Community-based family planning programs can be combined with additional health services, including disease prevention, prenatal and antenatal care and oral rehydration therapy. In some cases, income-generating activities are included.
Also, community-based distribution (CBD) workers are beginning to provide family planning services to youth and unmarried women, going beyond the traditional service population of married couples. Some examples of these integrated approaches include the following:
In 1969, the three-year-old Thailand National Family Planning Program sought to increase services to rural areas by allowing midwives to provide oral contraceptives. Midwives learned to use a checklist to identify relevant health concerns and refer a woman to a physician if necessary. After six months, pill use increased substantially in areas where the approach was used, compared to a modest increase in pill use in other areas. Continuation rates at six and 12 months were also higher among women served by midwives, compared with women who received pills from physicians.1
A study in rural Mali examined the impact of adding family planning services to an existing primary health care system. Some health workers in two districts provided contraceptives and information, while workers in two different districts provided only family planning information. Client surveys showed contraceptive use and knowledge increased more among people served by health workers who provided contraception. For example, men's ever use of condoms increased from 9 percent to 35 percent among people served by this group, and from 7 percent to 16 percent when only information was given.2
In an effort to add family planning to an existing community-based delivery system, a project in India has begun training 47,000 village medical private practitioners in the Uttar Pradesh state to provide family planning services. Providers practice a combination of traditional and modern medical practices; some have formal medical training while others do not. Four to six days of training includes family planning counseling, provision of condoms and pills, sexually transmitted disease prevention, and making referrals to obtain intrauterine devices (IUDs) or sterilization. Since participants are private practitioners, no supervisory system is used. The effort results in "a definite improvement in counseling skills and knowledge of pills, condoms, IUDs and sterilization," says Meenakshi Gautham, project manager in India for the U.S.-based INTRAH program.
In Honduras, community volunteers were trained to make referrals for family planning and other health services based on a checklist of simple questions involving each client's general and reproductive health needs. Volunteers contacted nearly 1,200 women in 11 villages and approximately 60 percent of the women were referred for services. Using "simulated clients" to evaluate the approach, volunteers made appropriate referral decisions 85 percent of the time, considered to be a successful result. The incorrect decisions were equally divided between clients who should have been referred but were not and clients who were referred when no service was needed.3
In Tanzania, community-based agents were as much or more productive if they provided other health services as well as family planning. A study compared the output of agents who only provided family planning and maternal and child health referral services with agents who provided these services in addition to other activities. Each agent providing the additional services saw an average of 147 clients per year, resulting in 21 couple years of protection (CYPs), while other agents on averagesaw 110 clients per year, with 18 CYPs. Agents said that providing a broader range of services made them more productive. Agents not providing such services as information and referral services about sexually transmitted diseases expressed a need to receive training for a broader range of services. The agents "pointed out that their community members ask them questions and request services beyond family planning."4
In a surveyof Kenyan CBD clients, where many different models are used, about 90 percent of respondents favored agents who can provide counseling, including information about sexually transmitted diseases. Most of those interviewed also supported CBD workers discussing family planning with young adults (80 percent) and unmarried women (83 percent). Scientists concluded that CBD agents should be trained more thoroughly in other reproductive health issues and encouraged to act as sources of information for other community members, especially youth.5
Intervention projects have shown that community family planning workers contribute to better maternal health. In Bangladesh, door-to-door family planning workers were trained to counsel pregnant women about how to recognize obstetric emergencies and the importance of seeking treatment promptly if the symptoms appear. To assist illiterate women, the workers used pictorial cards such as one showing labor pain lasting more than 12 hours as a reason to seek treatment.6
-- William R. Finger
References
Rosenfield AG, Limcharoen C. Auxiliary midwife prescription of oral contraceptives: an experimental project in Thailand. In Foreit JR, Frejka T, eds. Family Planning Operations Research: A Book of Readings (New York: Population Council, 1998)69-81.
Katz KR, West CG, Doumbia F, et al. Increasing access to family planning services in rural Mali through community-based distribution. Int Fam Plann Perspect 1998;24(3):104-10.
Operation Research Summaries. Community Volunteers Successfully Refer Women to Reproductive Health Services. New York: Population Council, 1998.
Chege J, Rutenberg N, Janowitz B, et al. Factors Affecting the Outputs and Costs of a Community-based Distribution of Family Planning Services in Tanzania. (New York, NY: Population Council, 1998)22.
Chege JN, Askew I. An Assessment of Community-based Family Planning Programmes in Kenya. Nairobi: Population Council, 1997.
Ashraf A, Ahmed S, Phillips JF. Developing doorstep services. In Khuda B, Kane TT, Phillips JF, eds. Improving the Bangladesh Health and Family Planning Programme: Lessons Learned through Operations Research. (Dhaka, Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh, 1997)20-21.
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