World Development Report 1984

health facilities. But less than 1 percent of the forty years old, who smoke and are over thirty-five
NGO facilities offered daily family planning serv- years old, who are breastfeeding, or who have a
ices, and only 7 percent offered part-time services. history of stroke, thromboembolism, cancer, liver
A new project is creating family planning service damage, or heart attack. The IUD is undesirable
delivery points in at least thirty of the NGO facili- for women with pelvic infection or a history of
ties. In addition, both government and NGO rep- ectopic pregnancy. Some women cannot be propresentatives
will sit on a National Council on Pop- erly fitted with diaphragms.
ulation and Development that will coordinate * If the side effects of one method cannot be
national efforts in population information, educa- tolerated, the availability of other methods
tion, and communications. improves the chance that couples will switch
Governments have also removed legal and regu- rather than stop using contraception altogether.
latory obstacles that restrict commercial distribu- For example, in Matlab Thana, Bangladesh, 36 pertion.
In Egypt the sale of oral contraceptives cent of women had switched methods within sixthrough
private pharmacies does not require a teen to eighteen months after initial acceptance.
physician's prescription, although their provision And a study in the United States showed that marthrough
government clinics serving rural areas ried white women aged twenty-five to thirty-nine
does. Several countries-including China, Mexico, had used an average of more than two methods;
Morocco, the Philippines, and Thailand-allow more than a third of those aged twenty-five to
pills to be distributed in facilities other than phar- twenty-nine had used three or more.
macies or health centers. Other options for stimu- * Couples' preferences are influenced by their
lating the private sector include removal of import fertility goals-postponing a first birth, spacing
tariffs on contraceptive supplies (Korea recently between children, or limiting family size. Women
eliminated a 40 percent tariff on raw materials for using the pill tend to be younger and to have had
domestically produced contraceptives); active gov- fewer births than those protected by sterilization;
eminment promotion of condoms, spermicides, and
pillsnth beomeasilyof supplied therougicomer - many of the former are spacing births, while the
pills that can be easily supplied through commer- latrhvcopedteifmles
cial outlets; and training of private pharmacists
and physicians who frequently have little knowl- * Some methods of fertility control may be reliedge
of modern family planning methods. giously or culturally unacceptable. Two-fifths of
the world's countries, comprising 28 percent of its
population, either prohibit abortion completely or
Improving quality permit it only to save the life of the mother. For
The quality of family planning services matters in religious reasons, sterilization is illegal in several
all phases of program development. In the early countries. When couples regard periodic abstistages
services are new, and contraception still nence as the only acceptable form of birth control,
lacks social legitimacy. Once programs are well programs should provide information on proper
established and accessible, quality counts because timing of abstinence, although this method carries
other costs of family planning-such as physical higher risks of unwanted pregnancy.
side effects-have replaced access as the factor lim- Due to sheer lack of alternatives, early family
iting the success of the program. Three ingredients planning programs offered only a limited range of
of quality-the mix of contraceptive methods, the contraceptive methods. In the late 1950s and early
information and choice provided, and program 1960s, the Indian program had to rely on rhythm,
follow-up-have contributed much to program the diaphragm, and the condom. Today, most
success (see Box 7.6). national programs offer a wider variety of methods,
although the number available at any given
THE METHOD MIX OF PROGRAMS. The number and outlet is often fewer than that implied by official
characteristics of available contraceptive methods statements. Some governments still promote a sinaffect
the ability and willingness of clients to prac- gle method because such an approach is easier to
tice birth control. Additional options are likely to administer or because certain methods, such as
increase acceptance, permit switching, and reduce sterilization and the IUD, are viewed as more
discontinuation rates. 'effective" and require less follow-up over the
* Some women have medical conditions that long run than do other methods. For example,
rule out certain methods. Oral contraceptives India, Korea, and Sri Lanka continue to emphasize
should not be prescribed for women who are over sterilization. Until recently, Indonesia had almost
143