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

The objective of this study was to evaluate the return of fertility in women who used Cyclofem(R) as a contraceptive method during the introductory studies conducted in Brazil, Chile, Colombia, and Peru. From these four cohorts, 101 women were eligible for the study. Thirty-one were not included in the study either because they refused to be interviewed, had initiated another contraceptive method the month after discontinuation, or were unable to be contacted. A total of 70 women were included in the study. Our results showed that the return to fertility rate after the discontinuation of Cyclofem was 1.4 per 100 women at the End of the first month and reached 82.9 at one year. More than 50% were pregnant at 6 months. Fifty-one (94.4%) pregnancies ended in a live birth, two were spontaneous first trimester abortions, and one was a hydatidiform mole. Return of fertility was not related to the woman's age at the time of discontinuation, her weight, or the number of Cyclofem injections. In conclusion, fertility is restored by 1 month following Cyclofem discontinuation. Users and potential users should be counseled regarding the rapid return of fertility after discontinuing this method of contraception. (C) 1997 Elsevier Science Inc.

Three AIDS prevention activities were incorporated into the services offered by PROFAMILIA in two operations research projects. The activities included: (1) informative talks given both to the general public and to members of target groups by PROFAMILIA's community marketing (CM) program field workers (or instructors); (2) the establishment of condom distribution posts in meeting places of target groups; and (3) mass-media information campaigns on AIDS prevention. Community-based distributors were able to successfully provide information on AIDS to their regular audiences as well as to deliver information and condoms to special target groups without negatively affecting family planning information/education/communication activities and contraceptive sales. A radio campaign that promoted condom use for AIDS prevention did not affect public perceptions about the condom and did not jeopardize PROFAMILIA's image.

The findings of three surveys and three studies used by Profamilia to evaluate and improve their voluntary female sterilization program are presented. The surveys measured sociodemographic characteristics of users, factors behind the sterilization decision, and user satisfaction with the operation in the short run and over time. The studies explored methodologies for more accurate cost-effectiveness analysis. Results of the projects were used by Profamilia management to identify areas of program strengths and weaknesses and to implement operational changes.

Three operations research experiments were carried out in three provinces of Colombia to improve the cost-effectiveness of Profamilia's nonclinic-based programs. The experiments tested: (a) whether a contraceptive social marketing (CSM) strategy can replace a community-based distribution (CBD) program in a high contraceptive use area; (b) if wage incentives for salaried CBD instructors will increase contraceptive sales; and (c) whether a specially equipped information, education, and communication (IEC) team can replace a cadre of rural promoters to expand family planning coverage. All three strategies proved to be effective, but only the CSM system yielded a profit. Despite this, Profamilia discontinued its CSM program soon after the experiment was completed. Unexpected government controls regulating the price and sale of contraceptives in Colombia made the program unprofitable. As a result, family planning agencies are cautioned against replacing CBD programs with CSM. Instead, CBD programs might adopt a more commercial approach to become more efficient.

Sterilization failure rates were computed using lifetable methods for sterilizations occurring between 1973 and 1982 in the Profamilia family planning clinic in Bogota, Colombia. Out of a total of nearly 45,000 sterilizations occurring during this period 503 sterilization failures were detected. Comparing methods, laparoscopy with the silastic band method had a significantly higher rate of failure, 1.5% after 5 years compared to 0.9% for laparoscopy with cautery and 0.6% for minilaparotomy.