FAMILY PLANNING SERVICES The new National Population Policy, 2000, adopted by the Government of India, has set as its immediate objective the task of addressing unmet need for contraception in order to achieve the medium-term objective of bringing the total fertility rate down to replacement level by the year 2010. The Reproductive and Child Health Programme is oriented to meet the health needs of women and children completely. With regard to family planning, the approach emphasizes the target-free promotion of contraceptive use among eligible couples; the provision to couples of a choice of contraception; and the assurance of high-quality care. An important component of the programme is the encouragement of adequate spacing of births, with at least three years between births……..

objectives By the end of this session, students will be able to: Clarify perspectives on family planning services. Identify healthcare services provided by family planning clinics Recognize coverage of services Explain priorities in sexual and reproductive health Discuss access to Primary Care Services Explaining importance of expanding and improving family planning services.

Perspectives on family planning services A consensus is growing that access to care may not be enough to improve poor reproductive health due to: 1.Perceptions of the quality of reproductive health services, 2.Constraints experienced by providers in the delivery of reproductive health services, 3.Impact of quality of care on reproductive health outcomes, 4.Perspectives of special populations: adolescents, men, women at the end of the reproductive lifecycle, refugees, HIV-positive men and women, and the urban and rural poor. As you can see… Knowledge of contraceptive methods is nearly universal in Bihar with 99 percent of currently married women recognizing at least one method of contraception and at least one modern method, up from 95 percent in NFHS-1 respectively. 2. Two-fifths (40 percent) of women knew a traditional method, up from 29 percent in NFHS-1. Source: Table 5.1 for NFHS-2 (p. 92); Table 6.1 for NFHS-1 – currently married women (p. 94).

Healthcare services provided by family planning clinics Female sterilization is the most widely known method of contraception, followed by male sterilization. Overall, 99 percent of currently married women know about female sterilization and 97 percent know about male sterilization. Knowledge about spacing methods is less widespread. The best known spacing method is the pill (75 percent), followed by the condom (64 percent) and the IUD (59 percent). Although knowledge of these spacing methods remain much lower than knowledge of sterilization, a look at trends since NFHS-1 suggests that knowledge has gone up! - only slightly over half of women in the early 1990s knew about the pill compared to three quarters today…….. Source: Table 5.1 for NFHS-2 (P. 92); Table 6.1 for NFHS-1 (pp. 94). National Family Health Survey-2

National Family Health Survey-2 A - MEDICAL SERVICES Comprehensive physical exams & health screenings Pelvic and breast exams Pap smear Blood pressure & weight check Pregnancy testing & options counseling Preconceptual counseling Sexually Transmitted Diseases (STDs), On-site diagnosis & treatment Birth control instruction & counseling Infertility education and referral For many years, the FP programme has been using electronic and other means of mass media to promote family planning. Studies have confirmed that exposure to electronic mass media has a substantial effect on contraceptive use. In order to explore the reach of family planning messages disseminated through various mass media channels, NFHS-2 asked women whether they had heard or seen any message about FP in the past few months. The results indicate that: Overall, FP messages have reached about two out of every five ever-married women in Bihar, with 72 percent of women in urban areas reporting having heard or seen a message from any source, compared to 36% in rural areas. The most common source of recent exposure is TV, with 62% of women in urban areas reporting having seen a message, and 16% in rural areas. Source: Table 5.13 (p. 114). National Family Health Survey-2

National Family Health Survey-2 B - SPECIAL SERVICES Prenatal care & delivery program HIV testing & counseling (Confidential testing for both you and your partner) Colposcopy & Cryotherapy & L.E.E.P. (Loop Electrosurgical Excision Procedure) Male services Teen services Prenatal substance abuse programs Mid-Life services Moving on to current contraceptive use and trends and intention to use………………………. National Family Health Survey-2

C - COMMUNITY EDUCATION SERVICES Workshops for schools, community groups, and others Consultation and training for professionals Parent education programs 1. Current contraceptive use in Bihar is 25 percent of currently married women, up from 23 percent in NFHS-1. Bihar’s CPR of 25% is the second-lowest among all states in the Union. Only Meghalaya is lower at 20 percent. (Table 5.7, p. 142, All India report) However, use of modern spacing methods remains low at 2 percent, and has declined slightly from 3 percent of women in NFHS-1. The share of female sterilization in contraceptive use has increased from 75% to 78% over the 6 year period. Notably, the share of male sterilization declined from 6 percent to 4 percent over the same time period. Source: For NFHS-2 data, Table 5.3 (p. 95, narr p. 96); for NFHS-1 data, Table

Service delivery Integration of family planning in MCH care, including HIV and STI services, cervical and breast cancer screening. Regular access to and availability of contraceptives supplies. Integration into primary health care. Turning to the differences in use of contraceptives in urban versus rural settings: Current use for any method is considerably higher in urban areas (39%) than in rural areas (23%). The urban/rural difference is also true for female sterilization at 27 percent in urban areas versus 18 percent in rural areas, and for modern spacing methods with 7 percent contraceptive prevalence in urban populations and only 2 percent prevalence in rural populations. Source: Table 5.4.

Cont. Strengthening links between different levels of health system. Skilled health professionals: midwives, nurses and doctors trained in FP and counseling techniques that respect individual human rights. Community health workers with proper FP training and supervision. This slide examines trends in contraceptive use between NFHS-1 and NFHS-2 by urban and rural residence. As may be seen, in both urban areas (the middle two bars) and for the rural areas (the bottom two bars), female sterilization remains the significant method of choice in both NFHS-1 and NFHS-2. Overall prevalence had remained about the same in urban areas, and increased only slightly in rural areas in the interim period between the all-India surveys. Table 5.4, p.95 for NFHS-2, and Table 6.4 (age 15-49), p. 101 for NFHS-1.

COVERAGE OF SERVICES Covered services include counseling, medical examinations, laboratory tests, and drugs and supplies furnished by the clinic in connection with family planning. It appears that both in terms of female sterilization, as well as use of modern spacing methods, there is very little variation in contraceptive prevalence between the three regions in Bihar. Whether considered regionally or for the state as a whole, prevalence is far below the all-India average. Source: NFHS-2 Bihar, Table 5.4, p. 98. All India, table 5.5. in the all-India final report

Priorities in sexual and reproductive health Inadequate sexual and reproductive health services have resulted in maternal deaths and rising numbers of sexually transmitted infections (STIs), such as chlamydia and gonorrhoea occur annually in aged 15 - 49. Many are untreated because of lack of access to services. The sexually transmitted human papilloma virus (HPV) infection is closely associated with cervical cancer. This slide presents contraceptive prevalence for India as a whole and for selected states Contraceptive prevalence ranges from 68 percent in Himachal Pradesh to the state with the lowest CPR at 20 percent----- Meghalaya. At 25 percent, Bihar has the second lowest contraceptive prevalence of an state, and is about half of the all-India average of 48 percent. Table 5.4, all-India report. National Family Health Survey-2

Priority areas include 1.A coordinated action plan to implement the Global STI Prevention and Control Strategy; 2.Support to countries to increase skilled health attendants 3.Coordinated work plans on improving reproductive, maternal, newborn and adolescent health; 4.Advocacy for inclusion of sexual and reproductive health in national economic planning ; 5.Strengthening the linkages between HIV and sexual and reproductive health through coordinated action in HIV prevention, care and treatment; 6.Joint training of country teams on the process for planning and working together at country level and joint competency reviews; How much does the use of contraception vary by the number of sons? We see here that for women with 2 children, but no sons only 11 percent use contraception For women with 2 children and one son, 21 percent opt for using contraception………….whereas Over one-third (38 percent) of women with 2 children use contraception when both children are sons. Table 5.4, p. 99 National Family Health Survey-2

Cont. 7.Coordinated work in countries addressing: Female genital mutilation/cutting Obstetric fistula Violence against women, including in emergencies A pilot program in two countries to introduce the Human Papilloma Virus (HPV) vaccine Human resources for health. And here are a few facts on sterilization………………… 1. Median age at sterilization is about 28 years, more than two years older than the all-India figure of 26 year. [Note: about 27 percent of sterilized couples have undergone sterilization before the wife was 25. ] 2. Two-thirds (68%) of sterilized couples underwent sterilization before the wife was age 30, and less than 2 percent took place when the wife was in her 40s. And male sterilization is not as common as it was a decade or more ago. Then, it made up 7 percent of all sterilizations, whereas today it has fallen and only 3 percent of men are sterilized. Median age of women at sterilization has declined marginally from 28 years during the eight or nine years before the survey to 27 during the two years before the survey. Source: Table 5.7 and narrative in sub-section 5.3, page 103 re: male statistic.

Preventing mother-child HIV transmission during breast feeding Giving HIV positive mothers a combination of three antiretroviral drugs (ARVs) during pregnancy, delivery and breastfeeding cuts HIV infections in infants by 43% by the age of one year and reduces transmissions during breastfeeding by 54% compared with the previously recommended ARV drug regimen stopped at delivery. Giving HIV-positive pregnant women (and those planning pregnancy) priority access to ARVs will help eliminate mother-to-child transmission of HIV. During the survey, currently married women were asked about their intentions to use a method in the future………. 1. The findings show that 57 percent of women who are not currently using any contraceptive method intend to use a method in the future. 2. And among these women, 28 percent not currently using contraceptives stated they intend to use contraception in the next 12 months. Source: Table 5.10, p. 110 and narrative p. 109

Service Delivery System Professional services related to family planning are available by primary care physicians in public and private practice. Certified nurse midwives, nurse practitioners. Pharmacies, laboratories, outpatient hospitals are eligible to provide services. Qualified Health Centers, Rural Health Clinics, Tribal Health Centers, private non-profit family planning agencies provide services as well. For women not using, but that intended to use in the future, another question asked was……What is the preferred method? 1. Not surprisingly, the large majority, 68 percent, say they intend to use sterilization. The next most preferred method is the pill (25 percent) and only 1 percent prefer that their husbands get sterilized and 1 percent prefer to use the IUD. [Note: 25 % of intended users say they prefer the pill, while only 1 percent of current users use the pill…………..suggesting some potential underlying demand for pills!] 2. There are important differences in choice of preferred methods by timing of intended use: Women who intend to use contraception in the next 12 months stated a greater preference for spacing methods (37%). While those intending to use them later, rely primarily on female sterilization. Source: Table 5.12 and narrative p. 112 National Family Health Survey-2

Expanding and improving family planning services is critical Efforts to expand and improve family planning services can have a significant impact on saving and improving the lives of women and their families. 1. Remove policy barriers limiting access, choice. Restricting advertising for contraceptive methods, limiting contraceptive distribution only to physicians, requiring unnecessary import duties and customs regulations for contraceptives. Next are some highlights on where women obtain their contraceptives and services National Family Health Survey-2

National Family Health Survey-2 2. Remove medical barriers that limit access and choice. Methods, medical recommendations and requirements should be updated to include the most appropriate and essential criteria. Unnecessary restrictions include requiring oral contraceptive users to have blood tests every three to six months and prohibiting injectable contraceptive use in women without children Provider bias against certain methods also influences the choices offered to clients. 83 percent of women use the public medical sector as the source for sterilization, compared to 16 percent from the private medical sector. Similar sources are used for male sterilization. 2. Almost half (49 percent) of IUD users obtain their method from the public medical sector, and almost half (49 percent) from the private medical sector. Users of pills obtain their supply from several different sources. Shops are the main source for more than one-half of users (56 percent) and the private medical sector is the source for about 20 percent of users. 4. Private shops are the major source for condoms (55 percent), followed by the private medical sector (23 percent). Eleven percent of condom users obtain their method from a private medical sector source. NOTE: Eighty-one percent of rural users obtain their contraceptives from the public sector compared with 56 percent of urban users. In urban areas, 34 percent of female sterilizations are performed by the private sector compared with 14 percent in rural areas. Source: Table 5.8, p. 106, narrative p. 103. National Family Health Survey-2

National Family Health Survey-2 3. Provide financial support for family planning services. Family planning is a cost-effective investment that saves lives and money. Costs of providing family planning services can vary considerably from program to program. Both donor agencies and country governments need to substantially increase their financial commitments to family planning to achieve this level of support. Moving now to informed choice and follow-up, NFHS-2 asked users questions about who had motivated them to use their current method, the types of information given, and follow-up. National Family Health Survey-2

National Family Health Survey-2 4. Make a broad range of methods available through various delivery routes. Clients are more likely to use contraceptives if they are presented with a choice of methods and services easily accessible. Programs should make a wide range of contraceptives available through a variety of sources, including maternal and child health clinics, prenatal and postpartum care centres, community-based distribution systems, STD services, health services for adolescents and men, and private sector. 1. And the findings indicate that only 15 percent of users motivated by someone else were told by the motivator about any other method of family planning other than the one they were currently using. 21 percent of users motivated by a public medical sector health worker were told about other methods, compared with 15 percent of users motivated by a private sector worker of someone else The situation is slightly better in urban areas (23 percent) as compared to rural (14 percent). Source: Table 9.9, narrative on pages 222-223. National Family Health Survey-2

National Family Health Survey-2 5. Use appropriate information, education, and communication strategies to inform people. Programs can help to ensure that couples have enough information to make an informed decision through face-to-face counseling with appropriate print materials and by using the mass media. All community-based communication channels and systems should be utilized, particularly those involving local leaders, healers, and events. All forms of communication should be culturally appropriate and respectful of the client's needs. Counseling process should be an interactive one; Another important element of informed contraceptive choice is explaining about any side effects at the time the method is being accepted……. 1. Only 16 percent of modern method users were informed about possible side effects of their current method by a health or family planning worker at the time of adoption of the method, less than the all-India average of 22 percent. 2. 19 percent of urban users were informed about side effects, compared to only 15 percent of rural users. Clearly, neither public or private health workers are providing couples with all of the information they need to make an informed choice about contraceptive methods. Source: Table 9. 10, narrative p. 224. National Family Health Survey-2

National Family Health Survey-2 6. Support provider training and supervision. Training workers in interpersonal communication and counseling skills as well as in technical aspects of contraceptive service provision yields positive results. Clients who receive services from trained providers are more likely to accept and use contraception, report fewer and milder side effects, and return for regular visits. Supportive supervision helps to reinforce skills learned in training. The situation is much better, however, with respect to follow-up services. In Bihar, 77 percent of users of a modern method received follow-up services, compared with the national average of 69 percent! ……. and Follow-up was slightly higher among acceptors of sterilization at 78 percent. Nevertheless, this implies that about one in five users of sterilization had no follow-up services provided to them. And only two-thirds (66%) of users of OTHER modern methods received follow-up services. Source: Table 9.10 National Family Health Survey-2

National Family Health Survey-2 7. Support research and evaluation of family planning methods and programs. Research on contraceptive technologies contributes to the development of new methods, improvement of existing methods, and knowledge of method safety. Research on how family planning programs operate can help determine the best ways of providing different contraceptive methods in diverse cultures and program settings. Information from both types of research is critical to expanding the acceptability and impact of family planning programs.   And…..[click to bring in the arrow]…… the last important aspect of family planning services is examining the unmet need for family planning. National Family Health Survey-2

Where do women get their modern contraceptive methods? Public medical sector 77% Private medical sector 18% Shop/Other 4% Family planning methods and services in Bihar are provided primarily through a network of govt. hospitals and urban family welfare centres in urban areas, and primary health centres (PHC) and sub-centres in rural areas. They are also provided by private hospitals and clinics, as well as NGOs. 1. The public medical sector, is the source of contraception for over three-fourths (77%) of current users of modern methods. The private medical sector, including private hospitals or clinics, private doctors, private mobile clinics, private paramedics, vaidyas, hakims, homeopaths, traditional healers, and pharmacies or drugstores, is the source of 18 percent of current users. 4 percent of current users obtain their methods from other sources such as shops, friends, and relatives, and less than 1 percent from NGOs. 2 Government hospitals are the main source (70%) for female sterilization, followed by private hospitals or clinics (13%), sterilization camps (7%), and community health centers, rural hospitals, or PHC (4%). Similar sources are used for male sterilizations. 3. About half of IUD users obtain their IUDs from the public medical sector, and the other half from the private medical sector. 4. Private shops are the major source for condoms and pills (55-56%) Source: Table 5.8, p. 106, narrative p. 103. Don’t know/ Missing 1% NGO/Trust 0.4%

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