 Michael A. Koenig is Associate Professor, Department of Population and Family Health Sciences, The Johns Hopkins University School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, MD 21205. E-mail: MKoenig@jhsph.edu. Gillian H.C. Foo is Independent Consultant, Baltimore, MD. Ketan Joshi is Research Analyst, Center for Communication Programs, The Johns Hopkins University. India's family planning program represents one of the earliest and most ambitious efforts in a developing country to address the issue of high fertility. Despite its more than four decades of existence, little is known concerning how the program is implemented at the field level, especially in relation to the quality of services provided. In this article, empirical evidence on the accessibility and quality of services provided through the Indian family planning program is reviewed and synthesized. The review highlights the serious and systemic shortcomings in quality of care that characterize the Indian program in such areas as restricted method choice, limited information provided to clients, poor technical standards, and low levels of follow-up and continuity of care. The factors constraining higher service quality are subsequently reviewed, and the prospects for improving quality of care within the Indian program are assessed. (Studies in Family Planning 2000; 31[1]: 118)
Homa Hoodfar is Associate Professor of Anthropology, Department of Sociology and Anthropology, Concordia University, 1455, de Maisonneuve Boulevard, West, Montreal, Quebec, Canada H3G 1M8. E-mail: HHoodfar@aol.com. Samad Assadpour is Adviser to the Deputy of Public Health Affairs, Population and Family Planning Program, Ministry of Health and Medical Education, Tehran, Iran. The Islamic Republic of Iran arguably has one of the most successful family planning programs in the developing world. This success is all the more interesting for advocates of population programs because the political leaders of the Islamic regime were once strongly opposed to family planning. Indeed, after gaining power following the 1979 revolution, they were responsible for dismantling Iran's relatively new family planning program and introducing pronatalist policies. This article provides an account of the different phases of the population policy in Iran and examines the diverse elements that led politicoreligious leaders to revise their views about fertility control and to participate in creating a workable family planning program. The complex formal and informal strategies that the political experts, the media, the religious authorities, and the government of the Islamic Republic adopted in order to achieve this about-face are described. The analysis is based on data collected by the first author during anthropological field research in 199396, by means of informal interviews with officials, with medical personnel, with family planning clients, and with religious leaders (Studies in Family Planning 2000; 31[1]: 1934)
Louise A. Hulton is a doctoral candidate, Department of Social Statistics, University of Southampton, Highfield, Southampton, SO 17, UK. Rachel Cullen works for International Planned Parenthood Federation European Network. Symons Wamala Khalokho is Director, AIDS Relief Uganda, Mbale District, Uganda. The principal aim of this study of adolescents in Mbale District, Uganda, is to provide program-related information about their behavior, motivations, and perceptions of risk with regard to pregnancy and HIV transmission. Twelve single-sex focus-group discussions were conducted, six with young people aged 1718 who were still attending school, and six with people of the same age who were not. The most important findings to emerge are that knowledge of safe-sex behavior and reported behavior have little in common and that the fundamental barriers to behavioral change lie within the economic and sociocultural context that molds the sexual politics of youth. Young males' lack of responsibility for the outcomes of their behavior is identified as an important barrier to improved sexual health. The imperative to explore ways by which young women might achieve status and identity and acquire material resources by means not related to their sexuality is highlighted. (Studies in Family Planning 2000; 31[1]: 3546)
ReportsMichel Garenne is Director of Research, CEPED, 15 rue de l'Ιcole de Mιdecine, 75270 Paris Cedex 06, France. Email: garenne@ceped.ined.fr. Stephen Tollman is Associate Professor and Kathleen Kahn is Senior Lecturer, Witwatersrand University, Agincourt Health and Population Program, Department of Community Health, Johannesburg, Republic of South Africa. The age pattern of fertility in a rural area of South Africa under demographic surveillance (Agincourt subdistrict) was investigated over the 199297 period. The total fertility rate (TFR) averaged 3.3 births per woman of reproductive age over the period, a major drop from earlier estimates in the same area (6.0 births in 197074). Age-specific fertility rates showed an atypical bimodal pattern. They were decomposed into two components of similar magnitude: premarital fertility (among women aged 1226) and marital fertility (among women aged 1549). The decomposition revealed the two underlying modes: a mode of premarital fertility (among women aged 1820) and a mode of marital fertility (among women aged 2830). Premarital fertility accounted for 21 percent of all births and for 47 percent of births among women aged 1226. This pattern of high premarital fertility appears to reflect a low incidence of contraceptive use before the first birth, especially among adolescents, a low prevalence of abortion, and a high contraceptive prevalence thereafter. This finding calls for a reorientation of the family planning policy, which until now has targeted married women and women who have been pregnant once, but has failed to address the contraceptive needs of young women before their first pregnancy, especially adolescents. (Studies in Family Planning 2000; 31[1]: 4754)
Nancy L. Sloan
is Program Associate, Beverly Winikoff is Program Director, Reproductive Health, Nicole Haberland is Program Associate, and Christa Coggins was Staff Program Associate, Population Council, New York. Christopher Elias is Senior Program Associate, Population Council, Thailand. The standard diagnostic tools to identify sexually transmitted infections are often expensive and have laboratory and infrastructure requirements that make them unavailable to family planning and primary health-care clinics in developing countries. Therefore, inexpensive, accessible tools that rely on symptoms, signs, and/or risk factors have been developed to identify and treat reproductive tract infections without the need for laboratory diagnostics. Studies were reviewed that used standard diagnostic tests to identify gonorrhea and cervical chlamydial infection among women and that provided adequate information about the usefulness of the tools for screening. Aggregation of the studies' results suggest that risk factors, algorithms, and risk scoring for syndromic management are poor indicators of gonorrhea and chlamydial infection in samples of both low and high prevalence and, consequently, are not effective mechanisms with which to identify or manage these conditions. The development and evaluation of other approaches to identify gonorrhea and chlamydial infections, including inexpensive and simple laboratory screening tools, periodic universal treatment, and other alternatives must be given priority. (Studies in Family Planning 2000; 31[1]: 5568) Evasius K. Bauni is Research Fellow and Ben Obonyo Jarabi is Consultant, African Population and Health Research Centre, Population Council, Post Office Box 17643, Nairobi. E-mail: ebauni@popcouncil.or.ke. Recently, the prevalence of contraceptive use has increased in Kenya. The twin risks of unwanted pregnancy and HIV/AIDS infection remain central concerns of reproductive health programs. However, we do not know how sexually active men and women perceive these risks, nor the strategies they consider appropriate to cope with these risks, nor the difficulties they face in trying to adopt appropriate sexual behaviors to minimize them. This study seeks to provide insights into perceptions, coping strategies, and constraints in the changing behavior of sexually active people in Nakuru District, Kenya. Twelve focus-group discussions were conducted, the results of which show that people in the study area consider the two risks to be serious problems, but that they neither use condoms within marriage nor refuse their partners sex even if they perceive a risk of acquiring HIV. These findings call for serious efforts toward fostering behavioral change in this area. (Studies in Family Planning 2000; 31[1]: 6980)
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