the question is not fully r-eso lved , there seems to be general agreement that combined oral contr-a- ceptives may have an adverse effect on lactation. TI,e risk of pregnancy is low c:uring the first four to six weeks postpartum, therefore hormonal contraceptives could be postponed untillactat10n is well established.

Another posslbility is to provide other methods of concraception which have no effect on lactation and then to transfer to the estrogen-progestin combined oral Fill, if this is considered the method of choice, after cessation of breast feeding (Thompson et aI" 1972),

4. Soci5l-Cultural Determinants and Fertility

In additioL to the biological and related factors associated with fertility, socie-cultural determinants should be noted. For example, the primary obstacles to familY planninR include: early age of m.~riage;

actitudes related to high levels of mortality, especially childhood mortality; the dependence of women's status in th~ family and society upon fertility; and the importance given to the bIrth of sons, or to

large f&~ilies as a means of ensuring support and security in illness or old age. Somctimes the methods used in provision of family planning care are not ncceptable in a given setting or for individual families.

Also, major or minor side effects may discourage acceptance or continua- tion, especially where there are no easily accessible health services of good quality for care and follow-up. Professional and auxiliary health vrorker s ' attitudes to family planning are also an important

consid0ration; traditional birth attendants, particularly, might perceive child spacing as Ieducing the need for their services. However, with proper orientation and appropriate support by health team members, they may play &positive role in efforts for provis~on of in~roved maternal and child care including famiIy planning.

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In summary, reproductive behaviour is affected by varying health and health-related factors, depending on the characteristics of each society under consideration.

III. THE RATIONALE Al\'D ADVANTAGES OF INTEGRATING FAMILY PLANNING WITH ¥ATERNAL AND CHILD HEALTH A."<D

OTHER FAMILY AND COMMUNITY I-'.EALTH MEASURES

The health benefits of family planning cited above illustrate that family planning is a health need for the family. However, many factors will affect decisions to seek and effectively to continue practising family planning. For example, in developing countries where childhood mortality is still high, parents find it difficult to alter their high fertility patterns. Their personal experiences, from an early age

onward, have taught them that some of their children will die, regardless of hat action they take. Retrospective, cross-sectional and longitudinal studies suggest that increased childhood survival is essential to the widespread acceptance of family planning and recognition of the fact that the practice of family planning and birth spacing will favourably

mflue-nce child survival (Hassan, 1966; Driver, 1969; Freedman et a1., 1964). The evidence from mathematical mOdels points in ths same direction

(~eer, 1969). It also seems that these dynamics have played a role in the demographic revolution (Omran, 1971c).

In fact, where infant and childhood mortality are high, isolated family planning programmes are unlikely to convince unresponsive or resistant couples. Many field workers have found that when family planning programmes are not integrated with or based on family health care provided in health services, it is difficult to sustain their initial impact. Of even greater significance are the more positive reactions of parents to programmes which include family planning among the other family l.ealt h care measures aimed at reducing child morbidity and mortality than to progra~es concerned solely with family planning.

Further documentary evidence is needed to support this observation.

The nature of modern concraceptive methods is such that supportive health services are required for their proper administration to couples

in need. ~mny aspects of family planning care require the personnel, skills, techniques and facilities of health services. The use of IUD, hormonal contraception and surgical sterilization requires health care

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E/CN.14/POP/1Z8 Page 10

---ror-c:~e ~~:Le~{~~n, impfeme"iit"itiorC foliow::up-and management 'oFside - . - - effects. The support of the medical community and the health teams is

highly desLr-ab l e , and its participation for s-rrvicmg the prog ramne

indisp~l~abl~. t~ere family planning progrmrrmes are not adequ~tely integrated with he 'lith programmes there is likely to be duplication and frap,mentation of reSJU~C~3. A~ the outset, it io important to secure the most prestigious medicsI s"f-pore possible for family p l anrring ef'forz s . The medical

r~ofession spo~ld be invo!vcd i~ sel~ctiTIg the ~ontraccptivemetnods to be provided. Unless medical and health workers at all levels, from academic professors to the Village midwife, are mobi.Hzcc. and suppcxt f ami Iy

pla~nir.g ~£forts, co~~nitysupport will be deficient. TIle provision of measures for family planning as a part of continuir.g far.lily haalth care in health services fosters acceptance of .cun~racoptive n;ot~lOcs in the face of rumours and concern among the general public. Finally, the continuing Care ?~J follcw-up required for medically admiaistered contraceptive methods can be mol"; eff'ici errtIy provided through mtegret ion of family plarhiing a~d h~alth services r~sources.

T:,el.'e ,,,:e many log! sxi c reasons for Ir.t egr-at ing prcgr3ll'Jlles for deali.r;« ..•:,':h the priority needs of mothers and chi1dren , including

family pl~nn~ng. Funds can be pooled, a stronger infrastructure developed, superv.is J.on str eng thened , dup Hcation of facilities avoided, and workers call ra:'. 'ice far,;ily planning to many of the reasons for the mother's visit for hea:th ~~re (the nce~ for family planning is most evident to parents in con.iect i.on with maternity and child care). In most of the world's

c0untri~s, ma~~cwer ?nd other health resourC0S are relatively scarce and carofu l consideration must be given to their most efficient use.

Where funJ= ~~d persunnel are diverted into isolated family planning pr0r':u,'Jj;,e:;, there is not only the danger that health services will be

we~];en"d but also the likelihood that basic infrastru-::ture, which is Inpor ccnc for health objectives of family planning will be weakened. It

"ould ~prear that. ad"inistration of family planning must be carefully balarced with other health services, and interdependent pr0grIDR~eS

developed.

It is recognized that at the present time adequate health services are s car-ce in the rural areas of the developing world. Accordingly there is concern abo-rt the relatively Iong period of time that will be requf red to strellsther he81th services and to bring about significantly reduced

dnf'arrt and childhood mortality, and for parents to recognize this r educt i.on. Eowever , many government s are equally concerned and are

plnnlli~g ~lld i~plementing programmes that will provide elements of the

ba~ic hea:th needs of the5e areas, including family planning care Incegrat ed with maternal and child health activities within he.rl th

services. The qucst ion is how best to balance the former with the latter,

con~id3ring carevJlly the special conditions of each country and its

varyin~ locales.

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1. Ma~Lty-Centred Family Planning (integrated MOi/FP care)

This approach to family planning aims at improving the health of mothers, children and the family and emphasizes the provision of

integrated adequate maternal and child and family planning care Lnclud.i.ng pr.enat.aI care. It provides screening and referral of high risk cases,

assi~tanceduring childbirth, care of the newborn, the infant and the child; counselling of both parents; nutrition advice and immunization;

monito::-ing of growth and development of Children, with family planning and contraception advice as appropriate; proper supervision of the use of the fertility regulation methods and follow up for possible complica- tions and management. It also includes advice for couples who need care for sub-fertility and infertility. This approach takes into account the fact that whenever there is contact with mothers and children through health services, in hospital, homes and health centres, the opportunity must be taken to improve maternal and child health care Inc ludmg family planning information, advice and service.

M~ternity care represents the most obvious element of health services for the introduction of family planning. In any population, a largo number of women can be found who have had rapidly repeated pregnancies. Many of them wish to avoid or postpone further childbearing, but do not knowhow.

Under the usual family planning programmes women are not contacted promptly after a pregnancy, and so enquiries repeatedly find them "currently

pregnant.", and therefore "ineligible" for contraceptive advice. In fact it has been determined that without contraception and without lactation, approximately 80 per cent of fertile women will conceive again within a

year following delivery. .

The antenatal, lying-in, postpartum and interconceptional periods seem to offer unique opportunities to advise women about family health in a systematic manner. When the pregnant women in either urban or rural areas c~n be seen by a nurse, midwife or doctor, education and health care . services for mothers and children, inCluding family planning, can be provided.

In addition, thrrnlgh the health personnel, the husbands can also be offered family planning education and services.

The advantages of providing family planning in relation to the maternity cycle and as an aspect of maternal and child health care are:

(i) (ii)

(iii)

Activities can be focussed on those known to be fertile;

Delivery or abortion is a time of high motivation for family planning for health reasons, and one often providing contacts with tho· health worker;

The trust that develops through contacts with health workers can influence women to accept and practice maternal and child health measures, including family planning;

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E/CN.14/POP/128 Page 12

(iv) Family planning is a health need for mothers and children and families, and should be a natural part of their health care;

(v) Integrated services seem more logical to the families and the need for family planning becomes more obvious to parents in connection with events in the reproductive cycle such as pregnancy, delivery and child care;

(vi) The technical and managerial skills and expertise of health

workers providing maternal and child care are most closely related to and thus suitable for provision of family planning advice and care;

(vii) The administrative structure and other existing resources can be used, avoiding duplication and competition. Cost/effectiveness

is greater than with other approaches;

(viii) Through continuity with maternal and child health/family planning care, follow-up and necessary reinforcing guidance can be provided;

(ix) Family planning and other maternal and child health measures can be provided together with the most convenient, accessible,

acceptable and meaningful form for the consumers in a given setting;

(x) Health measures to reduce child mortality will make couples more receptive to limiting the number of their children.

Except,in the case of postpartum sterilization, follow-up of the

mother should extend beyond the immediate postpartum period. IUD insertion can conveniently be done in the postpartum period, and oral contraceptives may be prescribed. However, follow up must provide continuing care,

reassurance about the frequent minor side effects which occur, and

reinsertion of spontaneously expelled IUOs. Many women neglect to return for postpartum attention, but do appear at child health clinics seeking care for their infants. By routine enquiries about the mothers' and f families' needs and desire for family planning during each contact for infant care, health workers can attend to and follow up a large number of mothers effectively. Furthermore, family planning can be logically

presented as a requirement for successful infant care and nutrition.

As abortion laws are being liberalized, in some countries, family

planning care may include early pregnancy diagnosis and access, if indicated, to qualified and safe abortion care in health services. Provision of

abortion care would include appropriate physical and psychological support and follow up of women as well as advice On contraception to avoid abortions becoming necessary.

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2. Other Activities in Health Services and Family Planning

Although the broadly conceptualized, integrated maternal and child health and family planning activities known as the maternity-centred approach, if fully implemented, can be capable of rep-ching a high proportion of the population in need of £qmily planning, other health activities and health workers can also mak~ meaningful contributions.

For example, nutrition rehabilitation centTes and ~aycare centres for preschool children are highly suitable settings fat', discussing health aspects of family planning with parents. Ifnere indicated, the provision of supplementary iron, in cases of low maternal haemoglobin levels, either through its additiOn to contraceptive pills or as a routine preventive measure for all contraceptive patients, is a highly promising approach.

Psychosis, cancer, mental retardation and other chronic diSeases are known contra- indications of pregnancy. Those providing care in such cases have the opportunity as well as the r-esponsIbi l Lty to ensure that effective, birth control services are provided. In fact, f~~ily planning care could be made avail.abIe to patients requiring any kind of medical and surgica:l. care.

:~ong the health disciplines which ~an contribute directly to family planning programmes, other than medicine, nursing and midwifery, is health education. The professional skills of the health educator are closely applicable to the problem of education for fertility management, through improving and supporting direct education measures, guidance of mass media, development of the health aspects of family life educ~tion (including sex educational aspects of school health and of out-of-school youth and adult' education programmes) strengthening marital counselling, and gaining the cooperation of com~Jnity leaders and group~ and other potential

co LIaborat ors ,

IV. REVIEW OF TIlE STATUS OF DEVELOPMENT OF FAMILY PLANNING AS A PART OF HEALTH SERVICES

•. V~riations in Planning and Evaluation

There is wide variation in patterns of progr~un~ pl~nning - from the

subjectrle projection of a~tivities based on past experience to the deliberate, ~

syste@atic and objective process of collecting data and mobilizing resources.

Most programmes combine both these patterns. The following is a general description of what has occurred in the past de~ade (Berelson, 1969).

In countries where health and humanitaYian concerns predominate, the stimulus for family planning usually origina~es in medical circles, often with lo~al, private family planning associations playing an active role in

creating a favourable climate of opinion. Vlliere economists are concernL~

about the effect of populat Ion growth on de', elopment plans, family planning

acti~ity typically originates in the planning board or its equivalent.

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E/CN.14/POP/128 Page 14

The official programme is most often the responsibility of the

Ministry of Health and at the field level is closely linked to the maternal

~ud child health care eiven in healt~ centres. A physician with experience in public health is usually appointed to direct the programme and often begins by designating family planning as another health service, to

be administered through the existing network of centres or through separate family planning clinics that are especially established.

An initial problem in planning a national p~ogramme is the need to relate the objective of family planning to those of national development and to present the health benefits of family planning in an explicit, convincing ahd consistent way. A common difficulty is that of setting realistic

objectives, which take sufficient account of such constraints as limited national resources and the current state of contraceptive technology with due consideration to local availability. This can usually be done by setting objectives on the basis of operational experience, which reveals what can realistically be expected to the programme. Another problem is the need to design a programme of adequate managerial format that will facilitate

implementation, monitoring and evaluation.

Some governments initiate special evaluation studies to assess the performance of their family planning programmes. Statistical data are usually collected on numbers of acceptors, procedures performed, and

supplies distributed. Various aspects of the programmes are evaluated but, as the UN Advisory Mission to India pointed out, the assessments tend to be scattered and ~ ~ in the absence of the overall plan for evaluation (United Nations, 1969, ST/SOA!SER.R/ll). The Mission suggested that, to be effective, evaluation of programme performance has to be undertaken at all stages and, ideallY,evaluation begins alon~ with the planning of programme operations and should take into account all objectives of the programme.

By 1969 it became apparent that the older programmes in Asia were reaching a plateau in their level of achievement. This levelling-off

reflects saturation and calls for future programme development. As services became available, the programmes reached those couples ready to adopt family planning who represented a large backlog of potential acceptors. Further programme development in these countries requires new modes of programme delivery, a variety of educational approaches, and studies of the optimum combinations of contraceptive methods to be offered in a given socio- cultural setting.

2. Current Status of Maternity-Centred Family Planning

The effectiveness of including family planning services in large hospital maternity units has been demonstrated. The Population Council beg,,'l an international postpartum programme in 1966 which has been expanded to over 250 hospitals, including mUlti-hospital networks in Colombia,

Honduras, Hong Kong, India, Indonesia, Pakistan, Philippines, Puerto Rico, Thailand, Tunisia and the United States of America. The primary purpose of

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E/CN. l4/pOP1128 Page 15

the programme is to reach fertile women immediately following delivery

or abortion when they are especially receptive to family planning. In fact, it has been shown that in an urban setting, where most deliveries occur in hospitals, the majority of fertile women will make contact with the

programme within a period of, say, three years.

During the first two years of operation of the 25 hospitals then participating in the programme, 236,000 new acceptors were enrolled representing 11 per cent of the estimated community target population.

A little more than half of the acceptors were women who had been

delivered 1n these hospitals and the remainder were "indirect acceptors", women who had been informed by others using the services and who had been attracted from the same community. Information outside the hospital was mainly by word of mouth. It is evident that this is a quite extensive and highly important means for providing information or for communicating the need for family planning programmes in health terms. In the seven hospitals in the United States 45 per cent of·the delivered cases accepted contraception; 21 per cent accepted in the 18 hospitals outside the United States (~atuchni, 1971).

Based upon the achievements of the postpartum programmes, WHO has developed ~. substantially broadened approach, i.6. maternity-centred programmes with the linked objectives o~ improving maternal and child health care and providing family planning as an integral part of this care at all stages of the maternity cycle and during child care (I~O

MCH/7l.2, 1971). The rationale and advantages of the maternity-centred approach were discussed in Chapter III.

This programme has been developed by ~~o since 1970, when a Consultation of experts from various countries, institutions and universities identified the following three main areas for action:

- an operational programme, designed to improve th~ obstetrical, gynaecological and paediatric services of major hospitals in urban areas where hospital-based family planning services would also be provided;

- field studies and pilot demonstrations to explore the extension of maternity-centred family planning activities to small units and rure.I areas;

- activities concerned with relevant education, training and the collection of data on health benefits of family planning.

As noted, the principal experience with this approach has been with postpartum programmes in large maternity hospital services. These have been given ~r~ority.becauselarge numbers of cases could be conveniently

r~ached adrnun1strat1vely and evaluated. There has been less experience w1th the postpartum approach in smaller maternity units, howe delivery

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TI/CN.14/POP/12Z Page 16

services and in rural areas. Some countries have had experience with developing rural maternal and child heaLth services and home delivery

progra~~es. Family planning activities are already well advanced in some of these, for example, the role of th~ rur~l auxiliary nurse-midwife in

India, the MCH regional training centres and health centre programmes in Thailand, and the; lady family pl anni.ng visitor and village organizer in

Pakistan.

To COver the bulk of the population, ic is essential to extend this activity to small units in rural areas since these areas have been less well served with MCP./family planning services and much more remains to be accomplished here. As rural maternal child health and family planning

care becomes a major part of gov~r~ent health programme? further experience and experimtnt in programme design should be forthcoming. Because the

e~erimental approach is necessary, documentation and evaluation of all aspects of such a programme should have high priority.

In 1970 WHO began the planning of maternity-centred programmes as described carlier, and by 1972, at the request of governments, WHO provided varying degrees of assistance to over 40 countries for development of this maternity-centred family planning programme (Report of the Director-General on the Work of WHO, 1972, page 126) . . Collaboration with UNFPA, UNICEf, the World Bank, USAID, the POpUlation Council, IPPF and other UN and private agencies has been prcminent in the development of these projL~ts.

Programmes emphasizing the extension of maternity-centred family planning activities to smaller health units and rural areas have recently been devc Iop td with WHO assistance j , some countries. In these programmes, clinical facilities, suppt rcs, equipment and transport to outlying areas arc being improved, and where possible the number of health centres may be increased to achieve better coverage of the population. Better systems of supervision are being planned ,0 permit optimum use of available medical and auxiliary personnel and related family health education programmes are beginning and community groups are being involved in this effort. Improved registration of vital statistics is being promoted. All levels of staff - but especially nurses and midwives - receive further training, largely through one or more centres selected by each country or territory to develop national training programmes and conduct pilot demonstrations and research.

The integration of family planning with maternal and child care is also developing with ~IflO assistance through a variety of other means. In a number of countries, maternity-centred family planning is included as one component of a comprehensive project to strengthen basic health services.

(19)

v.

PLANNING AD'lINISTRATION AND H1PLHlENTATION OF FAMILY PLANNING , IN THE CONTEXT OF HEALTH SERVICES

It is impossible to outline the ideal organization for a nat~onal fwmily planning progrr~rne, in view of the n~m:rous ~actors ~n whl~h.s~ch

organization would d~pend. The general admlnlstratlv~ set~lng, dIvIsIon of basic responsibilities, management of personnel, f mancIaf arrangements and other essential components are conditioned by the ba:ic struct~re

of governments, t.I;e availability of trained staff, the kind of r egiona l

~~d local authority which exists, the mode and level: of p~~ents ~nd a series of other factors which have an impact on publIC admInIstratIon and service in general.

Fundamentally, the introduction of family planning into health services i:wec-"c3 t~.:::s that ~_~e sir.1ilar to those faced in introducing and providing any other medical and public health measure. There are problems of

admin2.3tration and management of the training of staff, of introducing the subject of fertility re~Jlation inte health education activities, of relating the new services to the other ongoing health activities, of

team work, of reaching the populating (coverage), of developing appropriate health education progr]~es, of selecting specific technology suited to the commlnity, of ~upply channels, of transport, and of utilization and evaluation. Both from the viewpoint of the effects on health and from the oTganizational Viewpoint, services concerned with family planning and

tho~e conce~ned with the general health needs of a community are interdependent.

In the past two decades VniO has assisted governments in the prepara- tion of plans for the development of public health programmes. In some instances, the approaches to the establishment or expansion of public health services that were embodied in those plans were periodically

discarded and new approaches adopted, often without benefit of a thorough evaluation. Govermnents and WHO could have profited from such evaluations;

for example, detailed knowledge might have been acquired of those aspects that were successful and those that failed. However, a basic principle on which there is general agreement has emerged from WHO's experience of assistance to health programmes in developing countries: the fundamental differences ,n the conditions that influence health care - even in

ccuntries that are apparently at a similar level of development - make it indispensable for each country to evolve its own pattern of health services. To assist countries in their efforts to design a national health structure, WHO can give guidance on the basic principles of health care and on the management skills needed to deliver that care. Specific blueprints for the development of pUblic health services, which might be

copic~ by countries, have never been developed, nor would it be desirable to devise such plans.

Briefly, the organizational structure o£ a system of health care should indicate the levels of responsibility for policy ~aking, administrative supervision, and operational functioning, as well as the channels of communication both vertically - among these three levels - horizontally - with other sectors of the health services at each leVel.

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E/CN.14/POP/128 Page 18

Within this struCture, there are many decisions to be made; for example, the required number of peripheral health centres must be determined; whether peripheral centres should be developed before or after establishments at the intermediate or central level have been strengthened must also be determined. These decisions cannot be

generalized; they must be made by individual governments. Many of the activities in the I>HO research programme have been concerned with finding a mechanism that would enable governments to make such decisions objectively and sharpen a country's ability to develop its own pattern of health

services. One current effort in WHO that seems ~o be producing results adopts the following project systems analysis approach (I>HO PSA/71.1/Rev.l).

Before any programme is expanded, there must be an objective determination of what is functional and a decision taken on specific

programme goals. Then,during a one to two-year period of trial and error, programrneachievements that have been attained through the tactics employed can be compared with the goals. This apprJach differs fundamentally from the familiar demonstration or pilot project approach. It rests upen the use of a new mechanism that is derived from the modern managerial techniques employed in industry, and through which governments identify the development objectives of proposed projects and to plan the activities required to

achieve those objectives.

One salient.feature of the project systems analysis method is that evaluation is built into the planning process. The monitoring of progress' is held to be an integral part of project formulation so that plans are constantly tested and assessed. Modification of the plan continues until the service is operating at the level required to attain the project objectives. The evaluation techniques can also be used to follow up completed projects, so that no activities are expanded or new projects created without an assessment of the results of completed projects. The basic objective of technical assistance is the achievement of long-term and self-sustained development, and no project can be considered to have reached this objective until follow up measures have demonstrated it. The evaluation of project activities in a specific field can be extremely complex because many factors influence the final result. The problems inherent in the creation of isolated projects have brought about an appreciation of the need to coordinate and integrate projects into a comprehensive programme with broad objectives and prospects of effective impact.

Another characteristics of project systems analysis is its orientation:

it is truly suited to project-oriented national programmes. As such, it cannot form the basis of a.gency-oriented programme formulation, but it can be applied to family planning activities in countries aided by international agencies.

1. Problems of Organization, Administr~tionand Service

Countries with higher levels of health resources have been able to train health manpower relatively quickly to curry out family planning tasks. They have been able to utilize the multiple points of contact with

(21)

,

aE/CN.14/POP/128 Page 19

the target pGpul~t1Gns offered by h~alth services, and to provide the continuity of care and supervision that improve family p lanning efforts.

Better health resources are usualIy as soc i.at ed with i.mpr ovcmcnts in the other scc ic -e onomic factors that enhance succ es sfu I Earni.Ly plan.ung practice, not the least significant of these being an ef'fect i.ve administrative structure in the country gener~lly, and in the health s erv i.ce s specifically, t hrough which the p l anni ng , iI:1}'le:n~nt~,tion and evaluation of chc programme Can be conducted, conti o l l ed and supervised.

Health services are organized at centrc l , intermediate:.:d peripheral levels and the recognized levels

0>

administ rat ive action ar e for policy- making, for administrative and executive supervision, and for functional service.

In considering the problems of overall administration for the implementation of a family pl~nning profT~~e, actio::! ha3 to Le adapted to the three l ovol s of crgani zattonat s t.ructur e of health services.

1.1 Central level

The central administrative unit serves at the national level for planning, administrative ',nd policy formulation.

This central unit mayor may net be tho c cntral coord ' nating body for the national frunily planning programme, but will be conc&rned only with administering the programme within the pub11c health sector and ensuring clOSG cooperation and coordination with activities under the administrative control of other sectors or agencies.

In some countries without regional autonomy thi3 body will have national authority and administrative concrol. In othAr countries where r egioncLirati on is well (I.evclopen the main admi.rrist r at ton , control and supervision of the programme will bo at the regional headquarters. The reference made to the cerrt r a l level of administr.at Lon will apply equally to such administrations.

It is imporcant that the personnel involved with policy making at the central level should be familiar with ~nd active in field activities and peripheral unit problems.

The policy making responsibilities of the central body will relate to national policy on family planning activities, indicating the objectives, and targets of tho programme. The specific is,-;ves for which decisions will be required are the fiscal ~7~~~gemcht5for the progra~ze; the ~perational

standards, including the training of personnel and operational units;

evaluation criteria and system of data collection and analysis; thc development of training at professional ana auxiliary ~evels; enabling legislation; research policy; tho establishment of '::i0ld exner imerrts , pilot proj ects and demonstrat i.on units. .

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B/CN,14/POP/128

The administrative and executive action to be undertaken by the central unit will be concerned mainly with two areas' which ar o interdependent.

Firstly, the general planning fer the establishment cf a network of services for family planning within the public health s0ctor, including the provision

of the resources and transport required for the programme. Secondly, the

!

maintenance of coordination with other gcvcrnmcnt mi.ni.st rics or departmonts other sectors and agencies such as leading professional bodies and

community groups t~ encourare the integration of effort in th~ programme, and for ccoper~tion in the fields of cvalu~tiGn and rese2rch.

The major responsibilities of the central unit with regard to the functional operation of the programme will be in maintaining close personal contact with fi~ld activities to encourage and support uninterrupted

implementation of the propramme, including the continuous flow of supplies, and to provide necessary tlochnical guidance and supervision.

These activities m~y involve tho drafting of necessary legislation, the design of standard record systems, the preparation of various health education materials including mass media and desirable operational manuals for the gu i.dancc cf field workers.

1.2 Intermediate level

The intcrmediate organizction is chiefly responsible for the general administration of the work of several peripheral units and for providing consultant supervisien and referral services to such units.

Policy decisions may be requir2d particularly on the phasing of the programme in r-c l ation to local st:''1.t0[;ies; while administr at i.ve and executive action, as at the central level, will relate to the supervision of th~

logistics of the programme and the maintenance of coordination and

cooperation with other ag cnc i.es . The part i.cu l ar areas of concern will be training programmes. the provision of supplies, and evaluation techniques.

1.3 Peripheral level

In the earlier section on the rationale and advantages of integr~ting

family planning with other family and oommunity health measures, the

special problems of ccverage of rur~l areas were mentioned. The obstacles are compounded by seVere shortages of trained health personnel, limited facilities, and geographically uneven dispersion of villages. Access to basic health services is also affected by poor roads and lack of transport for patients and staff.

Resolution WHA 21.43 of the Twenty-First World Health Assembly requests that family planning be integrated within basic health services. This

conclusion was not based en assumption about the value of integration, but rather, it derived from considerab12 experience with single-purpose mass campaigns and was particularly pertinent to the nature of family planninf,

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E/CN.14/POP/128 Page 21

as a personal, preventive practice (Official Records \~O, 1963, No.168, pp 521.-22). An attack against an infectious disease may involve changing one or more components of man's environment, or may require only a single injection. Family planning involves the entire socia-cultural and

psychological complex of the conjugal relatio~ship itself, with couples being required to take repeated action of a highly personal nature.

Where coverage in rural areas is sought, emphasis must be placed on developing the health infrastructure at least to the minimum for

implementation of basic health services, inc1C1dine maternal and child ,health and family planning. In realistic efforts to expand programmes

to the periphery, financial costs and organi.zational difficulties

increase, particUlarly where recruitment, selection, training and super- vision of professional and indieenous staff are concerned. There also will be the need to improve physical facilities, purchase equipment and supplies, provide' and maintain transport for, personnel, improve reporting and

evaluation and adapt the programme to comraunity needs.

The main 'objective the maternity-centred approach outlined earlier is to extend priority integrated maternal and child health/family planning, as part of the health services" to dispersed rural populations, which in developing countries often comprise more than four-fifths of the total population. Two particular problems r.elated to adapting the maternity- centred approach in rural areas are the small number of women delivered by trained personnel and the need to involve the community, including traditional birth attendants, in the programme. As to the first problem, the introduction of improved and expanded maternity care and counselling on all aspects of family health through home visiting can help, as can the integration of family planning in child care services. As to the second problem, some steps are being taken to encourage '1ctive community participation in the family health/family planning programme (WHO/WES-OS09, 1971). Education of the parents on aspects of child health and the

importance of regular return visits for child health care should begin in the antepartum period. During bedside or home visits in the puerperium, the necessity of re~ular clinic attendance for the child should be given emphasis equal to that on family planning. Finally, when an IUD is inserted postpartum, or a prescription for a contraceptive given, the importance of child visits and the reasons for these should be reiterated.

It has been suggested that discussions with opinion leaders such as village headmen, members of town committees, religious leaders, youth

leaders, teachers and others would help legitimize family planning and create a climate that should lead to some re~.llar means of communication and community support for the programmes. Indigenous village field workers may be useful in identifying pregnant and postpartum women and expediting the referral of the women and their young children for maternal and child health care, including family planning. As a part of their activities, field workers also can assist opinion leaders in the generation of consumer involvement in the programme. The traditional birth attendant, whe in many developing countries attends the great majority of rural deliveries,

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