 Ruth Simmons, Professor, Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, MI 48109-2029. Peter Hall, Chief and Peter Fajans, Scientist, Technical Introduction and Transfer, HRP, WHO. Juan Diaz, Medical Advisor for Latin America and the Caribbean, Population Council. Margarita DIaz, Director, Department of Education, Training and Communication, CEMICAMP, Brazil. Jay Satia, Executive Director, ICOMP. John Skibiak, Associate, Population Council, has contributed substantially to this article, has provided technical assistance to three of the assessments, and has played an important role in the development and evolution of the strategic approach. The introduction of new contraceptive technologies has great potential for expanding contraceptive choice, but in practice, benefits have not always materialized as new methods have been added to public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/ World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP) has taken major steps to develop a new approach and to support governments interested in its implementation. After reviewing previous experience with contraceptive introduction, the article outlines the strategic approach and discusses lessons from eight countries. This new approach shifts attention from promotion of a particular technology to an emphasis on the method mix, the capacity to provide services with quality of care, reproductive choice, and users' perspectives and needs. It also suggests that technology choice should be undertaken through a participatory process that begins with an assessment of the need for contraceptive introduction and is followed by research and policy and program development. Initial results from Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, and Zambia confirm the value of the new approach. (Studies in Family Planning 1997; 28,2: 79–94)
Jagdish C. Bhatia, Professor of Health Management, Indian Institute of Management, Bannerghatta Road, Bangalore, 560 076 India. John Cleland, Professor of Medical Demography, London School of Hygiene and Tropical Medicine, London, U.K. Leela Bhagavan, Obstetrician and Gynecologist, Bangalore Hospital. N.S.N Rao, Consultant in Biostatistics, Ford Foundation Project, Indian Institute of Management, Bangalore. This article presents the results of an assessment of gynecological morbidity among 385 women with young children residing in a district of Karnataka State, South India. All three main modes of assessment (clinical examination, laboratory tests, and self-reports) reveal a high burden of reproductive tract infections. The two most common conditions, identified by laboratory tests, were bacterial vaginosis and mucopurulent cervicitis. Approximately one-fourth of the women had clinical evidence of pelvic inflammatory disease, cervical ectopy, and fistula. The contribution of sexually transmitted diseases to overall gynecological morbidity appears to be relatively modest; 10 percent were so diagnosed. Associated conditions of anemia and chronic energy deficiency were common. Severe anemia was found in 17 percent of cases and severe chronic energy deficiency in 12 percent. These results indicate that radical improvements in women's health in India will require far more than the diagnosis and treatment of reproductive tract infections. (Studies in Family Planning 1997; 28,2: 95–103)
Alex Chika Ezeh, Research Associate, Applied Research and Development and Gora Mboup, Country Monitor for francophone Africa, Demographic and Health Surveys, Macro International, 11785 Beltsville Drive, Calverton, MD 20705. This article examines gender differentials in the reporting of contraceptive use and offers explanations regarding the sources of these differences. Data from five countries where DHS surveys were conducted recently among men and women are used in exploring these differences. The gap exists in all five countries, with men (or husbands) reporting greater practice of contraception than women (or wives). Results from the bivariate analysis suggest that the gap is attributable to polygyny and to gender differences in how the purpose of contraception is understood, rather than to male extramarital sexual relations. Additionally, gender differences in the definition of certain contraceptive methods and differences in the interpretation of questions about contraception contribute to the observed gap. These findings are also consistent with results of the multivariate analysis. (Studies in Family Planning 1997; 28,2: 104–121)
ReportsTu Ping Professor, Institute of Population Research, Peking University, Beijing 100871, China. Qiu Shuhua, Vice President, Family Planning Association of China, Beijing. Fang Huimin, Senior Physician, Beijing Maternal Hospital, Beijing. Herbert L. Smith, Professor, Population Studies Center, University of Pennsylvania, Philadelphia. This report attempts to present a comprehensive analysis of the acceptability, side effects, and efficacy of Norplant® as used in rural areas, based on a field experiment conducted in four counties in Hebei and Shandong Provinces, China. The initial acceptance of Norplant was relatively high but waned after the first year in three of the four counties. Compared with clinical trials, the current study shows a lower prevalence but similar patterns of side effects. The pregnancy rate during the first two years of use is similar to that found in large-scale clinical trials conducted in China, but discontinuation due to other reasons is lower. A three-level logistic regression analysis shows significant variation in the probability of discontinuation due to side effects across counties. It also indicates an increase in the conditional probability of discontinuation with the duration of use. Whereas introducing Norplant® and achieving a very low failure rate and high continuation rate in rural areas is feasible under diverse socioeconomic conditions, the results vary significantly across different areas. Particular attention should be paid to the local factors that may affect results. (Studies in Family Planning 1997; 28,2: 122–131)
Michel Garenne, Directeur de Recherche, CEPED, 15 rue de l'École de Médecine, 75270 Paris Cedex 06, France. Fabrice Friedberg, Statisticien-Economiste, ENSAE, Malakoff, France. A simulation model was developed to test the accuracy of indirect estimates of maternal mortality (the sisterhood method). The model generated a first generation of grandmothers, a second generation of mothers (with brothers and sisters), and a third generation of children (births). In the second generation, maternal mortality was introduced. Empirical values for the parameters of fertility and mortality were taken from a prospective survey in Senegal (Niakhar). Results based on 100 simulations of the same situation revealed several limitations of the sisterhood method: The indirect estimates could fall as far as 33 percent from the true values on individual cases; the indirect estimates tended to be systematically higher than the direct estimates; their range was wider, as were their confidence intervals; and biases were particularly strong for the younger age groups of respondents. Reasons for these biases are explored. (Studies in Family Planning 1997: 28,2: 132–142)
Joseph J. Valadez, Senior Associate, Department of International Health, Johns Hopkins University School of Hygiene and Public Health and Health Programs Coordinator, PLAN International, 3260 Wilson Boulevard, Suite 11, Arlington, VA 22201. Rikka Transgrud, Regional Representative, Family Care International. Margaret Mbugua, Head, Supervision and Evaluation Unit, Division of Family Health, Kenya Ministry of Health. Tamara Smith, Associate Director, JHPIEGO. This report demonstrates the use of Lot Quality Assurance Sampling (LQAS) to evaluate the technical competence of two cohorts of family planning service providers in Kenya trained with a new curriculum. One cohort had just finished training within two months of the study. The other cohort was the first group trained with the new curriculum about one year before the study. LQAS was adapted from industrial and other public health applications to assess both the individual competence of 30 service providers and the competence of each cohort. Results show that Cohorts One and Two did not differ markedly in the number of tasks needing improvement. However, both cohorts exhibited more tasks needing improvement in counseling skills as compared with physical examination skills or with all other skills. Care-givers who were not currently providing services accounted for most service-delivery problems. This result suggests that providers' use of their skills explains their ability to retain service-delivery skills learned in training to a greater degree than does the amount of time elapsed since they were trained. LQAS proved to be a rapid, easy-to-use empirical method for management decisionmaking for improvement of a family planning training curriculum and services. (Studies in Family Planning 1997; 28,2: 143–150)
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