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PIP: Over 1 million people live on 8 small islands in the Eastern Caribbean: St. Kitts-Nevis, Montserrat, Grenada, St. Vincent, Antigua, Barbados, St. Lucia, and Dominica. Starting in 1985 the International Planned Parenthood Federation, Western Hemisphere Region has carried out a series of contraceptive prevalence surveys in these countries. Current information is provided by these surveys in the areas of fertility levels and preferences, contraceptive knowledge and use. Also, socioeconomic, historical and demographic background and analysis such as fertility patterns, desire for additional children, and breastfeeding data; contraceptive awareness including family planning methods and sources; contraceptive use by method, source, and timing, satisfaction, and male attitudes are provided in the surveys, but not in the report abstracted here. The total fertility rate (TFR) and the contraceptive prevalence rate (CPR) for the 8 islands are as follows: St. Kitts-Nevis (1984) 2.9 TFR, 40.6 CPR; St. Vincent (1988) 2.9 TFR, 58.3 CPR; Antigua (1988) 1.8 TFR, 52.6 CPR; Barbados (1988) not given, 55.0 CPR; St. Lucia (1988) 3.2 TFR, 47.3 CPR; Dominica (1987) 3.2 TFR, 49.8 CPR. The islands have unusual demographic patterns related to extensive out-migration.^ieng

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For 20 years, female sterilization has been increasing in popularity as a contraceptive method in Costa Rica. However, contraceptive sterilization has never been allowed explicitly under Costa Rican law. In 1976 the Costa Rican National Assembly instituted more stringent guidelines regarding medical sterilizations in order to eliminate contraceptive sterilizations, which had been occurring under relatively loose interpretations of national policy. Data from the 1976 National Fertility Survey and the 1981 Contraceptive Prevalence Survey indicate that the change in policy had only a short-term effect. Period sterilization rates fell substantially after 1976 but rebounded considerably by 1980, and the estimate of the proportion of married women who will ultimately be sterilized was approximately .5 for the periods both before and after 1976.

PIP: There has been a rapid decline in fertility in Costa Rica in the past 2 decades as a result of dramatic increases in the use of contraceptives, female sterilization being one of the most popular. The objection of certain groups to contraceptive sterilization was responsible for a change in procedures designed to eliminate sterilization for contraceptive purposes. However the enforcement of this policy has had little or no long term effect since medical versus contraceptive indications for the procedure cannot be defined precisely, and surgical sterilization for medical reasons is an important part of any modern health program for women. Other examples of government effort to eliminate access to certain forms of contraception or to reverse fertility declines, especially Eastern European countries such as limiting the availability of abortion, have had only very short-lived impact on birth rates. Romania provides the most striking example. In 1966, before stringent regulations in regard to abortion went into effect, the abortion ratio per 1000 live births was 3050; in 1967 it was 333, when abortion was legally limited to women over 45; or women having 4 or more children; or with specific medical indications. But the ratio increased to a level close to 1000 by 1972; abortions were being performed more frequently on the grounds of adverse mental health consequences, which were classified as a medical indication. The general conclusion from the cases cited in this paper is that once low fertility norms are widely accepted in a society that is accustomed to access to the effective contraception needed to fulfill those norms, the ability of a government to restrict access to certain methods of contraception is substantially limited. Studies of family planning in developing countries show that the task of initiating a fertility decline is very difficult as high fertility norms are deeply integrated into social systems and not easy to dislodge. However, once low fertility norms and associated behavior are firmly established, they are equally difficult to dislodge.

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PIP: The use of cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA) is explained and demonstrated in evaluating Third World family planning programs. CBA, which aids decisions on alternate uses of investment funds, e.g., family planning versus new schools, helped convince Third World governments to adopt family planning programs because of their economic value in overall development. CEA is a technique which can show which family planning delivery systems work best for the money expended as measured, e.g., by cost per acceptor, per "couple-year of protection" against the risk of pregnancy, or per birth averted. This is increasingly necessary in the 1980s as funds for family planning are being pinched in both developing and donor countries. At the same time it is estimated that annual expenditures on family planning in the Third World must rise from the current $1 billion to $64 billion by the year 2000 if this population is to be eventually stabilized. Following a general description of the 2 techniques, 9 case studies from Brazil, Colombia, Ghana, Haiti, India, Thailand, and Zaire are presented to demonstrate what cost-effectiveness analysis has revealed about such issues as integration of family planning with health services, use of paramedical staff and community-based distribution to promote contraceptive use, and important factors to include to ensure comparability of findings. Such studies have already aided family planning program decisions. Several ways that cost-effectiveness analysis can be improved in practice to make it most useful include: 1) all inputs must be included, 2) services and methods need to be evaluated, 3) cost per acceptor should be relied on less, 4) user characteristics must be taken into account, and 5) anticipating cost-effectiveness analysis, the data needed should be built into the project at the planning stage.^ieng

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