The attitudes and views of women, the primary users of family planning methods, are important to consider when introducing any new contraceptive method.
Women's decisions about use, non-use or discontinuation can be affected by their perceptions of contraceptive risks and benefits, concerns about how side effects may influence their daily lives, and assessments of how particular methods may affect relationships with partners or other family members. Incorporating women's perspectives into contraceptive introduction strategies can help local family planning programs increase user satisfaction, improve continuation rates, and expand method use, experts suggest.
Several international and national organizations are conducting research to learn more about women's perspectives. One multicountry study found that contraceptive effectiveness was extremely important to women, and many cited effectiveness as the primary reason for choosing a contraceptive method, according to Dr. Rachel Snow, principal investigator. Approximately 550 contraceptive users and non-users took part in focus group discussions as part of the study, which involved women who lived in poor urban and suburban areas in Cambodia, India, Mexico, Pakistan, Peru, South Africa and the United States.
For example, women in Udaipur, India said effectiveness was a major concern and must be balanced with method side effects. Women in Lima, Peru listed effectiveness as the first attribute of an ideal contraceptive.
The ideal duration of effectiveness for a long-term reversible method was three to five years, study participants said, and some suggested three months to a year as the ideal length of effectiveness for injectable contraceptives.
Women were questioned about side effects, particularly their tolerance for menstrual bleeding disturbances. Tolerance for amenorrhea varied, but most women said they would not accept heavy or more frequent bleeding.
The study also questioned women about their knowledge of barrier methods. Researchers found that women knew very little about these methods, other than the male condom. In Karachi, Pakistan, study participants said the idea of using barrier methods would be "terrifying" or "difficult" due to inability to negotiate method use with their partners.
"Most of the studies that have been done do not offer much information on non-users," says Dr. Snow, an assistant professor at the Harvard University School of Public Health in Boston. "That has weakened our ability to take a scientific approach to understanding what women want in contraception."
While Dr. Snow cautions that the results should not be construed to apply to all women in a particular country, findings do offer insights that may help scientists involved in development or refinement of contraceptives and can offer information that may help family planning program managers in introduction and service delivery.
Female-controlled
In recent years, women's health advocates have asked scientists to intensify their research on female-controlled barrier method contraceptives. Barrier methods offer the advantage of protection against pregnancy and some types of sexually transmitted diseases.
In response, FHI, the Population Council and WHO recently began a study on introducing the diaphragm into family planning programs. The two-year prospective study will explore women's views on acceptability, as well as method effectiveness, says Carol Joanis of FHI, a technical monitor for the study. In addition, researchers will try to determine the demands placed on service delivery systems when the diaphragm is added to the mix of existing contraceptives, and researchers will examine the impact of training regarding the diaphragm on health providers' knowledge, attitudes and practices.
"We want to introduce the diaphragm using good standards of care, where women have access to several methods and individual counseling," says Susan Palmore, director of FHI's Policy and Research Utilization Division, who has worked with WHO and the Population Council to coordinate the study. "Women who come into a clinic will be given information about all contraceptive methods. Then we want to see which women will choose the diaphragm and how they use the diaphragm in a real-life setting."
Women are typically instructed that prior to sexual intercourse they should put spermicide on the diaphragm, insert the device into the vagina to cover the cervix, and leave the diaphragm in place for at least six hours after intercourse. For repeated acts of intercourse, additional spermicide should be added.
The diaphragm study will explore whether women modify those instructions to suit their lifestyles and what impact those modifications might have on satisfaction and effectiveness. For example, some women might use the diaphragm only during the fertile periods of their menstrual cycles, some may use the diaphragm without spermicide, others may ask their partners to use condoms for additional protection against pregnancy or sexually transmitted diseases (STDs).
The study is under way in Colombia, Turkey and the Philippines -- countries where the diaphragm is not widely used. Up to 2,100 diaphragm users in at least 14 health clinics will participate.
Clients will be monitored for six to 12 months to determine patterns of diaphragm use, satisfaction with the method, perceived advantages and disadvantages, partner satisfaction, and reasons for discontinuation. Clients will be questioned about whether convenience, cost or user-control were factors in their choice of the diaphragm. They will be asked about problems, such as difficulties with insertion or irritation from spermicide. Also, they will be asked about their partners' views on the diaphragm, whether their partner influenced their choice of methods, and the woman's ability to determine family size and spacing of births.
Similar data will be collected from 600 women who have chosen other reversible contraceptive methods.
As part of the study, participating counselors and clinicians attend a training program, which offers information on all contraceptive methods, but focuses on diaphragm fitting, counseling and the study protocol.
By using client interviews, focus groups, observations in clinics, and surveys of providers, researchers will measure the rates of diaphragm acceptance when women are given the opportunity to choose it from an array of methods; learn women's reasons for discontinuation or continuation; and identify characteristics of clients who are likely to accept and use the diaphragm effectively.
Results will help health ministries, donor agencies, policy-makers and family planning program managers if they plan future introduction or reintroduction strategies for the diaphragm. Also, the study could be replicated in other countries to learn about variations in use and satisfaction among clients and providers in other cultures.
Village perspectives
In Bangladesh, a nongovernmental organization has made efforts to include women's perspectives when contraceptives are introduced in local villages. The Bangladesh Rural Advancement Committee (BRAC) works to improve the quality of life for the country's poor through economic, educational and health programs. The organization began a distribution program for oral contraceptives and condoms in 1972, but two years later found the pill continuation rate was 42 percent -- less than expected.
To improve continuation rates, BRAC organized "village committees," in which local residents talked to health workers about their contraceptive needs.
"We talk about continuation -- what are the pros and cons of the methods," says Dr. Sadia Afroze Chowdhury, director of BRAC's health and population program. "The village committees are primarily made up of women, and they tell us what they feel would be most appropriate for the women living there."
The committees have offered valuable information for health providers, Dr. Chowdhury says. For example, one meeting revealed that women did not want to use intrauterine devices (IUDs) because they feared the side effect of heavier bleeding.
"We know what contraceptive methods are available in Bangladesh, so we know what we can offer, but we have to know what the family planning consumer wants," says Dr. Chowdhury. "If the community is not interested, they won't come in for services. The village committees have helped us sharpen our focus. It has been a mutual learning experience and we change our programs according to women's needs."
Farther south in Asia, the Vietnam Women's Union, an 11-million member group that works to improve the legal rights of women and children, has made family planning one of its priorities.
Union members work closely with the Vietnamese Ministry of Health and the National Committee on Family Planning, providing information and education on contraception to community members. The union trains local residents to encourage neighbors in their villages to consider family planning. In 1991-92, the Women's Union held 371 workshops to train 20,000 people.
The Women's Union has conducted a pilot program in which trained volunteers provided education, information and counseling about user-controlled contraceptives, such as the condom and oral contraceptives, which are available in pharmacies and do not require a visit to a health clinic.
"In each pilot commune, there are 10 trained volunteers taking care of 70 to 100 women of reproductive age," writes Mrs. Vo Thi Thang, vice chairperson of the Women's Union. "One year after the model program was implemented, contraceptive use, particularly use of pills and condoms, ranged from 30 to 60 percent in different communes." 1
In Vietnam, the use of modern contraception is 37 percent among married couples, with IUDs as the primary means of family planning. Several organizations, including WHO, are working with the Women's Union to expand women's choice of methods through the introduction of other contraceptives.
Currently, the Women's Union is working with a WHO task force to develop a proposal to introduce the three-month injectable method, depot-medroxyprogesterone acetate or DMPA.
"Having members of the Women's Union participate in the process adds a different set of perspectives," says Dr. Peter Fajans of WHO. "The Women's Union members are more likely to have an insight into women's perspectives on the problems experienced by women living in rural villages, the problems with service delivery and women's ability to have the contraceptives of their choice."
The effort to include women's perspectives in contraceptive introduction has grown, in part, out of the international movement for women's rights. Many women's groups have called for improvements in health care, including increased access to family planning and reproductive health services, as a way to improve the overall status of women.
To foster a dialogue between women's health advocates and scientists on family planning issues, WHO sponsored "Creating Common Ground" meetings in Europe, Asia and Latin America. Participants have strongly urged the inclusion of women's perspectives on the research and introduction of contraception.
At the Common Ground meetings, women and scientists have discussed their differences in perspectives on family planning. For example, scientists have traditionally measured contraceptive safety through clinical studies on toxicology and carcinogenicity. Women's health advocates say they are also concerned about the effect of a particular method on overall health and about side effects, such as menstrual bleeding disturbances. Scientists measure acceptability through continuation and discontinuation rates. Women's health advocates suggest that indicators of acceptability include measurements of informed choice and user satisfaction as well.2
A precise understanding of the users' perspectives is not easy to obtain. "It is fashionable these days to say we must find out from 'real women' what they want," says Adrienne Germain of the International Women's Health Coalition. "Those who seek to do this must take into account whether the women they are asking are free to say what they want, and whether their circumstances -- their knowledge, information, experience in making choices about anything, access to well-trained providers -- actually allow them to imagine what they might want in a contraceptive.... Women often do not have the technical information to fully perceive whether a method is good for them or not."
User satisfaction
In the West African country of Mali, where only 1 percent of married women use modern contraception, FHI is studying women's views on the introduction of Norplant, the subdermal implant that protects against pregnancy for five years. FHI surveyed 325 Norplant users and 300 users of other methods to ask about satisfaction with method choice and with service delivery after six months.
The survey found that the majority of women were satisfied with Norplant, but some suggested improvements in the service delivery system.
"The aspect of the method women like most is that it is easy to use, and to a lesser extent, that it lasts five years," says Karen Katz of FHI, who worked on the Norplant introduction study. "The majority of women had already recommended Norplant to another person. What they like least is the side effect of bleeding disturbances.
"The principal reasons why users of other methods did not choose Norplant were that they did not know enough about it or preferred the method they were currently using."
Most women were satisfied with the counseling they received, but 15 percent said they wish they had received more information, particularly about disruption of menstrual cycles, a common Norplant side effect. Women suggested the best ways to improve Norplant services were to provide more information and education on the method, find a solution to bleeding problems and reduce clinic waiting times.
"Satisfaction is a difficult concept to measure because clients are often reluctant to be critical," says Katz. "Therefore, we asked a number of related questions to get at different aspects of satisfaction. That way, we can further ascertain what women liked and what needs improvement."
Mali's Division of Family and Community Health, part of the Ministry of Health, Solidarity and the Elderly, will include the survey results in its evaluation of Norplant introduction. Information gained from the survey will be used to evaluate whether or not to expand Norplant provision in Mali.
In Southeast Asia, at the request of the Vietnamese Ministry of Health, FHI conducted a study on user satisfaction of two contraceptive methods -- IUDs and quinacrine nonsurgical sterilization. The retrospective study involved more than 3,000 women who had used IUDs or quinacrine and was conducted to assist the government in its evaluation of whether quinacrine should be considered for widespread introduction. Due to concerns from women's health advocates, donors and international health organizations about quinacrine safety, the Vietnamese government has discontinued quinacrine sterilizations until further evaluations are done.
Women were questioned about their perceptions of how IUD use or quinacrine sterilization affected their health and other aspects of their lives, including relationships with their husbands, ability to work, and ability to care for children. Also, the survey measured satisfaction by asking women about fear of pregnancy and method failure. And the survey questioned women about their access to services, waiting times in health clinics, counseling from providers, and informed consent. 3
Eighty-six percent of the quinacrine acceptors said the method was a good choice for them, and 80 percent of IUD acceptors were happy with their method. The majority of women in both groups reported that contraceptive use had not affected their sex lives, but some women in both groups noted that method use did affect other aspects of their lives, including their ability to do farm work and housework. Some reported such side effects as dizziness, fatigue or headaches.
Most women were satisfied with waiting times at clinics and said the clinics were close to their homes, so travel was not a problem. More than 80 percent of women in both groups said they received counseling about possible side effects and where to get help for problems before they received their method.
"What we learned in the study is that effectiveness is important to women," says Dr. Cindy Waszak. "Satisfaction with a method is often determined by the woman's perception of how well the method does or does not prevent pregnancy. In Vietnam, where there is a country-wide effort to expand women's access to affordable, safe contraception, this type of information can be used in developing future introduction or reintroduction strategies."
To learn more about women's satisfaction with family planning, FHI is conducting the Women's Studies Project. The five-year project, funded through a cooperative agreement with the U.S. Agency for International Development, is examining women's perceptions of how family planning has positively or negatively affected numerous aspects of their lives, such as work, education, relationships with spouses, and community participation.
"Local women's health advocates have been involved in this project from the outset," says project director Dr. Nancy Williamson. "Women's health advocates were interviewed, along with scientists, government officials and health providers, to help determine areas of interest for research. Women's health advocates serve on in-country advisory committees that monitor research, and they will be instrumental in disseminating research results to local communities."
Results from the Women's Studies Project, which will be conducted in the Philippines, Indonesia, Brazil, Bolivia, Egypt and Zimbabwe, are being used to improve family planning programs and policies, to ensure they reflect women's needs.
New methods, new options?
As national and international organizations develop contraceptive introduction strategies that take into account women's perspectives, they should consider the impact of introduction of a new method on women's overall health and welfare. Some scientists and women's health advocates have suggested that introduction of a new method will do little to enhance women's health if the current health-care system is ill-equipped to perform procedures, to give counseling, or to manage side effects.
In Indonesia, family planning policy-makers decided not to introduce Cyclofem, a monthly injectable, when researchers concluded it would do little to expand women's contraceptive options.
Introductory trials in six public health centers found that Cyclofem gave women a contraceptive choice that did not interrupt menstrual bleeding patterns, was highly effective, and allowed for rapid return to fertility.
However, when other factors were considered, the addition of Cyclofem meant only "relatively modest" increases in women's access to quality care, researchers said. Two other types of injectable contraceptives were already available in Indonesia, and because women had to return to the clinic more often for repeat injections costs to clients would be higher than with injectables that lasted two or three months. In addition, Norplant had recently been introduced for women seeking a long-term contraceptive method. 4
"In addition to user perspective, you must look at logistics, service delivery systems, training needs. Does the service delivery system have the capability to provide the new method with an appropriate level of quality of care?" says Dr. Ruth Simmons, co-chair of a WHO steering committee on contraceptive introduction and technology transfer and a professor at the University of Michigan in the United States.
"You must ask these questions within the broader context of women's reproductive health."
-- Barbara Barnett
Footnotes
Interagency Meeting on Vietnam: Final Report. Research Triangle Park: Family Health International, 1994.
Creating Common Ground: Women's Perspectives on the Selection and Introduction of Fertility Regulation Technologies. Geneva: World Health Organization, 1991. Creating Common Ground in Asia: Women's Perspectives on the Selection and Introduction of Fertility Regulation Technologies. Geneva: World Health Organization, 1994.
Hieu DT, Vinh DQ, Tong NK, et al. A Retrospective Study of Quinacrine Sterilization in Vietnam. Unpublished paper. Durham: Family Health International, 1995.
Simmons R, Fajans P, Lubis F. Contraceptive introduction and the management of choice: the role of Cyclofem in Indonesia. Contraception 1994; 49(5):509-25
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