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June 2003, Vol. 9, No. 2 Experimental Programs In the early 1990s, surveys conducted in Ghana showed that people’s desire for family planning was largely unfulfilled, despite two decades of policies aimed at making inexpensive family planning services available. Research also showed that mortality in remote rural areas was substantially higher than in urban communities. In response to this situation, the Ghanaian Ministry of Health designed the Community Health and Family Planning experiment at its Navrongo Health Research Centre (NHRC), a field station in rural northern Ghana. The Population Council provided research support and administered funding for this experiment. Many respected observers had stated that improving access to family planning services in rural sub-Saharan Africa would have little or no effect on fertility because kinship networks, family structures, and marriage customs favor large families. Recent results from the Navrongo experiment have provided an altered perspective on the issue. Two strategies In one strategy, Ministry of Health nurses live and work in community-constructed health centers and provide health and family planning services door to door. In the other strategy— known as zurugelu, which means “togetherness” in the local language—door-to-door services are provided by local volunteers and supported by community leaders. These leaders also host community gatherings, known as durbars, that foster community dialogue about health and reproductive matters. The study is being conducted in four geographic regions in the Kassena-Nankana District. People in Area 1 are exposed to the zurugelu strategy. Residents of Area 2 receive care from nurses. In Area 3, people benefit from contact with both the zurugelu and nurse outreach strategies. In these three experimental areas and in Area 4, the comparison area, residents have access to Ministry of Health fixed-location clinics. The NHRC’s central scientific resource is the Navrongo Demographic Surveillance System, which registers all demographic events— including births, deaths, migrations, marriages, and pregnancies—that occur in the lives of all 142,000 individuals residing in Kassena-Nankana District. The system also provides continuous estimates of fertility rates for approximately 43,000 women of reproductive age. Change seen Phillips and his colleagues examined the effect of the experiment on knowledge of contraceptives, desire to limit childbearing, reported contraceptive use, and fertility. Controlling for several potential biases, the researchers found that when nurse outreach and zurugelu were combined, married women’s knowledge of contraceptives improved significantly more than it did in areas where either the zurugelu or the nurse outreach strategy was implemented separately. Outreach by nurses, meanwhile, had the strongest influence on women’s desire to limit childbearing. The researchers found that after one year of nurse outreach activities, women in that study group were 40 percent more likely to want to limit fertility than women in the comparison group. Women’s fertility preferences in the zurugelu-only area were not significantly different from those of women in the comparison area. Women who experienced both nurse outreach and zurugelu were 20 percent more likely than women in the comparison group to want to limit their childbearing. "By emphasizing exchanges between nurses and individual women, the nurse outreach approach may introduce women to new ideas about childbearing that do not immediately arise from zurugelu activities in the community," says Jackson. Does the desire to limit childbearing translate into contraceptive use? A statistical analysis showed that one year of exposure to nurse outreach and zurugelu implemented together increased reported modern contraceptive use among currently married women by 24 percent, a significant change. In the two areas where each of the strategies was implemented separately, no significant change was reported in contraceptive use. Evidence that fertility has fallen in all experimental areas, however, suggests that some women who use family planning may deny doing so. When the two interventions operated jointly, their fertility effect equaled the sum of the influence of each arm operating separately and resulted in a 15 percent reduction in fertility between 1994 and 1999. Additive effect Other results from the Navrongo experiment, including effects on child survival, are expected in the future. Source Outside funding See Also
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