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This paper describes the efforts of Family Health International to develop a simple, standard and replicable methodology to estimate expenditures on family planning in developing countries. The study found that it is not possible, at least at this time, to develop such a methodology. Numerous problems were encountered in making expenditure estimates. First and most important, expenditure accounts are not always readily available. Even when these accounts are available, they may require some adjustments. In some instances, for example, the salaries of health workers who also provide family planning are in the health accounts, whereas in other cases the workers covered in the family planning accounts spend some of their time providing health services. Allocation variables then must be developed to separate spending on family planning from that on health. In some instances allocation variables were developed and used to separate family planning from health expenditures, but in this case allocation variables were not available and a cost analysis was performed. It is concluded that it takes considerable time and effort to estimate expenditures, and that the approach that was followed varied by country, reflecting the data available to make estimates.

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Concern about rapid growth in demand for reproductive health services in developing countries has created interest in productivity and costs of existing programmes. Staff costs usually constitute the largest share of total service costs, meriting special effort to ensure that they are measured accurately. Several techniques have been used in the literature to analyze staff activity, but these techniques have not been validated. This paper reports on a study conducted in three Ecuadoran clinics. The study uses an observational time-motion (TM) technique as a benchmark, and compares results from three other techniques to those obtained using TM. None of the alternative techniques produces estimates that agreed with TM estimates; deviations from TM are particularly large for non-contact time, defined as clinician activities carried out when clients are not present. Implications of these findings for productivity and cost studies are discussed, and possible avenues for future research are proposed.

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In order to determine the validity of infant mortality estimates based on retrospective reporting, the Honduran Ministry of Health carried out a follow-up survey of women interviewed in a 1987 national survey. Women were interviewed approximately 14 months after the baseline survey and were asked about the outcomes of their pregnancies and the survival status of their young children. The overall infant mortality rate calculated from the follow-up survey was lower than that obtained from the baseline survey, due to the particularly low rate among the group of women who were pregnant at the time of the baseline survey. Possible explanations for this low rate are discussed.

PIP: Indirect and direct methods may be used to estimate infant mortality rate (IMR). Respondents surveyed retrospectively about births, deaths, and corresponding dates often, however, omit or misreport vital events. Prospective studies virtually eliminate the potential for these types of errors. To test the validity of IMR estimates based upon retrospective reporting, this paper compares the former with estimates drawn from baseline survey data obtained 14 months prior. Baseline data came form 10,159 women ages 15-44, interviewed in 1987, by the Ministry of Health of Honduras. 1048 women were pregnant at baseline, and IMR was estimated to be 48/1000. The follow-up survey questioning pregnancy outcome and survival status of respondents' young children achieved a 74% response rate, and yielded an estimated IMR of 26/1000 for newborns. IMR estimated from follow-up data is probably unrealistically low given mortality trends and socioeconomic conditions in HOnduras. 3 sources of error potentially contributing to low IMR for the cohort of newborns are considered: pregnancy denial, unreported, and underreporting of pregnancies. Future studies should be conducted with more than 1048 pregnant women, baseline survey should be improved to better detect pregnancies, and regional and community studies should be considered in an effort to reduce study cost and boost response rates at follow-up.

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Data from the 1984 National Maternal-Child Health and Family Planning Survey in Honduras showed that one fifth (n = 711) of the children under five had experienced diarrhea on the day of the interview or the two days preceding the interview. The health care behaviors of the mothers of these children and the factors associated with these behaviors were the focus of this study. Only 22% of the mothers consulted medical personnel concerning the diarrhea episode; 74% treated their children with some type of medication while only 17% of the children received the recommended treatment, oral rehydration therapy. Most children were treated inappropriately, often receiving a combination of antibiotics, antidiarrheals and other drugs. Bivariate and multivariate analyses showed that the variables that most consistently predicted any and all three of the behaviors were the child's age and the severity of symptoms. Mothers of children two years and older were less likely to consult or use ORT than mothers of children 6-23 months of age. Mothers whose children's diarrhea had lasted three or more days or who were vomiting were usually twice as likely to consult, give any type of treatment, or give ORT than mothers whose children had diarrhea for fewer days or who were not vomiting.

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In 1984, the Honduran Family Planning Association launched a contraceptive social marketing program by introducing the oral contraceptive, Perla. This report examines the impact of the program on overall oral contraceptive use, use by particular subgroups, source of supply, and costs. Although use of oral contraceptives increased only slightly over the period 1984-87 (from 12.7 percent to 13.4 percent among women in union aged 15-44), the social marketing program significantly increased its share of the oral contraceptive market (from 7 percent in 1984 to 15 percent in 1987, and from 20 percent to 40 percent of sales at pharmacies). For the Honduran Family Planning Association to have realized cost savings as a result of clients switching from community-based distribution programs and commercial supply sources to contraceptive social marketing programs, the association would have had to reallocate its resources. Instead, the number of distributors in the community-based distribution program increased, while the amount of couple-years of protection from oral contraceptives decreased.

PIP: Researchers used data from 2 national surveys of maternal-child health and family planning (1984 and 1987) and from a 1989 study of economic costs by method and program to examine the impact of the contraceptive social marketing program of the Honduran Family Planning Association (ASHONPLAFA). ASHONPLAFA launched the program in 1984 by introducing the oral contraceptive (OC) Perla. Between 1984 and 1987, OC use increased minimally (12.7-13.4% among 15-44 year old women in union), yet the contraceptive social marketing program increased its share of the OC market (7-15% overall, 20-40% at pharmacies). The analysis showed that costs to ASHONPLAFA would fall if more women bought OCs from the contraceptive social marketing program instead of the community- based distribution (CBD) program, and if the resources earmarked to the CBD program in urban areas decreased. Yet, the number of distributors in the CBD program in urban areas actually increased, so ASHONPLAFA did not achieve cost savings. Further, the amount of couple-years of protection from OCs fell. The findings showed that market forces did not work and may not do so in like programs, where profit is not a goal and managers are not held accountable for cost increases. They also indicate that, in urban areas, the contraceptive social marketing program can serve more clients and the CBD program can be cut back. Further research is needed to examine whether and by how much ASHONPLAFA could reduce the CBD program without losing clients.

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This paper examines deliveries in a rural community of northeastern Brazil served by midwives who had received training that included the referral of pregnancies with complications; such training is essential to improve obstetrical care in rural areas of less developed countries. Data were collected on 1,661 women, of whom 62% gave birth in their homes and 38% in hospitals. The women referred to hospital were more likely to be primigravidas, to experience complications during labor, or to have had a stillbirth in the past. The parturients who were sent straight to hospital were more likely to have completed primary schooling or to have obtained prenatal care. The infant mortality rate was 32/1,000 births and the early neonatal mortality rate 14/1,000. For referred pregnancies these mortalities rose to 128 and 24, respectively. The factors significantly associated with perinatal mortality were advanced maternal age, the presence of prenatal pathology, abnormal presentation, complications in labor, and previous stillbirth. The low rate of perinatal mortality for young women and nulliparas and the disproportionally high number of nulliparas with deliveries in hospitals suggest that the midwives and health professionals providing prenatal care are aware of the problems associated with the first delivery and hence are providing prompt and appropriate care to these parturients. Family planning is recommended, especially for grand multiparas and older mothers. The early detection of abnormal presentation and the transfer of these women to surgical facilities should improve perinatal prognosis.

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While prevalence of vasectomy is low in Brazil, female sterilization is very high. The potential for growth of vasectomy services may be related to attitudes and practices of physicians. In 1984, 660 physicians at seven major hospitals in São Paulo were randomly selected from a total population of 2207 physicians in these hospitals. They were interviewed about their attitudes towards family planning in general, and specifically towards voluntary sterilization. A high degree of vasectomy among this medical community is indicated by its relatively high prevalence among married physicians and their spouses; about one in ten reported that either they or their spouse had had a vasectomy. Half of the physicians who perform sterilizations perform vasectomies: 22% of obstetricians and gynecologists, 85% of surgeons, and all urologists. In general, physicians would recommend vasectomy and tubal ligation equally often to their clients. Depending on the circumstances, up to 85% of all physicians recommend some sterilization procedure. Recommendation was modified by the type of procedure a physician performed, and by the patient's characteristics. Physician's recommendations of sterilization increased with age and parity of patient and was related to the health conditions and socioeconomic circumstances of the couple.

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In 1984 a prospective study of 1645 women and 1677 births in a rural community in north-eastern Brazil showed the infant mortality rate to be 65 per 1000 live births. Neonatal, post-neonatal and infant mortality are analysed to determine the most important risk factors for each period. Post-neonatal survival depends largely on factors relating to child care, while neonatal deaths are more likely to be associated with biological factors. The principal cause of death, diarrhoeal disease, was responsible for a third of the deaths.

PIP: In 1984 a prospective study of 1645 women and 1677 births in a rural community in north-eastern Brazil showed the infant mortality rate to be 65/1000 live births. Neonatal, post-neonatal and infant mortality are analyzed to determine the most important risk factors for each period. Data were obtained from all women in Trairi who gave birth between May 1984 and April 1985, and all mothers were followed-up on 4 occasions by hospital personnel or a TBA when the child reached 6 weeks and 6, 12, and 18 months of age. When an infant death occurred, community leaders and TBAs notified hospital personnel and a physician visited the mother, completing a questionnaire on the cause of death. Neonatal deaths were related to problems associated with pregnancy and low birthweight, factors associated with post-neonatal mortality are related to infants of younger women and of mothers of high parity. Low birthweight babies had an increased risk of post-neonatal death when mothers only had 1-3 prenatal visits; they were 14 times more likely to die during the post- neonatal period than those whose mothers had 4-5 visits and weighed 2500-4999 g. Infant mortality could be prevented by child survival interventions such as breastfeeding, oral rehydration therapy, and early diagnosis. Post-neonatal survival seems to depends on factors relating to child care, while neonatal deaths are more likely to be associated with biological factors. Diarrhea was responsible for 1/3 of all deaths.

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This paper presents data on the characteristics of oral contraceptive users in Honduras, obtained from a point-of-purchase survey conducted in pharmacies in 1986. The oral contraceptive Perla, provided by the Social Marketing Program, accounted for 42 percent of sales. Forty-five percent of those using Perla were considered "new" users; either they were purchasing contraceptives for the first time or had used only Perla. Almost half of those who switched to Perla previously had obtained their orals in the noncommercial sector. Brand substitution occurred among users of commercial brands at about the same rate as among Perla users (51 percent versus 55 percent). Most women switching contraceptives did so within two months of their last purchase.

PIP: A point-of-purchase study was conducted in pharmacies in Honduras in 1986 to determine characteristics of oral contraceptive users. The Social Marketing Program, which provides the contraceptive Perla, accounted for 42% of the sales. Of those using Perla, 45% were new users, either buying contraceptives for the 1st time or using only Perla. Of those who switched to Perla, half previously had obtained oral contraceptives in the noncommercial sector. Oral contraceptive users, of both Perla and commercial brands, substituted brands at about an equal rate. The study revealed that most women who switched types of oral contraceptives did so within 2 months of their last purchase.

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PIP: Over the July 1, 1983 through June 30, 1984 period, data were collected on all women admitted to a sample of Bolivian hospitals for treatment of complications associated with abortion to determine the sociodemographic characteristics of these women along with the proportion of abortions that were illegally induced. Data was collected on the patients' symptoms, the complications involved, the medical treatment provided and hospital resources used, the patients' patterns of contraceptive use and their subsequent contraceptive plans for 4371 women hospitalized for complications associated with pregnancy loss. 992 (23%) of the abortions were classified as illegally induced; 3379 (77%) were classified as spontaneous. Women with induced abortions were more likely to have a fever exceeding 38 degrees Centigrade, infection, traumatic lesions, and excessive blood loss and also were more likely to receive antibiotics and blood transfusions. Due to abortion-related complications, 20 women, 16 of whom had reported induced abortions, received a total hysterectomy. 15 of these 20 women were less than 30 years of age and 5 had no living children. 7 women died during their hospitalization. The case-fatality rate among the 992 patients classified as having induced abortions was 6/1000 compared to 0.3/000 among women classified as having spontaneous abortions. Only 7% of the study population reported using modern clinical contraceptive methods in the month prior to conception. In sum, the physical and psychological costs of abortion to some women were high as was the cost to hospitals of treating these women. The study results indicate an obvious need to improve the delivery of family planning services in Bolivia.^ieng

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This paper presents data on contraceptive use and fertility in Honduras obtained from a household survey conducted in 1984, and compares these data with similar information obtained from surveys carried out in 1981 and 1983. About half of the increase that has taken place in contraceptive use in Honduras is accounted for by sterilization. In 1981, 27 percent of women in union aged 15-49 years were practicing contraception; in 1984, the percentage of those 15-44 was 35 percent. The increase in urban areas was smaller (from 47 percent to 51 percent) than in rural areas (from 16 percent to 24 percent). Also, fertility remained almost unchanged in urban areas while declining in rural areas. Information from questions on place of purchase, price, and brand of contraceptive (for orals) was used to determine source of supply. The use of multiple questions to determine source results in a higher percentage of contraceptive use attributed to the Honduran Family Planning Association as compared with answers to a single question. The duration of breastfeeding in Honduras has increased, with the greatest changes occurring among women in urban areas and women with the highest levels of education. Efforts have been made to promote breastfeeding in urban areas and these results suggest that the efforts have been successful.

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PIP: Oral contraceptives have many advantages, but sometimes also have side effects which can cause users to switch appropriately or inappropriately to less effective methods or abandon contraception. In Brazil, 2/3 of married women of childbearing age were using contraception in 1981, and 1/2 of these were using orals. Contraceptive behavior following reported side effects in users of oral contraceptives in Southern Brazil is examined in this study, in relation to diverse factors. Among 2904 currently-married women, aged 15-44, almost 75% reported that they had used the pill at some time, and of these, 45.6% were still doing so. Data on perceived side effects were gathered for all women. There was no independent medical evaluation of the effects, so the data did not necessarily represent actual prevalence of pill related problems. Women who reported problems with the pill were less likely to be current users (25%) than women who did not (65%). However, overall contraceptive prevalence was about the same in both groups (66.2% and 67.0% respectively), indicating that women who stop using oral contraceptives usually switch to another method. However, they are more likely to be using traditional methods than women in the general population, especially if they want more children. Termination of pill use varies little according to the type of problem reported. Women with problems who sought medical attention were more likely to stop using the pill, and 82.4% of women advised to stop by their physician did so, but the major factor affecting discontinuation was the reported experience of a problem. The most frequently reported problems were headaches (38.1%), nausea (34.1%), nervousness (27.9%), and vertigo (18.3%). Physician intervention should help to avoid women's abandoning oral contraceptives unnecessarily.^ieng

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The purpose of this study was to examine the factors that affect approval for and completion of sterilization in Rio de Janeiro. Of 2,186 new female family planning clients, 1,256 requested sterilization and 925 were approved for surgery. Among the approved women, 639 scheduled surgery and, of these, 595 were sterilized within three months of approval. While approval is dependent mainly on demographic variables, especially age and parity, follow-through by a woman is related to her education and income. The steps that a woman must complete to obtain a sterilization also affect whether she ultimately undergoes surgery. Almost no women were scheduled for sterilization during their initial clinic visit. Women who were not scheduled because they lacked certain documentation were more likely to follow through than women who, in addition to lacking documentation, were asked to switch from an inefficient contraceptive method (or no method) to a more modern one. The lessons to be learned from this study provide useful information to programs in other countries that are concerned about maintaining high standards but do not want to discourage women in their efforts to be sterilized.

PIP: The purpose of this study was to examine the factors that affect approval for and completion of sterilization in Rio de Janeiro. Of 2186 new female family planning clients, 1256 requested sterilization and 925 were approved for surgery. Among the approved women, 639 scheduled surgery and, of these, 595 were sterilized within 3 months of approval. While approval is dependent mainly on demographic variables, especially age and parity, follow-through by a woman is related to her education and income. The steps that a woman must complete to obtain a sterilizaion also affect whether she ultimately undergoes surgery. Almost no women were scheduled for sterilization during their initial clinic visit. Women who were not scheduled because they lacked certain documentation were more likely to follow through than women who, in addition to lacking documentation, were asked to switch from an inefficient contraceptive method (or no method) to a more modern one. The lessons to be learned from this study provide useful information to programs in other countries that are concerned about maintaining high standards but do not want to discourage women in their efforts to be sterilized. Approval rates increased with age of the youngest child. Women whose last pregnancy ended in an abortion were more likely to be approved than were women whose last pregnancy ended in a delivery. The woman's motivation--as assessed by the timing of her decision to have a tubal ligation and whether she made previous attempts to have surgery--was not important in determining approval. The number of steps a woman had to complete to undergo sterilization was important in determing whether she, in fact, obtained the sterilization. More than 1/5 of the women said that they did not obtain the signature of their partners to indicate that they approved of the sterilization. In the follow-up interview, 8.2% of the women gave this as a reason for not having had the surgery. Sterilization programs in other countries should be reviewed to make sure that sterilization is not being limited to only the most perservering women.

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Information on the activities, practices and social context of pregnancy and delivery care provided by traditional birth attendants (TBA) is a critical requirement in planning, monitoring and evaluating maternal health programs in many countries. As a result of experimental studies in which such information was obtained by a variety of methods, and a review of alternative methodologies, a set of guidelines has been developed for the collection of such information. High-lighted are the need for good background knowledge on the local situation, involving TBAs themselves in design and collecting methods, a system of supervision to ensure adequate training and careful monitoring, and finally sharing the findings with the TBAs as well as with health officials.

PIP: Information on the activities, practices and social context of pregnancy and delivery care as provided by traditional birth attendants (TBA) is a critical requirement in planning, monitoring and evaluating maternal health programs in many countries. As a result of experimental studies in which information was obtained by a variety of methods, and a review of alternative methodologies, a set of guidelines has been developed for the collection of such information. The need for good background knowledge on the local situation, involving TBAs themselves in design and collecting methods, a system of supervision to ensure adequate training and careful monitoring, and finally sharing the findings with the TBAs as well as with, health officials are stressed. Early development efforts in Egypt and Brazil are described and the lessons learned are summarized. Some new data collection strategies currently in use are also discussed. It was found that TBAs, whether or not they are literate, can report information on several variables. Improvements made in the data collection instruments as a result of these projects assure better information on referrals and contraceptive intentions. Better study design helps to assure more complete reporting of cases. A number of guidelines evolved: good background information on the local situation should be obtained; TBAs should participate in development of a data collection system; an appropriate system of supervision should be set up adequate training and careful monitoring of data collection activities are essental; and study findings should be shared with health officials and TBAs.

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Between October 1980 and July 1981, 1,878 women were attended by traditional birth attendants (TBAs) at four obstetric units in rural areas surrounding the city of Fortaleza in Northeast Brazil. Of these women, 232 (12.4 per cent) were referred to a hospital in Fortaleza for delivery. The most important indicators for referral to hospital were: presence of an antenatal problem, complication of labor, or malpresentation. Based on record review, 65 referred women with none of these conditions were classified as low risk and 42 women not referred were classified as high risk (at least one such condition present). Of 1,878 deliveries, 32 (17 per 1,000) terminated as fetal deaths, and 12 infants died before discharge from hospital or obstetric unit (six per 1,000). The death rate was much higher for the high-risk cases (156 per 1,000 referrals, 95 for nonreferrals). Although some women may have been inappropriately referred while others who should have been were not referred, the system of referral has allowed TBAs to attend uncomplicated deliveries and to refer women with complications.

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This study presents information on cesarean section rates for the last baby born to 1,746 women in Northeast Brazil between January 1978 and the date of a 1980 household survey. For hospital deliveries, the c-section rate is 19 per cent. Rates were highest in the major urban areas and lowest in rural areas. Within residence categories, the section rate was related directly to education, early prenatal care, and delivery in private hospitals.

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In 1980, a study to determine interest in and access to sterilization for females was initiated at two Ministry of Health hospitals in Honduras. Results of the baseline study showed that 42 percent of women desiring sterilization from the Tegucigalpa hospital and 21 percent from the San Pedro Sula hospital had had a tubal ligation. A second study was conducted two years later, following up the interested but unsterilized women from the baseline study. Results show that 33 percent of women in the Tegucigalpa group, compared to 15 percent in the San Pedro Sula group, had been sterilized. Part of this difference can be attributed to an increase in sterilization facilities in Tegucigalpa over the two years after the baseline study was conducted. Among the major reasons women gave for not having been sterilized were financial and time constraints. Over the two-year period, the authors estimate that, of women interested in sterilization at delivery, 52 percent in total were sterilized in Tegucigalpa and 29 percent in San Pedro Sula.

PIP: In 1980, a study to determine interest in and access to sterilization for females was initiated at 2 Ministry of Health hospitals in Honduras. Results of the baseline study showed that 42% of women desiring sterilization from the Tegucigalpa hospital and 21% from San Pedro Sula hospital had had a tubal ligation. A 2nd study was conducted 2 years later, following up the interested but unsterilized women from the baseline study. Results show that 33% of women in the Tegucigalpa group, compared to 15% in the San Pedro Sula group, had been sterilized. Part of this difference can be attributed to an increase in sterilization facilities in Tegucigalpa over the 2 years after the baseline study was conducted. Among the reasons women gave for not having been sterilized were financial and time constraints. Over the 2-year period, the authors estimate that, of women interested in sterilization at delivery, 52% in total were sterilized in Tegucigalpa and 29% in San Pedro Sula. Results show that in Honduras as elsewhere in Latin America, obstacles to sterilization exist in the form of cost, travel time and family-related constraints. Institutional requirements and availability of facilities also creat barriers for clients. Fear of surgery was not a very important reason for not getting sterilized among women in the baseline study, only those who said they still wanted to be sterilized were interviewed for the 1982 study. The fees for sterilization are US$17.15 at Materno Infantil (or blood can be given instead) and US$10.0 at Leonardo Martinez and Centro Medico Quirurgico, but financial help is available for women who cannot pay. A new study will be carried out in Tegucigalpa to determine the impact of the various changes aimed at improving access to sterilization there. Programs to be studied include the availability of new facilities to provide postpartum sterilization at Materno Infantil and the provision of travel money and additional facilities that make it easier for a women to complete sterilization requirements at Centro Medico Quirurgico.

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Results of household surveys carried out in four states in the Northeast of Brazil showed that female sterilization is the most prevalent method among women who want no more children. Many women who indicated an interest in tubal ligation, however, had not been sterilized. Access to sterilization depends on the type of hospital in which the child was delivered and the type of delivery the woman had. Over 60% of the sterilized women reported that they had a tubal ligation at the time they were hospitalized for a cesarean delivery. Compared with unsterilized women, the sterilized women are characterized by relatively higher education levels and a greater likelihood of urban residence and were far more likely to have had cesarean deliveries and, therefore, to have qualified for postpartum sterilization on medical grounds.

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