The postpartum approach to family planning

uolume

113 May

American

Journal

number

1

1, 1972

Obstetrics and Gynecology

of

OBSTETRICS The postpartum approach to family planning Experiences in Thailand,

ALLAN

G.

SOMSAK Bangkok,

from 1966 to 1971

ROSENFIELD,

M.D.,

VARAKAMIN,

M.D.,

F.A.C.O.G. M.P.H.

Thailand

Thailand has had a postpartum program since 1966 in 4 large Bangkok hospitals and since 1969 in an additional 11 rural hospitals. The results have been dramatically successful, and a total of 99,434 women have accepted family planning services within 3 months of delivery or abortion, the majority accepting an intrauterine contraceptive device (IUD) or female sterilization prior to discharge from the hospital, usually on Days 2 to 4 post partum. There were more than 48,000 immediately postpartum acceptors of an IUD, which is thought to be the largest series of such cases reported in the literature. One hospital had over 66,000 IUD acceptors (direct and indirect) between 1965 and 1971 and continues to average more than 700 total new acceptors per month. Two rural Maternal and Child Health Centers have had over 70 per cent of obstetric patients to accept family planning services, the vast majority choosing either an IUD inserted prior to the discharge from the hospital or a female tubal ligation. The successes are primarily due to major efforts placed on motivation during the antenatal and postpartum periods. Based on the success of this program, it is recommended that the term “postpartum program” be abandoned in favor of the postpartum “concept,” in which family planning becomes a routine part of postpartum care, offered in all institutions providing maternity services. The fact that the majority of rural women in many parts of the world are delivered at home, supervised only by traditional personnel or relatives, means that the activities must be modified to meet this situation, which will have different requirements and needs from a hospital-based program.

From the National Family Planning Program, Ministry of Public Health, The Population Council. Received 1972.

for

publication

January

10,

f;;;pted

for publication

January

12,

Reprint requests: Dr. Allan G. Rosenfield, The Population Council, P.O. Box 2-75, Bangkok 2, Thailand.

and

T H E s E R 10 u s N E s s Of the population problem, as it faces most countries, has become increasingly apparent to key government and private leaders throughout the world, although the magnitude of the problem is not always appreciated. There are many concerned individuals, however, who feel that nothing short of massive efforts will

2

Rosenfield

and

May I, 1972 Am. J. Ohstet. Gyiwol.

Varakamin

bring about the required solutions in the near future. Increasing numbers of countries have now adopted national population-family planning policies and programs to begin to face the issue. While there are arguments as to whether family planning programs alone can bring the required solution+ 2 and many “beyond family planning” proposals have been made,3 it is safe to say that family planning programs must be an integral part of any attempt to lower birth rates. This report will describe one approach to family planning implementation, which has been most successful in Thailand and which has significant implications beyond the present activities. Family planning has only come of age in the past few years. Before that time, it was thanks to the efforts of a few pioneering and dedicated people in a variety of countries, dating back to the remarkable work of women like Margaret Sanger and many other brave colleagues, that any family planning work was done at all. These workers, against strong opposition, established family planning clinics and eventually private family planning associations. Their clinics simply offered services to those who were in need and already self-motivated. In time, they began motivational activities, usually aimed at all fertile married women, rather than at any specific target group. In 1965, Taylor4 recommended the postpartum period as a time when women should be most amenable to the practice of contraception. While, in retrospect, this should have been an obvious fact to most practicing obstetricians, it remained for a social scientist, Berelson, to launch the first large-scale study of this approach in 1966, when the Population Council initiated a project, called the International Postpartum Family Planning Program, at 26 hospitals in 19 cities in 15 countries.“-7 The cooperating hospitals provided special family planning information and education to women in both the antenatal clinics and the postpartum and postabortal wards and offered readily available contraceptive services. These services were generally offered prior to discharge from the

hospital and in the postpartum clinics. Initially, the intrauterine contraceptive device (IUD) was the primary method utilized, although hormonal contraception, female sterilization, and, in some cases, traditional methods were also offered. Funds were provided to hire additional personnel, where necessary, to give supplements to the salary of already overworked personnel, and to purchase necessary clinic equipment and supplies, including contraceptives. Special forms were created so that comparative evaluative studies could be carried out among the patricipating hospitals. In 1966, the Thai Government had not given official support to family planning. The population of the country at that time was approximately 30 million with a populas tion growth rate of over 3.0 per cent. While it wasavnt to a small number of leaders that this rate of growth was having serious adverse effects on over-all social and economic development, the official government position was one of caution; the problem needed further evaluation and study. Thus, when 4 large hospitals in Bangkok joined the International Postpartum Program, the clinics at these hospitals were among the first in Thailand to offer family planning services through an outpatient clinic service.

Materials and methods The 4 Bangkok hospitals became participants of this international project in March, 1966; Thailand was the only country in the study outside the United States with 4 participating hospitals from one city. Two of the hospitals (Chulalongkorn and Siriraj) were medical school teaching institutions; one (Women’s) was a large women’s hospital of the Ministry of Public Health; and one (Vajira) was a large general hospital of the Bangkok municipality. From the beginning of the project through June, 1971, care was provided for 353,832 obstetric and abortion patients (hereafter referred to simply as obstetric patients) in these 4 hospitals, an average of over 60,000 cases per year. During this period of time, there were increasing numbers of obstetric patients cared for each

Volume Number

113 1

year, as hospital obstetric care became increasingly more popular in the modern urbanized capital city of Thailand. Thus, in 1970, 72,247 obstetric patients were hospitalized at the 4 hospitals; the largest of the four, Women’s Hospital, cared for 24,293 patients. In 1969, the Thai postpartum program was expanded outside Bangkok to 10 rural hospitals of the Ministry of Public Health; eight were provincial hospitals of the Department of Medical Services, located in provincial capital cities or towns (most provincial ‘capitals are quite small, the second largest city in Thailand being only approximately 90,000 people) ; the other two were special Maternal and Child Health (MCH) centers (composed of a school for auxiliary midwives and a 60-80 bed maternity hospital) of the Department of Health, located in the provincial capital towns of Khon Kaen and Yala. In March, 1970, an additional new MCH center was opened in the capital of Rajburi Province and was added to the project. All of the hospitals in this expanded program are used by at least 1,400 obstetric patients per year. By the end of 1971, the 11 institutions had provided care for 112,420 women. Table I presents the number of total and obstetric beds in each of the hospitals, together with the number of deliveries and abortions for one year (1970). In all participating hospitals, special efforts were made to provide information, education, and motivation to pregnant and recently delivered or aborted women. Most of the hospitals stressed person-to-person contact, usually with the use of existing personnel or, in some cases, specially hired motivators. In some of the institutions, posters, tape recordings, and public address systems were utilized. Whenever possible, emphasis was placed on direct communication with every patient, particularly while in the postpartum (or postabortal) period. Intrauterine devices and female sterilization were offered to women in the immediate postpartum period in the hospitals as well as in the postpartum and other clinics. Because

Postpartum

approach

Table I. Participating program,

Thailand

Bangkok

planning

3

hospitals, postpartum (1970 data) Total beds

Hosgital

to family

Obstetric beds

Deli+ cries

Abortions

hospitals

Chulalongkorn Siriraj Vajira Women’s Subtotals

1,236 1,328 600 1,437 4,601

315 340 35 311 1,001

15,725 17,983 9,365 22,216 65,@9

1,242 1,860 1,779 2,077 6,958

80 80 50 210

80 80 50 210

4,504 2,182 1,459 8,145

153 98 19 270

330 333 350 293 602 475 450 250

41 50 45 40 50 48 75 33

3,247 2,500 -882 3.072 6;169 4,413 4,175 2,118

353 403 522 934 790 839 829 857

Subtotals

3,083

382

26,576

5,527

Grand totals

7.894

MCH

centers

Khon Kaen Rajburi Yala Subtotals Provincial

hospitals

Chantaburi Cholburi Khon Kaen Lamuang Nak&nrajasima Pitsanuloke Ubol Udorn

1.593 100.010 12.755

most Thai women breast-feed, since this practice is so important for the early nutrition of the infant, and because of possible interference with lactation by oral contraceptives, the pill is not offered to patients until at least 6 to 8 weeks post partum. In the international program, a new series of terms were created to provide some measure of the effectiveness of the program. All patients who were delivered or who received treatment for an abortion at a participating hospital and who accepted sterilization or contraception within 3 months were termed “direct acceptors,” the implication being that the women accepted, at least in part, as a result of the informational and motivational efforts of the hospital staff. Although there are, in many cases, other governmental family planning staff and clinics in the cities and provinces in which the postpartum program hospitals are located, acceptors are counted as direct acceptors only if they accept at the same hospital in which they were delivered or where they aborted. The motivational

4

Rosenfield and Varakamin

activities of these other personnel were not thought to have played a significant role in referring postpartum patients back to the hospitals since services can be provided at the local clinics. A further breakdown of direct acceptors was described : “Immediate direct acceptors” was used for those women who accepted (primarily an IUD or sterilization) prior to their dis+arge from the hospital, and “delayed direct acceptors” indicated women who accepted after discharge but within 3 months of the delivery or abortion. All other acceptors were termed “indirect acceptors.” In this latter group, some women may have been informed of the services indirectly through friends or relatives who were obstetric patients. It is possible that the 3 month cutoff is somewhat arbitrary, since some women motivated in the hospital may have accepted beyond the 3 month cutoff date, but it does not really seriously affect the over-all results. In 1970, the Population Council, in conjunction with selected participating hospitals, conducted a follow-up survey of acceptors in the international program, with the use of the same questionnaire in each country, so that comparisons could be made.8 Because of the volume of acceptors and the duration of their programs, 4 Bangkok hospitals, which had participated since the beginning of the program, were chosen for the study, allowing for 36 or 48 month continuation rate calculations. In addition, two of the ten hospitals in the expanded program were chosen for the sample with the use of probabilities proportionate to the numbers of acceptors between March 1, 1969, and September 30, 1969. At the Bangkok institutions, a systematic sampling fraction was set, with those accepting before September 30, 1968, being sampled more heavily than those accepting between September 30, 1968, and September 30, 1969, the cutoff point for the study. At the other 2 hospitals chosen for the study, Khon Kaen MCH Center and the Cholburi Provincial Hospital, acceptors were selected for follow-up with the use of varying, nonintegral sampling fractions. At these latter

two hospitals, only 12 month continuation rates were possible. Adjustments were made for nonresponses, and the “interview values were inflated by the reciprocals of the selection probabilities.“* Home visits were made to those who did not respond to a letter which requested them to return to a central point to be interviewed. For those patients not located, the patient record card was used if the acceptor had returned for postacceptance visits. For purposes of convenience and practicality, the sample chosen was limited to acceptors from previously established geographic boundaries, and all acceptors from outside these boundaries were excluded from the follow-up study. A total of 2,650 women were scheduled for interview in Thailand, ranging from 886 acceptors at the largest hospital to 156 at the smallest. The data collected in the international follow-up survey were analyzed with the use of the life-table technique. Two measures of the length of time that women continued to use contraception were used.* In the first, “first-method” continuation rates were analyzed. Thus, the patient was using the original method at the time of the interview, she had become pregnant while using it, she had stopped and was not pregnant, or she had stopped and had become pregnant subsequently. The second system of measurement was called “all-contraception” continuation rates, which simply refers to the present use of any method of contraception (the first one or any subsequent one), and continuation rates were then calculated with the same type of breakdown as above (still using a method, pregnant while using, not using and not pregnant, and not using and subsequently pregnant). Results Of the 199,837 acceptors of family planning services at the 15 Thai hospitals participating in the international program by the end of November, 1971, approximately half were direct acceptors, the majority of “For national

fur-thrr follow-up

details study,

of the methodology see Reference 8.

of

Volume 113 Number 1

Postpartum

Table II. Obstetric through

November

case load and direct 30, 1971

acceptors,

Obstetric (including

Hospital Bangkok hospitals Chulalongkorn Siriraj Vajira Women’s

*Direct

Percentage accepting before discharge (immediate acceptors) (%)

19,976 13,812 9,096 20,183

294 203 134 297

95 73 79 71

339,384

5,726

63,067

928

80

12,803

388

6,552

196

75

3/70 3/69

3/69 4/69 4/69 3/69 3,‘69 5/69 4/69 3/69

totals

III).

Total

Average/ month

6,223 4,220

296 128

4,089 3,372

195 102

;3

23,246

812

14,013

493

83

9,982 9,601 4,099 10,930 19,324 13,892 13,038 8,308

302 300 128 331 586 448 407 252

2,928 3,432 1,468 3,067 4,805 3,041 2,301 1,312

89 107 46 93 146 98 72 40

76 96 95 91 64 75 94 93

-

89,174

2,754

22,354

691

82

-

451,804

9,292

99,434

2,112

81

acceptors = all patients who accept within

(Table

acceptors*

1,285 1,508 906 2,027

Average/ month

3 months after delivery

whom (81 per cent) were classified as immediate direct acceptors, receiving an IUD insertion or sterilization prior to discharge from the hospital (Table II). Chulalongkorn Hospital and Women’s Hospital reported the highest number of direct acceptors, averaging close to 300 per month, followed by Siriraj Hospital and 2 of the MCH centers (Khon Kaen and Rajburi) which averaged approximately 200 per month. At the 15 hospitals there have been over 48,000 immediate direct acceptors of intrauterine devices, with insertion taking place most frequently on the second to fourth day post partum. A basis for comparison among these hospitals of varying sizes is attempted by calculating 2 ratios, both with the use of the total number of obstetric and abortion cases as a denominator

Direct

87,393 102,557 61,583 137,851

Subtotals Grand

cases abortions)

The

numerator

5

Thailand,

4/66 4/66 4/66 4/66

Subtotals Provincial hospitals Chantaburi Cholburi Khon Kaen Lampang Nakorn-Rajasima Pitsanuloke Ubol Udorn

program,

planning

Total

3/69

Rajburi Yala

to family

Date Program started

Subtotals MCH centers Khon Kaen

postpartum

approach

or an abortion.

in the first instance is the total number of direct acceptors, and, in the second, it is the number of immediate direct acceptors. While the 4 Bangkok hospitals have recruited an average of 16 per cent of all obstetric patients as family planning acceptors (with a high of 22 per cent and a low of 13 per cent) since 1966 and the 8 provincial hospitals have had an average of 22 per cent since 1969, ranging from 12 to 34 per cent, the 3 MCH centers have recruited 56 per cent, with two of the three actually recruiting over 74 per cent. During 1969, at Yala MCH Center, a record of 85 per cent of all obstetric patients accepted sterilization or contraception, the highest figure yet recorded in the international study. At all the participating hospitals, a majority of the direct acceptors were immediate direct ac-

6

Rosenfield

and

May 1, 1972 .4m. J. Ohstet. Gynecol.

Varakamin

Table III. Ratios of acceptors

to obstetric and abortion case loads, postpartum program, Thailand Direct acceptors

Immediate acceptors

Obstetric and abortion ca$e load

Obstetric and abortion case load

Hospital

1971 (%)

All years (%I

1971 (%I

All years (%)

Bangkok hospitals Chulalongkorn Siriraj Vajira Women’s

26 15 13 17

22 13 15 14

25 10 9 13

21 10 lo 10

Subtotals

18

I6

14

13

62 61 82

49 68 81

40 60 63

38 67 64

MCH centers Khon Kaen Rajburi Yala Subtotals

65

59

51

49

Provincial hospitals Chantaburi Cholburi Khon Kaen LamPaw Nakornrajasima Pitsanuloke Ubol Udorn

32 37 37 30 28 22 23 19

29 36 35 27 24 22 16 15

31 36 34 30 15 17 22 17

20 34 33 24 15 16 15 14

Subtotals

27

24

23

20

25

19

20

15

Grand

totals

ceptors, with Rajburi MCH Center as the leader with 76 per cent of obstetric patients accepting prior to discharge from the hospital, with over half of them accepting female sterilization. The great majority of acceptors (68 per cent) in this program chose the IUD (Lippes loop), with female sterilization ( 16 per cent) and oral contraception (14 per cent) accounting for most of the remainder (Table IV). Only 1 per cent accepted injection (medroxyprogesterone acetate) in research studies at the 2 medical school hospitals, and 1 per cent chose other methods. In only 1 hospital (Siriraj) did oral contraceptive acceptors approach IUD acceptors, with approximately equal numbers of patients accepting each method, One hospital, Chula-

longkorn, has had over 66,000 new IUD acceptors, from the opening of their family planning clinic in 1965 (about 6 months prior to joining the international program), to the end of 1971 (including 11,929 acceptors in an active mobile clinic established in 1967) .s The age and parity of acceptors in the over-all Thai postpartum program revealed a median age of 28.0 with 62 per cent under the age of 30 and a median of 3.2 living children, with 55 per cent having had 3 or less children. Over 30 per cent of the acceptors were actually under age 25, and over 35 per cent had 1 or 2 children. Most women accepted because they did not want further children, although 24 per cent accepted for purposes of spacing. Surprisingly, there was no difference between IUD and pill acceptors, with slightly over 60 per cent of women in both groups accepting for purposes of limitation. The majority of acceptors had 4 years or less of basic education and, in the 11 hospital expanded program, close to 90 per cent of the women resided in areas classified as rural. Two of the MCH centers which have had great success in recruiting high percentages of obstetric patients had acceptors younger and of lower parity than those in the overall Thai program, with many more women accepting for purposes of spacing. An analysis of all acceptors at these 2 centers in January, 1971, revealed that 72 per cent were less than 30 years of age, 46 per cent were less than 25, and 15 per cent were less than 20. The majority of the acceptors at these 2 centers (75 per cent) stated that they wanted more children later. At the third MCH center, by comparison, 56 per cent were less than age 30, 26 per cent were less than age 25, and 1 per cent were less than age 20, and only 19 per cent stated that they wanted more children. Of the 2,650 women scheduled for interview, 1,590 were located and interviewed. An additional 716 women had made postacceptance visits to the clinic, allowing for calculations up to the time of the last visit. Table V presents the IUD continuation-rate

Volume Number

113 1

Postpartum

Table IV, Total program,

Thailand, Total

acceptors (direct 1966 through No.

and indirect), 197 1

IUD

by method

Pill

approach

to family

planning

7

and year, postpartum

Injection

Sterilization

Other

of

acceptors

Year

%

No.

%

No.

15,807 20,369 20,066 35,824 48,835 58,936

12,379 14,994 12,434 23,762 32,219 33,756

78 74 62 66 66 57

836 2,008 3,528 6,189 7,525 13,889

5 10 18 17 15 24

2,573 3,251 3,361 4,803 8,057 10,448

16 16 17 13 17 18

199,837

129,544

65

33,975

17

32,493

16

1966 1967 1968 1969 1970 1971* Totals *11 months

No.

1

)

1

%

No.

1

387 447 766 708

No.

1 1 2 1

2,208

1

19 116 456 623 268 135

1

% 1 2 2 1 -

1,617

1

only.

Table V. IUD continuation rates (“first method” and “all contraception”), hospital and by numbers of month of use, postpartum program, Thailand “First method” (months) Hospital Chulalongkorn Siriraj Vajira Women’s Khon Kaen (MCH Cholburi (provincial All

*- =

%

Less than

12

center) hospital)

82 87 73 76 90 80 79

1

24 70 76 58 55 65

1

36

by

“All ]

61 59 45 41 -

48

12

55

85 95 80 83 90 86 85

I* 47

55

contraception” (months) 1

24

/

36

74 80 66 69 73_

1

67 66 52 54 62

48 61 54

100 women.

calculations (“first-method” and “all-contraception”) for the 6 hospitals that participated in the follow-up study. The combined “firstmethod” continuation rates for all the hospitals in the study were 79 per cent at 12 months, 65 per cent at 24 months, and 47 per cent at 48 months. With the use of the “all-contraception” measure, the rates were 85, 72, and 54 per cent, respectively. The highest “first-method” rates were noted at the Khon Kaen MCH Center (90 per cent at 12 months) and Siriraj Hospital (87 per cent at 12 months and 76 per cent at 24 months). Because of the relatively small number of oral contraceptive users, the pill continuation rates were not calculated for each individual hospital but rather for all hospitals combined and revealed a ‘Yirstmethod” rate of 72 per cent at 12 months and 53 per cent at 24 months and “allcontraception” continuation rates of 77 per cent at 12 months and 59 per cent at 24 months. Continuation rates for the combined hos-

Table VI. Twelve-month

continuation rates of living children and by method, program, Thailand

by number postpartum No.

of

living 1 2 3 4 5 6+

children

1 IUD 65 76 77 83 84 88

1

Pill 63 71 70 89 93 85

pitals were cross tabulated by the number of living children for both methods of contraception and revealed that the rates increased in direct relation to the number of children (Table VI). A similar trend was noted when the calculations were related to the age of the acceptor, although in the international study these calculations were carried out by region rather than by country. The reasons for discontinuation of the IUD are shown in Table VII for the 4 Bangkok hospitals and the 2 hospitals outside Bangkok. Closure rate because of expul-

8 Rosenfield and Varakamin

Table VII. Reasons for discontinuation of months

of use, postpartum

program,

of IUD Thailand

by type of hospital

and by number

Reason Institution

Four Bangkok hospitals

Hospitals outside Bangkok

-

12 24 36 48

1.4 2.3 2.8 2.8

7.6 11.0 13.4 15.2

7.1 11.6 15.9 18.2

3.4 6.6 8.0 8.6

No need 0.3 0.8 1.3 1.3

Planned pregnancy 1.2 2.4 3.8 6.9

12

0.0

6.0

2.0

7.2

0.0

1.6

Month

Unplanned pregnancy

Expulsion

sion at the end of 12 months was 7.6 in Bangkok and 6.0 outside Bangkok, with the Bangkok rate, at the end of 48 months, rising to 15.2. The actual expulsion rates were higher than the closure rates for expulsion because many of the patients who expelled the loop had reinsertion. At the Chulalongkorn clinic, for example, of the first 9,026 cases of known expulsion, over 80 per cent underwent reinsertion.s When the IUD was first inserted in the immediate postpartum period, the expulsion rates, which were in the range of 30, were felt to be unacceptably high. y, lo It was theorized that with the use of the standard short inserter the IUD was being placed in the dilated lower uterine segment and was then expelled in a large percentage of cases as the uterus involuted. The Population Council, together with the manufacturer, then developed a long inserter which allowed the IUD to be placed high in the fundus, with the use of a Size D loop with a special long tail. As experience was gained with immediate postpartum insertion and with the use of the longer inserter, the expulsion rate fell to approximately 14 to 15, only slightly higher than the rates when insertion occurs 6 or more weeks post partum. In addition, no increase was noted in the incidence of perforation or infection, 2 major concerns when immediate insertion was first proposed in Thailand. The expulsion rates remain unacceptably high when insertion is attempted on the day of delivery; Days 2 to 4 post partum are recommended as the most appropriate time for immediate postpartum insertion. The 12 month unplanned pregnancy rate

Side effect

Personal

Totals

21.2 35.1 45.5 53.6 17.0

at the Bangkok hospitals was 1.4, rising at 48 months to 2.8. There were no pregnancies at 12 months in the other 2 hospitals. Side effects and personal reasons (inconvenience, husband objection, fear, etc.) were the other major causes of discontinuation, with more women at the Bangkok hospitals discontinuing because of side effects than because of the oppersonal reasons. Outside Bangkok, posite occurred, with no ready explanation for this difference. Relatively few discontinued use because of no need (widowed, divorced, etc.) or because of a planned pregnancy. While the table does not differentiate between immediate IUD acceptors and all other IUD acceptors, the expulsion rates are slightly higher for the immediate group and, because the acceptors are somewhat younger and of lower parity in the immediate group, more discontinue for purposes of having additional children. Comment

The postpartum program in Thailand has been remarkably successful. It started at a time when the Government had not given official sanction to family planning activities, and the 4 Bangkok hospitals were among the very few places, other than a private doctor’s office, where family planning services could be obtained. The interest shown in those early years has been sustained, and each of the 4 original Bangkok hospitals continues to be among the leaders in family planning in Thailand, even though new clinics have now been opened throughout the country. Chulalongkorn Hospital appears to be the world’s leader in terms of the total number of IUD

Volume Number

113 1

insertions, with over 66,000 new IUD acceptors since 1965. During the early years of this remarkable clinic, acceptors came from 66 of Thailand’s 71 provinces simply through word-of-mouth spread of information, since public informational activities about family planning were not allowed by the Thai Government at that time.ll Thailand has provided a surprisingly large percentage of all acceptors in the International Postpartum Program, both in the early years when there were 4 participating hospitals and more recently with 15 hospitals. Of the 218,000 acceptors from 62 clinics in 11 countries in Southeast Asia, West Asia, and Latin America who constituted the universe for the international comparative follow-up survey, * Thailand with 81,279 acceptors accounted for over 37 per cent of the total. During the year 1970, there were 164,226 new acceptors in 119 participating hospitals in the over-all international program7; Thailand, with only 15 hospitals, accounted for 48,832 new acceptors, over 30 per cent of the year’s total. The volume of obstetric and abortion cases in Thailand, however, has been high, and the percentage of these patients who have accepted family planning services ( 19 per cent) is approximately equal to the percentage noted in the worldwide program, although the over-all Thai figure had risen in 1971 to 25 per cent. The program in Thailand has been primarily an IUD program with a large number of insertions in the immediate postpartum period. In the international program, Thailand has accounted for over 70 per cent of all immediate postpartum acceptors, and the more than 48,000 cases by the end of 197 1 is thought to be the largest series of such cases yet reported. The procedure has proved both safe and effective, with no increase in the incidence of infection or of perforation and with expulsion rates which, with experience and the use of a longer inserter, are only slightly higher than in regular cases. As has been noted in the over-all international postpartum program,‘? 8 acceptors in the Thai postpartum hospitals are younger

Postpartum

approach

to family

planning

9

and are of lower parity than is the case in most other family planning programs. Reports from national programs in Korea, Taiwan, Hong Kong, Tunisia, and the Punjab in India, for example, show a median age at acceptance of between 31 and 34 years6 In the Thai program, on the other hand, the median age was 28.0 with 62 per cent of all acceptors being less than 30 years of age. While many of the women of parity 1 and 2 accepted for purposes of spacing, the great majority of acceptors with 3 or more children stated that they did not want any more children. The activities at the 4 original Bangkok hospitals provided contraceptive services to approximately 5 per cent of all married fertile women between the ages of 15 and 45 in Bangkok during the first 2 years of activities,6 a figure which rose to approximately 12 per cent by the end of 1970. But, of even greater importance has been the visibility of this program to government leaders and politicians, as well as to the medical profession. It was most appropriate that successful family planning programs should be developed first at 2 prestigious Thai medical schools and at the largest hospital of the Ministry of Public Health. Family planning activities thus received moral sanction because of the reputations of the hospitals and physicians involved. The hospitals have played an important role in national family planning training activities. Between 1968 and 1970, more than 300 doctors and 700 nurses of the Ministry of Public Health received family planning training in Bangkok. The doctors from the 4 Bangkok “postpartum” hospitals (only one of which belonged to the Ministry of Public Health) assisted by giving lectures in the didactic part of the course, and their hospital clinics were used for practical clinical training. More recently, the MCH centers and the provincial hospitals began providing inservice training in the field of family planning for personnel from their respective departments in the Ministry. The cost of the program per family planning acceptor has varied from $1.00 to

10

Rosenfield

and

Varakamin

slightly over $3.00 (United States currency), depending on the hospital. Even the higher figure is lower than reported costs of many family planning programs.12 The total cost per acceptor would be slightly higher if indirect costs (costs incurred through the use of existing personnel and facilities) were included in the calculations. The programs at some of the provincial hospitals and MCH centers since the programs were initiated in 1969 have been quite impressive. The high percentages of obstetric patients accepting family planning services, primarily in the immediate postpartum period, are unique in the international program. The newest institution in the program, Rajburi MCH Center, recently set another new record when, in 1970, close to 45 per cent of all women delivered in that institution underwent tubal ligation. The successes of the 3 MCH centers are such that it is worth attempting to describe their activities in detail. Prior to the onset of the expanded program, the Director of the MCH Division held training courses at each of the 3 centers, attended by all hospital personnel working in the clinics, delivery room, and wards. Doctors from the original Bangkok hospitals assisted in the training, which was conducted in the evenings for 3 successive nights (this time being chosen as the time at which the largest numbers of hospital personnel could attend). The course included the basics of population dynamics, stressing the effects of the population problem on health and on general social and economic development in Thailand. The methods of family planning to be used in the program were described in some detail, with emphasis placed on female sterilization and the IUD. Finally, particular attention was paid to motivational activities. The Director of the MCH Division made it perfectly clear to all personnel that he gave this project high priority and that he expected all hospital personnel to participate. While in the Bangkok programs and in programs in other countries some of the funds were to be used to employ additional personnel to work in this program, this was

May 1, 1972 Am. J. Obstet. Gynecol.

felt to be impractical if the program was to have reproducibility throughout the country. Therefore, in the expanded program in Thailand, the concept of utilization of existing personnel to do the work without the employment of separate personnel was tried. To compensate for the extra workload, a small monthly supplement was provided. Because of the record keeping requested by the Council, it was agreed to employ one clerk to keep the special records required for the research activities. It was felt that if all existing personnel took part in the motivational activities as a part of their regular work no special motivators would be needed. The doctors were encouraged to make time available to do immediate IUD insertions every day. Outpatient family planning clinics were run anywhere from 1 to 5 days per week, depending on the hospital and the volume of acceptors. In some cases, the opening of the family planning clinics several days per week did cause hardship for the hospital and required some shifting of personnel from other activities to staff these clinics. At the MCH centers, patients received information concerning family planning in the antenatal clinics from the nurse/midwives and from the auxiliary midwife students, with each patient receiving individual attention at least one time. Upon admission to the labor room in early labor, the patient was again provided with information concerning the family planning services available in the hospital and the benefits to be gained by the patient in planning her family. Finally, and most important, all hospital personnel involved with postpartum care on the wards made particular efforts to talk about family planning with the patients. While it might appear that such intensive informational activities would attract some patients with minimal motivation, who would therefore be more likely to discontinue, the IUD continuation rate data from the Khon Kaen MCH Center, which at 12 months was 90 per cent, the highest in Thailand, would strongly suggest that this was not the case. That the continuation rates are high may be related to the well-coordinated follow-up

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activities of these centers. Each center has several public health nurses assigned who do home visiting for MCH and family planning, often accompanied by the auxiliary midwifery students. Most acceptors living within the confines of the province in which the center is located, with the exception of a few truly remote areas, are visited at home at least once at 2 weeks post acceptance and again at 3 months. The women are also requested to return to the clinic for a checkup at 1 and 6 months. It is suggested that the unusual attention paid to patients at these centers has been well worth the effort in terms of rate of acceptance and continuation. It is fair to say that the 3 MCH centers are not only among the most successful family planning clinics in the international postpartum program but can be compared favorably to the best family planning clinics of any program yet reported. The Population Council, in comparing the effectiveness of various family planning programs, has divided the total number of acceptors by the number of obstetric cases of a given hospital. While it does not seem appropriate to the authors to relate indirect acceptors to the obstetric case load, the MCH centers and one provincial hospital have most dramatic percentages. These hospitals average over 100 per cent, i.e., they have more family planning acceptors than obstetric cases. For the 4 Bangkok hospitals, this percentage is about 33 per cent, and, for the 8 provincial hospitals, it is approximately 50 per cent. What is particularly unusual is that these centers have been successful in providing both obstetric care and family planning services, almost as soon as they have been opened. Outside of Bangkok, approximately 85 per cent of all women in Thailand are delivered of their babies at home without trained personnel in attendance, in fact, without ever having seen trained health personnel. Most of these deliveries are conducted by traditional personnel or by relatives. Of the 84 Thai provincial hospitals, only 8 had more than 1,000 deliveries performed in 1969, the first year of the expanded program.

Postpartum

approach

to family planning

11

Many physicians and social scientists, in explaining this phenomenon, suggested that rural Thai women preferred, as part of the cultural pattern, to be delivered at home. these new centers were And yet, when opened, offering delivery services in clean surroundings to rural women, at very low cost, women came in large numbers. During 1969, its first year of operation, the Khon Kaen MCH Center became one of the three largest obstetric units outside of Bangkok. And, by 1970, it had the second largest number of family planning acceptors in Thailand (averaging almost 500 new acceptors per month), second only to the Chulalongkom Hospital in Bangkok, although there were approximately a fourth as many deliveries as any of the 4 large Bangkok hospitals. The

future

The successes of the MCH centers in Thailand provide a model and a rationale for a more rapid expansion of MCH services as a means of improving both maternal and child care and family planning. Taylor and Berelson13 have recently published an exhaustive feasability study in several countries entitled “Comprehensive Family Planning Based on Maternal/Child Health Services” and have estimated the probable costs of making a major effort at the improvement of MCH services throughout the world, While these costs are high, in the long run this may prove the strongest footing for family planning and, at the same time, provide a much needed health service. The activities in Thailand provide support for this concept, particularly if the services of these MCH centers can be duplicated on a smaller scale in even more rural settings. Such a plan has recently been prepared, and a pilot study in which small MCH subcenters, attached to existing health facilities, will be developed, along with an improvement in the definition of the role of the auxiliary midwife and the development of effective supervisory capabilities. One serious problem that presents itself as attempts are made to expand the postpartum concept relates to the shortages of medical

12

Rosenfield

and

Varakamin

personnel. Even in the large hospitals taking part in this program, physicians, who arc usually hard-pressed for time, are required to spend a great deal of time doing IUD insertions. More important, as the activities spread to rural areas, there are critical shortthat exists in ages of doctors, a situation countries throughout the world. A recent paper-l4 presents the rationale for the use of paramedical personnel to insert IUD’s and to prescribe oral contraceptives. The conclusion, based on a review of the world’s literature on the subject and on personal experience, is that it is indeed safe to use paramedical personnel for these purposes. It is even suggested that paramedical personnel doing the work full time will often do a better job than medical personnel doing it part time. We suggest that if we are to reach the majority of women in need we must expand the roIe of nurses, auxiliary midwives, and other health personnel. This is true not only in rural areas where doctors are in such short supply but also in large hospitals, where the physician’s time would be better spent on more pressing clinical problems. An obvious conclusion that can be drawn about the postpartum program, we believe, is that there actually need not be a “postas such; rather, the sucpartum program” cess of the postpartum come@ should be publicized as widely as possible. The lesson learned is simply that women are particularly easily motivated concerning family planning during and after pregnancy and that efforts should be aimed at that period of time, whether patients are delivered in the hospital or in the home. Even in the more general national family planning activities of the Thai Ministry of Public Health, in which no special postpartum approach is used, over 60 per cent of all acceptances occur within 6 months of the last delivery or abortion.15 All hospitals in which deliveries take place and in which family planning services are to be provided, because of either national policy or interest of the hospital, should utilize the postpartum approach. Discussion about family planning should become routine

in the antenatal clinics and on the wards, as proper nutrition and care of the newborn infant are routine at the present. The day should come, in the not too distant future, when family planning practice post partum is as normal a procedure as the immunization of children. As suggested by Wolfers,lG we should, in the future, give contraceptive prescriptions routinely to all postpartum women and then talk about what percentage of patients have not accepted services post partum. It is not anticipated that hospital dehvery will apply for the majority of women in developing countries for many years to come, no matter what type of accelerated MCH program is developed. But that does not mean that the lessons learned in postpartum programs cannot be applied immediately. Existing health personnel and family planning field workers should focus their attention first on pregnant and recently delivered women. There are relatively easy ways of obtaining the names of these women, from the village head man, village volunteers, district segistration offices, etc., depending upon the country concerned. While others have advocated approaching all eligible women or special groups such as high-risk women,17 the postpartum women may be the easiest to locate and are a particularly fertile group. It has been estimated, for example, that over 53 per cent of all women become pregnant again within 3 months after the first postpartum menstrual period.’ Within a few years, all eligible and high-risk women will, in fact, have been covered because among those not having a pregnancy within, say, three years the great majority are practicing family planning, are sterile, or are not at risk. In addition to the temporary measure of attempting to approach all pregnant and recently delivered women for the purposes of encouraging the practice of family planning, a major attempt is needed to improve overall rural maternal and child health coverage and care. While personnel and facilities are greatly inadequate for the job, a paradoxical situation exists in several countries in which just

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even the small number of existing facilities and personnel are underutilized. Thus, efforts must be focused first on improving the services that already exist and then on expanding these services in a systematic and effective way. Plans have been prepared by Taylor and Berelson13 and by the World Health Organization,18 and we believe that action should be taken on their recommendations as soon as possible. The sooner rural women are provided with a bare minimum of antenatal and postpartum care, the sooner we should see significant improvement of family planning services both for purposes of limitation of the number of children and

Postpartum

approach

to family planning

13

for spacing of the children. This would be a major step forward in the provision of family planning services throughout the world. Many people took part in the postpartum programs described herein. Particular credit is due to Dr. Winich Asavasena, Director, Maternal and Child Health Division, Department of Health, for the programs of the 3 MCH Centers, Dr. Nibondh Suvatthana, Chief Medical Officer, Department of Medical Services for the 8 Provincial Hospitals, Dr. Aree Somboonsuk of Chulalongkorn Hospital, Dr. Supom Koetswang of Siriraj Hospital, Dr. Tuangparch Dharmapanij of Vajira Hospital, and Dr. Jiree Limtrakam of Women’s Hospital.

REFERENCES

1. 2. 3. 4.

5. 6. 7. i: 10. 11.

Davis, K.: Science 158: 730, 1967. Blake, J.: Science 164: 522, 1969. Berelson, B.: Stud. Family Plan. 1: 1, 1969. Taylor, H. C.: In Berelson, B., Anderson, R. K., Harkavy, O., et al., editors: Family Planning and Population Programs, Chicago, 1966, University of Chicago Press, p. 433. Zatuchni, G. I.: AM. J. OBSTET. GYNECOL. 100: 1028, 1968. Zatuchni, G. I., editor: Postpartum Family Planning, New York, 1971, McGraw-Hill Book Company, Inc. Forrest, J. E:. Rep. Popul. Family Plan. 8: 1, 1971. Sivin, I.: Rep. Popul. Family Plan. In press. Somboonsuk, A., and RosenfieId, A, G.: Int. J. Gynaecol. Obstet. 1971. In press. Banharnsupawat, L., and Rosenfield, A. G.: Obstet. Gynecol. 38: 276, 1971. Fawcett, J. T., and Somboonsuk, A.: Stud. Family Plan. 1: 1, 1969.

12. Ross, J. A., In Berelson, B., Anderson, R. K., Harkavy, O., et al., editors: Family Planning and Population Programs, Chicago, 1966, University of Chicago Press, p. 759. 13. Taylor, H. C., and Berelson, B.: Stud. Family Plan. 2: 22, 1971. 14. Rosenfield, A. G.: AM. J. OBSTET. GYNECOL. 110: 1030, 1971. 15. Rosenfield, A. G., Hemachudha, C., Asavasena, W., and Varakamin, S.: Stud. Family Plan. 2: 181, 1971. 16. Wolfers, D., Quoted in Taylor, ‘H. C., and Berelson, B.: Stud. Family Plan. 2: 45, 1971. 17. Perkin, G. W.: AM. J. OBSTET. GYNECOL. 101: 709, 1968. 18. World Health Organization: Maternity-Centered Family Planning Programme: Guidelines, Geneva, 1971, World Health Organization.