• As continuing family planning clients outnumber new clients by a widening margin, programs can do more to serve their clients effectively by adopting a continuing-client strategy. • A continuing-client strategy can help programs focus on clients not only when they first choose a contraceptive method but also as their reproductive and family planning needs change. • When family planning providers establish and maintain good relationships, they can help their clients avoid unintended pregnancies throughout their reproductive lives.
Bleeding changes are common among women using hormonal contraceptive methods and IUDs. These are among the most effective reversible family planning methods and many women choose them for this reason. But the monthly bleeding changes they cause often lead to dissatisfaction and discontinuation. Many women who discontinue a contraceptive method do not immediately begin to use another one or they switch to a less effective method leaving them at risk of unintended pregnancy. Combined hormonal methods--oral contraceptives (OCs) monthly injectables the patch and the vaginal ring--tend to make monthly bleeding shorter and more predictable. Progestin-only methods--long-acting injectables implants and progestin-only OCs (the "minipill")--and the hormonal levonorgestrel-releasing IUD can cause changes that range from breakthrough bleeding and spotting to no monthly bleeding. Copper IUDs can cause somewhat heavier and longer bleeding. A methods effects can differ among women or differ over time for an individual. (excerpt)
August 2005 Volume 31 Number 8 Primary care practices typically are made up of hard-working, intelligent people who want to do the very best for patients. So why are practices struggling financially? Why are the clinicians and staff overworked and often burnt out? Why are practices’ internal systems often complicated, tedious, and timeconsuming? Why is there such turnover in the front office as well as among clinicians? What goes wrong? These are familiar questions. Although partial answers have been proposed, we generally have difficulty seeing the whole picture. If we shine the light on one problem and it improves, what happens to all the other problems to which we temporarily didn’t give as much attention? To create hope for a better future for primary health care, as well as for patients and practices, we need a different way of thinking. New methods, approaches, and strategies are needed that will prepare us for whatever the future may hold. When we design or use an intervention for organizational improvement, we make assumptions about the nature of the system we are targeting. For example, the way we see the problem defines the solution, and the solutions we have define the problems we see. We sometimes see the organization as a machine, sometimes as a culture, and sometimes as an organism. Improvement strategies typically treat practices as something with many moving parts that can be independently isolated and “fixed,” and as such, optimally How Complexity Science Can Inform a Reflective Process for Improvement in Primary Care Practices Performance Improvement
The best decisions about family planning are those that people make for themselves based on accurate information and a range of contraceptive options. People who make informed choices are better able to use family planning safely and effectively. Providers and programs have a responsibility to help people make informed family planning choices. Decisions about childbearing and contraceptive use are most likely to meet a persons needs when they reflect individual desires and values are based on accurate relevant information and are medically appropriate-that is when they are informed choices. To make informed choices people need to know about family planning to have access to a range of methods and to have support for individual choice from social policies and community norms. Informed choice offers many benefits. People use family planning longer if they choose methods for themselves. Also access to a range of methods makes it easier for people to choose a method they like and to switch methods when they want. Peoples ability to make informed choices invites a trusting partnership between clients and providers and encourages people to take more responsibility for their own health. Enabling clients to make informed choices is a key to good-quality family planning services. (excerpt)
This Population Reports issue focuses on family planning and the importance of advocacy in family planning programs. Key evidences supporting family planning programs are summarized. This article presents the importance of advocacy for the improvement of the family planning programs in developing countries. Advocacy for family planning is becoming crucial as demand for reproductive health care grows. As many as 600 million people have used contraception, and millions more would do so with better access to good-quality services. Although fertility levels are falling in much of the world, rapid population growth remains a critical issue in most developing countries. This is where advocacy is very much needed. Through advocacy, many individuals and countries will benefit especially in the area of family planning. The benefits include saving the lives of women and children; offering women more choices; and encouraging adoption of safer sexual behavior. Through effective family planning programs, population growth will also be affected. Slower population growth helps protect the environment and it aids development.
Counseling about family planning (FP) and other reproductive health issues requires a set of specific skills designed to facilitate informed decision-making. The GATHER approach to counseling--Greet, Ask, Tell, Help, Explain, and Return--has documented effectiveness in FP programs. The more of the GATHER elements a counselor uses, the more satisfied clients are with their care and the more likely they are to use contraception. This guide provides detailed information on each of the 6 elements of the GATHER model, including key phrases, sample provider actions, and teaching exercises. A chart presents information on available FP methods--mechanism of action, advantages, disadvantages, use requirements, and follow-up. Special sections address topics such as FP for women who are breast feeding, emergency oral contraception, and counseling adolescents. Other sections offer guidelines on responding to a client's feelings, "active listening," talking about sex comfortably, and advising without being controlling. Finally, a checklist is included so counselors can rate themselves on each of the GATHER skills. An earlier version of this guide has been used around the world for the past 10 years.
Family planning programs are increasingly making quality of care the highest priority. With improvement in quality of care, contraceptive use is safer and more effective, information and services are more accessible, clients make informed choices and are more satisfied. In addition, family planning providers find their work more rewarding and the general public has a positive view of health care and its providers. Applying the lessons of the quality movement of health care and family planning, programs and providers are finding more creative approaches that suit reproductive health care in developing countries. In addition to adopting a client-centered approach, these efforts suggest that the three sides of the quality triangle are equally essential: quality design, quality control, and quality improvement.
New information, new understanding, and new approaches promise to help men become full partners in better reproductive health. Men, as well as women, play key roles in reproductive health, including family planning, but increasing men's participation has been difficult. Adopting new perspectives can help.
People move for many different reasons and their circumstances vary widely. Still they are alike in three important ways: 1) Disruption: Most have left behind the support of traditional values extended families friends and familiar ways of life. With limited means they face new and uncertain situations. 2) Differences: Culture and language often set them apart from their new neighbors. Reproductive attitudes and behavior often differ as well. 3) Difficulties of access: Many are ineligible for health care benefits unfamiliar with family planning programs and unable to obtain information easily. An estimated 16 million people migrate each year from rural to urban areas of developing countries excluding China accounting for about half of recent urban growth. In addition about 2 to 4 million people migrate internationally each year. Another 18 million people--over five times the number 20 years ago--have fled their own countries as refugees. Also about 20 million people are internally displaced. They have fled their communities and sought safety elsewhere within their own countries. (excerpt)
This issue of "Population Reports" explores the concept of "unmet need" for family planning (FP) and presents new strategies FP programs can use to meet this need. To focus on unmet need, FP programs solicit the statements of women through surveys, identify the groups most likely to be interested in accepting contraception, and attempt to reach these groups with services. Unmet need affects over 100 million women in developing countries (a third of them in India) and an average of 20% of all married women of reproductive age in the developing world. Strategies to address unmet need should 1) maximize access to good quality services, 2) emphasize communication, 3) focus on men as well as women, and 4) collaborate with other services for new mothers and young children. This report opens with an introductory summary and then focuses on the relationship of unmet need and FP programs through a consideration of the concept and measurement of unmet need, the extent of unmet need, trends in unmet need, abortion as an indicator of unmet need, and unmet need versus demand for contraception. The second major section addresses the reasons for unmet need (which include health concerns and side effects, lack of information, family and community opposition, a perception that there is little risk of pregnancy, and apparent ambivalence). The third section considers who has unmet need and discusses unmet need levels by women's characteristics as well as differences among women with unmet need. The next section details the program implications and strategies mentioned above. Finally, a process to address unmet need is presented that depends upon analysis, strategic design, implementation, and monitoring/evaluation. Among the highlighted information is a checklist of possible programmatic steps to address the most common reasons for unmet need.
To make informed choices about family planning, women and men need accurate information in the media as well as in the clinic. The media are looking for news important to the millions of people they reach each day. Thus helping the news media cover family planning fully and accurately merits the efforts of every family planning program.
As they mature and become sexually active, more young people face serious health risks. Most face these risks with too little factual information, too little guidance about sexual responsibility, and too little access to health care. Meeting young adults' diverse needs challenges parents, communities, health care providers, and educators. Despite urgent needs, program efforts have been slight and slowed by controversy.
The practice of female genital mutilation (FGM) is thought to be 2000 years old and continues today in many areas of Africa, the Mid-East, and Asia. An estimated 100-132 million women have undergone the procedure, and 2 million more are subjected to it each year during infancy, childhood, or adolescence. The World Health Organization has defined four categories of FGM. Type 1 entails removal of the prepuce and, sometimes, all or part of the clitoris. In type 2, the clitoris is removed along with all or part of the labia minora. Type 3 (infibulation) involves removal of the clitoris, some or all of the labia minora, and the sealing of the labia majora with only a small opening remaining for the flow of urine and blood. Type 4 is a general category that includes other operations on the external genitalia as well as procedures done to the vagina. The FGM procedure itself can lead to shock, death, and infection. Long-term physical effects of infibulation include difficulty in urinating, in having sexual intercourse, and in delivering a baby. The psychological and psychosexual consequences of FGM remain to be identified. FGM is still practiced because it affords status to women in certain cultures. Efforts to eradicate the practice have been made by international agencies, governments, and grassroots community advocates. Public education as well as legislative action are important tactics as are working to educate health care providers and providing alternatives to FGM as well as alternative employment opportunities to FGM practitioners. In Western countries, anti-FGM efforts are centered on women in immigrant and refugee communities. Research efforts are underway in order to provide an understanding of FGM that will allow the design of effective eradication strategies. Community input will be vital in designing and conducting such campaigns.
Over the past 30 years, family planning programs have helped millions of people to have the smaller families that they want. As programs have learned how to meet people's needs, contraceptive use has spread rapidly.
This report discusses the challenges and costs involved in meeting the future needs for family planning in developing countries. Estimates of current expenditures for family planning go as high as $4.5 billion. According to a UNFPA report, developing country governments contribute 75% of the payments for family planning, with donor agencies contributing 15%, and users paying for 10%. Although current expenditures cover the needs of about 315 million couples of reproductive age in developing countries, this number of couples accounts for only 44% of all married women of reproductive age. Meeting all current contraceptive needs would require an additional $1 to $1.4 billion. By the year 2000, as many as 600 million couples could require family planning, costing as much as $11 billion a year. While the brunt of the responsibility for covering these costs will remain in the hand of governments and donor agencies (governments spend only 0.4% of their total budget on family planning and only 1% of all development assistance goes towards family planning), a wide array of approaches can be utilized to help meet costs. The report provides detailed discussions on the following approaches: 1) retail sales and fee-for-services providers, which involves an expanded role for the commercial sector and an increased emphasis on marketing; 2) 3rd-party coverage, which means paying for family planning service through social security institutions, insurance plans, etc.; 3) public-private collaboration (social marketing, employment-based services, etc.); 4) cost recovery, such as instituting fees in public and private nonprofit family planning clinics; and 5) improvements in efficiency.
