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标题：Assessment of a New Approach to Family Planning Services in Rural Pakistan
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作者：Mehboob Sultan ; John G. Cleland ; Mohamed M. Ali 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2002
卷号：92
期号：7
页码：1168-1172
语种：English
出版社：American Public Health Association
摘要：Objectives. In 1993, the government of Pakistan started a new approach to the delivery of contraceptive services by training literate married women to provide doorstep advice and supplies in their own and neighboring communities. This report assesses whether this community-based approach is starting to have an impact on contraceptive use in rural areas. Methods. A clustered nationally representative survey was used to collect data on contraceptive use and access to services in each cluster. Two-level logistic regression was applied to assess the effects of service access, after potential confounders were taken into account. Results. Married women living within 5 km of 2 community-based workers were significantly more likely to be using a modern, reversible method of contraception than those with no access (odds ratio = 1.74; 95% confidence interval = 1.11, 2.71). Conclusions. After decades of failure, the managers of the family planning program have designed a way of presenting modern contraceptives that is appropriate to the conditions of rural Pakistan. The new community-based approach should be steadily expanded. (Am J Public Health. 2002;92:1168–1172) With 137 million inhabitants, Pakistan is the world's seventh most populous nation. According to United Nations projections, the population will grow to 285 million by 2050, at which time Pakistan will rank as the world's fourth largest country. 1 The main reason for this huge projected increase and the rise in relative ranking is the slow pace of fertility decline. The level of childbearing started to fall in the 1980s, from about 7 births per woman; for the period 1995 to 2000 it was estimated to be 5.0 births per woman, a value considerably higher than for other countries in the region (3.1 for India, 4.4 for Nepal, 3.1 for Bangladesh). 1, 2 Socioeconomic factors offer no obvious explanation for this divergence between Pakistan and its neighbors. For instance, the country is considerably richer and more urbanized than Nepal and Bangladesh, and levels of literacy and life expectancy are similar. 3 Furthermore, there is no evidence that Pakistani couples want particularly large families. The 1975 Pakistan Fertility Survey showed that, on average, married women wanted 4 children, a number typically found in Asian surveys at that time. 4 The most recent national survey (1996–1997) found that the average desired family size was 3.5 children. 5 It also confirmed the existence of a large unmet need for contraception: 38% of married women wanted no more children but were practicing no method of birth control. What distinguishes Pakistani couples most clearly from their neighbors is a reluctance or inability to translate reproductive preferences into appropriate behavior. The wide gap between preferences and practice stems partly from a prevailing (but erroneous) belief that Islam is opposed to contraception, and concerns about side effects and health hazards of modern methods. 6, 7 It also reflects the low political priority given to family planning for much of the last 30 years. In the 1960s, President Ayub Khan initiated a vigorous family planning program that was widely applauded as a model for other Islamic countries. However, it had serious design defects. It relied heavily on one method, the intrauterine device, and on financial incentives to clients and providers. It achieved little and was discredited when Ayub Khan fell from power. 8 For the next 20 years, first under the regime of Prime Minister Zulfiqar Ali Bhutto (1971–1977) and then under that of President Zia-ul-Haq (1977–1988), family planning was a low priority. During this period, several different approaches were tried, but implementation was poor and a sense of urgency was lacking. The reasons stemmed partly from domestic political considerations. Family planning was a low priority for Bhutto probably because it was so closely identified with his bitter political rival, Ayub Khan. Zia was reluctant to promote family planning vigorously because he drew much of his political support from conservative religious elements. 9 During his tenure, for instance, expenditure on family planning was sharply reduced and television advertising of family planning messages was banned. The political climate improved in the 1990s. Family planning has received steady support from successive regimes, and there have been several encouraging developments. Social marketing of contraceptives has expanded, and efforts are being made to involve private medical practitioners more closely in service provision. Perhaps the most promising initiative is the deployment of specially trained literate women to provide contraceptive information and basic services in their own and surrounding villages. A large body of international evidence shows that community-based initiatives are often effective at raising contraceptive use, 10, 11 and the results of small-scale projects in Pakistan have been positive. 12 This approach has worked particularly well in Bangladesh and is thought to be largely responsible for the unexpectedly large decline in fertility there. 13 In April 1992, a team of senior officials from the Ministry of Population Welfare, Pakistan's lead agency for family planning, visited Bangladesh. Later that year, a plan was announced to recruit and train 12 000 female village-based family planning workers by 1998. Recruitment criteria were specified. Family planning workers are married women aged 18 to 50, with at least 10 years of schooling, who currently reside in a rural area. Recruits are trained for 7 months; the training comprises 4 months of classroom instruction interspersed with field practice. Duties include the compilation of a register of local married women of reproductive age who should be visited at home at regular intervals. Workers are supplied with oral and injectable contraceptives and condoms for distribution, together with a range of medications for the treatment of sick children. For this work, staff receive a monthly salary of 1500 rupees, equivalent to about US $25. Supervision takes the form of monthly visits from female managers, who are provided with transport. Workers also visit district centers to collect supplies and salary. In 1994, the Ministry of Health launched a very similar but larger program involving female community-based health workers, called “lady health workers.” Recruitment criteria, training, remuneration, supervision, and method of service delivery are almost identical to those adopted by the Ministry of Population Welfare. While the main emphasis of the Ministry of Health program is on maternal and child health, the provision of family planning services is part of the package and lady health workers are supplied with oral contraceptives and condoms. The 2 ministries collaborated to minimize overlap in the placement of workers. By the end of 1996, about 5500 village-based family planning workers and 30 000 lady health workers had been trained and were operational. While the Ministry of Population Welfare program has been carefully monitored by several small-scale studies, which have documented practical problems of implementation 14, 15 but also encouraging signs of success in 4 Punjabi communities, 16 the Ministry of Health program remains unevaluated. This report assesses the impact of this new approach to the provision of family planning services in Pakistan. Specifically, we sought to determine whether or not use of modern reversible methods of contraception is higher in rural localities served by these community-based workers than in other localities. Attention was restricted to rural areas because the family planning workers, unlike the lady health workers, do not operate in towns and cities. The focus on reversible methods (thereby excluding sterilization) stemmed from the fact that many sterilizations preceded the start of the outreach programs. Moreover, the primary emphasis of the programs is on reversible rather than permanent methods.