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correlat<strong>in</strong>g <strong>the</strong> number of children to women's naturalresistance or propensity to pregnancy (h<strong>in</strong>di buntis<strong>in</strong> orbuntis<strong>in</strong>); <strong>and</strong> that a woman's fertility decreases as <strong>the</strong> ageof her youngest child <strong>in</strong>creases.In <strong>the</strong> 2008 NDHS, 93 per cent of those who cited<strong>in</strong>fecundity, subfecundity or <strong>in</strong>frequent sex as <strong>the</strong>ir reasonfor not us<strong>in</strong>g contraception were 30 years old <strong>and</strong> older.For sexual frequency, it is possible that women may beoverestimat<strong>in</strong>g <strong>the</strong> decl<strong>in</strong>e <strong>in</strong> sexual activity s<strong>in</strong>ce <strong>the</strong>percentage of women report<strong>in</strong>g sexual <strong>in</strong>tercourse with<strong>in</strong>four weeks of <strong>the</strong> survey showed an almost constant 66 to64 per cent for those aged 30-44, <strong>and</strong> a not so large drop to56 per cent for those aged 45-49.Opposition to family plann<strong>in</strong>gReligion-based opposition to family plann<strong>in</strong>g is low,rang<strong>in</strong>g from 3 to 6 per cent dur<strong>in</strong>g <strong>the</strong> four surveys. On<strong>the</strong> issue of family plann<strong>in</strong>g, it appears that o<strong>the</strong>r issuesare more important to women even though <strong>the</strong> majority of<strong>the</strong>m are Catholics. It is possible, however, that <strong>the</strong> Catholichierarchy's campaign aga<strong>in</strong>st contraception may be hav<strong>in</strong>gan effect through o<strong>the</strong>r routes, such as heighten<strong>in</strong>g women'sworries about <strong>the</strong> safety of contraceptives.Those who cited opposition by <strong>the</strong>ir husb<strong>and</strong>s were few,about <strong>the</strong> same as that from religious beliefs. However,<strong>the</strong> 2008 NDHS showed that 20 per cent of women hadhusb<strong>and</strong>s who wanted more children than <strong>the</strong>y did. Thepercentage peaked at 27 per cent for women <strong>in</strong> <strong>the</strong> lowestwealth qu<strong>in</strong>tile. This could mean that some women whosay that <strong>the</strong>ir non-use is due to a desire for more childrenare merely echo<strong>in</strong>g <strong>the</strong> wishes of <strong>the</strong>ir husb<strong>and</strong>, <strong>the</strong>rebyunderestimat<strong>in</strong>g <strong>the</strong> role of men's opposition as a factor <strong>in</strong><strong>the</strong> non-use of contraception.A community health worker participant <strong>in</strong> a focus groupdiscussion stated: “We had a patient, her husb<strong>and</strong> wouldfeel her up <strong>in</strong>side to check for <strong>the</strong> IUD str<strong>in</strong>gs. Once heknew for sure, he had <strong>the</strong>m removed. As a result, someof <strong>the</strong> women stopped us<strong>in</strong>g <strong>the</strong> IUD”. O<strong>the</strong>r women,however, responded by “devis<strong>in</strong>g ways” to circumvent <strong>the</strong>irhusb<strong>and</strong>’s dictates, such as putt<strong>in</strong>g contraceptive pills <strong>in</strong>vitam<strong>in</strong> bottles, hid<strong>in</strong>g <strong>the</strong>m <strong>in</strong> <strong>the</strong>ir mo<strong>the</strong>r’s house, orhav<strong>in</strong>g <strong>the</strong>ir DMPA shots while br<strong>in</strong>g<strong>in</strong>g <strong>the</strong>ir childrenfor treatment <strong>in</strong> <strong>the</strong> cl<strong>in</strong>ic.Access <strong>and</strong> <strong>in</strong>formation issuesAccess <strong>and</strong> related issues are low, rang<strong>in</strong>g from 2 to 7 percent dur<strong>in</strong>g <strong>the</strong> four surveys. It is possible, however, thatmany non-users have not tried any method at all or for asignificant amount of time to be able to comment on accessproblems, such as cost, distance <strong>and</strong> availability. It is alsopossible that, when women are able to overcome <strong>the</strong>ir ma<strong>in</strong>barrier such as safety issues, o<strong>the</strong>r problems such as accessmay <strong>the</strong>n come to <strong>the</strong> fore, especially for poor women.Evidence for access problems exist <strong>in</strong> ano<strong>the</strong>r section of <strong>the</strong>2008 NDHS. When women were asked about problems<strong>in</strong> gett<strong>in</strong>g health care for <strong>the</strong>mselves when ill, 65-74 percent <strong>in</strong> <strong>the</strong> two poorest qu<strong>in</strong>tiles identified “money fortreatment” as <strong>the</strong>ir top problem, <strong>and</strong> 59-71 per cent picked“no drugs available” as <strong>the</strong>ir second highest concern.Quantity <strong>and</strong> quality of careInsufficient quantity <strong>and</strong> quality of contact <strong>and</strong> <strong>in</strong>teractionwith health-care providers on family plann<strong>in</strong>g matters maycontribute to <strong>the</strong> persistently high safety concerns of women<strong>and</strong> possibly o<strong>the</strong>r problems that can be remedied by faceto-facecounsell<strong>in</strong>g <strong>and</strong> education. In <strong>the</strong> 2008 NDHS, 31per cent of women non-users visited a health facility <strong>in</strong> <strong>the</strong>previous 12 months, <strong>and</strong> only 32 per cent of those womenwere at least told about <strong>the</strong> availability of family plann<strong>in</strong>g.*Ano<strong>the</strong>r 8 per cent of all women surveyed were visited byFP workers at <strong>the</strong>ir homes. Overall, only 18 per cent ofwomen non-users had a family plann<strong>in</strong>g*3 <strong>in</strong>teraction <strong>in</strong>one year.Aim<strong>in</strong>g for good quality <strong>in</strong> health care is a vital goal <strong>in</strong>itself, built on shared values of car<strong>in</strong>g for <strong>the</strong> vulnerable,<strong>and</strong> on fairness <strong>and</strong> equity. In addition, good qualityencourages susta<strong>in</strong>ed use of services <strong>and</strong> expansion of <strong>the</strong>user base. In family plann<strong>in</strong>g, <strong>the</strong> first empirical evidenceon <strong>the</strong> practical value of good-quality care came from astudy by RamaRao 44 <strong>and</strong> colleagues published <strong>in</strong> 2003on 1,460 new family plann<strong>in</strong>g users at 80 service deliverypo<strong>in</strong>ts <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es.*4 They found that <strong>the</strong> quality ofcare received at <strong>the</strong> time a woman adopted a contraceptivemethod <strong>in</strong>fluenced her contraceptive use at follow-up,with probabilities of cont<strong>in</strong>ued use <strong>in</strong>creas<strong>in</strong>g as quality<strong>in</strong>creased: 55 per cent for low-quality care, 62 per cent formedium-quality care <strong>and</strong> 67 per cent for high-quality care.The quasi-experimental operations research componentof this study done by Costello 45 <strong>and</strong> colleagues provided avery detailed look at how family plann<strong>in</strong>g services measureup to a proposed quality of care framework by JudithBruce, shown as categories <strong>in</strong> Table C. In facilities whereno <strong>in</strong>tervention was done (control sites, represent<strong>in</strong>g <strong>the</strong>typical situation <strong>in</strong> <strong>the</strong> areas studied), 859 family plann<strong>in</strong>gclients were <strong>in</strong>terviewed about whe<strong>the</strong>r or not each detailedaspect of high-quality care was met. The top one fourth of<strong>the</strong> quality of care list shows that public health facilities<strong>in</strong> <strong>the</strong>se areas do very well on friendly <strong>and</strong> satisfy<strong>in</strong>g<strong>in</strong>terpersonal relations, clean facilities <strong>and</strong> respect<strong>in</strong>g<strong>and</strong> support<strong>in</strong>g <strong>the</strong>ir clients' chosen methods. However,<strong>the</strong>y performed quite poorly <strong>in</strong> address<strong>in</strong>g clients' safetyconcerns – side effects, warn<strong>in</strong>g signs, how to manageproblems <strong>and</strong> even IEC materials that could tackle <strong>the</strong>seissues – which l<strong>and</strong>ed at or near <strong>the</strong> bottom fourth of <strong>the</strong>quality of care list.310
In <strong>the</strong> 2008 NDHS three similar questions were askedon <strong>the</strong> <strong>in</strong>formation given to women who started a methodwith<strong>in</strong> <strong>the</strong> previous five years. The results roughly matched<strong>the</strong> percentages for equivalent items <strong>in</strong> Costello's study:68 per cent were <strong>in</strong>formed about possible side effects orproblems; 67 per cent were told about what to do <strong>in</strong> caseside effects developed; <strong>and</strong> 63 per cent were <strong>in</strong>formedabout o<strong>the</strong>r methods that could be used.The Department of Health recognizes <strong>the</strong> key role ofquality of care <strong>and</strong> has identified as one of its three ma<strong>in</strong>goals a “more responsive health system” – one which respectspatients' dignity, privacy <strong>and</strong> autonomy; <strong>and</strong> gives promptcare, adequate amenities, access to social support network<strong>and</strong> freedom to choose a health provider. In its 2005-2010 National Objectives for Health, <strong>the</strong> Departmentc<strong>and</strong>idly described <strong>the</strong> public's poor perception of primaryfacilities (rural health units, health centres <strong>and</strong> barangayhealth stations), which provide <strong>the</strong> bulk of non-surgicalfamily plann<strong>in</strong>g. Perception <strong>and</strong> reality have impacts onone ano<strong>the</strong>r, so this basel<strong>in</strong>e observation is important.Accord<strong>in</strong>g to <strong>the</strong> Department, “Public primary facilitiesare perceived [to be of ] low quality. Those who bypass <strong>the</strong>primary health facilities are not satisfied with <strong>the</strong>ir services.Diagnosis is poor, result<strong>in</strong>g <strong>in</strong> repeat visits. Medic<strong>in</strong>es <strong>and</strong>supplies are <strong>in</strong>ferior <strong>and</strong> rarely available. The personnelare often not available, especially <strong>in</strong> rural areas, <strong>and</strong> areperceived to lack both medical <strong>and</strong> people skills. Wait<strong>in</strong>gtime is long, facility schedule is very <strong>in</strong>convenient, <strong>and</strong>facilities are rundown”.O<strong>the</strong>r barriers to seek<strong>in</strong>g familyplann<strong>in</strong>g shared by focus groupdiscussion participants:• Requirements for patients to presenta donation <strong>and</strong> barangay clearance a<strong>the</strong>alth centres or any identification <strong>and</strong>prescription at <strong>the</strong> drugstore• Patients overhear some providerscompla<strong>in</strong><strong>in</strong>g that <strong>the</strong> patients “lookshabby, dirty, like <strong>the</strong>y came straightfrom <strong>the</strong> garbage dump”• Some providers “do not like to servethose com<strong>in</strong>g from a different barangay,so what <strong>the</strong>y do is ask for barangayclearance to prove that you are with<strong>in</strong><strong>the</strong> health centre's area of responsibility”,which leads to hoard<strong>in</strong>g <strong>and</strong> waste ofavailable supplies• Some providers require proof ofmenstruation as assurance of nonpregnancyprior to method provision,especially IUD <strong>and</strong> tubal ligation:“They will ask you to swab a cotton ball<strong>and</strong> show it to <strong>the</strong>m”. For <strong>in</strong>jectables,“patients must do <strong>the</strong> pregnancy test,drop ur<strong>in</strong>e, <strong>in</strong> front of <strong>the</strong>m”. A womanwho did <strong>the</strong> test <strong>in</strong> <strong>the</strong> toilet was scolded.• “I saw a patient who was probablyat one month after childbirth <strong>and</strong> shewanted to have a method. A midwifetold her, ‘Just come back after your sixthmonth’. That's all she said”.• “I had a friend who was <strong>in</strong> a maternityhospital who told a young girl, ‘So whatdo you do now, <strong>the</strong>y won't let you gohome without an IUD’. The young girldid not want an IUD”.• “They do not cut <strong>the</strong> IUD str<strong>in</strong>gs after<strong>in</strong>sertion. They tell you to return forfollow-up so <strong>the</strong>y will cut <strong>the</strong> str<strong>in</strong>gs”.InequityInequities <strong>in</strong> <strong>the</strong> use of modern contraception to fulfill<strong>the</strong> dem<strong>and</strong> for family plann<strong>in</strong>g are less severe than <strong>the</strong><strong>in</strong>equities exhibited <strong>in</strong> maternal care, as exemplified by<strong>the</strong> use of skilled attendants at birth (see Figure 12). Forexample, <strong>in</strong> <strong>the</strong> 2008 NDHS, use of skilled attendantsby women <strong>in</strong> <strong>the</strong> richest qu<strong>in</strong>tile was 3.6 times <strong>the</strong> rateof use by those <strong>in</strong> <strong>the</strong> poorest qu<strong>in</strong>tile. In <strong>the</strong> use ofcontraceptives, however, <strong>the</strong> richest versus poorest ratiowas only 1.2. Urban women had 1.6 times higher use ofskilled attendants compared with rural women, but <strong>in</strong>311
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Family Pla
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ForewordThe Asia <
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Part 1Part 1Asia <
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Ensuring that <str
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of methods for all, in</str
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and undertake <str
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Report on the Regi
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SESSION 1: Changin
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that improving <st
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at a hospital would be offered post
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Bounkoung Phichit, Deputy M
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medicines
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Thus, while knowledge of modern met
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Hon. Mr. Malakai Tabar, Chairman, P
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curricula. If the
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dialogue as well as regional <stron
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BackgroundGlobal development effort
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TableTable1EventNational policyYear
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A third observation is that reporte
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TableTable2Current Contraceptive Pr
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Figure(-1.2), Cook Island</
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FigureTableTable3Trends in<
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Nam. Nearly all economies i
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2008 2009% Bilateral % Multilateral
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family planning wi
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IntroductionFamily
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The advent of the
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FigureFigure1Oceania and</s
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next 25 years, however, TFR fluctua
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FigureFigureFigure2Total fertility
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family planning pr
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esponsible for the
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that estimates of CPR for earlier p
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Figuremarried at an older age compa
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As previously mentioned most <stron
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FigureFigure945Relationship between
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The concept of “unmet need” has
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TableTable8Percentage of th
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TableTable9Percentage of reasons fo
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family planning pr
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As far as the supp
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Socio-cultural challenges tofamily
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likely to use contraception than yo
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15 Tests of statistical significanc
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of the South <stro
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104
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Figurewill exceed the</stro
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in urban (67%) tha
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ased service delivery poin<
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Most FWAs who were recruited two to
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are considered, unmet need for effe
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Households pay the
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Effective public-private partnershi
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ConclusionThe Bangladesh Fa
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the Family
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National Institute for Population R
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IndiaIndiaFamily <
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IntroductionThe use of contraceptiv
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TableTable2Indicators of tra<strong
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FigureFigureFigure1Contraceptive pr
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TableTable5Indicators of contracept
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TableTable6Adjusted odds ratios for
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FigureFigure3Contraceptive prevalen
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TableTable7Adjusted and</st
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the north
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TableTable10Differences between nor
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TableTable11 Total fertility rate <
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End Note1The first camp was success
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152
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154
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Figure1980s and ex
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health care and ed
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assistance from UNFPA and</
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in CPR. Likewise,
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International supp
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in development has
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__________ (2007). Population <stro
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170
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TableTable2What has the</st
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174
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per cent of women reported us<stron
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is provider bias that such methods
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TableTable7skewed distribution of h
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TableTable8TableTable9182
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that of the nation
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TableTable12 7some policies that ex
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The system guides the</stro
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FigureFigure4Total donor expenditur
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FigureFigureagain
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Impact of family plannin</s
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marketing of contr
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United States Agency for In
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200
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acceptable. From an NGO perspective
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FigureThis trend of limited donor f
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Figureto have the
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FigureFigure5Percentage change <str
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FigureFigure6Desire to limit childb
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coordination betwe
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the 1980s
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Policy Management.__________ (n.d.,
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218
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Population Activities (UNFPA) for a
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where family plannin</stron
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Thus an objective assessment of <st
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226
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Figureeconomic growth durin
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TableTable1TableTable2For spac<stro
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eflect a provider bias (e.g., <stro
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The Indonesian delegation was very
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than in ensur<stro
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in-country <strong
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(Ministry of Healt
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242
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244
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FigureTrends and p
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TableTable3Unmet need for contracep
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TableTable5TableTable6TableTable725
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TableTable8TableTable9Malaysia, abo
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previously mentioned is based on fo
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TableTable16births and</str
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FigureFigure3TRF54.5Scatter plots o
Page 270 and 271: ReferencesAng, Eng Suan (2007). Stu
Page 272 and 273: Demographic data sheet: population
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Page 276 and 277: NuptialityIn Myanmar nuptiality is
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Page 282 and 283: FigureIn Myanmar, out of six select
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Page 290 and 291: FigureHIV/AIDS. An HIV-positive wom
Page 292 and 293: National Population PolicyMyanmar i
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Page 300 and 301: Nay Pyi Taw, 26 October 2010.53 Sit
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Page 312 and 313: FigureFigureFigure3Use of modern co
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Page 348 and 349: includin</
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modern method and
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married or in unio
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Figureolder. Both the</stro
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TableTable15The immediate past Nati
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out that the “ne
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Commodity securitySupply cha<strong
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is able to achieve. In Papua New Gu
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Qualitative assessments by a number
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increasin<
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service delivery poin</stro
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Population: Views from Men
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1545-1730Day 2: December 9Session 2
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Day 3, December 10Session 50830-100
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15Mr. Tong Sithen1
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54Ms. Shadiya IbrahimAssistant Repr
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93Mr. Melkie AntonProject OfficerUn
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131Dr. John P. SkibiakDirectorRepro
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International <str
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