PIP: What proved to be a lively yet highly technical conference on the assessment of the acceptance and use-effctiveness of family planning methods was held in Bangkok last June by ECAFE on the initiative of Dr. C. Chandrasekaran, the regional demographic adviser. The meeting was attended by a strong contingent of demographers, sociologists and statisticans from the USA and by workers from Hong Kong, India, Indonesia, Korea, Malaysia, Pakistan, the Philippines, Singapore, Taiwan and Thailand. There were representatives of FAO, WHO and the Population Division of the UN. The conference considered and debated a wide range of issues involved in evaluation, from the definition of terms to detailed procedures in the calculation of indices and the detection of fertility trends. A certain amount of new ground was broken with the introduction of the concept of "extended use-effectiveness" (the study of pregnancy rates among acceptors of a method beyond the point of discontinuance) and the presentation of new methods of calculating births prevented by contraceptive use. Some progress was made towards laying down standards for the frequency of performance of surveys, both of K.A.P. in populations at large, and of contraceptive continuance and event-rates among acceptors. Attention was given to the special problems of evaluation presented by oral contraceptives, and by data on abortions and sterilizations. The proven usefulness of the life-table method of studying use-effectiveness was reaffirmed, and work on refining this now basic tool of evaluation was reported. A number of quite different schemes of data collection and processing for study of the characteristics of acceptors was described, and it was accepted by the participants that, although as much standardization as possible was desirable, each programme must make its own selection from the range of possibilities in the light of specific conditions. In addition to the main lines of analysis of use-effectiveness and programme effectiveness, the conference spent some time on discussion of such subjects as cost analysis, sensitive indices of fertility change, and the use of models in connection with programme study and evaluation. The specific evaluation needs and procedures of a number of countries in the ECAFE region were described. Although the conference fell far short of providing a comprehensive and agreed set of rules for the evaluation of family planning programmes. Indeed this was not its objective it admirably performed the function of acquainting theoretical and practical workers with each other's problems, and ensuring that all concerned were brought up-to-date on the progress being made in the region in the development and use of evaluation tools.
The sensitivity and specificity of each of five screening tests were estimated in each of three to ten countries by testing subjects drawn from the general populations of adults over thirty-four years of age. This permitted comparisons among countries and among the different tests (fasting, postprandial, and postglucose urine tests, and fasting and postprandial blood glucose values). Sensitivity and specificity of each test varied widely among populations. For example, the sensitivity of the two-hour urine glucose ranged from 17 per cent in Nicaragua to 100 per cent in East Pakistan. Apparently specificity and sensitivity of such tests are influenced by many factors including both the circumstances under which the tests are performed and the characteristics of the population tested. It is, therefore, not possible to predict prevalence rates reliably by extrapolating from the results of screening tests. However, we believe the data for specific populations on the sensitivity and specificity of various tests will provide a rough guide in predicting the cost-effectiveness of alternative approaches to case detection in those particular countries. For instance, these results suggest that roughly 56 per cent of the occult diabetics in Costa Rica in this age group would be detected by a two-hour urine glucose, but only about 41 per cent of those in whom this test was positive would prove to have diabetes. Even modest changes of criteria in defining either "diabetes" or "abnormality" of the screening results produced marked changes in rates of sensitivity and specificity. With few exceptions, tests which were more sensitive were, comparably, less specific, and the reverse was also true. Rates of "diabetes" were markedly influenced by modest changes in diagnostic criteria.
PIP: Organizational and content features of various national family planning programs are reviewed. The Thai program is cited as an example of a family planning program organized on a massive unipurpose compaign basis. The Korean and Taiwan programs have utilized special field workers while upgrading the general health care network. 3 major problems with family planning programs are: 1) the lack of experience with such programs; 2) lack of commitment at the highest political levels; and 3) medical conservatism. Utilization of all available contraceptive methods instead of reliance on 1 method would improve most programs. Nursing and auxiliary personnel could be trained to take over the work of physicians in family planning programs. This is already being done with IUD insertion and pill prescription in several programs. The postpartum tubal ligation approach has proven effective and should be extended. There is a place in all national programs for both the private and the commercial sectors. Incentives for clinics, personnel, and acceptors might spread family planning more rapidly.
A study of 300 Malaysian women who were fitted with the Copper-7 intrauterine device is presented. Two per cent of the acceptors were nulliparous. Insertion was easy in 97-7% of the cases and the side effects were minimal. In a study of over 4,634 women-months a low cumulative expulsion rate, at 12 and 24 months of use, of 3-1 and 3-6 respectively, was observed. However, relatively high cumulative rates of pregnancy of 4-3 and 9-2 occurred at 12 and 24 months of use respectively. Out of a total of 19 pregnancies, in 12 cases the device was found to have descended, a finding not commonly reported. One woman experienced translocation of the device five months after insertion, and in this instance, the device was removed by laparotomy. The findings in this study and their implications are discussed.
PIP: 40 experts representing Nepal, Malaysia, Thailand, Singapore, Korea, and the Philippines participated in a 3-day workshop in Manila in March 1976 for the purpose of discussing and proposing ways of dealing with the financial problems confronting the population programs of the individual countries. The Inter-Governmental Coordinating Committee for Southeast Asia Family/Population Planning sponsored the workshop. The recommendations made at the meeting were: 1) standardization of financing reporting procedures by the region's country programs on family planning; 2) closer coordination between donor agencies and policy-making bodies of country programs in the disbursement of funds; 3) frequent exchanges of experiences, ideas, technicaL knowledge, and other matters pertaining to the financial management of such programs; and 4) inclusion of applicable financial management topics in the training of clinical staffs and those involved in follow-up operations. Additionally, a proposal was made that national population organizations or committees develop research and evaluation units. Workshop discussion sessions focused on financial planning and management, accounting and disbursement of funds, use and control of foreign aid, cost of effectiveness and benefit analysis, and financial reporting.
PIP: In 1976 the United Nations's Economic and Social Commission for Asia and the Pacific launched a comparative study on integrated family planning programs in a number of countries in the region. In November 1979 the study directors from the participating countries meet in Bangkok to discuss the current status of the studies in their countries. The Korean and Malaysian studies were completed, the Bangladesh study was in the data collecting phase, and the Pakistani research design phase was completed. The meeting participants focused their attention on the findings and policy implications of the 2 completed studies and also discussed a number of theorectical and methodological issues which grew out of their research experience. The Malaysian study indicated that group structure, financial resources, and the frequency and quality of worker-client contact were the most significant variables determining program effectiveness. In the Korean Study, leadership, financial resources, and the frequency and quality of contact between agencies were the key variables in determining program effectiveness. In the Malaysian study there was a positive correlation between maternal and child health service performance measures and family planning service performance measures. This finding supported the contention that these 2 types of service provision are not in conflict with each other but instead serve to reinforce each other. Policy implications of the Korean study were 1) family planning should be an integral part of all community activities; 2) family planning workers should be adequately supported by financial and supply allocations; and 3) adequate record keeping and information exchange procedures should be incorporated in the programs.
PIP:
The International Fertility Research Program is carrying out several studies focused on breastfeeding's contraceptive protection. A longitudinal study is investigating the relationship between breastfeeding and the return of ovulation and fertility after childbirth. The impact of factors such as the early introduction of supplementary foods, resumption of menses, and sexual practices on the return of ovulation will be analyzed. The study, which will be conducted at 4 geographic sites, will include a total of 100 women who are breastfeeding and a control group of 40 nonlactating mothers. Its ultimate goal will be to determine the optimum time for breastfeeding women with different cultural needs to start using contraceptives. A second study will seek to determine whether progestogen-only oral contraceptives (OCs) have advantages for lactating women. Trials in India, Malaysia, Argentina, and Egypt will compare 1000 lactating women who use progestogen-only OCs with an equal number of women who use nonhormonal contraception in terms of contraceptive acceptance and side effects and infant weight gain. The third study will survey breastfeeding patterns in relation to changing child spacing trends in a sample of 4000 women from Lagos, Nigeria. Analyzed will be the proportions of women who are using a modern method of fertility control, the proportions protected from unwanted pregnancy by the traditional practices of prolonged breastfeeding and sexual abstinence, and determinants of recent changes in the prevalence and duration of breastfeeding.