Public Disclosure Authorized Child and Maternal Health Services in Rural India - The Naraugwal Experiment VOiiumc 2 fmltegrate(l IliiiliV Planuing Mid ficaltI (Care lirl E. Tavlor, R . S.S. Surma, RoJbfertL. Prlrker, lillia.rn . Reinke, Public Disclosure Authorized and Rashid Fuarwee -3e Public Disclosure Authorized Public Disclosure Authorized 309 Child and Maternal Health Services in Rural India The Narangwal Experiment Volume 2 Integrated Family Planning and Health Care Carl E. Taylor R. S. S. Sarma Robert L. Parker William A. Reinke THE JOHNS HOPKINS UNIVERSITY Rashid Faruqee THE WORLD BANK Publishedfor The World Bank The Johns Hopkins University Press Baltimore and London Copyright © 1983 by the International Bank for Reconstruction and Development / The World Bank 1818 H Street, N.W., Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America The Johns Hopkins University Press Baltimore, Maryland 21218, U.S.A. The views and interpretations in this book are the authors' and should not be attributed to The World Bank, to its affiliated organizations, or to any individual acting in their behalf. The map appearing in chapter 1 was prepared exclusively for readers of this book; the denominations used and the boundaries shown do not imply, on the part of The World Bank, any judgment on the legal status of any territory or any endorsement or acceptance of such boundaries. Editor James E. McEuen Figures KathyS. Rosen Map Larry Bowringand Josephine Dugan Bindingdesign Joyce C. Eisen First printing December 1983 Library of Congress Cataloging in Publication Data Main entry under title: Child and maternal health services in rural India. (A World Bank research publication) Contents: v. 1. Integrated nutrition and health care/ Arnfried A. Kielmann [et al.]-v. 2. Integrated family planning and health care / Carl E. Taylor ... [et al.] 1. Child health services-India-Narangwal. 2. Maternal health services-India-Narangwal. 3. Rural health services-India-Narangwal. I. Kielmann 1. Kielmann, Arnfried A., 1935- . II. Taylor, Carl E. III. Series. [DNLM: 1. Rural health- India. 2. Child health services-India. 3. Maternal health services-India. WA 310 C534 / WA 310 C534 1983] RJ103.14C43 1983 362.1'9892'00954 82-23915 ISBN 0-8018-3065-6 Child and Maternal Health Services in Rural India The Narangwal Experiment Carl E. Taylor and Rashid Faruqee Research Coordinators A WORLD BANK RESEARCH PUBLICATION Foreword The twovolumes of this study arebooks I have long been waiting for: waiting to find corroborationor refutation of what initiallymay have beenno more thanhunches or surmises,born of valid observation but not subjectedto any rigorousstatistical analysis. My genera- tion was broughtup in an age when quantitativeanalysis had not yet developedinto the modern technologyof interventionthat it is to- day. It is true, of course, that this technologymay often lead one astrayby forcingupon one what will be no more than spuriousref ine- ments that the multitude of individual responses,which depend so much on exogenousfactors, will bear. Nevertheless,one feels for- tified when one's subjective hunches are supported by objective statisticalanalysis. When they are not, one is still loth to shed one's hunches but gives more serious thought to doubts.And doubts are far more importantthan certitudes. In the late 1950s through the early 1970s, the certitudesof many nationalpolicies to improvethe well-beingof people in the devel- oping countrieswere almostexclusively the establishmentof family planningservices, the developmentof contraceptives,and the ex- tensionof family planningcommunication. Reduction of fertility, it was argued, was a straightforwardfunction of these services: they alone would deliver the goods. Internationaladvice and aid bore down on nationaldoubts, and anyone who pleaded that mortality (especiallyinfant and child mortality),or the state of nutrition, or the low levels of literacy and women's participationin economi- cally productive activitywas a far more obdurate enemy than high fertilitywas shunned like a pariah. Policy prescriptionsand action programs that relied almost ex- clusivelyon these assumptions--inwhose aid, again,many statisti- cal correlationswere invoked--didnot, however,work the way they were expectedto. Already in the 1950s the United Nations had con- vened a distinguishedinterdisciplinary group of scholarswho fore- told why they would not (UnitedNations 1953). C. Chandrasekharan (1961;see also WHO 1954) also had producedthe Mysore study,which identifiedmany determinantsand imponderablesand the cunningways in which they interactto affect fertilitybehavior. Vi FOREWORD Some of these determinants had been spelled out by critics of Malthus as early as the second quarter of the nineteenth century when, as a resultof social, cultural,and economicfactors, natural fertilityin Europehad already declinedto levels lower than in de- veloping countries a century later. Socialist thought in the last quarterof that centuryhinted that education,health (particularly reductionof infant,child, and maternalmortality), women's liber- ation and work outside the home, equity, and income were the chief determinantsof a woman's right and decisionto have the number of childrenshe desired.The developmentof contraceptivesand family planning communicationcame more or less after the other determi- nants had begun to work in Europe. But these interrelationsand his- toricalpaths were ignoredfor the developingcountries in the haste to achieve quick results that kept eluding their sponsors despite the pressuresalready mentioned. Againstthis faith in the primacyof contraceptivesupply andser- vices together with family planning communicationthat prevailed throughoutthe 1960s and well into the 1970s,small groupsof men and women persisted in investigatingmore comprehensiveapproaches to the complexproblem of child and maternal health in the developing world. For India, the Khanna study (Wyon and Gordon 1971) yielded important and complex relationships,as did Project Poshak (Go- paldas 1975) and several of the evaluationexercises conducted by the PlanningCommission of India, which ultimately led to substan- tial attitudinaland policychanges fromthe period of the Fifth Five Year Plan onward. A series of interimresearch conclusions emerging from the NarangwalProject, which had its origin as early as 1955 in the NarangwalRural Health TeachingCentre (itbecame the Narangwal RuralHealth ResearchCentre in 1961),have whetted the appetitefor the full accountthese volumes provide. The chief value of these books to me lies in their statistical rigor, complexity,and rectitudebordering on welcome understate- ment and a disinclinationto attempt blanket answers.The conclu- sions they containcannot, of course,be the last word on policy is- sues or on the understandingof subtle interrelationships.Rather, the principalvirtue of the books rests in the way the authors have questionedassumptions that need investigationbecause they are so firmlyembedded in faith and honest endeavor. There were difficultiesin the way of continuingthe NarangwalEx- periment, but these were quite unconnected with the objectives, content,and worth of the Experiment.The way in which the Experiment FOREWORD vii was conductedand analyzedmust not sufferobloquy, and surelynot for the wrongreasons. I did not have then,nor do I have now,any misgivingsabout the solidworth of theExperiment and themessages it hadbegun to conveyas longago as 1968-69,to whichthe books bear ampletestimony. And for this I mustcompliment the authors for their devotion,persistence, and rectitude.These volumes are indispens- ableto thosewho, like them, hustle while they wait, work with faith yetare visited by doubt,and look for rigor and comprehensiveness in researchdesign and methodology. AsokMitra Professorof PopulationStudies JawaharlalNehru University NewDelhi November1983 Contents Foreword by Asok Mitra v Definitions xix Preface xxiii The Narangwal Population Project Team xxix PART ONE The Narangwal Population Experiment Chapter 1 Background, Design, and Policy Issues 3 Carl E. Taylor Background 3 Why Integrate Health Care and Family Planning? 5 What Is the Evidence for Integration? 10 Purposes Underlying the Research 13 The Narangwal Setting 14 Design and Data Base 19 Differences between Villages 23 Summary of Variables 24 Analytic Model 29 Policy Questions for Analysis 32 Chapter 2 Main Research Findings on Policy Issues 33 Carl E. Taylor, William A. Reinke, Rashid Faruqee, Robert L. Parker, and R. S. S. Sarma Integration of Health and Family Planning 33 Effectiveness 35 Effect of Integrated Services on the Use of Family Planning 36 Effect of Sociodemographic and Attitudinal Variables on the Use of Family Planning 38 Effect of Integrated Services on Fertility 40 Effect of Integrated Services on Health 41 Considerations in Integrating Services 42 Efficiency 43 Time in Relation to Output 44 Cost in Relation to Output 45 Equity 47 Considerations in Targeting Services 48 Effect of Targeting Services on Equity 49 Gaining and Maintaining Community Support for Targeted Services 50 x CONTENTS Framework for Implementing Integrated Services 51 Practical Steps in Developing Integrated Services 51 Use of Family Planning Entry Points in Routine Services 53 What Special Projects Can Do 54 PART TWO The Detailed Findings Chapter 3 The Use of Family Planning 59 R. S. S. Sarma and Rashid Faruqee Use of Contraceptives 59 Acceptance of Project Contraception 61 Practice of Project Contraception 63 Adjustment