NoturaFamil1y /44-- Planning Development of National Programs

Editors Claude A. Lanct6t

Mary Catherine Martin

Mary Shivanandan

with

Technical Editors

Elizabeth Barber Gould

Jeff Spieler Nancy Williamson

IFFLP/FIDAF * Washington, D.C.

3 Natural Family Planning, Development of National Programs"'as produced as part of the proceedings of the Third International Congress of the Interna­ tional Federation for Family Life Promotion held in Hong Kong, November 1983. The production and publication of this monograph was supported in part under contract with Family Health Intema­ tional, Research Triangle Park, NC, and partiallylo funded by the United States Agency for Ittema­ tional Development. The views expressed by the contributors do not reflect the views of Family Health International, the United States Agency for International Development, or the International Federation for Family Life Promotion.

Art direction by Joseph A. Taney Photographs supplied by members of IFFLP except one by the Irish Tourist Board Production by KM Associates, Bethesda, MD Set in Garamond by Litho-Comp, Bethesda, MD

© 1984 by International Federation for Family Life Promotion. All rights reserved

Library of Congress Catalog Card Number 84-080847

Printed in the United States of America Acknowledgments

This monograph on the development of States), Catholic Fund for Overseas national natural family planning (NFP) pro- Development (United Kingdom), Comit6 grams worldwide is the result of significant Contre la Faim et pour le Development teamwork. The International Federation (France), and the Latin American Commit­ for Family Life Promotion (IFFLP) first ex- tee of the United States Catholic presses appreciation to Dr. Malcolm Potts, Conference. Director of Family Health International IFFLP extends special thanks to the (FHI), who supported this international Catholic Marriage Advisory Council seminar and monograph project at the (C.M.A.C.) of Hong Kong. Dr. Ramon Ruiz Third IFFLP International Congress in and his wife, Dr. Irene Osmund, with their Hong Kong in November 1983. FHI sub- local organizing committee provided con­ sidized more thar half the participants to gress participants with their most memor­ the seminar from various national pro- able congress to date. Professor Alfredo grams and also subsidized significantly the Perez of Chile made substantial contribu­ production, editing, and publishing of this tions in the initial conceptualization of this monograph. seminar and in his work as chairman of the The major authors of this work, both sessions in Hong Kong. those who shared with IFFLP their national In the preparation, editing, and publish­ program experience and those who con- ing of this monograpi, iFFLP expresses its tributed t vpmatic and special interest gratitucle to Mary Shivanandan, Director of papers, deserve particular thanks. In addi- KM Associates, who undertook the task of tion to these authors and the several coordinating the editing and production of national delegates who enriched the pro- this first major monograph for IFFLP. ceedings either by their comments or reac­ ti,_ ns, IFFLP expresses 2ppreciation to the The editorial committee included M. funding agencies who subsidized either Shivanandan, Dr. Claude Lanct6t, Execu­ partially or completely the participation of tive Director of IFFLP and Project Coor­ many NFP manyprogram delegates to the Hong educationaldinator, and andDr. NFPMary consultantCatherine Martin,to the Kong Congress and to this seminar in par­ ticular. Among those who, besides FHI, Federation. Dr. Martin also acted as provided travel scholarships from the facilitator and prepared the summary of the public sector were the United Nations Fund major themes and program issues. for Population Activities, the World Health The committee was ably assisted in Organization, Family Planning Interna- Hong Kong by Dr. Nancy Williamson, the tional Assistance (a major U.S. AID in- project officer for FHI, and Jeff Spieler, termediary), and the United States Agency who also provided editorial consultation. for International Development directly via Elizabeth Gould rendered invaluable assis­ IFFLP's African project. Private funding tance in the technical editing of the papers. agencies included Misereor, Adveniat, Finally a special word of appreciation is Missio (all. from Germany), Propagatione offered to Sonia A. Arsich and Shirley Fide (Rome), Development and Peace Hearn, secretaries of the IFFLP Washington (Canada), Catholic Relief Services (United office, for typing and translation services.

5 Table of Contents

5 Acknowledgments 9 Preface 10 Introduction 12Africa 14 Family Life Program Development in French-speaking Africa: FrancoisGuy 21 L'Action Familiale of Mauritius: Herv Juste 27 The Family Life Movement of Zambia: Raymond Muchindu and RichardCremins 32 Rwanda 33 Seychelles 34 South Africa 35 Tanzania 3Americas 38 Development of a National NFP Program in Chile: PatricioMena-Gonzalez 44 L'Action Familiale of Haiti: Fritz Francois 51 Diocesan Development Program for NFP: James T. McHugh 58 Argentina 59 Canada 61 Mexico 62 Peru 6Asia/Oceania 66 Australian Council of Natural Family Planning: John P. Gallagher 7i The NFP Movement in India: Kathleen Dorairaj 83 AustraliaIWOOMB 84 Bangladesh 86 Calcutta 88 Korea 89 Pakistan

6 go Europe 92 Centre de Liaison des Equipes de Recherche: Jean Mutricy 97 Catholic Marriage Advisory Council of Ireland: Andrew Kennedy 101 Austria 102 Italy/CISF 103 ItaIy/NFPSRC 104 Malta 106 Portugal 107 United Kingdom/CMAC 108 United Kingdom/NFPTA Il Program issues 112 Development of National Natural Family Planning Programs: Marie-PauleDoyle 117 Experiential Learning and the Professional in NFP: Thomasina Smith Borkman 125 Comments: 125 Stephen Burke, United States of America 127 Kathleen Dorairaj, India 128 FdgarPaz-Gonzalez, Venezuela 130 Discussion

132 NFP Education, Training and Service Development: Anna Flynn 140 Family Fertility Education Resource Package: W DonaldClarke 143 Comments: 14 5 Maureen Ball, New Zealand 144 Thomas Iilgers, United Statys of America 145 Andrew Kiura, Kenya 147 Notker Klann, W. Germany 148 Clara Lockhart, Dominican Republic 150 Mary atherineMartin, United States of AmericallFFLP 151 Discussion

155 NFP Program Evaluation and Accountability: Ron H. Gray and Robert Kambic 167 Research on Natural Family Planning in the Phillipines: John E. Laing 178 Comments: 178 Marie Mignon Mascarenhas,India 180 Ku'ang-lHo Meng, Korea 182 Sheilagh O'Rourke, Ilaiti 183, Discussion

186 Summary of Program Issues 195 Appendix: List of NFP Centers Selection of Books and Pamphlets Newsletters and Periodicals Survey and Review Articles Audiovisual Materials

7 Two roads diverged in a wood, andI- I took the one less traveled by, And that has made all the difference. ROBERT FROST Preface

During the past 10 years, there has been acting and working with many of the con­ a broadening interest and excitement in tributors of the present monograph. The natural family planning (NFP). Much of this proceedings of the Airlie House Con­ interest has resulted from advances in ference were published in a.book that may understanding of the methods as well as have helped change the tcrminology from research in evaluation and accountability, rhythm to natural family planning. The Positive program experiences from all definition that evolved was: "Natural fain­ parts of thc world combined with the ily planning methods are means by which work of investigators using the latest tech- a couple uses the daily observations of niques have begun to bring credibility to signs and symptoms of the fertile and in­ the NFP movement, fertile phases of the menstrual cycle to Beginning in the 1930s, Dr. Ogino in guide the timing of intercourse according Japan and Dr. Kn2.us in Austria identified to their desire to achieve or avoid a the time of ovulation in relation to the pregnancy. " menstrual cycle and helped to develop the This definition emphasizes that absti­ calendar-rhythm method. Their theory, nence is a part of the method, hence the which was based on the length of previous term "periodic abstinence." Natural cycles, was limited in effectiveness by ir- methods are more than techniques cf fer­ regularities that occur in many women's tility control. They also involve the cycles. Their work did, however, mark the challenging task of education in which beginnings of what are now called natural conjugal love is intimately linked with methods of conception control. From this openness to life. there deve.oped during the 1950s the In November 1983 the Third Inter­ temperature or thermal method, and, by national Congress of the International the end of the decade, the sympto-thermal Federation for Family Life Promotion and cervical mucus methods. The latter (IFFLP) was held in Hong Kong. Since the two methods, which use either several meeting brought delegates from all over parameters (sympto-thermal), or a single the world, it provided an ideal focal point index (cervical mucus), are a great advance to examine the developmental aspects of a beyond the Ogino-Knaus method, since representative sample of NFP programs as they depend on scientifically based obser- well as the resources, instruments, and ma­ vations for determining the fertile period. jor curricula for teachers. Through this ex­ In 1970 two American groups, the Na- change, narticipants were able to enhance tional Institute of Child Health and Human their own programs and assist others. This Development and the Human Life Founda- fruitful exchange resulted in this mono­ tion, co-sponsored an international graph, which provides an update on world­ meeting on the status of natural methods wide advancements and accomplishments of fa-ffily planning. I was privileged to of NFP programs. serve as co-chairman of that meeting (later kno wn as the Airlie House Conference) William A. Uricchio, Ph.D. which provided the opportunity of inter- President, IFFLP

9 Introduction

proportion of the This monograph focuses on nadonal its choices to a large" systems of natural family planning programs, their population through existing and other educational development, needs and characteristics. It family health care arises out of the proceedings of a seminar channels. monograph is both to with delegates from NFP programs in 35 to The goal of this of developing national 40 countries. The three-day seminar was reflect the reality a worldwide basis and to held in Hong Kong, in November 1983 NFP programs on aspect. Specific during the Third International Congress of analyze the development and developmental ap­ the International Federation for Family Life characteristics various resources and Promotion (IFFLP), which brought proaches including described as an aid to the together 425 participants from 73 instruments are new programs. countries, establishment of is divided into two sec­ IFFLP was created in 1974 in Washing- The monograph presents some 20 or ton, D.C., following an international sym- tions. The first section programs. Nine major posium on NFP convened by the Human more developing in the four geo­ Life Foundation. Beginning as an associa- programs were selected or zones of the Federa­ tion of delegates from 14 countries, IFFLP graphical regions has grown in the last 10 years to a thriving tion-Africa, the Americas, Asia-Oceania, detailed analysis by the international nongovernmental association and Europe-for Another dozen pro­ of over 60 countries with some 120 authors/delegates. presented in a summary members, who have a primary interest in grams have been more representative pro­ the promotion of natural family planning. form only. The chosen from The growth of NFP parallels develop- gram descriptions were affiliates. ment in natural childbirth and breast- among 40 IFFLP feedng in Western health-care circles. For the most part, NFP programs and Grass-roots groups sprang up in both services have been developed in a private family developed and developing countries to network outside the major public pro­ practice and teach this alternative, non- planning programs, and a majority of basis of invasive form of family planning. During grams have a religious origin and the last ten years, ihe scientific basis of the operation. Dr. Frangois Guy's description two major NFP methods, the ovulation of his NFP development consultation work (cervical mucus) and sympto-thermal in Africa for the last eight years illustrates in metho(, has been well established and how NFP programs have been spreading reviewed in the scientific literature. The French-speakiig Africa through Church­ NFP movement now appears ready to offer based groups.

10 The second section of the monograph rhythm and its potential as an integral part analyzes in greater depth program develop- of the national family planning program. ment, training and s, rvice development, Professor Ronald Gray and Robert Kambic and program evaluati3n. in addition to the from Johns Hopkins University present presentations of the: major theme, com- criteria for evaluation of NFP programs. rents were invited '.rom several additional The editorial committee, composed of speakers. The preientation on program Dr. Claude Lanct6t, who was also the proj­ development by Mirie-Paule Doyle, former ect coordinator, Mary Catherine Martin, an IFFLP president 'r,. m Canada, introduces a NFP educational and development con­ discussion of primary orientations, sultant to IFFLP, and Mary Shivanndan, philosophy, stricture, leadership, and editorial, research and media specialist in funding. Dr. Thomasina Borkman, a social NFP, summarized discussion from the par­ scientist, provides a challenging analysis of ticipants and developed the final summary the dominant characteristics of existing of the total seminar. The com-!1lttee NFP programs and suggests a mechanism accepts full responsibility for the aelection for monitoring the impact of new of the highlights for both the summary and developments on NFP programs. discussion. The respective authors are The ieart af NFP programs is the quality otherwise responsible for their own contri­ training of its teachers and development of butions, which do not necessarily reflect its educational services. There are two the opinions of the editorial committee of presentations on this critical area. Dr. Anna IFFLP. Flynn of Birmingham, England, outlines In the last section or appendix of this steps necessary to establish a quality serv- monograph, we have included a compre­ ice. Dr. W.D. Clarke brings us the impor- hensive choice of program addresses and tant contribution of the World Health identified major teaching and development Organization, which developed the Family instruments as well as an NFP reference Fertility Education Resource Package bibliography. published in 1983, after five to six years of The monograph was designed primarily field testing with six IFFLP member to be a helpful tool and reference for those organizations. engaged in NFP program and service devel­ NFP program evaluation and account- opment. We hope it may be of value to ability is one of the primary challenges of anyone interested in NFP, whether in the next decade. Dr. John Laing illustrates government, church, medical or academic several years of research analysis in the circles, as well as the general public. Philippines on the demographic impact of The Editors

11 Africa

Africa was chosen as a priority region by Zambia illustrates the second generation the International Federation for Family Life of NFP programs in Africa. The Ministry of Promotion in the development of natural Health in Zambia has adopted a favorable family planning soon after the establish- policy towards natural family planning. ment of the organization In March-April Special efforts are being made to develop a 1977 the African delegates presented an national NFP training program based on Initial request at the first IFFLP zonal meet- the recently published World Health ings held in Yaounde, Cameroon. A second Organization Family Fertility Education request was presented in the form of a Resource Package. Formal NFP services in resolution at the First General Assembly of both the public and private sectors are also IFFLP members in Cali in June 1977. being developed. A general development plan was pre- Concurrent with NFP development pared in early 1978. As a result, during a sponsored by IFFLP in Africa, promoters of period of five years NFP was implanted in the ovulation method, Drs. John and several African countries. Dr. Francois Evelyn Billings have invited their collabora­ Guy's article illustrates this first implanta- torstoWOOMBworkshopsandcongressesin tion phase with personal reflections on his Australia and lFurope. Program!' of a few of own and his wife's involvement in intro- these (the Seychelles, Rwanda, South Africa, ducing NFP or self-observation methods to Tanzania, and Kenya) are described in this French-speaking Africa. monograph briefly. Delegates from 26 African Mauritius has been the pioneer African countries attended the Third International program of 20 years'1standing, serving as a Congress of IFFIP in Hong Kon, ,n November prototype. In November and December 1983. 1981 IFFLP organized a trainers' workshop In August 1983, with support from the in Mauritius with field visits. This bilingual United States Agency for International De­ workshop brought together 65 participants velopment, IFFLP initiated a five-year NFP from 20 African countries and govern- demonstration and evaluation program in mental observers from 8 countries. Zambia and Liberia, based on the lessons The second phase of the continental NFP and experience of the Mauritius program. development program was initiated in It is hoped that in 1984 a similar NFP tech­ 1983. It combines five to eight years of nical assistance program will be extended demonstration/evaluation natural family to 10 or 12 French-speaking countries. planning projects in 10 or more African countries.

12 L%

I

Children of Togo, Africa

13 Dr. Francois Guy Famly Life Program Development in French-speaking Africa

FRANCOIS GuY FranjoisGuy, M.D., co-founder of CLER; pioneer NFP worker in Africa, France, and Mauritius; founding affiliate member of IFFLP; IFFLP voting member forIREC (ResearchInstitutefor Childand Couple), Grenoble,France

This paper describes the shared ex- commentary on his experiences as a field periences of the author and his wife as worker in Africa under seven headings: consultants to IFFLP in Africa. Over a (1) the child andlife, (2) man and woman, periodofseven years, 54 visits were made (3) family disintegration,(4) a spiritual to 24 countriesto promote naturalfamily dimension, (5) time andfailure, (6) com­ planning and faimily life through public ingfrom abroad,and (7)five beliefsfor a information sessions or training work- strategy. The author sees thesefive objec­ shops. Dr. FranqoisGuy offers a personal tives as an essentialfoundationfor any

14 action. They are: determinationof a pre- Zambia. In two countries-namely, Egypt cise objectivc, self-reliaice, community and Gabon-contacts were unfortunately participation, choice of concrete objec- lost. tives, and an appropriate matching of The primary purpose of this paper is to ambitionand action. He defines the peda- share a few personal comments not from a gogical approach he has gradually research or sociological point of view but adopted to attain these ends. from that of someone involved in field com­ The first part of this paper presents the work. (The authors have already exten­ shared experiences of the author and his mented on several of these areas in wife as consultants to the International sive field reports.) We have chosen seven Federation for Family Life Promotion headings to share what these activities have have (IFFIP) for Africa from 1976 to 1983. The helped us discover and how they Federation had undertaken a large five-year helped us to modify our way of tninking (2) man plan with consultants visiting both French- and acting: (1) the child and life, (4) a and English-speaking Countries, and woman, (3) family disintegration, The French consulting team consisted spiritual dimension, (5) tine and failure, primarily of the author, Dr. Frangois Guy, (6) coming from abroad, and (7) five beliefs and his wife Mich .le. Mrs. Christiane Ferot for a strategy. of the Coordination Center for Research The Child and Life When we came to Teams (CLER) accompanied them on two Africa, vie were influenced by such notions trips. All in all, 54 visits were made to 24 as Third World overpopulation and its con­ sequences for the world situation. We had countries for a total of 384 days over a six- learned_ to tenmper our judgment on the and-a-hallyear period. These visits were of different types: 32 were primarily ex- question by attributing aTn equal iespon­ ploratory with public information sessions sibility to socioeconomic factors and for groups of various sizes to introduce recognizing the exareme diversity of situa­ NFP; 27 were training workshops of at tions. We had heard of the concepts of least three days' duration; and four vl ere "vitalism" concerning fertility and the national or international meetings and con- child. This philosophy, which puts man at ferences (YaOuIndd in 1977, Abidjan i the service of life in all its forms, is a factor 1978, Mauritius in 1981, and Zalre in of cosmic unity and a link between in­ 1982). These visits were grouped into 13 dividuals and generations. The child is separate trips of three to eight weeks' indispensable "pour 6tendre son nom et sa duration. race" (to spread one's name and one's The map of Africa that accompanies this race), whatever the economic context. Ac­ report identifies the 24 countries visited cording to the proverb: "Beaucoup d'en­ with the number of visits (one to five) to fants et pas d'argent, ce n'est pas la each. The results of this field consultation pauvret6; beaucoup d'argent et pas d'en­ between 1976 and 1983 can be sum- fants, ce n'est pas la richesse" (Many marized as follows: children and no money is not poverty; 1. Support to existing family promotion much money and no children is not organizations, as in the case of visits to the wealth). Congo, Madagascar, Morocco, Mauritius, We discovered generally that, except in R6union and its dependency Rodrigues, a few countries with small areas, Africa is Rwanda, Seychelles, and Zaire. dramatically underpopulated. We were 2. Creation of new organizations now told this by an African minister of health. affiliated or in the process of seeking affilia- The majority of governments, in spite of tion with IFFLP, as, for example, Burundi, prompting from international organiza­ Cameroon, Upper Volta, and Togo. tions, are quite reluctant to embark on na­ 3. Sustaining contact and information tional programs of family planning. At the exchanges. Examples are Benin, Central most they accept the idea of child spacing, African Republic, the Ivory Coast, Kenya, and the problem of sterility often concerns Niger, S6n6gal, Tanzania, Tunisia, and them more: "We can find all the money we

15 AFRICA

M Isla

Seychelles

Rodrigues 40 Madaga Mauritlus Reunion want to limit births," they sometimes say, couple in Africa does not exist, that men "but very little 'o help women have and women live side by side, performing children." their specific tasks without any dialogue. We also learned that, for men and There is a real prohibition of showing feel­ women, the idea of birth regulation is often ings and even more of verbal communica­ unacceptable, even scandalous. Some say, tion. Love does not exist, we were told; "It is improper to speak of this" or "Here, marriage is an alliance between two we are in favor of fertility." If we propose families to ensure the continuation of the to speak of child spacing, they ask us to blood lines. Sexual life is a taboo subject speak instead of sterility and its treatment. with strict rules. We discovered, however, One woman said to us, "I do not want to that there exists between man and woman do anything to prevent pregnancy. The an authentic communication, a bond built other women will laugh at me if I am not out of confidence, esteem, attentiveness, pregnant." and selflessness. "We do not speak of love; Our African friends have delivered us, at we live it," said one man. "The man who least partly, from the Malthusian outlook says to his wife, 'I love you,' behaves as a that rejects children and have contributed little child towards his mother," criticized to the evolution of our own outlook. In- another man. stead of speaking to African audiences of We have heard them speak of sexuality birth limitation, we now speak of the and of child spacing and say that for them mastery of fertility. "We do not want to abstinence is normal and that it is the most fear or fight fertility," we say. "Rather, we widely used of the traditional methods. We want to understand it better in order to have observed their desire to reflect and d'rect it." their capacity to adapt to various discus­ Today we propose a double approach: sion techniques and to participate in to understand and to serve life. To give life spirituality movements (such as Teams of is a blessing, a fundamental need for any Our Lady and Marriage Encounter in being whatever its age or status. We try to Brazzaville, for example). bring out this basic attitude from the Our goal is to offer couples knowledge, groups we meet. We propose an exchange but also and primarily to help them or discussion of the advantages (but also discover each other, to reveal themselves the problems) of large families, separating to each other. We are increasingly con­ deliberately the knowledge of fertility (fer- vinced that it is impossible to speak of child tility awareness), which we invite every- spacing without becoming interested in one to admire, from the use of self- the couple's life and problems. observation methods ("Mdthodes d'Auto- In speaking to African audiences, we Observation" or NFP) to space births or ex- have had to evolve our approach. After an plore the problem of sterility, initial introduction on dialogue between During a session one day, a man said to the partners, Iusually propose to the group me, "We understand that you are not an exchange on the topic. In this phase, against the child. You speak of children as men and women separately ask themselves an African would." Toward the end of one or each other such questions as: What do session in Cameroon, a participant ex- you admire in your husband? In your wife? plained, "I now understard better that we Do you have areas about which you find it must modify our way of life; the child is difficult to speak and share? What do you not an accident, but an essential factor in do when things are not going well between the life of the couple. It is by considering you? My role is then to gather the contribu­ the child in a positive fashion that we must tions from each, to stimulate discussion on reorient our thinking." Alfre.l Sauvy, the areas that have been presented as essential, famous French demographer, said, "It is and to draw some conclusions. For exam­ the love of the child which leads to the pie, I might underline the importance of planning of the family." money questions in the home or the Man and Woman We have heard that the presence of friends. There are as many

17 possible solutions as there are couples, but school a group of boys and girls who were mutual trust and respect appear to be from the same neighborhood. They were necessary preconditions. And in this questioning us on the mechanisms of life, fashion the audience itself contributes and heredity, and sexual maturity. It was im­ molds the exchange. pressive to observe side by side the twen­ Some women express their appreciation tieth century and age-old traditions. to the men: "They had never told us such Is it surprising to observe that these men, ab­ thi.ngs." Others are happy and appreciative women, and youth have difficulties in "of what thcy have discovered as good and sorbing within one generation what most beautiful in a couple's life." A village chief, others have taken centuries to assimilate? cause who witnessed such a meeting with these Such brutal transformations are the themes, observed: "This is the first time of much anguish and disorientation. children's that men and women have discussed such Parents do not understand their the topics. We hope to pursue such exchanges behavior when they come back from in the future." city. They say, "The children have trodden Family Disintegration We have frequently over their education and our traditions as heard that the joint family system is the which they should have considered structure of the traditional African family. sacred gifts." Children reject the traditional us," It is described as having tight cohesion bet- pattern: "Our customs crush and bore off ween itc members, dead or alive. "There they sometimes admit harshly. Cut are in the vilhage," writes Alex Haley in from the village and isolated in the city, order Roots, "three tyoes of people: first, those they are ready to attempt anything in situa­ we see; second, the ancestors; and third, to survive. In this difficult economic an those waiting to be born." Built around the tion, the duty of hospitality becomes elders, who direct it because they have unbearable burden for those in the city the wisdom, experience, and knowledge, the who should be ready to receive all system maintains itself through solidarity, relatives from the village. not that is, a sense of hospitality and sharing As foreigners in Africa, we must among all its memb'ers. It survives thiough judge its customs. But as well-meaning the fertility of the couples who make it up. observers, we could invite reflection on to To get married is in some way, according them, asking our listeners, for example, tradi­ to Monsignor Tsinda, "to exercise a discover the initial rationale of these wi-1l ministry of life and of the blooci line." tions that are now criticized. They Yet, in the reality of the African situation, then discover their richness and find how, our friends have helped us discover the im- in the current context, the traditions might portance of the "destructuration" of the evolve while still meeting their initial ob­ African family (the word was coined by jective. We often refer, as an example, to one of them) and of the growing polariza- the case of traditional breast-feeding and tion and sociocultural distances most pro- that of the initiation rituals. Such traditions nounced between the city and rural areas address essential values, such as the role of and between youth and the elders, the body in the acquisition of knowledge, I was struck by a scene that occurred of the community in its transmission, of during a meeting organized in Tamberma difficulties and the necessary time for country in northern Togo, which is away maturation. from the major communication centers A Spiritual Dimension The meaning of life, and well known for the survival of its tradi- the solidarity between the living and the tions. We visited one of the well-known dead maintains a kind of familiarity with tatas, or multilevel huts, where in a the invisible and explains the "diffuse separate room a few carefully tended live sense of the sacred" spontaneously present cinders are kept; tney are believed to be in- at the heart of the African tradition. It is dispensable to the survival of the family. open to all forms of religious search, Yet only a few hours later and a few hun- whether that of Islam, of Christianity, of dred yards away, we met in the local Animism, ,cone of the numerous sects one

18 encounters today. several years. We have without question A spiritual perspective is present in most experienced discouragement, but we have activities in the traditional African context. learned the meaning of failure and of timf.. In the People's Republic of the Congo, for During a presentation one day, Iwas in­ example, there is a rather exceptional situa- viting the part'cApants to reflect tiat in tion of work unicrtaken together by family planning a so-called failure was a government ministries, mass educational new life. A couple in the audience with an organizations, and Foy'cr Chr6!iens. Each infant a few months old asked to speak. respects the others' convictions for a long- "We did not understand the methods very term involvement in family life education wel! and my wife became pregnant," said and promotion. the man. "It was certainly an unplanned Africans recognize what has been pregnancy, but it is not a failure; it is our achieved in the promotion of the family child.'" Elsewhere, at the end of a session in and of womcn by the different churches, a village, a man reminded the audience that whethcr they be the Catholic Church or one cannot plow a field by throwing the in­ related groups such as the Foyers de struments across the field, but that one Charit6 (Retn'at Centers), parish associa- must accompany the plow along the tions or educational Christian corn- furrow. munitics. They respect the family life work And since then? We dare to speak of the of other Christian denominations such as pedagogical value of failures and to admit the I.uthcran-sponsored Family Life Mis- that what counts is to live with the same sion movement initiated by Walter and rhythm of thought and action of those with Ingrid Trobisch or the French-Speaking whom we hope to work. We readily cite Africa region of the Scripture Union in the words of Monsignor Agfe, Bishop of Abidjan, inspired by Charles and Evelyn Man: "To work in Africa, one needs three Maire in the Ivory Coast, the associate things: initially some patience, then more regional secretaries, patience, and finally patience." We remain Mlany countries can indeed confirm the sensitive to observations from an African basis of the affirmation by John Paul II in collaborator: "You Europeans think that in Brazzaville on May 5, 1980: "The State can order to succeed it is enough to have rely on the collaboration of the Church as techniques and money. You forget that it long as it is a question of serving man and must take time and that we are, after all, contributing to his integral development.' only people." It is in Africa, in the field, Without closing our eyes to difficulties that we have perhaps best understood this and misundertandings, we appreciate that pastoral approach of "progressive the sense of hospitality and the natural growth," or the law of graduality that was welcoming disposition of Africa's people underlined in 1980 in Rome at the Synod permit meetings with groups of completely on the Family and in FaniliarisConsortlo. opposing orientations yet in a climate of Coming from Abroad What picture do we trust and appreciation. project of ourselves when we come as ex­ Time and Failure We ha- ' learned the ir- pe~ts, consultants, or technical assistants? I portance of demographic problems, the had never fully reflected on this question principles of planning and evaluating pro- until one day an African called out to me, grams, and the criteria of efficiency and "You, the expatriates!" I realized the com­ method and user-failure rates. We have plexity of our situation, we who intervene discovered in the field dropouts, unex- in such a particular area as family life, in a plained or unplanned pregnancies. We country with traditions and a culture so dif­ have met enthusiasm without follow-up, ferent from our own. How are we to define the burnout of teachers, and the departure ourselves? of those who appeared the most motivated What did we meet in fact? First, we and who had received significant support. found a lack of trust and a hostility toward We have witnessed the disappearance of our views, even before we presented groups with which we had worked for them. "Here are people who do not have

19 children themselves and who come to pre- fertility, integrates abstinence as a positive vent us from having any," one group said value. If we sometimes oppose the two ma­ to us upon our arrival. The misunderstand- jor approaches in family planning, that of ing was easy to dispel, techniques and that of awareness, it is We found rejection of our propositions, because they appear to us fundamentally which appear to the Africans as incredible, different in their essence or in their "Settle first the disagreement between underlying understanding of life and man. various methodologies and come back Technique by itself cannot solve the prob­ later to talk," said one African government lems of man. worker to whom I had explained the dif- Our second need is the belief that each ferent approaches to family planning. But individual holds within himself or herself sometimes there was a warm and even en- the necessary elements for self-promotion thusiastic reception, no doubt due to the and development, whatever the sociocul­ newness of the information as well as to tural level. This is the principle of self­ the African traditions of hospitality and reliance, which provides u, with the per­ tolerance. More often we were met by manent will to encourage, stimulate, and realism. A Catholic told me, "We do not help ini the development of these capabili­ need foreigners to come to observe and ties and not to destroy, 'eplace, or absorb direct us, but don't get any complexes. We them. have as much difficulty in understanding Third, we need to insist that priority be you as you have in understanding us. This given to community participation in family should not prevent us from working and conjugal educatio:i. The community is together, however." Elsewhere a minister the locus of interpursonal relations, and clarified, "It is up to us to receive from community leaders are known and ac­ abroad what is good for us and to adapt it cepted persons. Moreover, such an ap­ to our country, just as the foreigner might proach brings together the most interested take from us what is good for him." men (too often forgotten) and women who We rejoice in observing that family prob- in the last resort arc the only real agents of lems constitute one of the best facilitators change in the concrete reality of their daily for international relations. We know that lives. It favors autonomy and reduces we are at the disposal of our hosts. We dependence on professionals and techni­ must listen to them first and then help cians. It fa 'ilitates the circulation of infor­ them analyze their situation and undertake mation within the group and helps to raise an inventory of their needs. Then we must its consciousness, Finally, it can grow share what we know and what we have beyond a country and spread to an inter­ had experience with so they can choose group collaboration as we currently what might be useful. We must assist them observe with Foyers Chr6tiens of Brazza­ in their own development if they so wish ville (Congo) and l'Action Familiale of and hell) them relate their experiences with Mauritius. those of other countries we know and with The fourth need is for priority to be whom exchanges might be arranged. The given to focusing on realistic expectations objective for us is literally to become "un- in the short term. At the end of a session, I needed servants." In other words, it is our often ask the participants, as an exercise, to task to work ourselves out of a job. predict what they will undertake in the Five Beliefs for a Strategy In conclusion, I coming month and not in the following would summarize under five headings the year! This is to help them recognize that it lessons learned from our development ex- is easy to establish grandiose projects but perience of the la)st eight years in Africa. difficult to define a more modest action What do we need? and to decide on the first steps. First, we must have a clearly defined ob- A limited action, carefully undertaken, jective. Gir goal is not the spread of known and supported by those who initi­ natual family planning, but the discovery ated it, serves as a sign or anchor on which of a life style which, through the laws of further steps can be based. All of our

20 teaching is concerned with concrete real- translates for the audience. In return I ask izatioris. Training is given on practical that he share the remarks and observations knowledge, no! from books but from of the group! problems encountered and possible The final need is for a realistic estimation solutions. of our ambitions and work. Michle and I Local sessions are necessary even iftheir have had the exceptional privilege even quality is not high, because often they ar beforef 1976 (our first visit to Mauritius was more effective in motivating the p,rtici- in 1963) to be associated with research and pants, facilitating the identification of field work, especially in Africa. We have future leaders and needs, and developing had close contacts with couples and with better teaching aids and instruction. The men and women who are quite different teaching techniques should be varied sO from us in their life style, traditions, that everyone can participate actively and culture, and religion. They have received express himself or herself. tIs and invited us to share in their problems The diversity of language in Africa fIre-and ioys. We must thank them for all they quently makes it necessary to work with an have taught us and for expanding our out­ interpreter. Our experience shows us that, look, transforming our ways of thinking far from being an obstacle, this technique and action. Because of them and often in can in general be beneficial if the speaker spite Of ourselves, we have been led to and interpreter have taken the time to reevaluate ourselves and our actions. We prepare the session together. The slower have learned to put into perspective our delivery pace allows repetition of ideas and problems and ambitions and perhaps to be can give a margin of freedom or initiative more modest, tolerant, and patient. to a competent intcrpreter, who usually As my concluding statment, I would like knows better than the speaker which ina- to share this reflection of Emmanuel ages are most appropriate for the audience. ,ounier, the Ficnch philosopher: "We can Knowing who the interpreter will he has only commit ourselves to questionable sometimes made it possible for us to work challenges and imperfect causes. To refuse together to decide on a general plan from commitment because of imperfection is to which hc can work as he sees fit. I can pro- refuse the human condition." vide him with material, which he then

L'Action Familoale of Mouritius

HERVEJUSTE Hervj Juste, adrinistrativesecretary of IAction Familiale of Mauritius; IFFLP board member for Africa (1983-86); !FFLP-NFP (levelopment consultant

Mauritiusis an islandnation in the Indian of Mauritius is about 970,000, and the Ocean located 500 miles east of .tladagascar. islands population density is about 530 per- With a territory of about 2,000 square kilo- sons per squarekilometer. With a crude birth meters, it is slightlY smaller than Rhode rate of 27 and a crude death rate of 7.2, the Island,the smallest U.S.state. The population rate of natural increase is 1.9 percent per

21 year. These rates imply a doubling time of 37 referralservices are availablefor couples years and a pr9jectedpopulationfor the ycar with physiological or marital problems. 2009 of about 1.2 million persons. Educationin "Love andLife" is offered to About 43 percent of thepeople live :n urban schJools. areas. More than a tbird-36.3percent-are L 'Action Familiale receives funds from under the age of 15, and 6.4 percent are six!y international agencies, local tax­ orolder. A life expectancy ofclose to 65years deductible contributions, and grants-in. Prevailsfor the population as a uhole. with aidfrom t.;e government. From 1965 to males living to the age of 60. 7, andfemales 1982 about 31,000 couples were taught livingan additionalst.years.The infantmor- NFIP, about 16.5 percent of all women or tality rate is 'bout 35per thousandbirths. couples using a birth control method. The population of Mauritius is about 69 Systematic evaluation has not yet been percent Indian and28 percent Creole. 7e of- undertaken. ficial language is English, but French and Creolearea.'so spoken. Fifty-onepercentof i Growth and Develupment people are Hindu, 30 percent are Christian, L'Action Familiale (Family Action) was and 16 percent are Muslim. Tbe per capita officially established on April 24, 1963, at gross national product was estimated at the initiative of Msgr. Jean Marg6ot, then USS738 in 1981. vicar general of the Mauritian diocese. He The official government podulationpolicy was advised and assisted in his endeavor is to reduce population growth for Iemo- by a team of doctors and couples. At that graphic reasons. In 1972 the government time there was a national demographic assumed responsibilityfor fami, planning problem of exceptional scale and urgency and maternal and child health services, al- it,the country. The total population in though the Famnily PlanningAssociation and 1963 was 713,731. The crude birth rate L 'Action Familialecontinue their activities, was 39.9 per '.!-ousand, and the annual rate It was estimated that in 1981 about half of of population growth was just over 3 per­ all married women of reproductive age in cent. A density of 384 persons per square Mauritiuswere usingsome form ofcontracep- kilometer gave Mauritius one of the highest tive method, with the public sector providing population densities in the world. seri'icesfor39.4percent ofall marriedwomen Projections published at the time in­ and the private and commerical sectors dicated that, if the rate of population serving 11.2 percent. growth were maintained, by the end of 1987 there would be 1.6 million persons in L'Action Familialeof Mauritiuswas of- Mauritius and even a declining birth rate ficially established in 1963 on the initi- might yield a population of 1.2 million by ative of Msgr. Jean Margiot to provide that date. Catholic couples with a naturalmears of Public opinion was already beginning to family planning and to promote the hap- show some concern about the conse­ pinessand welfare offamilies. It was soon quences of the population explosion, and serving other religious and ethnic groups many couples, especially Catholics, were and in 1965 was given financial support already practicing traditional birth control by the government. L 'ActionFamilialeis a methods, such as breast-feeding and the nongovernmental organization with a Ogino-Knaus method of calendar rhythm. boardofseven directors,one of whom is a Msgr. Marg6ot and his team decided, representative of the Ministry of Health therefore, to provide. particularly to andPopulationControl. Catholic couples, a scientific natural Since 1973 couples have been instructed method-the thermal method-which had in the sympto-tbermalmethod of NFP.Ser- been presented earlier that year by Father vices are provided in both urban and Stanislas de Lestapis. Couples were taught rural ares. Trainingprogramsare held the basal body temperature (BBT) method for teachers almost every year using lo- of charting for the detcrmination of the fer­ cally developed teaching materials. Free tile and infertile periods of a woman's

22 menstrual cycle. I hey were therefore able l.'Action Familiale stresses the impor­ to exercise some control over conception tance of Ce development of the potentil and hence their family size. The idea of the of every humai being, aid for that reason regulation of fertility through the use of it was decided a' thle very beginning of the periodic abstinence was thus officially association to infest in educating couples propagated. Couple-to-coupic action in human, conjugal, and family life. NFP rapidly popularized BBT method. cannot be taught as a mere birth control Drs. Franoi. and Michblc Guy, two device but is presented as a mode of life to French doctors, who visited the country in foster understanding between husband August 1963, were invited in December and wife. The couples are requested to 1964 to impart their experience gained in respect life, especially t'i, .,le of the un­ the field of NFP in Grenoble to the local born child; to respect the fecundity of the pioneer team. They devoted two years of woman and the couple; and to develop their lives to the development of the NFP responsibility toward a better and more program, in tr.!nliiig of instructors and in enlightened conjugal and family life. the introdvction of a youth sex education In addition to teaching the basic aspects program in secondary schools and youth of NFP-that is, the anatomy and physi­ clubs. Their invalable .v)rkwas essential ology of the male and fetnale reproductive to the success of l'Action Fainfliale's organs and the indicators of ovulation­ program. l'Action Familiale also teaches couples how Voluntary instructor couples, who to be responsible parents, how to feed their numbered morc than a hundred at the children, how to maintain a dialogue within early stages of the association, set out to the family, and other family values. work in six urban and tural areas. Their ac- L'Action Familial.'s outreach program tivitics were SUp-erviscd and their training very soon enlisted clents from the other completed through regular meetings. Very ethnic and religious gr,-ups of the popula­ soon, through constant sharing on the part tion, namely, the Hindus, the Muslims, and of the growing number of couples forming the Chinese. The government's decision In the association, the aims and objectives of June 1965 to give financial support the movement emerged clearly, and its through giants-in-aid to the association methods of action were defined. Legal gave official recognition to the national status was granted to l'Action Familiale in character of the program, which was pro­ 1964. viding free service to the Mauritian com­ munity at large. Objectives, Philosophy, and Principles Incorporated under the 'Action Famili- Service and Training ale ordinance, No. 38 of 1964, the associa- L'Action Familiale is a nongovernmental tion has as its objectives "to promote the organization administered by a board of welfare and happiness of families, to foster seven directors elected at a general the ide s of harmonious married life and assembly convened every three years. A responsible parenthood, and to support representative of the Ministry of Health the propagation of all natural methods of and Population Control, namely, tl_ prin­ regulating childbirtl." According to the cipal medical officer of the Maternal and philosophy of I'Action Familiale, birth reg- Child Health/Family Planning Division, has ulation is not just a technical problem; it sat on the board since 1974. arises from the choice made bv a properly The board members nominate a number informed couple, aware of the biological, of commissions to advise them. At present psychological, and socioeconomic aspects there are five commissions-the NFP corn­ of their lite. The choice exists only when mission, the youth commission, the the coupie have clearly understood the medical and psychotherapy commission, values at stake and are not subjected to any the finance commission, and the informa­ moral, intellectual, religious, or politicAl tion and education commission. In 1974 pressures from the outside, the Mauritius Family Planning Association's

23 contraceptive clinics were integrated into two weeks. The frequency of the visits is the Maternal and Child Health Division, gradually decreased until the couple and 'Action Familiale was invited to send a becomes autonomous. representative to the Division's newly L'Action Familiale has recently begun in­ formed National Family Planning troducing and promoting the use of the Committee. modified mucus method as itis taught in In addition to its national NFP program, India by Dr. K. Dorairaj. It is stil!double­ l'Action Farniliale conducts a human and checked by BBT. The introduction of the fanily life education program in secondary cervical mucus method has been a blessing schools and youth clubs and a marriage for many couples, especially those for counseling and psychotherapy service for whom the woman's cycle was long or ir­ people with conjugal and marital prob- regular. It has also greatly relieved tht. con­ lems. It also contributes to the marriage stant anxiety and tension associated with preparation program orb- ized at the the previously unpredictable return of fer­ parish level. tility before menstruation in the post­ Program evaluation has not been under- partum period and in the premenopausal taken, but with the inclusion of l'Action period. Farnilialo in the program evaluation project Training of Personnel A training program designed by tle IFFL1P and funded by the for trainee teachers/educators is held prac­ U.S. Agency for International Develop- tically every year. They meet for about ment (USAID), alternative org,nizational four hours each week for at least 15 weeks. frameworks will be explored. Theoretical topics are presented, dis­ Service Until six years ago, the national cussed, and evaluated. At the same time the NFP service was divided into 12 regions ac- trainees are exposed to practical experi­ cording to the availability of volunteer ence with a qualified instructor who is heads of regicns. It has since been teaching the method to couples and realigned into nine districts, which corre- educating them in the related topics of spond to the standard geographical statis- family life promotion. Trairiees must be tical areas used by the Ministry of Health's satisfied NFP users who hold at least a evaluation unit. Personnel presently in- primary level school certificate. dlude I full-time national NFP coordinator, Over the years, l'Action Familiale has 3 part-time supervisors, 13 full-time moti- developed its own training manual and vators, and 126 part-time educators, as curriculum materials. A guide for educators well as a few trainee educators. The entitled "Livret de i'Educatrice," as well as a educators, wilo teach at the grass-roots "Cahier de Schdmas" have been published. level, at first taught only the BBT method. The handbook for users is very popular In 1973 they began instructing couples and and is used by many Africn and European women in the sympto-thermal method, French-speaking NFP organizations. emphasizing both BBT and cervical mucus Support Services A free, pan-time medical as fertility indicators. Recognition of other service is available all over the island for signs and symptoms is taught to those who women or couples who are having difficuk are interested. Initial and follow-up instruc- cycles or gynecological problems that zion are done either through weekly home interfere with the observation of fertility visits or at the centers, of which there were indicators. Couples who are having con­ 60 in 1983. The centers are located in jugal or familial problems may seek help crucial areas in both rural and urban places. from our team of marriage counselors During the first month and perhaps a!so whose training war, completed early this during the second month, the couple is year by our consultant psychologist, Dr. visited each week at home and is instructedJ Robert Fernando. in the fertility indicators on the basis of Another service provided by l'Action observations made in the preceding Familiale is the human life education pro­ period During the next three months, gram for youth in second:3ry schools and educators visit the couples at home every youth clubs. This program offers not only

24 sex education 5ut also an education in the amount of US$43,818. The local U.S. "Love and Life." The program has three Embassy and the French Embissy have main objectives. to inform youth in a contribute(d to self-help projects, and geneal but clear and objective way about Misereor has donated cars and financed the the different aspects of sexuality, love, saiary of a youth educator. Missio subsi­ marriage, and the family; to educate them dizcd trvel for a representative from to adopt responsible attitudes and choices l'Action Fnilialc to the first IFFLP interna­ in everyday life; and to reassure them that tional congress in C.;ii in 1977. the problems they are iacing during L'Action Familiale's contributions to the puberty and adolescence are natural and field of NFP include its participation as a can be handled. This program also enables founding member of IFFLP in 1974. Dele­ the youth to express themselves, discuss gates were mandated twice to be repre­ their fears and worries, and work toward sentatives for the African zone. The realistic solutions to their problems in a association was invited to participate in sphere where there is still much inhibition. Nt!' experts' meetings directed by the Outreach Activities L'Action Familiale World lcalth Organization and UNFPA in educational and motivational prograrns are 1976 and 1980. A program review and supported by monthly television and evaluation was conducted in 1982 respec­ weekly radio programs. A monthly tively by Geraldine L. Conner, D.S.W., and 10-minute television program and radio Nancy W. Vceder, Ph.D., of Boston, Massa­ programs of about the same length are pro- chusetts. Fairfield University carried out a duced. They arc broadcast in two lan- survey in 1971. guages, the patois Crcolc and Bhojpuri. Evaluation Fhanclal Support Table 1shows the number of new accep­ During its early years, l'Action Familiale tors and users trained during the last four relied on volunteer couples to teach NFl', years. There are four categories of users or but with increasing socioeconomic prob- clients at l'Action Familiale. "Beginners," lems, the number of volunteers has or "learners," are women and couples decreased. who have had instruction and have begun Grants-in-aid from the government have to chart but have not yet completed one been received since 1965. For the financial cycle. The "nonregistered" category in­ year ending December 31, 1982, the grant cludes those who have charted one com­ was Rs 829,515. In January 1978, however, plete menstrual cycle and have filled out a governmental decision curtailed aid, thus the association's intake form, providing in­ preventing the establishment of NFP' formation on family and reproductive outreach programs in peripheral villages. history. "Registered" women and couples Other sources of funding include the are those who have completed three cycles public, who may take income tax deduc- and are recognized as official users by the tions for donations to the association. Ministry of Health, which receives Some RsIO,000 are also raised by the sale monthly records from l'Action Familiale. of thermometers, charts, and books. About "Autonomous" couples are those who three-quarters of the 1983 budget of have completed and successfully used NFP Rsl,072,000 went to pay wages and methods for three to nine cycles and are salaries of personnel, considered to need no further instruction. L'Action Familiale also secures funds Table 2 shows the number of new from such international agencies as Missio, recruits registered for each year from the Misereor, Church World Service, Catholic period 1965 to 1982. The total number of Relief Services, Family Planning Interna- couples instructed during this period was tional Assistance (FPIA), and the U.S. 31,682. The total number of recruits is Agency for International Development. about 1(.5 percent of all the women or FPIA finded a two-year comprehensive couples using a birth control method in the program of l'Action Familiale in 1974-75 in cotintry. itrepresents 8 to 9 percent of the

25 with abstinence is the main total number of married women in the that difficulty for unplanned pregnancy. reproductive ages. cause Although the number of recruits has re­ there seems to be a gradual Table I New acceptors trained annually: mained steady, 8 in the number of drop­ Mauritius_ 1980- 3 downward trend outs, especially in the "unplanned preg­ C2E.or, of user 1980 1981 1982 1983 nancics" and "no longer interested" Beginners/larncrs 2,394 2,262 2,413 2,567 Nonregtstered 2,054 2,107 2,206 2,133' categories. svstematically evaluated P.egistcred 1,431 1,540 1,710 1,810 We have not we Autonomous 557 764 1,071 1,404 these and other phenomena, nor have examined such areas as cost-effectiveness and use-effectiveness of learning and con­ We believe, however, that Table 2 Recruits registered annually: tinuing users. aspect of our NFP ser­ Mauritius, 1965-82 the new supervision a great deal toward Year Number vice has contributed made it 1,615 the efficiency of the method, has 1965 has con­ 1966 1,953 less strenuous to the couple, and 1967 1,989 tributed to early autononiy of couples. For i968 1,892 the past three years zone supervisors and undergone special and 19701969 2,266i1,872 motivators have and 2,004 sustained training in chart review 1971 and follow­ 1972 1,739 quality control of instruction 1973 1,716 up of clients in order to provide clients 1974 1,903 with good service. 1975 2,001 and Needs 1976 1,969 Accomplishments 1977 1,752 L'Action FamiliAe has developed a 1978 1,252 sound national NFP program. Statistics of 1979 1,078 the last few years confirm its increasing ef- 19130 1,431 of 1,540 fectivcness with a lower proportion 1981 percentage of 1982 1,710 dropouts ani a higher Total 31,682 autonomous couples. The program is -ell rooted in the corn­ The reasons given for dropping out of munity and the family, and we believe that the program are shown in Table 3 for the the family life education efforts of the last past four years. The category "no longer few years are beginning to bear fruit. Our NFP interested" includes the following reasons: committed staff, especially the other contraceptive methods, difficulty teachers, arc recruited from and work in with abstinence, impatience of husband, their respective communities. They difficulty with method, and conjugal or demonstrate a strong client orientation, familial problems. "Other causes" includes which Iis been well documented in the illness, emigration, menopause, hysterec- Conner and Veeder study. con­ tomy, lost to follow-up, infertility, divorce, We plan over the next few years to service in-laws, and death. Very few method tinue to emphasize program and have been registered, and it seems evaluation, and to obtain and feed back failures field service statistics through effectivehpeo Table 3 Categories ofddoouts from NFP suevio oftahr.W of teachers. We hope to program: Mauritius 908 supervision network Reasonoram:ou rtu0 19882 1 strengthen beginthe field to respondsupervision to requests Reason for dropout 1980 1981 1982 1983 and even evnbgntrsp dtoeqss 293 293 248 187 an Planned pregnancy other African countries to assist them pregnancy 105 190 163 144 rom Unplanned in training their own NFP teacher­ longer interested 186 145 91 88 No teams. Other causes 231 273 202 182 supervisor We expect that the ongoing United Total 815 901 704 601 States AID/IFFLP evaluation program will

26 enable us to learn more about our recruit- the government that our contribution as a ment and outreach efforts in the hope of non-governmental organization is worthy improving them. Finally, if, as evexpect, of continued and equitable support. Such we are able to document that FAction governmental subsidy would enable I'Ac­ Familiale provides an effective and cost- tion Familiale to expand and meet a grow­ efficient NFP service, we hope to convince ing community demand.

Mathilda Mufwaya of Zambia Nursing Ser­ vices, and Sr. Mary Gabriel of Family Life Movement of Zambia The Family Life Movement of Zambia

RAYMOND MUCHINDU and RICHARD CREMINS

Raymond Muchindu, secretary of Family Life Movement of Zambia, Lusaka, Zambia: Richard Cremins, SJ., director USAID-FLMZ Demonstration Project, Zambia; assistantat St. Ignatius Parish, Lusaka, Zambia

ZAMBIA, former.' known as Northern Rhod- natural increase is an annual 3.2 percent, esla, Is a country in southern centralAfrica and,Ifpresentrates continue, thepopulation witb a territory of about 753,000 square will double in 22 years andwill reach a pro­ kilometers and a populationestimated at 6.2 jected 11 million by theyear 2000. Population million in1983. With a crude birth rate of 48 density in 1982 was 8 persons per square anda crudedeath rateof 16, Zambia'srate of kilometer, and about 40 percent of the popu­

27 lation lived in urban areas. Forty-sixpercent establishment of a counseling service. of allZambians were under the ageof 15, and only 3 percent were 65 years old or older in Growth and Development 1980. Life expectancy at birth is estimated at The present Family Life Movement of 49.1 years for males and 52.5 years for came about as a result of females. The infant mortality rate is about Zambia (FLMZ) International Federation 105 per thousand live births, down from 159 contacts with the which perthousand in 1970. for Family Life Promotion (IFFLP), About 99 percent of the people of Zambia were initiated by letter from the Council are Africans, mostly Bantu tribes, and the for the Family in 1979. In that same year, a remaining 1 percent are Europeans and Family Life Promotion Committee was set Asians. English is the official language. Reli- Up by the Christian Council of Zambia, the gions include a predominance of animists, Zambia Episcopal Conference Develop­ along with 21 percent Roman Catholics, and ment Commission, and the Zambia Coun- Protestant, Hindu, and Musrlm minorities. cil for Social Development to prepare a The percapitagross nationalproduct in 1981 national meeting on family life and natural was US $586. child spacing. The meeting was held in Family planning is encouraged by pacing. The meet was eld in Zambia's government and was specifically September 1979, and it was decided to with a mandate to mentioned in the 1979-83 Third National continue the committee Development Plan. The Health Alinistry, with organize a family life movement. funding from WHO and UNFPA, is Imple- The committee set about to persuade the menting a three-year maternal and child Ministry of Health to give natural family health andfamilyplanningprogramdesigned planning a place in its programs, and its ef­ to reach ruralareas. The main source of con- forts met with success when, in 1980, the traceptive supplies is the Family Planning permanent secretary of the Ministry of Association of Zambia. Health decided to include NFP in health programs. The committee continued to The Family Life Movement of Zambia meet every month unti! its family life activi­ (FLMZ) was initiated in 1979 to foster a ties seemed sufficiently developed to healthy and happy family life in general establish the proposed movement. A and to promote naturalfamily planning meeting of interested persons was con­ in particular. It collaborates with the vened on April 25, 1981, at the Natural Ministry of Health and other government Resources Development College, Lusaka, bodies as uell as private social service and there the movement's constitution was organizations and churches. With no adopted and a national executive commit­ religiousaffiliation,FLMZ serves all inter- tee of 10 was elected. The Ministry of estedpersons. Health reaffirmed its support of the move- The organization trains couples and ment's objectives and activities on Febru­ teachersin NFP; collects and disseminates ary 24, 1982, when it selected Dr. M. information on NFP; keeps an inventory Tyndall and Sister Juliet Manda to carry of resource materials and makes them out, on a part-time basis, the activities of available. It has been funded by private the movement. donors,fund-raisingventures, and now is Within a year, several family life groups participating in a large contract with had been formed at the local level. It is ex- USAID through IFFLP. In 1982, 22 pected that prcvincial committees will be teachersand340 users were trained. established after a sufficient number of NFP programs are now an accepted local groups have been set up in each part of government health programs in province. Zambia, and FLMZ participates in shap- The movement enjoys more support in ing governmentpolicy towardsfamily life urban areas than in rural areas because education in schools. NFP materialshave more promoters and teachers live in been published in English, Bemba, and towns. It is intended, however, to reach as Nyanja. Short-term goals include cer- many rural people as possible wiien lificationfor trainers4nd tutors and the enough teachers are trained. The approach

28 will be through existing loca) leadership, movement are to promote family life and hospitals, churches, and other institutions. marriage enrichment programs; to pro­ The FLMZ has no religious affiliation and mote respect for human life at every stage therefore serves all interested persons, of its development from conception to regardless of their religious beliefs. When death; to provide motivation and educa­ the federation of local family life gioups is tion concerning responsible parenthood established, its members may, if they wish, and fertility control by natural methods; to be affiliated with churches or other groups. coordinate the activities of its members Representatives of these family life and to offer them the services they need; to groups will elect the executive committee represent them to the government and to at an annual general meeting. The ex- other national and international bodies; ecutive appoints the director, who is ad- and to promote social action on behalf of ministratively responsible for carrying out the family. its policies and decisions. The committee Services Provided So far, the programs may also set up subcommittees focusing on and services provided include the follow­ different aspects of the work-for exam- ing: training of couples in the use of natural pie, training and counseling. The move- methods of fertility control; training of ment's basic principles are those of IFFLP, educators in the natural methods; collect­ which it has joined as one of its national ing and disseminating information about members. We have no official record 4~f family life and natural methods of child our members' religious backgrounds, but spacing; keeping an inventory of resource they include a majority of Christians and materials and making them available; and some Hindus and Muslims. combating abortion by remedying the Most of our clients come from the causes that lead people to seek it. educated group, but we are gradually ex- English is our official language, but te.iding our efforts to reach less-educated clients are taught in any of the languages and poorer classes. Every attempt is being they may understand better. We com­ made to teach NFP to couples, although monly use Nyanja, Bemba, Tonga, and husbands typically attend only the first one Lozi; English is used only in teaching more or two sessions. Another category of educated clients. clients is couples who are about to marry. Financial Suppdrt The movement at first Private-sector NFP teachers a, recruited depended on an annual budget of about from among users. In the public health ser- US$20,000 from Misereor in addition to vice (there are no private hospitals or subscriptions from local members and clinics), nurses assigned by the Ministry of other contributions. Small fund-raising Health are trained. Traditional birth atten- ventures also contributed to its financing. dants are also recruited. Funds to begin a counseling service were Aims and Objectives The Family Life received from a Samaritan group, which Movement of Zambia was founded for the later dissolved. purposes of working for a healthy and hap- The generous assistance from Misereor py family life as one of the foundations of will end in December 1983. We now have human development and for providing raised enough money in Zambia to support leadership, guidance, and education in the our activities for at least a year. We are also fields of family life education in general, planning to establish a private company to and natural child spacing in particular. The run a business, whose profits will be given FLMZ collaborates with all other bodies in- to the movement. This business will prob­ terested in these fields, including such ably be a gasoline station in Lusaka. In ad­ governmental departments as the Ministry dition, we have acquired a site for an office of Health, Ministry of Labor and Social Ser- building that will provide some rental in­ vices, Ministry of Education, and Ministry come as well as accommodation for our of Youth and Sport. It also cooperates with own needs. social service organizations and churches. Relations with Public Health Programs The In general, the aims and objectives of the movement's relationship with the Ministry

29 of Health is very cordial. in addition to giv- gram. Before supplies of thermometers ing NFP methods a place in their policy and became available toward the end of 1982, releasing staff to work with us, the Ministry the only method taught was the muctis has agreed to collaborate in our five-year method; since then, however, the demonstration program. We are also temperature and sympto-thermal methods engaged in dialogue with other govern- have been taught. This allows clients to mental ministries mentioned above with have a choice of methods. regard to family life education in schools. Candidates for teacher training must be The Catholic Church approached Misereor NFP users if they are not medical person­ for funds on our behalf, and the Christian nel. Nurses who are nominated by the Council of Zambia and the Zambia Council Ministry of Health need not be usrs, but for Social Services collaborated in our they should at least respect the wishes of foundation. the client. We are following a "gradual" Our five-year demonstration program, approach with respect to selection criteria which began in August 1983, will complete since we are at present making a first entry its first phase by the end of 1984. The total into Ministry of Health services. budget will be about US$156,715. USAID Training has normally rcquir.d about is providing the funds through IFFLP. In its five days of lectures, discussions, testing, initial stage, the program will be carried out and demonstration, followed by a super­ in three provinces to allow for easy vised practical period of six months. We supervision, plan to increase the training period to ten The present headquarters of the move- days of classwork with six months of prac­ ment is at Woodlands, a suburban shop- tical work. ping area of Lusaka. Until August 1983 the The costs of training vary de.pending on Catholic Secretariat provided office ac- the charges at the institution where the commodation and secretarial support. At workshop takes place. The minimum has the provincial level, NFP has reached eight been about US$15 per day for each of the nine provinces in the country, and trainee's room and board. Additional costs approximately 33 delivery centers have include transport, release time, equipment been or are being established. and supplies, and FLMZ staff time. With regard to affiliation of NFP pro- There are currently 4 trainers, 16 tutors, grams with medical delivery systems, only and 47 teachers affiliated with the pro­ a few hospitals have a system in which NFP gram, none of whom is full-time or paid by clinics operate side by side with clinics of- the program. All are either volunteers or on fering artificial methods. A sound base has release by their employers. Virtually all been laid, however, for almost every clinic NFP workers have continued in the pro­ to adopt the same system once enough gram; a very small number have taken tem­ NFP teachers have been trained. This is one porary leave when they changed jobs. For of the aims of the five-year demonstration the past two years, teacher evaluation and program. continuing education have been con­ ducted by the trainer/tutor team in one- or NFP Education, Training, two-clay seminars. and Service Development Service Delivery The number of users or Teacher Training Since there was no train- acceptors trained in the last few years is as ing program in Zambia when FLMZ was follows: before and in 1981, there were 11 first established, all our first NFP trainers teachers and 110 users; in 1982, 22 and tutors were trained abroad. They, in teachers and 340 users were trained; in turn, have taught teachers when funds per- 1983, only ;4 teachers and 60 users were mitted and when experts from overseas trained. The drop in 1983 was duc to the were available to give guidance. As yet, financial crisis the movement faced in the Zambia has no program for certifying NFP first half of the year. The figures for 1982, teachers, but it Is expected that such a pro- the movement's best year to date, reflect gram will emerge during the five-year pro- the fact that two training workshops for

30 teachers were held in that year. texts adapted to local conditions have been Users are selected from motivated and published, including the booklet "Fruitful interested persons who agree to use only Love," in English, Bemba, and Nyanja. The NFP methods. We do not l.ive records movement involves people from different showing what percentage of Users choose areas and religious beliefs in a common each method offered, but nearly all the program. It has gathered together scattered earlier clients followed the mucus method NFP initiatives and turned them into a na­ alone. Since thermometers have become tional movement, and has qualified to be a available, more are choosing to use the partner of IFFLP in its five-year NFP sympto-thermal method. Cost per user has demonstration program in Africa. Finally, not been estimated, an important accomplishment has been to Most acceptors are more interested h- encourage NFP in neighboring countries. spacing their pregnancies and in achieving The greatest challenges in the long term pregnancy than in limiting the size of the are to make the whole population aware of family, although the actual percentages of NFP and to help in making NFP services users according to motivation for using available to all who want them. Shorter­ NFP have not been calculated. The lack of term goals include financial self­ a record-keeping system in Zambia sufficiency; trainer, tutor, and teacher prevents us from producing statistics on training and certification; the involvement pregnancy rates, percentage of autono- of doctors, especially male doctors, in the mous couples, and coi tinuation rates (one NFP program in Zambia; establishment of a estimate of continuation iput the rate at be- counseling service; and providing support tween 70 and 80 percent). Fourteen of the and an alternative to abortion for women 1981-82 users have become teachers. with unwanted pregnancies. Outreach plans for the future call for Program Evaluation and Accountability establishing family life groups in every In the past, the program has been ac- area, devising a syllabus for family life countable to Misercor for the expenditure education, and mounting public relations of funds. With the new five-year demon- and motivation campaigns. Our greatest stration program, it will be accountable to needs at present are for personnel-trained IFFLP and USAID. As a federation.of local NFP teachers, motivators, trainers, and groups, the movement is also accountable coordinators at the provincial and district to formal and informal NFP groups, levels. We also need such material through which it relates to the community. resources as office space for national and It is also ac-ountable to government and to local centers; transport, which is essential public opinion, for reaching rural areas; training materials, including films, slides, videotapes, and Accomplishments and other visual aids; and office equipment. Development Needs In addition to continued scientific The greatest accomplishments of the research on the underlying basis of NFP FLMZ to date include establishing the methods, Zambia has particular popula­ credibility of NFP within the Ministry of tion-related research needs. They include Health so that NFP programs are now ac- the identification and clarification of Zam­ cepted as part of health programs. Par- bia's population problems, the role of birth ticipation in shaping the policy of the attendants in NFP and family life educa­ government with regard to family life tion, and a study of traditional attitudes education in the schools has also been an toward child spacing and methods for important accomplishment. Some NFP spacing pregnancies.

31 current program is structured around three Rwanda NFP demonstration centers in Kigali, Butare, and Kabgayi covering the central

and southern regicns of the 7ountry. The primary national center is in Kigali, and the other two are regional centers. In 1978 a Rwanda delegation attended The NFP teacher training program is well the WOOMB International Congress in established and lasts two weeks. The NFP Melbourne. This initiative was jointly teacher trainees are selected by the various sponsored by the bishops of Rwanda in programs or centers, which then send collaboration with the American Catholic them to either of the three major centers. Relief Service office in Kigali and the The costs of training NFP teachers is borne Ministries of Public Health and of Social Af- essenrially by the centers that send them fairs and Community Development. for training. In 1979-80 a first NFP demonstration To date, 40 teachers have been trained and service center was set up in the capital by the Gikando-Kigali center and 57 of Kigali. In the following years a local net- teachers by the Butare center. The national work began to extend to the other regions program has not yet set up its teacher of the country. In 1983 the national NF? evaluation program. program was called Family Action of From 1980 to 1983 the average number Rwanda (l'Action Familiale du Rwanda). of new NFP users has been about 118 per NFP activity began in a mixed urban and year. A new user becomes registered as rural context in the suburbs of Kigali with such after submitting at least three charts, the NFP service attached to a medico-social coming regularly to follow-up, having center licensed by the government but visited at least once as a couple, and cor­ belonging to the Catholic private health rectly following the rules of the ovulation system of the Archdiocese of Kigali. The method. socioeconomic levels of the clients range The NFP service is currently limited to from the very poor peasant up to the the teaching of cervical mucus by the government employee. The initial NFP ovulation method (Billings). The average teachers were recruited from among the cost of teaching a new user couple has not permanent social service staff of the been computed to date. Officially NFP medico-social centers. teachers are not recruited from NFP user The goals and objectivLs of the services couples, but a certain number of autono­ have remained the same from the begin- mous user-couples automatically become ning: first, to offer responsible parenthood assistant or extension teacher facilitators as a fundamental duty of the human person (motivators). in family and social life; and second, a con- The NFP program is largely insufficient cern for appropriate child spacing within with its principal obstacle being the lack of the maternal and child health context. The competent and qualified staff. Another demographic goal of reducing fertility has need is educational materials adapted to always been judged to be secondary and community needs. subject to the free, conscious, and respon- Two research areas would appear to be sible decisions of each family. most useful: biomedical research into the The NFP service is offered in the two of- stability and reliability of various fertility ficial languages of the country, French and and infertility parameters, and psycho­ Kinya'wanda. It is usually integrated with social research, especially research into the other medico-social activities or within psychology of the couple using NFP from human development in general. The ex- various cultural traditions as well as isting infrastructure of the center assumed research into the evolution of their rela­ the initial expenses of the NFP service. The tionship and sexual experience.

32 time basis. Seyc helles During 1977 l'Action Familiale received a first international aid grant of US$3,000 from UNFPA, but the Ministry of Health then withdrew one of its delegated nurses. Fortunately, a teacher from the Ministry of The first stage of NFP development Education obtained a two-year leave of began in 1971 with the arrival of a Swiss absence to work with l'Action Familiale couple trained by the Doctors Guy. Two and visited Mauritius for continued Seychellian nurses at the Ministry of Health education. along with Father Herv6 Roduit and Dr. A fourth period began with the govern­ Ferrari took steps to inform several ment's new five-year health plan. L'Action parishes of the role and goals of l'Action Familiale succeedel in participating in the Familiale (Family Action). The primary goal discussions and presented its own five-year was to offer to the Catholic population a plan, but its recommendations were not natural method of family planning. At the adopted. end of 1972, 26 persons had received their Toward the end of 1980 it 'as decided NFP teachers' certificates from l'Action to concentrate on natural family planning Familiale. (both the ovulation and sympto-thermal The second stage occurred when a methods) and to promote this work with second Swiss couple took over the earlier the Ministry. In 1981 a small pamphlet in work in NFP, primarily training teachers Creole on feminine reproductive physiol­ and conducting in-home follow-up visits of ogy and fertility parameters was published. couples using the temperature method of The high point of 1981 was the national NFP. The teachers would gather users from NFP seminar, conducted over five even­ different parishes for information sessions ings and arranged by the National l'Action on NFP and family life education. The Familiale Committee with the contribution preparation of a sex education program for of Drs. Michzle and Francois Guy. youth was also undertaken. At the perma- At the beginning of 1982, a general study nent center of l'Action Familiale, a room day was arranged with all the clergy of the was especially prepared to permit free Seychelles. During the year l'Action medical consultation for women having Familiale, in addition to its specialization in difficulty practicing NFI'. Postpartum visits NFP, attempted to integrate itself with the for information and education on NFP national program on "Family Planning, were also initiated as an outreach effort in Family Life Education, and Youth," with various delivery centers. some success. The third stage began in 1975 with the The organization continues to partici­ departure of the Swiss couple. The move- pate in the preparatory meetings for the ment was now entirely the responsibility five-year health plan (1983-88), but its ac­ of Seychellian staff. In spite of repeated ef- tivities have become more and more diffi­ forts to train teachers, many left l'Action cult. Only the permanent center of Mont Familiale because of the difficulty of ob- Fleuri is open for daily visits from new ac­ taining permanent work within the ceptors, follow-up visits from users, or in­ l'Action Familiale system. To compensate quiries from those who want to receive for this loss, Mrs. Glora Gresl6, a information on NFP. We are actively remarkably talented NFP teacher in awaiting a brighter and more promising southern Mahe, was employed on a half- future.

33 Africa Clients come from all walks of life, all South fricareligions and races. Teachers are recruited So uth from satisfied users or nurses. Our objectives are to set up programs on fertility awareness and the digni:y of womanhood in schools, youth groups, and meetings and to staff them In 1978 five participants were sent from parent-child teachers; to establish South Africa to attend the WOOMB inter- with competent train teachers, and conduct con­ national Congress and teacher training centers, workshops; and to pro­ workshop in Melbourne, Australia. On tinuing education seminars for medical their return they began teaching in Port vide introductory church workers, and those in­ Elizabeth, Cape Town, Johannesburg, and personnel, ministry. The ovulation method Kimberley. In 1980 four women were sent volved in in English, to Biimingham, England, to train in natural is the main service provided Tswana, Pedi, and Zulu. family planning. One of these is active in Afrikaans, have been made with the the Eshowe area. Other areas opened in Informal links planning clinics. Some Pretoria in 1979, and from this center government family on NFP and others refer Rustenburg in 1981, Orapa-Botswana and have literature clinics. There is no affiliation Harare-Zimbabwe in 1982. Ga-Rankuwa in clients to NFP delivery services although Bophuthatswana began as a teacher train- with medical and nurses are involved in ing center in 1981 and caters mainly for some doctors present headquarters is in the training of nurses. Mariannhill Mission training. The Sunnyside. All teachers Centre was opened in 1982, and three of- NFP Department, except for one full-time ficial teacher training workshops have are part-time Center. The total been conducted so far this year. Courses teacher in Johannesburg to 1984 from records are mainly in Zulu. The Durban center was budget from 1980 was provided by sales of started from Johannesburg. Instruction is kept in retrospect given by bishops or also available in Newcastle, Pietermaritz- books and donations amounting to burg, Mafikeng, Kimberley, Hlabisa, after presentations, were R10,449.70 Nklanda, and Phalaborwa. R10,179.24. Expenses Over the years Mary Higgins of Ireland, for the headquarters. teacher training certificates the Drs. John and Lyn Billings, Kath Smyth Originally Australia and Australian and Sue Hall of Australia, Fr. W. Gibbons, were issued from used. Since 1981 ac­ M.D., Fr. D. St. Marie of El Salvador, Sr. teaching materials have been given out Francesca Kearns of Guatamala, and Mrs. creditation certificates and Tswana/English Mercedes Wilson of Louisiana have con- in South Africa, and talks are used. ducted talks and teacher training in our books, slides, films, be taught on a one-to-one country. Teachers may of up to 26 women at a Informal national meetings between the basis or in groups but other NFP meth )ds center leaders were held at various centers time. OM is taught, are mentioned. The in 1978, 1980, 1981, and 1983. Lesotho and contraception may take a year because also sent representation. A national con- training of nurses Trainees buy their own stitution is under consideration at the of irregular hours. charts; the premises are pro­ moment. This national program is to be books and teachers are all part-time under the South African Catholic Bishops' vided. The 59 only one teacher has Conference (SACBC), Commission of volunteers, and of pregnancy). Christian Services, Department of Health dropped out (because is informal. All teachers Care and Education. As yet there is no Teacher evaluation board of directors. are users. been undertaken. At The service is attached mainly to church- No surveys have Center there ha',e been 241 related institutions, with teacher training the Sunnyside 979 to 1983. The cri­ also associated with Ga-Rankuwa Hospital new users from I is a client who and the Medical University of South Africa. terion for an acceptor

34 returns for at least one follow-up. Fifty- users telling friends and organizing talks in nine percent of acceptors are planning their homes. Larger groups are organized pregnancy, 18 percent want child spacing, in halls. It is the responsibility of clients to and 23 percent are limiting their families, keep the follow-up appointment. Our The program is accountable to the greatest needs are in teacher training, SACBC. Monthly reports are sent to the organizing a national program, wo-rking Archbishops of Pretoria, Johannesburg, with the public sector, and involving the and Durban. Outreach is informal with medical profession.

tary basis. There are no organized records of the users' data as The objectives such. of the group are: (1) to train teachers of NFP on the diocesan and parish levels (religious sisters, medical and nursing personnel, NFP started and user couples will be in 1976 at the request of the trained to teach other couples); (2) to create bishops of Tanzania as their active family and youth councils at national, dio­ response to Humanae Vitae. It was started cesan, and parish levels; (3) to integrate by the Mother and Child Health (MCH) NFP services in all Christian, mainly National Coordinator. In 1977 Missio (Ger- Catholic, mother and child health services; many) gave funds for one year's salary for and (4) to make teachers as well as couples an extra teacher. aware of the hazards of contraception. In 1979 the Family and Youth Apostolate The ovulation method is mostly taught (FYA) Coordinator was employed to work as this is easily understood by people at all in close cooperation with the MCH and levels. Handouts and a booklet have been NFP coordinator in giving both family lifL prepared in Swahili, the national language. education and NFP information to couples, We have also developed resource materials priests, religious sisters and seminarians in for teaching nonliterates. They include the diocese. In 1981 the Maryknoll Fathers analogy with the seasons to explain donated US$ 12,000 as a subsidy to NFP for periods of fertility and infertility, printing the teacher's guide and teaching substances from local plants to simulate aid materials. types of mucus, and symbols rather than There is no constitution as such, as NFP colors to show different phases of the and FYA were spread from the national menstrual cycle. level to diocesan-later parochial-levels. Our organization cooperates with the There are 10 dioceses which are members Ministry of Labor and Social Welfare, the because they have an NFP teacher and Ministry of Information and Culture and another 10 dioceses have a family and Youth, and the Tanzania Parents Associa­ youth council. There are 16 NFP teachers tion. We have established successful pro­ who are actively teaching on national and grams in the Dar es Salaam archdiocese and diocesan and/or parish levels on a volun- Dodoma diocese.

35 Americas

I ......

, - . ',l ,

NFP Instructor Suzanne Widmer with client, Diagnostic Center, Hospital Clinic, Univer­ sidad Cat6lica de Chile

36 In the vast region of the Americas, natural family planning programs have gradually been implanted in 12 to 15 countries and are growing progressively. They have developed in different ways according to national character and circumstances. The oldest NFP program Serena (Service de Regulation de Naissances) in Canada illustrates the experiential or grass-roots strengths of the early pioneers. This pro­ gram capitalized on the bilingual capabili­ ties (both French and English) of its early leaders and with government subsidies was able to spread to all Canadian provinces. The Chilean program benefited greatly from strong support from both the Catho­ lic Church and medical institutions. Dynamic professional contributions from medical schools with their research and clinical resources have been especially im­ portant in the development of this national program. Haiti demonstrates how NFP can be im­ planted in a developing country with limited resources and simple rural teachers. Many of the teachers and a majority of the clientele are illiterate. In the United States the Diocesan Devel­ opment Program for Natural Family Plan­ ning provides an example of the integration of NFP into the church network of com­ munity and diocesan services, especially those related to family life promotion. This is also the case in Venezuela and the Dominican Republic. Other NFP programs in the Americas illustrate various types or models of development. After a slow initial phase of implantation, NFP programs are now expanding steadily in response to the needs and resources of their respective communities.

37 Development of a National NFP Program in Chile

PATRICIO MENA-GONZALEZ Patricio Mena-Gonzalez, ALD., associate professor in obstetrics and gynecology, Faculty of Medicine, Universidad Na­ cional de Chile; IFFLP voting delegate representing the National Family Life Commission of the Bishops Conference of Chile

Chile is located on the western coast of gov'ernment held pretiously given to family southern South Anerica. flbe Andes MoAon- planning as a health improv'ement measure. tains are on its eastern border, and the 'acific In 197 , the most recent yearfor uhich figures Ocean forms its a estern horde.r. A pomlation are atailabtle, about 266,000 acceptors of o"about 11. 5 millio pcrswts lives it a ter- famyil planning elthods wvere reported in ,'itfo)!' ofalmost 76o,(,00 squtare kilometers. A Chile, a marked increase .,'rom the 153,000 crude birth rate of 22 per thousand is offset b2y acceptors in 1976. a crud1e dead' rate of - per tbousand, resulting in an annual rate of natural intcrease of 1.7 percent. If present trends continue, Chte will have nerl'1/5 million p)lersons bY 2000, and Developmen! of a national natural the doubling timnejor today :s population is 45 family planningprogram in Chile began years. Eighty-one percent qf C'ile's people are in response to an appealfrom the Nuncio urban dutellers, and tle overall population of His Holiness Paul VI in Chile in 1976. density is 15 persons per square kilometer. Since then two professorsof obstetrics and Aboutt a thirdofthe pcople are tnderthe age gyinecology have been working together, of 15. attdabout percent are 60 or over.F'sti- training their own collaborators andjoin­ mates of lije ex'pectancy are 63.8 ,'tarsj.or ing forces to organize an NFP teacher males and -.4yearsJorjfimales.with lIft ex- traitting course tinder the sponsorship of pectancy for the population as a whole esti- the Comisi6n Nacional de Pastoral mated at 66 y.ears. 77e infant mortalityrate is Familiar and accountable to the Chilean about 35per thotsand births. Conferencia Episcopal. This course has 77e ethnic comnposition of the poptlation is become a teacher training school. Seeking 66percent lestizo, 25percent Spanish, and 5 to serve the Church in the practical ap­ percent intligetous Indian. The official plication of its doctrine of responsible lan,wuageis Spanish, ant the population is parenthood the organizers have suc­ predominantly Roman Catbolic. I'er capita ceeded in selling tip more than 30 NFP gross national prodtuct in 198/ t'as 52,560; teaching centers throughout the country, the .'"979 income per capita wtas SI, 950. two of ,vhichare located in the hospitals of Gotvernment polic' has been pronatalist lhe Faculties of Medicine of the Univer­ since /979 wt'hen tihe got'ernment, disturbed by sidades de Chile and Cat6licade Chile. the couttryIot' birth urate, withdreuw stpport 7he other centeis are accountable to for familY planning activities. This position is various state and private institutions, and a shift from tle strong backing the Chiean in particular to dioceses and parishes. All

38 these institutionsfinance their own NFP May 1981, when his activities became an activities. In addition,economic aid is at official program of the School of Medicine present being received from the United of the Universidad Cat6lica. The program Nations F'Tnul for Population Activities included welfare work, teaching, and (UNFPA) for a specific project. Betueen research, and it obtained its own premises them, the two groups have traineda total with regular working hours, files for of 76 teachers,threeof uwhom work in NFP clinical records, and centralized statistics. in other countries. A totalof3, 167 usersof Meanwhile, Dr. Mena-Gonzalez, con­ NFP hate been trained to date, most of vinced of the value of NFP after a long and them using the ovulation method (O1). exhaustive exanination of development Various precoded materials have been programs based on artificial contraception, dieveloped, such as a system of modular responded to the Pope's appeal. He elim­ teaching adapted to the users' rates of inated all contraceptives from his own learning and instrumentsfor analysis of work and began teaching OM to his private acceptability, and follow-up of users. gynecology patients, designing his own These enable research to be conducted on teaching instruments and records for users. various characteristics of recruitment, In April 1978 all teaching of natural teaching-learning,and follou,-up of NFP methods was transferred from his private users. An important challenge is the for- office to a parish in Santiago, San Pedro de mal incorporationof a nationalcivic in- Las Condes. A group of teachers col­ stitution in the field of NIP to serve as a laborated in this work under the direction comprehensive social organfor recruiting of Professor Mena's wife. The name of the acceptors andfor obtainingfinancing to parish was to remain identified with the meet the country's NFPneeds, team that originated there. Its members called themselves the "Equipo San Pedro," Development of a National although subsequently (in 1982) they were NFP Program in Chile to leave that locality to settle in more In mid-1976 the Papal Nuncio in Chile suitable premises at the request of the Con­ the late Msgr. Sotero Sanz Villalba. urged a ferencia Episcopal de Chile. group of Catholic doctors, in compliance In March 1979 a Comisi6n Nacional de with the wishes of Hi4 Holiness Paul VI, to Pastoral Familiar was set up as a depen­ study the application of the ovulation dency of the Confcrencia Episcopal de method developed by the Drs. Billings. Chile. The commission's board of directors Two professors of obstetrics and gynccol- invited the two profes.,.urs and Senora de ogy who attended this meeting and were Mena to participate in its work, and members of the country's two largest together they formed a Grupo de Trabajo faculties of medicine lost no time in start- para la Defensa y Promoci6n de la Vida ing on preparations to meet the Pope's re- (Working Group for the Defense and Pro­ quest. Both Dr. Alfredo P~rez, a professor motion of [.ifc). By this time the field of ac­ in the Universidad Cat6lica de Chile, and tion was nationwide. Drs. P6rez and Mena Dr. Patricio Mena-Gonzalez, associate pro- and Sra. de Mena joined forces to imple­ fessor of obstetrics and gynecology, ment a national training program for Universidad de Chile, attended the Con- teachers of natural family planning gress of the International Federation for methods, which was launched in March Family Life Promotion (IFFLP) held at Cali 1980 and inaugurated by the Secretary of in 1977. Shortly thereafter, they put indc- the Conferencia Episcopal, Monsignor pendent initiatives into effect. Bernardino Pinera. This program con­ Dr. Alfredo P6rez went to Australia tinued to be the responsibility of the under the auspices of the World Health Equipo San Pedro and still is today. Pro­ Organization (WHO) to acquaint himself ft sor PCrez has been training teachers with the Billings method at the place where under an independent system as circum­ it originated. Professor Prez continued stances dictate. working on NFP in his private office until In May 1981 the Faculty of Medicine of

39 the Universidad de Chile (the national state Cat6lica and the Universidad de Chile pro­ university) inaugurated a Center for grams, respectively. In both universities Natural Family Planning Methods, whose the clients have extra-religious motiva­ mission was to operate as a research, tions, unlike those attending the centers teaching, and welfare center within the under the auspices of parishes or other framework of university activities. The Church institutions, where the motivation Equipo San Pedro now has at it: disposal- is cbedience to teaching. Most of the ,."trough the informal network of its teachers are midwives or nurse midwives, members-the necessary instnments for but some are housewives or professionals taking new and essential steps in the work specializing in other disciplines. What of spreading knowledge of NFP. really matters is that teachers must accept Thus two parallel NFP groups have and practice in their own personal lives the grown up, one centered in the Universidad lessons taught with respect to the transmis­ Catblica and the other in the Equipo San sion of life and must refrain from all profes­ Pedro, both affiiiated with the Comisi6n de sional activities that imply the use of Pastoral Familiar. Each 'as followed its contraceptives or abortifacients. own style and pattern in the performance The aim has been and is to serve the of a common task, preserving the advan- Church in the practical application of its tages of the originality and creative impulse doctrine by making natural methods acces­ of human groups working in different cir- sible to the population. The objectives are cumstances, but united by common aims, to provide services to users; to undertake friendship, and the Church. Today both teaching at all levels in the universities; to are developing multiprofessional and train NFP teachers; to conduct research on volunteer groups in preparation for the the various aspects of the problem; and to establishment of a national organization keep in close contact with the activities of which will enable them to undertake new the Comisi6n Nacional de Pastoral Famil­ and more complex tasks. iar. It is also a goal to progress from coor­ The activities of both groups are urban dination to integration where appropriate; in character, an appropriate circumstance to incorporate formally a national civic in­ in a country whose total population is 80 stitution in the NFP field; and to link up percent urban. In one case (Universidad with NFP groups and organizations in Cat6lica), their activities have a markedly other countries as well as with inter­ university character, whereas in the other national NFP organizations. (Equipo San Pedro) they reflect a complex All natural methods are taught, but the organization which today embraces more ovulation method is particularly stressed. than 30 teaching centers. Each is adminis- Recently we began experimenting with tratively independent, but they are linked courses on family life in the hope of im­ at the technical and human levels, with a proving the recruitment and follow-up of clinic providing advisory assistance in couples at the lower socioeconomic levels. technical, scientific, and welfare fields (Consultorio Universidad de Chile) and a Finance teacher training school accountable to the As regards financing, in the case of the Comisi6n Nacional de Pastoral Familiar. Universidad Cat6lica, it has depended suc­ The teaching centers are attached to the c7ssively upon WHO, the Comisi6n Na­ Church (parishes, dioceses, and so forth), cional de Pastoral Familiar, and, since as well as to the municipality (Municipali- 1981, the School of Medicine of the dad de Providencia), the Ministry of University itself. The Equipo San Pedro Health, other state health institutions, or was financed at first by voluntary contribu­ private hospitals. tions, during 1980-81 by the Comisi6n The clientele attracted by the two teams Nacional de Pastoral Familiar, and subse­ is predominantly middle or upper middle quently, again by voluntary contributions. class, with 6 percent and 20 percent from Wages and other expenditures have been the lower income strata in the Universidad covered by various institutions (Univer­

40 sidad de Chile, municipalities, state. family planning based on artificial con­ ecclesiastical, or private organizations), to traception, sterilization, or abortion. The which were added in 1983 UNFPA and the clinic belonging to the Universidad Colegio Medico de Chile (indirect Cat6lica is located in the diagnosis center financing), of the lospital of the Universkdad Cat6lica de Chile. It maintains Budget allocations informal relations (amounts given in US$) with a number of teachers working in 10 Universidad supplementary care centers. The Equipo Cat6lica de Chile San Pedro is coordinated on the basis of Year Source Amount the teacher training school--the Center for 1980 Comisi6n Nacional de Teaching of NFP Methods, accountable to Pastoral Familiar $16,700 the Comisi6n Nacional de Pastoral Farnliar 1981 School of Medicine, in Santiago, Chile. Its satellite provincial Universidad Cat6lica 15,000 centers are in Calama, La Serena, San 1982 School of Medicine, Felipe, Valparaiso, Curic6, Chill5n, Con­ Universidad Cat6lica 15,000 cepci6n, Araucania, and Punta Arenas. 1983 School of Medicine, There are 31 centers in all. Universidad Cat6lica 15,000 In some cases the NFP programs are ver­ 1984 School of Medicine, tical programs within the context of public Universidad Cat6lica 15,000 or private hospitals or clinics; some are in­ tegrated with maternal care programs or Equipo San Pedro are totally independent of the health con­ Year Source Amount text, such as those run in dioceses, 1980 Comisi6n Nacional de parishes, and our own teacher training Pastoral Familiar $16,700 school. 1981 Comisi6n Nacional de Pastoral Familiar 16,700 Teacher Training 1982 Private contributions, and Service Development Universidad de Chile 10,208 Training programs for teachers in both 1983 Private contributions, groups have certain requirements for the Universidad de Chile, acceptance of trainees. The programs both Municipalidad de Provi- present definitions of theoretical and prac­ dencia, Colegio Medico, tical objectives relating to fertility detec­ and UNFPA* 48,784 tion and techniques for teaching users; 1984 Same sources as 1983 31,265 ethical and moral principles of the teaching *Equipment of the Church on sexuality; and develop­ funds, Research and Teaching ment of aptitudes for the diffusion of Center, Universidad de Chile values implicit in natural methods and necessary for The the recruitment and follow­ two working groups have carried up of users. Both programs offer practical out different tasks. For example, the teaching of a tutorial type, with biomedi­ Universidad Cat6lica has collaborated with cal, pedagogical-administrative, and a ministerial body (Consejo Social de ethical-moral seminars, periodic appraisals, Ministros) in a program for nationwide dif- and a final examination. Teaching material fusion of natural methods. The Equipo San for the programs consists of the OM atlas, Pedro has developed informal links with technical textbooks, documentation on various Chilean organizations. teaching, and essays on sexuality ap­ As regards the future, we have been proached from the Christian standpoint. In authorized to work in various clinics or addition, audiovisual material and self­ centers accountable to the Ministry of teaching tests are used. Teachers are Health, but as yet we have received no trained in all natural methods. The dura­ budget. We maintain no link whatever tion of the course depends in the last with institutions or clinics concerned with analysis upon the qualification of the can­

41 didate for coping with the practical realities Follow-up users (in percentages) of welfare work. Continuation Pregnancy rate In the Universidad Cat6lica the training rate Life Table 13.3 course lasts six months; the Equipo San Universidad Cat6lica 49.0 Pedro 20.6* Pedro requires a minimum of 90 hours of Equipo San ° Universidad de Chile 43.4 17.0 practical work and then authorizes these *Considered as dropouts 28 percent who planned teachers to return to their teaching sites to piegnancies. take on a small number of users. The -Includes errors of method, teaching-learning, Equipo San Pedro has adopted this strategy and use, Pearl Index. because it considers that a long maturation Ctiterion for defining period-probably several years-is re- a autonomy of the couples quired to become a thoroughly reliable teacher. It also sees the need for continuing Universidad User co iple not requiring follow-up to Cat6lica interpret their signs and symptoms and education with periodic refresher courses, to keep aproper record. as well as supervision in the field. Teachers Equipo User couple not requiring frequent ad- thus trained have managed to gain a San Pedro vice, tiscrs with approximately three footing in distant provinces despite the months use of the method. We define lack of specialized medical support and as a spacing/limiting user couple one who resumes intercourse after being skepticism on the part of local society. trained to detect fertile and infertile They have laid the indispensable ground- periods with reasonable accuracy. work of awareness of church and society­ "sowing the seed" for future efforts. In the Universidad Cat6lica program, The approximate cost of training each practically none of the users wished to teacher is US$200, exclusive of study become teachers; about three percent of material, per diem, and travel. The Univer- the Equipo San Pedro users did. sid-id Cat6lica has seven teachers (one full­ time, three half-time, and three volunteers) In n d C abiit In the Universidad Cat6lica the program addition to ten volunteer associate in administration is accountable to the direc­ Tahers, Sntor of the hospital. With respect to achieve­ Thrcent fulltim,Sn per ha ent the ment of objectives and adherence to goals full-time, 91 percent part-time). and philosophical viewpoints, it is ac­ Eight-threepercent percent are voluntees. Out of countable to the dean of the Faculty of t he e an Pedro ac - 59 teachers trained, 47 are Medicine the total of i o mal o the operating abroad c in ae to the working in (inChile, rugayBrailandIreand,3 are ad 9(15 countable in all respects, informally (in Uruguay, Brazil, and Ireland), and 9 (15 boards of directors of each institution and ericet)ehavedroppedt.s ain technical and philosophical matters to Service delivery statistics are presented the Comisi6n Nacional de Pastoral below for a number of categories. Familiar. We are particularly interested in keeping Number of new users taught per year ormdclclege nomdadse and seek 1980981 982 183 urmedical colleagues informed 1980 1981 1982 1983* to do so by communicating results to 512 608 502 Universidad Cat(lica 488 associations and keeping our Equipo San Pedro 53 324 421 259 scientific doors always open to those who want to Methods taught (in percentag:-.i) get to know us. To the general public infor­ OM ST BBT mation is transmitted through interviews, Universidad Catolica 71 29 - talks, and lectures, the press, television, Equipo San Pedro 85 5 10 and radio. To evaluate teaching effec­ *Includes January-July 1983. tiveness, precoded modules, comprising content, the time taken, Nature of acceptors (in percentages) the entire teaching and the name of the teacher responsible are available. All of this information is linked pregnancyPlanning Spacing Limiting socioeconomic Universidad Cat6lica 5.5 88.5 6.0 up in the data bank with Equipo San Pedro 6.o 70.0 13.0 and cultural, biological, and reproductive

42 behavior information. In the future it will all sorts of difficulties, and in some cases be easy to calculate teaching costs for each they have generated new NFP centers, all sector and for each teacher by relating total of them embodying the values of the time taken with the number of users. Church in the field of family planning. All the foregoing effort has had no quan- We consider that the following are our titative impact on national funily planning greatest challenges: (I) to succeed in the programs, but we are well known and the establishment and mass diffusion of NFP at service provided is felt to be trustworthy. I the national level; (2) to establish the would say that we are progressively more educational and cultural strategies that will and more sought after, particularly among enable us to recruit a large popular the better-educated sectors of society. clientele; and (3) to incorporate a formal In order to step up recruitment of clien- organization capable of meeting ihc coun­ tele at a low socioeconomic level, we have try's present and future NFP needs. This started educational programs on family life organization would satisfactorily channel for the pregnant women who are cared for current efforts without sacrificing the in the prenatal clinics, which couples must originality of spirit of enterprise of each attend together. These programs empha- working group. It would be a social organ size communication, mutual respect, for the recruitment of new adherents in dif­ sexuality, and love. ferent social, economic, and cultural or As regards the follow-up of our users, we religious circles. It would also seek and ob­ have statistics on pregnancies, dropouts, tain financing. and time of use, ,as well as on the learning We need to train more teachers under process. In all centers the Pearl index is steadily improving programs, and we need used, and in the university centers life more gynecologists to act as advisers to the tables as well. As an indicator of accep- te)chers. Concurrently we need to set up a tability of NFP, the Universidad Cat6lica permanent secretariat to maintain coor­ prefers to label as dropouts those who dination of the national system. We also abandon the program after teaching and need to obtain financing for congresses, after four months' use. In the Equipo San per diem allowance and advanced Pedro, specific acceptability surveys are courses intended for adviser-gynecologists made before teaching and in the course of and teachers. Support is also needed for the follow-up of users, study seminars for members of the clergy Accomplishments and Needs and religious orders who are connected We consider that the following have with education and pastoral promotion of been our greatest accomplishments: family life, so that they will have an oppor­ 1. To have established in two univer- tunity to explore NFP in its biological, sities in a developing country NFP teaching cultural, psychological, religious, and and research programs, with professional spiritual dimensions. personnel in charge, and subject to all the We consider it advisable to seek spon­ evaluation criteria, of university medical sorship for our work from State health, programs. education, planning, information, and 2. To have established an NFP teacher research institutions, as well as from training school under the aegis of the Com- churches and sociocultural bodies isi6n Nacional de Pastoral Familiar, on the representative of national activities. basis of which a system of NFP centers We also regard the administrative and interconnected by the school has been operational aspects as an indispensable gradually set up. They are centers with a component of organic growth. In our view common methodology but with indepen- it is scientific research that will lead us to dent administrations; they are capable of participate in dialogue with the professions adhering to their stated goals in the face of and the scientific world.

43 Fritz Fransois L'Action Fomilicle of Haiti

FRITZ FRANCOIS

Fritz Franfois, national coordinatorof l'Action FanilialeofHaiti

Haiti occupies about 28,000 square kilo- African descent. French is the official meters of the Island of Hispaniolain the West language,and Creole is spoke by the majority Indies. It sharesthe islandwitb its neighborto of the people. The predominant religion is the east, the Dominican Republic. Its popula- Roman Catholicism, practiced by about 80 tion of nearly 6 million persons has a crude percent of the population. Protestants con­ birth rate of 41 per thousand and a crude stitute 10 percent of the population, and death rate of 14 per thousand. Tbe annual Voodoo is also a popularreligionin Haiti. rateof naturalincrease,2.7percent, implies a Per capita income in 1980 was about $260. doublingtime ofonly 26yearsand a projected Percapitagross nationalproductwas $297 in populationof 8.9 million in the year 2000. 1981. Population density is 220 persons per Haiti'sgovernment is committed to the con­ squarekilometer, and abouta quarterof the cept of a smallfamily, andfamily planningis population lives in urban areas. The popula- a priority in the nationalhealth plan. Abor­ tion is quite young, with 41 percent under the tion is prohibitedby law with no exceptions. age of 15. About 6percentof thepeople are 60 years old orover. Life expectancy is 51.2 years L Action Familiale, 'Haitiwasfounded for males and 54.4 yearsforfemales. Infant by a steering committee in Port-au-Prince, mortality is estimated to be between 113 and the capital in November 1971. In July 130 deaths per thousandbirths. 1973 it was recognized by the govern­ Ninety-fivc percent of the people are of ment. L'Action Familialeof Haiti(L'AFH)

44 is a nonprojssional, nonchurch move- secondaryschool education.Only oneper­ ment. It has several Protestant members cent has finished secondary school. among its educatorsandleaders. Yet, it is During the last three years (1980-82) the a member of the Episcopal Conference of program registered 7,286 new NFP users Haiti, which is the responsible legal and with only 286 unplannedpregnanciesand financialentityfor the program. 379 dropouts. L 'Action Familiale of Hai'i is also a nonmedical and nonprofessional move­ ment. The majority of teachers are Development of the farmers, and the method of teaching is National NFP Program primarily by the extension method with L'Action Familiale of Haiti came into ex­ home visiting. Al! signs orparameters of istence in i971 after much pioneering the fertile and infertile phases of the work by a Dutch missionary priest, Father menstrual cycle (temperature, cervical Michel Welters. In 1964 through a mutual mucus and cervical changes) are taught, friend in the University of Louvain, Father yet the couple is left the choice and Welters came in contact by correspon­ preference of which self-observation dence with two beginning national NFP methods or combination of indices thcy programs: Centre de 1 ;a;-n des Equipes prefer according to their motivation and de Recherches (CLER) in France, and life circumstances. Most opt for the Serena-Canada. Between 1964 and 1969, sympto-thermal method to limit births, he reviewed extensively the informal From 1972-76 IAH was administered scientific NFP literature and taught himself by a steering committee in Port-au-Prince the sympto-thermal method. In 1967 while dijferent initiatives with the ST Father Welters taught the first couples of method were undertaken across the coun- his parish the strict basal body temperature try. In December 1976 the general (BBT) method of NFP. assembl , of members meetingfor the first In 1971 a first medical coordinating time requested a nationalstructure more committee of physicians in the capital, representativeof the various regionsof the Port-au-Prince, was formed and approved country. Seven persons are uorking full- by the Episcopal Conference. In the time and 190 part-time. A first subsidy following year, the first coordinating com­ from UNFPA was obtained in 1976 for mittee chose the name "l'Action Familiale $13,500. Since 1980 this grant has been d'Haiti" (Family Action-Haiti) to denote its replacedby a USAID grantwhich in 1983 similarity in philosophy and approach to allocated$30,000 to the program. l'Action Familiale of Mauitius. lo 1972 the Since 1976 the program has also re- committee also drafted the constitution of ceived constant financial support from the or',,anization, and in July of 1973 'Ac­ Misereo, Germany, with the objective of tion iamiliale d'Haiti was officially establishing and demonstrating the ef- recognized by the government. From 1972 ficacy of the ST method in Haiti. From to 1975 l'Action Familiale d'Haiti ('AFH) 1982 to March 1983 at Misereor'srequest, was led essentially by its medical coor­ an in-depth evaluation by a cona ltant dinating committee of which Father from the Harvard Center for Population Welters was the secretary. Studies was conducted on the work of the When the World Health Organization program, wehich concluded that NFP submitted its preparatory report to the "could become te preferred method of Haitian government, it mentioned that the Haiti." sympto-thermal method should be inte­ The average clientele of users has the grated into the government plan. By not following characteristics: one-third supporting the proposal, the bishops lost Protestant and two-thirds Catholic; one- an opportunity. The Haitian offices of the third marriedand two-thirds in irregular World Health Organization (WHO) and of unions; 77 percent illiterate 11 percent the United Nations Fund for Population Ac­ with elementary and 11 percent with some tivities (UNFPA) have always remained

45 open to-if not very supportive-of NFP accomplished. As an immediate future ob­ but they cannot initiate by themselves any jective, I'AFH would like to see the govern­ action without the participation of the ment finance its ST-NFP program but leave government of Haiti. The government the stnicture and work approach of I'AFH itself will take no initiative if it does not independent. For the next few years, as we receive a proposal directly from the continue to offer ST to all interested per­ Episcopal Conference. In spite of this, sons, we plan to (1) popularize throughout I'AFH in 1976 was able to obtain its first Haiti basic knowledge of the menstrual subsidy of US$13,500 from the UNFPA cycle so that every woman can learn about with the possibility of a gradual increase. her fertile and infertile periods; and Since 1979 this subsidy has been replaced (2) popularize the notion of the cervical by one from the U.S. Agency for Interna- mucus as the major fertility sign replacing tional Development (USAID) from whom the Ogino (calendar) method. I'AFH received US$30,000 in 1983. Up to Haiti is one of the seven countries in US$34,000 is predicted for 1984. which, according to the World Fertility In 1976 Misereor, a German Catholic Survey, more than 5 percent of women use funding agency, offered a special subsidy periodic abstinence. The World Fertility to I'AFH with the objective of showing the Survey of 1977 has shown that in Haiti 2 credibility of the (ST) sympto-thermal percent of women received IUDs, 7 per­ method in Haiti, in the hope that it might cent took the pill, and 25 percent used then be integrated into the governmental periodic abstinence as a family planning plan with international funding. In 1980 method. Misereor wanted to reduce its assistance. The success of our first objectives is Since the demonstration was not yet com- especially related to a change in structure pleted, supplementary funds were re- undertaken in 1977. Although the coor­ quested for another three years to continue dinating medical committee played an the demonstration and establish the effec- important role from 1972 to 1976 in tiveness of the NFP methods. developing and building credibility, it was From April 1982 until March 1983, too localized in the capital, and the physi­ Misereor supported a special evaluation of cians did not have enough time to expand the AFH program which was undertaken activities. In December 1976 the general by an anthropologist from the Center for assembly, meeting for the first time, Population Studies of Harvard University. requested that a more representative struc­ The evaluation was generally positive. ture of all the regions of Haiti be estab­ L'AFH was described as a "highly profes- lished. In fact, between 1970 and 1973 sional organization with few equals in there were many different experiments in Haiti. Certainly there is no other local rival NFP-ST conducted by Father Welters in organization which could compete with collaboration with a small working group I'AFH's achievements with such a small in different areas of the country. In August budget. L'AFH offers its clients a ST-NFP 1973 the coordinating committee organ­ service which is well conceptualized and ized a national training workshop with 220 of the highest possible quality." The participants from 45 communes. evaluator concludes her report: "I per- During the general assembly of 1976, the sonally undertook this evaluation with question of greater participation by the many questions and doubts concerning the provinces in the direction of the move­ effectiveness of ST in Haiti. Now I am not ment was raised. In response in April 1977 only convinced that it can work and does the national committee was constituted, work but that with the appropriate recom- composed of a full-time national coor­ mendations it could be the metbod of dinator and a national administrator with choice for Haiti." (Method of choice is representatives from each region or underlined by the evaluator.) diocese, each elected for four years. This is The objective in requesting an extension the structure that pertains now. There is no of funds from Misereor has therefore been more general assembly or coordinating

46 committee, only this new representative Inadequate medical structures. national committee which meets every two months. Clientele The regional director is assisted by a The average clientele has the following regional facilitator and a regional ad- characteristics: ministrator. The regional director repre- Religion: 33% Protestants, 67% Catholics sents the region with full authority. A Marital status: 66% are not married but live in region consists of several zones with zonal "concubinage" supervisors who oversee the NFP teachers. Family size: 65% have a small family of one to With the restructuring in 1977, 'AFH three children became a national movement with its head- 29% have a family of four to six children quarters in Port-au-Prince, a training center 6% have a large family of seven to in Gonaives, and three additional centers ten children in Cap-Haitien, Hinche, and Port-Salut. Age of users: 16% are young (15-24 years of age) 54% are young adults (25-34 years) 30% are older (35-50 years) Service Delivery Literacy: 77.6% are illiterate or nearly so L'AFH is nonsectarian as far as its NFP Schooling: 10.6% have graduated from primary services and sex education of youth pro- school grams are concerned. Not only does it help 10.6% have attended one to three many user couples who are Protestants, grades of secondary school but among its leaders are Protestant I%have graduated from secondary is school teacher couples. A Jehovah's Witness one of its regional coordinators. Services Since 1972 Creole, the language spoken are offered to everyone without distinc- and understood by everyone, has been tion, whether married or not, practicing used. All the teaching brochures and NFP or not, divorced or remarried. This pamphlets have been published in Creole. choice of a nonsectarian approach is not In addition to its NFP activities, 'AFH always understood by every bishop, priest, also conducts sex education for young sister, or nurse. people through audiovisual presentations Without this nonsectarian approach it and the distribution of publications. It also would have been difficult, if not impos- has published a few items on primary sible, to coordinate nationallV all the health care, intestinal parasites, and various activities such as training, financ- venereal diseases, but its primary activity ing, administration, and the selection of remains NFP. teachers and supervisors. The Family Hygiene Division of the This approach does not exclude relation- Ministry of Health is responsible for the na­ ships with the Church and* the bishops. tional coordination of all family planning The Episcopal Conference is legally and activities. L'AFH's relations with this group financially responsible for I'AFH. The legal are quite cordial. It supports l'AFH for representative of rAFH is one of the three major reasons: (1) the outreach or ex­ bishops selected by the Episcopal Con- tension approach of l'AFH (teachers ference in agreement with the national visiting clients) is unique, and the clinical committee. model of the Division of Hygiene cannot L'Action Familiale is nonmedical and easily duplicate it; (2) NFP should be nonprofessional. There is no physician, lay available to the population, and I'AFH is nurse, religious nurse, or midwife. Prac- competent to provide this service; (3) the tically all of the teachers are farmers, and educational approach of I'AFH is basic to up to 80 percent have not completed their human welfare and complementary to the primary education. The approach is action of the ministry. Relationships with couple-to-couple. Our organization other ministries (Social Affairs, Education, reaches everywhere, even the farthest cor- and Health) are also quite cordial, as are ners of Haiti, whereas contraceptive ser- those with the Catholic bishops. Relations vices are dependent on the country's with physicians, lawyers, and legislators

47 are very sporadic. There is no movement relies mainly in its training program on a similar te I'AFH in Haiti. series of 21 drawings. For the training of the NFP user as a teacher, the instruction is simple and com­ Training of Teachers plete, illustrated with examples and testi­ All the dioceses (except one) have their monials following the plan of the teachers' own regional coordinators. Normally the booklet. (Everything is explained in terms recruitment of teacher trainees is from of the woman's cycle.) Comprehension is satisfied NFP users, just as the supervisors tested by special questions during the are selected from competent teachers and course. The teacher follows the same ap­ regional coordinators from the supervisors. proach in teaching the client in home visits At first (1970-76) NFP users were usually using as a reference the actual current cycle trained at the parish level according to de- of the woman. The teacher makes two mand. The permanent center in Port-au- visits per week in the first month, then two Prince has served since 1975 as a national visits per month for the next two months, meeting center, a library and resource and occasional visits during the next three center (thermometers, slides, cassettes), months until autonomy is reached. It is a and a continuing education center. Various tiring but fruitful schedule. group sessions for teaching were held in In isolated areas where there is an several areas of the capital. It is o lly since absence of nearby NFP teachers, a traveling 1981 that the Port-au-Prince center has team (national coordinator, national ad­ begun to be used as an actual teaching or ministrator, and supervisor) undertake a reference center for users, on an individual three-step training program for users of basis. In 1984 it is hoped that this center three days each, at intervals of one and a will also be used for group follow-up of half months and three to four months. users. These teacher-trainee sessions are 5 hours The first permanent intermediate center per day or 15 hours per session, for a total was established in Gonaives (1976-80). It of 45 hours for the formal training of an was used initially as a training center for NFP teacher stretched out over a five- or teacher trainees selected from among the six-month period. users from the different dioceses, who To train a teacher in his or her own were taught between 1970 and 1976 in the parish costs about US$45.00. If this train­ parishes. In 1980, with the help of ing is undertaken at the Gonaives Center, it Misereor, a formal training center was built costs US$75.00. The continuing education for the continuing education of all I'AFH of a teacher is estimated at US$25.00 per personnel. year. The cost of teaching NFP to a new The training of users follows the guide- user is estimated at US$13.00. lines of the teachers' booklet, which has To become NFP teachers, trainees must been regularly updated every year or two be qualified u ;ers for at least six months (Editions: 1972-73, 1979-81, and 1983). and have at least four years of elementary The teachers' booklet is the essential guide schooling. Initially the new teacher follows for teaching NFP clients. When a user only three to five new users. There is no wants to become a teacher, the same guide specific certification for NFP teachers. is also used, but it is better explained and Evaluation is usually done orally during understood. The various editions of the training workshops. Such training sessions teachers' booklets follow the same outline, are usually in small groups of 12 to 20 namely, the woman's menstrual cycle; the trainees or individually for 2 or 3 persons. observation of cervical mucus, taking the The user must mark the charts with the temperature, and basic interpretation prin- standard 1-2-3 on each consecutive high ciples; and special circumstances such as temperature day to show that the high postpartum, premenopause, and postpill. tctmperature phase has stabilized (identify­ Although I'AFH has an elaborate library ing the temperature shift). This way the with many books, magazines, and slides, it teacher can verify the comprehension of

48 Woman learning NFP under supervision in Gros Morne, Haiti

the user. Temperature charts are sent to the of the fertile and infertile periods leaving regional Supervisor every six months so the couple to choose their preference in she or he can verify the work of the self-observation methods or a combination teacher. In some areas, regional continuing based on their motivation or lifestyle." For education sessions are done monthly for I'AFH, this choice belongs essentially to the one day or every three or four months for couple, not to the professional or the NFP three days. Every two or three years, teach- teacher. Our principle is to teach and ex­ ers undergo a written multiple-choice test plain everything, enlighten the couple, and on NFP theory and chart interpretation, let the couple make their own choice. Experience in Haiti shows that couples NFP Methods Taught in Haiti prefer the strict ST, meaning they prefer to In the beginning (1976) I'AFH taught wait for the stabilized high temperature only NFP. Gradually we also began to ex- phase. plain all contraceptive methods with their advantages and disadvantages. This was Personnel done both to promote NFP and to respect Currently I'AFH has 155 part-time NFP fully the freedom of choice of the couple as teachers and 40 zonal supervisors, of stated in article 3 of our constitution. Cur- whom four work full time. There are also rently , percent of our new users have three national full-time workers. previously used some form of contraccp- Our salary scale is as follows: tion. From these persons come our most dedicated users. In fact, we hardly need to speak of contraception nowadays, since national coordinator $200 (full-time) the people have already had their own ex- national administrator $150 (full-time) perience with it. and supervisor At first the strict use of the temperature zonal/regional coordinator $120 (full-time) method of NFP was taught. In the ensuing regional coordinator $60-$80 (part-time) years, the observations of cervical mucus zonal supervisors $20-40-60 (part-time) were integrated into the teaching, and teachers $10-$20 (part-time) more recently (since 1981) cervical There are no volunteer workers since changes have also been taught. The up- the teachers receive $10 per month for 50 dated constitution (1981 revision) states hours of work. under article 2, "L'AFH teaches all the signs In general, the teachers stay in their own

49 territory. The lack of financial resources is generai to winum Lim; IL.puvll,,,u, . . the primary limiting factor. Dozens of has delegated this function. The funds in the potential teachers have presented them- received from abroad are deposited diocese to be selves but have had to be refused. The accounts of the bishop of the I'AFH. number of teachers remains stationary at used for the quarterly needs of about 150. With adequate funding we Achievement of I'AFH's Goals The objec­ could easily increase the number of tives to be reached by everyone are spelled teachers by 50 per year at $10 to $20 per out in detail in I'AFH's constitution. Up to month. We agree, however, with the now, to verify our objectives we have used evaluator (1982-1983) that this level of a moderately developed yet efficient sys­ remuneration is completely inadequate for tem of reporting as follows: the work contributed. * a registration form, to separate the in­ learners; Summary of the Last Three Years terested from the registered registration form for breast­ New e a special Reistered New Non- Unplanned feeders and the unmarried; Years LtWr Registered Pregnancics Dropouts * an activity log sheet for the teacher to 19O8( 1,576 N/A 123 167 enter the visits made to registered or non­ 1981 2,170 N/A 76 126 registered users; 1%. 1,871 667 87 86 * an activity time sheet to identify the Total 5,617 286 379 teacher's time given to information, teach­ A new user is considered a registered and travel; user if the ST is followed for three com- ing, for each plete cycles. After six completed charts, e a family registration form users are considered autonomous if they registered user; can interpret their own charts and graphs. e a dropout record, explaining the We are not using the Pearl formula for ef- reasons for dropout; fectiveness any more, but from January • a meeting sheet summary indicating 1978 until June 1979-over 13,908 date, place, participants, and topics; months of exposure-resulted in 3.8 * a monthly activity record for each pregnancies per 100 woman-years. teacher/coordinator compiled by the zonal The average cost to train a user until supervisor; autonomy is US$13.00. The number of s a teachers' activity summary in clients seeking to become pregnant is very which supervisors summarize their low, about 10 per year. The majority of the teachers' work. users have reached their family size and In addition to these administrative seek to limit their fertility. Most of our reports, the zonal coordinators verify the learning users can interpret their records work of each teacher in their area. The na­ and become autonomous after six com- tional coordinator visits all regions at least plete charts. once a year. A major problem is that we cannot meet the demand for ST because of Evaluation and Accountability insufficient resources, so we have stopped Financing The national committee over- doing any publicity. We do not evaluate sees all funding and seeks to divide our demographic impact because our work equitably the available funds to satisfy all is too limited. What is of primary interest to needs. The committee discusses how best us is the Haitian couple. to use the meager resources available. At the end of each year we compare the statis- Accomplishments and tics of each region to assess the best train- Development Needs ing strategy: at the centralized (regional) or Our most important achievement is to decentralized (local) levels. We evaluate have shown that the ST method can be strategies to increase the number of understood and followed by poor and illit­ teachers or supervisors and to minmize the erate people with great success and cost per user per region. The overall and perseveranc . What we consider our final report is communicated to the vicar greatest challenge is how to raise the

50 awareness of Haitian Christian leaders our work. (bishops, priests, sisters, and committed Our program would greatly benefit from laymen). Our greatest needs are (1) public applied clinical research on the preovula­ and official recognition of I'AFH by the tory normal infertility in the ordinary Episcopal Conference of Haiti before both menstrual cycle as well as in the special cir­ the Government of Haiti and its Christian cumstances of postpartum, premeno­ community and (2) adequate funding of pausal, and postpill women.

Diocesan Development Program for NFP

JAMES T. MCHUGH

Msgr. James T. McHugh, director, Dio­ cesan Development Program for NFP (NCCB Pro-Life Committee Washington,D.C.

The United States ofAmerica occupies more tuales anld 77. 5for females). The infant mor­ than 9 million square kilometers, mostly in talit.),r'ite is about 1.4 per thousand. North America. Forty-eigbt of its 50 states are The United States ethnic composition contiguous, but the largest state, laska, is reflects a diverse cultural heritage. The north and u'est of the others, and the fiftieth population is predominantly of European state, Hawaii, isfar west of the mainland in origin, but nearly 26.5 million blacks were the Pacific Ocean. The 1980 census counted recorded in the 1980 census. About 14.6 226.5 million inhabitants, and recent esti- million persons identified themseles as mates put the current population at more than tlispanics. The oficial language is Fnglish. 234 million. A crude birth rate of 16 and a Christianityis the mna/or religion (there areno crude death rate of 9 result in a current an- official religions in the United States), and nual rate ofnatural increase of0.7 percent. At about 52 million Americans are Roman present demographic rates, the p;opulation Catholics. 77.ere is a tilt,e tariety of lrotes­ would double in 95 years, and the projection tant denominations inl the country. for the year 2000 is for a population of 268 Per capita gross national product in the million. United States t-as S12, 530 in 1981, and per The population density isabout 25 persons calpita income in 1978 tas S8,612. per square kilometer; about three-quarters of There is no oficial polic)' on family plan­ Americans live in urban areas.About a qutar- ning in the Untited States. Services are freely ter (23.9 percent) of the people are under the availablefrom government or priv'ate outlets. age of 15. 77Te fastest grouwing segment of the Abortion has been legal since 1973. population is the oldest age group; 15.2 per­ cent are currently 60 and oteer, and that pro­ portion is expected to increase steadily 1.Life The Diocesan Det'elopmient Program expectancy stands tit74 )'ears (69.3 yearsJor for Natural Fanily Planning was estab­

51 lished by the National Conference of of the three years. Catholic Bishops (USA) in 1982 to help the There are more than 1,000 identifiable dioceses of the United States initiate a NFP progims throughout the United comprehensive NFP program; coordinate States, many of which are small, isolated, the efforts of existing NFP provider and without sufficient resources. Most of groups; integrate NFP services into all these programs have at lezst some loose af­ diocesan-sponsored educational, health filiation with the Couple-to-Couple care, and social services; and expand League, WOOMB-USA (now Family of the presentNFPprograms. Americas Foundation), St. John's Human 7he underlying philosophy of this pro- Life Center in Collegeville, Minnesota, or gram is that naturalfimily planningis at the Creighton University Natural Family the service of the family; that is, it is con- Planning Center. Although the work of sistent with a Christianvision of marriage each of these national groups is helpful, the andfamiy life and of human sexuality, bishops realized that continued develop­ 7eaching couples to practice NFP' suc- tant of natural family planning must take cessfully involves a commitment to specif- place at the diocesan level. By "develop­ ically Cbristianvalues and is one aspectof ment" is meant a determined effort to the Church's overall pastoralconcern for establish a systematic program involving thefamily. all the appropriate resources of the dio­ The nationaloffice assists the dioceses ceses so as to render knowledge of NFP in implementing the Diocesan Develop- "accessible to all married people and also ment Planfor NFP in a variety of ways. to young adults before marriage through Carryingout the programat the local level clear, timely and serious instructions and is the responsibility of the diocesan NFP education given by married couples, doc­ coordinatorand diocesan advisory com- tors -rd experts" in the words of Famili­ mittee, working with and through dio- aris Consortio. This effort must be set in cesan agencies and in collaborationwith the context of the Church's overall teach­ independent NFPprovidergroups. ing on conjugal love and responsible During the past twenty years, impressive parenthood, which sees NFP as a funda­ gains have been made in developing the mental approach to human sexuality that various natural family planning techniques places conjugal intimacy in the larger con­ and validaring their reliability. But is Pope text of marital rights and responsibilities. John Paul II notes in his Apostolic Exhorta- For the most part, the NFP program is part tion on the Family, there is need for "a of the diocesan family life program in each broader, more decisive and more system- diocese, although in some dioceses it is the atic effort to make the natutal methods of responsibility of Catholic Social Services or regulating fertility known, respected and some other agency. applied." Extremely important to this develop­ Accordingly, at the recommendation of ment effort is the involvement of priests Terence Cardinal Cooke, chairman of the and religious sisters, many of whom are ac­ Committee for Pro-Life Activitics of the Na- rive participants in the existing programs. tional Conference of Catholic Bishops Further involvement of parish priests is (NCCB), the episcopal conference estab- highly desirable, and the contribution of lished the Diocesan Development Plan for many nurses, either in hospital-based pro­ Natural Family Planning, effective January grams or as part of a husband-wife team, 1, 1982, for a period of three years. The has been a major asset. primary purpose of the Diocesan Develop- Development also involve., ictive par­ ment Plan is to assist the dioceses of the ticipation on the part of Catholic hospitals, United States in initiating, coordinating, social service agencies, and educational in­ and expanding programs of natural family stitutions. Catholic colleges and univer­ planning. This project has been funded by sities, particularly those associated with the Knights of Columbus, who hae pro- nursing schools, can provide facilities and vided a grant of S150,000 per year for each ongoing programs for the training, supervi­

52 sion, and accreditation of NFP teaches. The Role of the National OftfIe Catholic social service agencies are hnpor- Unquestionably, the major effort goes tant because very often they have a net- on at the diocesan level under the leader­ work of service sites throughout the ship of the diocesar, NFP coordinator (ap­ diocese, and their social workers are in pointed by the bishop) and the diocesan contact with couples seeking assistance in NFP advisory committee. Guidance for im­ making responsible decisions regarding plementation of the diocesan program is parenthood. found in the Diocesan Plan for Natural Family Planning Development, authorized by the NCCB Committee for Pro-Life Ac­ Objectives of the Diocesan tivities and published by the national office Development Program of the Diocesan Development Program The Diocesan Plan for Natural Family located in Washington, D.C. In general Planning Development' is directed toward terms the responsibilities of the national of­ helping each diocese inItiate a comprehen- fice include efforts to provide consultation sive NFP program; coordinate the efforts of and advice through visits to the dioceses existing NFP provider groups; integrate and by phone; provide ongoing communi­ NFP services into all diocesan-sponsored cation regarding NFP resources and the educational, health care, and social ser- activity in dioceses; enlist the support of vices; and expand present NFP programs. national and international agencies in A broad-based, multidisciplinary diocesan fulfilling the goals of the program; develop NFP advisory committee assesses needs education2l and service models for use by and resources, sets goals and priorities, and the dioceses and other church agencies and serves as the advocacy group in promoting organizations; sponsor or conduct national the full diocesan NFP program. In addition, or regional meetings of the diocesan coor­ a diocesan coordinator of NFP programs is dinators or agencies related to them; and responsible for day-to-day implementation sponsor specific research or program of the program. development seminars in areas related to The advisory committee and diocesan implementation of the diocesan program. NFP coordinator are responsible for pro- The project established by the National moting NFP at all levels of diocesan activity Conference of Catholic Bishops is under and for developing and implementing a co- the direction of the NCCB Committee for herent and consistent diocesan NFP pro- Pro-Life Activities. The late Terence Car­ gram based on diocesan needs, resources, dinal Cooke of New York was chairman of and priorities. the committee,. which includes 11 other In implementing the diocesan program, bishops from the designated regions of the the advisory committee and coordinator country. The national office is staffed by a give primary attention to the following director, an associate director, and a activities: secretary. Administrative resources of the 1. expanding the number of NFP in- episcopal conference (United States structional sites in diocesan service agen- Catholic Conference) are available to the cies and at various central areas throughout Diocesan Development Program. A na­ the diocese tional advisory committee, composed of 2. conducting professional updating diocesan directors, is currently being and training for health care personnel, organized. priests, religious sisters, existing teachers, and key diocesan administrators Philosophy of the Diocesan 3. establishing quality control systems Development Program for all NFP instructional services From the foregoing description cf the 4. forming a diocesan committee of ex- history and structure of the Diocesan isting NFP provider groups Development Program, it is clear that the 5. sponsoring NFP instructor training program is very much an ecclesial entity. It programs within the diocese. was established by the bishops, is subject

53 to the bishops, uses the resources of the Furthermore, the choice of natural fain­ episcopal conference and dioceses, and is ily planning is not simply the choice of a one part of the Church's overall apostohte reliable, aesthetically satisfactory method to the Christian family. There arc other of birth control, but the affirmation of private, nonconfessional agencies, as well mutual love and the acceptance of "dia­ as governmental and international agencies logue, reciprocal respect, shared respon­ involved in natural family planning pro- sibility and self-control." grams, but this specific program is based This philosophy was carefully and on the statement of Pope John Paul II in briefly summarized by Cardinal Cooke two Familiaris Consortio that "the ecclesial months before his death in his address to community at the present time must take the national meeting of diocesan NFP coor­ on the task of instilling conviction and of- dinators held in Washington, D.C., July fering practical help to those who wish to 17-21, 1983: live out their parenthood in a truly respon- The family is first of all a community siblc way." Pope John Paul states quite of persons who are called by God to clearly that instructing couples in NFP is a live together in love and mutual responsibility of the "ecclesial com- respect, and to share their love with munitv," that is, the Church. one another and with the larger soci­ Accordingly, natural family planning is ety of which the family is a part. seen as a service to the funily that is consis- Fundamental to family life is the com­ tent with a Christian vision of marriage, mitment of the spouses to a lifelong, family life, ard hunan sexuality. Training faithful, exclusive union in which they couples to practice natural family planning share with God in the ongoing work successfully also involves a commitment to of creation. Because of the respon­ the following specifically Christian values: sibilities and the risks of childbearing, the value of conjugal love as a lifelong, a negative attitude has developed faithful interpersonal commitment; the toward parenthood and often toward mutual effort of the spouses to decide the child. God has called them to responsibly on the timing and limiting of cooperate with Him in a special way in births in light of duties to God, to them- the work of creation. Others who are selves, to the family they already have, and unmarried do not share this God­ to the society of which they are a part; the given prerogative, nor do they have realization that in their childbearing and the right to take it on themselves. And childrearing the cou)le participates with the child, who stands as a testimony of God in the ongoing work of creation and God's creative love, is also a lasting redemption; the value of the child as a per- testimony of the love and mutual com­ son called into existence by God and mitment of its pa.ents. In your educa­ redeemed by Jesus Christ; and the nor- tional efforts you must emphasize this, mative character of the Church's teaching and not become distracted by the regarding the moral unacceptability of arti- problems of the moment nor preoc­ ficial methods of contraception as well as cupied with the reliability of natural sterilization and abortion. family planning simply as a means to In light of these theological understand- avoid childbearing. Your pedagogy ings, the Diocesan Development Program must include a balanced emphasis on is in fact a pastoral effort to assist couples in conjugal love and responsible parent­ understanding that sexuality, in the words hood, always remembering that of FamiliarisConsortio "is by no means parenthood is a privilege and a gift. something purely biological, but concerns the innermost being of the human person Activities as such. It is realized in a truly human way As ind;cated above, implementation of only if it is an integral part of the love by the Diocesan Development Program calls which a man and a woman commit them- for the designation of a diocesan coor­ selves totally to one another until death." dinator for NFP and a diocesan advisory

54 committee that will serve as a leadership hospitals in the United States, 503 re­ group. It also involves systematic develop- sponded to the survey. Of these, slightly ment of programs to train teachers and the more than one-third (177) reported that designation of sites where couples can be they presently have some type of NFP pro­ instructed and assisted in mastering the gram. With regard to future development, techniques. 56 hospitals with a program and 54 with­ During the first 18 months of activity, out one showed strong interest in initiating 151 dioceses have appointed a diocesan or expanding a program, indicating an op­ coordinator, and efforts at implementation portunity for immediate follow-up. An ad­ have resulted in a series of diocesan con- ditional 182 hospitals (66 with and 116 sultations and regional and state meetings without present efforts) also expressed of coordinators involving 60 dioceses. some interest in expanding or initiating These meetings indicate that diocesan ad- NFP1 services. visory committees are at various stages of The hospital-based NFP service pro­ formation, although in some cases the role grams tend to be a cooperative effort on of the advisory committee is performed by the part of hospital staff and trained NFP the advisory board of the sponsoring couples, and the hospitals expressed in­ agency. The national office of the Diocesan terest in recruiting additional teaching Development Program has sought to assist couples and establishing criteria to ensure the dioceses and provide a national service competent teaching and backup services. through various projects or activities. There are presently some very good train­ Consultation has been the primary effort ing programs, and the Diocesan Develop­ of the national office and staff during this ment Program has the resources and is first 18 months in order to stimulate ready to assist dioceses in establishing diocesan leadership activity and to hclp in- competent training programs. dividual dioceses evaluate their efforts and Most of the hospital programs are small, assess their needs. At the outset a survey teaching fewer than 200 couples per year. questionnaire was sent to each diocese to The majority of clients are seen three or enable the national office to construct a four times, but a substantial number of pro­ diocesan profile and to pinpoint the most grams, including the iarger ones, see pressing needs. The consultation service is couples six or more times. New clients progressive; that is, it is directed first to come from word-of-mouth recommenda­ establishing or expanding diocesan NFP tion by couples using NFP, from prc-Cana leadership and second to developing those conferences, physician referral, and refer­ specific services or programs necessary for ral from other agencies. The hospitals look the growth of a diocesan NFP program. forward to closer cooperation with the Consequently, although the majority of diocesan NFP coordinator in this are, of dioceses have concentrated on establishing recruiting. leadership and a systematic program, in a The survey indicates room for closer small number of dioceses the initial contact cooperation from physicians and clergy has already resulted in the establishment of and religious sisters. A significant number a teacher training program. Similar efforts of hospitals expressed interest in conduct­ are anticipated in many other :-,oceses by ing information and education prograns 1984. for physicians, staff, and chaplains, an ac­ Discussions with diocesan coordinators tivity that could be expanded to include indicated that some Catholic hospitals pro- the parish clergy. vided NFP services, but it was difficult to On the strength of the information de­ assess the quality and potential of these rived from this survey, guidelines for the hospital-based programs. Accordingly, in initiation of a hospital-based NFP program conjunction with the Catholic Health are being developed, and specific consulta­ Association, a survey of natural family tion to meet the needs of hospitals will be planning programs in Catholic hospitals provided. Again, it must be kept in mind was undertaken. 2 Of the 633 Catholic that assist:nce to Catholic hospitals is coor­

55 dinated with the diocesan programs so that standing of human sexuality and the pro­ each hospital is an integral part of the dio- cess of human reproduction. In effect, this cesan effort. requires an understanding of the fertility As a consequence of the initial consulta- cycle in women and the mutual respon­ tion, a number of other issues have come sibilities of the spouses in practicing to the fore. The dioceses articulated the periodic abstinence. This basic under­ need for some program to awaken the in- standing of human reproduction and of the terest and enthusiasm of priests and doc- fertility cycle has come to be known asfer­ tors. Neither group is looked upon as a tility awareness, and among those in the primary teaching resource, but both NFP movement, it is generally accepted groups can do a great deal in informing and that instruction in fertility awareness motivating young couples. should begin in the adolescent years.3 Ac­ Education of priests and seminarians is cordingly, many of the diocesan personnel seen as a high priority in the Church's com- are involved in secondary school instruc­ mitment to NFP. Priests need to be in- tional programs, and a number of dioceses formed of the scientific reliability of NFP have established pilot programs for secon­ and of the benefits that couples derive dary schools. Experience to date indicates from a commitment to NFP. Priests also that fertility awareness is best taught in the need to be encouraged to serve as spiritual context of education in marriage and fam­ counselors and motivators for couples. To ily living. The Diocesan Development Pro­ do this effectively, priests need to see NFP gram will continue to monitor these pilot within the total context of Christian family projects and provide information to the life, and they must appreciate their own dioceses. unique role in giving couples an enriched understanding of Christian marriage and A national meeting of diocesan NFP responsible parenthood. coordinators was held at the Catholic To reach this audience, a series of University of America, Washington, D.C., meetings was held with theologians in- July 17-21, 1983. There were 120 par­ terested in and supportive of NFP. This ticipants from 70 dioceses. The Center for provided both information and biblio- Family Studies at Catholic University graphical material. A second step involved cosponsored the meeting which focused circulating outlines to theologians, physi- on (1) the relationship of family con­ cians, and teaching couples and asking for mitments and values to NFP; (2) the philo­ their specific comments and suggestions. sophical and theological assumptions Finally, after surveying the literature and regarding Christian marriage and sexuality heeding the recommendations, the national that are fundamental to conjugal morality office published a small book entitled A and NFP; and (3) diocesan natural famly Theological Perspective on Natural Fano- planning program strategies and instruc­ ily Planning. The book contains four tional techniques. The major focus on essays on the theology of marriage, con- family life and marriage as a sacrament jugal love, responsible parenthood, and served to emphasize th? pastoral dimen­ conjugal morality and NFP. Each essay is sion of the diocesan program. The con­ followed by an outline, a compilation of ference program provided a forum for the statements from the Second Vatican Coun- interchange of information and experience cil, and the encyclicals or addresses of among diocesan personnel; it also offered recent popes. The book also contains an substantive presentations on the major annotated bibliography. It is directed to themes. The reliability of the various NFP priests and teaching couples to assist them methods was considered to be important, in their overall educational and pastoral but conference participants also recog­ work with engaged and unmarried couples. nized the need for more information about It is generally recognized that a positive the marriage relationship and the ap­ attitude toward natural family planning is propriate means of motivating couples to based on a mature and balanced under- practice NFP successfully.

56 Accomplishments and Needs for dealing with government; for others, it Experience has shown that a great deal is anticipated that they will serve the need more must be done to communicate the of regional communication and collabora­ reliability of NFP and the latest educational tion. It is too early to assess the impact of techniques to physicians and other health these groups or to predict their future care professionals. Many of them still activity. equate NFP with simple calendar rhythm, The first 18 months of activity has been and many also fail to perceive the dif- encouraging and holds promise for further ference, both moral and anthropological, implementation of the Diocesan Develop­ between contraception and natural family ment Program. Many dioceses have evi­ planning. Linacre, the journal of the Na- denced a readiness to expand their present tional Federation of Catholic Physicians' efforts, and there is a clear sense of identity Guilds, is committed to publishing compe- developing among the diocesan leaders. tent articles on NFP, as is Hospital Pro- The positive response of the dioceses has gress, the journal of the Catholic Health tended to validate the basic premise of the Association. Diocesan Development Program, that is, More regular and more structured com- that future NFP development must be a nvtnication between the national office strong diocesan priority, and it must be and the dioceses is called for and is ex- seen as one part of tile Church's pastoral pected to be accomplished by the regular mission to married couples and families. publication of a newsletter. A national ad- The work of other national and regional visory committee is being formed to assess NFP agencies and organizations is sup­ the program needs of the dioceses and to portive and helpful, and these groups are assist the national office in establishing expected to have an active and cooperative pcdorities and meeting the more general role in future development efforts. The needs. basic challenges remain to communicate Some efforts need to be taken to com- the reliability and personal advantages of municate progress in NFP program devel- NFP to increasing numbers of couples; to opment to governmental agencies and to create a public atmosphere favorable to the assure that access to natural family plan- practice of NFP; to give greater credibility ning be available to couples. This has been to Catholic teaching on Christian marriage, a difficult problem in the United States, conjugal love, responsible parenthood, where attitudes in the family planning sec- and conjugal morality; and to strengthen tor toward NFP have been based on a lack the Church's pastoral care for married of information and/or skepticism. The sec- couples and families by integrating NFP in­ tor has a history of strong reliance on tech- struction into existing marriage and family nological innovations to assure efficiency life programs. and effectiveness at the program level. Consequently, the needs and aspirations of married couples with regard to NFP have Notes often been overlooked or disregarded. The governme-it has provided funding in the I. See Diocesan Plan for Natural Family Plan. past for the development of instructional ning Development (Diocesan Development Program materials, but new ways need to be found for NFP, 1511 K Street, N.W., Washington, D.C., for governmental agencies to assist NFP 20005), 1981. This basic manual explains in detail each of the facets of the Diocesan Plan and provides agencies in program development and the references to other materials useful for implement- delivery of services. This will not be easily Ing a diocesan program. achieved, nor does it relieve the Church of 2. For more information see Mary Martin and W. its basic pastoral responsibility. Walker, "Survey Discloses NFP Practices, Prefer­ Regional NFP organizations have begun ences in U.S. Catholic Hospitals," HospitalProgress, February, 1983; and J. McHugh, "NFP Services in to emerge, independent of Church struc- Catholic Hospitals," Linacre,August, 1983. tures and agencies. For some, these 3. For some in the family planning field, the term regional organizations are seen as vehicles "fertility awareness" means understanding the fertil­

57 ity cycle so as to limit the use of other contraceptives during the fertile phase on the part of both husband to the fertile phase. In natural family planning, the and wife and making appropriate efforts to integrate term includes a commitment to periodic abstinence such abstinence into the conjugal relationship.

method, but other indicators are taught when it is deemed necessary. In April 1982 the permanent secretary for the family of the Episcopal Conference Until 1975 the expansion of the natural of Argentina created the so-called Area de methods of family planning in Argentina Planificaci6n Familiar Natural (Natural was limited to some small groups without Family Planning Office) which, within a funds. Having developed from a strong year, took the name Area de Servicio a la religious motivation, these groups in many Vida (Service for Life Office). It offers pro­ ca es lacked adequate technical experience. motional activities to the 58 dioceses in the In 1964 the Centro de Asesoramiento country. Matrimonial (CAM or Marriage Counseling Each program has a form of organization Center) was founded under the sponsor- appropriate to its own distinct require­ ship of the Acci6n Cat6lica de Profesio- ments. Some bishops have undertaken the nales (Catholic Professionals' Movement) coordination of activities within their own but independent of it. Between 1975 and organizational structure; others have en­ 1979 CAM received institutional support trusted them to lay and family apostolate from the Fundaci6n para la Educaci6n, la organizations. In many other locations, in­ Ciencia, y la Cultura (Foundation for stitutions similar to CAM have been estab­ Education, Science, and Cultural Affairs), lished in the capital and in the state of and since 1980 it has functioned as a center Buenos Aires. They include Centro de affiliated to Fundaci6n Acci6n Familiar Orientaci6n Familiar (Family Orientation (FUNDAFA or Family Life Foundation). Center), Centro de Orientaci6n Cristiana Between 1976 and 1981 CAM received Matrimonial (Christian Marriage Orienta­ two important subsidies from Misereor tion Center), and Centro de Asesoramiento (Germany) in the sum of approximately Familiar (CAF or Family Life Counseling US$50,000 with a local matching contribu- Center) of San Justo. tion of US$100,000. This opportune grant As of 1983, 40 courses training approxi­ facilitated the installation of its first ser- mately 1,000 teachers have been con­ vices oni marriage counseling in Catholic ducted. They work within institutional parishes by well-prepared, paid instruc- settings in private facilities or both, and at tors. This grant enabled delegates from 'resent provide monthly services of ap­ Argentina to participate in the First World proximately 800 initial consultations na­ Congress for the Family of the Americas tionwide. The instructors, who are persons and provided funds to publish an account of homogeneous technical, ethical, and of the first three years of the application of religious backgrounds, have formed a the Billings method in Argentina. rather unique association called Club de In­ Since 1980 CAM has instituted the Filial structoras Amigas de Lyn Billings (Friends Argentina WOOMB (WOOMB-Argentina of Lyn Billings' Instructors Club). Its cur­ Affiliate) and begun its program of courses rent president is Mrs. Marta Peyret de for the training of administrators and in- Zubizarreta. Owing to the relatively high structors on the natural methods of family sociocultural level of the urban areas, most planning throughout the country. Strong of the instructors are high school emphasis is placed on the ovulation graduates.

58 couple representing each province. The voting power of this couple is weighted ac­ cording to tile number of teacher couples it represents. The headquarters of Serena Canada is in Ottawa; Quebec, Ontario, Saskatchewan, and Manitoba have offices In 1955 Gilles and Rita Bre-ault began and paid staff. There are more than 100 helping couples in the tamily planning delivery centers across the country. There field. After being joined by several other is no formal affiliation of Serena NFP pro­ couples, the Montreal team in 1962 took grams with medical delivery systems. the name Serena, SErvice de REgulation However, approximately 10 hospitals have des NAissances (Service for Birth Regula- developed NFP centers using Serena tior:). By 1967 the group had about 30 teachers or former teachers is their staff. teams in the province of Quebec. In 1972 The initial teacher training consists of 12 expansion to the rest of the country (nine to 15 sessions of approximately two hours provinces) began, and in 1983 Serena had each. The sessions cover the basics of NIP, 500 teacher couples. special circumstances, how to chart, The Serena progran is based on couple- periodic abstinence, counseling and to-couple meetings in teacher couples' teaching skills, and the moral aspects of homes. Information is also given to small family planning. groups in various locations: parish halls, Traiining is done at the local level, but schools, hospitals, health or social service cerzification and accreditation is the centers. Services are also available in rural prerogative of the national level after the and urban locations. Typical clients are successful passing of exams and the recom­ young couples in 'he first 10 years of mar- mendation of the local team's leaders. The riage, or preparing for marriage. They are training is usually by lecture, but sup­ lower middle-class, both French- and plemented by role playing and supervision English-sieaking, and Catholic. They of the first teaching sessions. Serena reflect the majority of the population. specializes in the sympto-thermal method. Serena has little access to ethnic minorities, A good knowledge of the other natural although work with them has begun. methods is also given. t'he training is Teacher couples are recruited from usually spread over a period of six months. satisfied clients and have the same The cost is minirmal-about $30 a couple. characteristics. Trainees are selected from married Serena's objectives are to: (1) provide in- couples who are themselves using periodic formation on family planning, (2) teach the abstinence as a means of family planning. A sympto-thermal method, and (3) support few other criteria must also be met. There the couple practicing loving periodic con- are approximately 500 teacher couples af­ tinence as a family planning method. The filiated with the program. All are objectives have not changed since the volunteers. The dropout rate during the organization was founded; they have training period is 30 percent. After ac­ become more defined. Serena teaches the creditation the average involvement is four sympto-thermal method in French and years. Continuing education is assured by English. Other family life development or team meetings, provincial training ses­ health services are not offered since there sions, and publication of newsletters and are many other associations and agencies documents. There is no formal evaluation which do so. of the teacher's performance. Serena Canada has received an annual Serena gives information to approx­ support grant from the federal government imately 10,000 new couples a year. How­ since 1972. Two provincial programs ever, it is not possible to say that all these receive funding from their provincial couples are acceptors as the follow-up is governments. The board of directors of done only at the initiative of the new user. Serena Canada is made up of at least one The only criterion for accepting new users

59 is that both members of the couple attend teacher training program in the province of the class. There are a few exceptions, but Quebec. in general instruction is given to both part- Many research projects have been sub­ ners. SerenaOneitofdthe provinciagegroupstteachesaGMteaches mainly the ST method. mitted to funding agencies to evaluate One of the provincial groups teaches OM pregnancy and dropout statistics, as well as and ST to all new users, and offers a third use-effectiveness of learning and continuing night for follow-up as part of the package. sers, but none have been granted. Our Serena teacher couples are volunteers; u to prepare statistics operate from their own homes so very program cannot afford they 1982 we par­ is involved. If expenses at the unless funding isprovided. In provinciallittle expense and national level are taken into ticipated in a survey prepared by Montreal pronialaatio mal levae tken cot University which showed that 16 percent consideration, we may estimate the cost of Quebec women using a temporary for a new userfor couplecoplene use att $10S10 each.ofQecwmnusgatmpryech.method of family planning were using a family planning. How- Our acceptors are mostly spacers. method of natural Couples planning a pregnancy represent ever, only one-third of the total population of our clientele. approximately five percent were using a temporary method at the Under normalUnde circumstancesnomalcirumstnce coplecouples dotime.do wr Thissn surveyeprr was consideredehda repre­ h not require follow-up for more than three ti e th s u asionsdr ee- months. Few couples require this follow­ up. We cannot say if the reason is that they Probably our greatest accomplishment is can manage, or that they have dropped having succeeded in building a very well out, nor can we evaluate the continuation articulated organization where powers and rate and the pregnancy rates. responsibilities are shared at all levels. A few couples become teacher couples, Members are committed, active, and but there are enough of them to renew the responsible. The group is growing steadily local groups (five or six couples at a time). in enthusiasm. We have also succeeded in We do not actively nor systematically getting substantial public funding with no recruit teachers unless members are about strings attached. to leave. The greatest challenge is to find nongov­ The program must account for its funds ernmental funding to replace or supple­ to the members and to the grantors (federal ment what we already have. We would and provincial governments). Objectives also like to be able to answer, through are set by the groups for each level, and at research, all the questions posed pre­ each level. From time to time these objec- viously in terms of prevalence, acceptors, tives are brought to the national level and success rate, continuation rates. put into a national perspective. Five-year The greatest needs are an executive plans are prepared in consultation with director and a secretariat for the 10 provin­ every level. Goals and philosophy are set at cial groups, more material resources and the national level by representatives of the better public relations. We hope public in­ provincial corporations. There is a con- stitutions like hospitals, health units, social stant mechanism of feedback between the services, schools, will sponsor their own national office and the teacher couples. programs. Research that will benefit our The evaluation of teaching effectiveness program the most will be in the area of is done in some groups by having the special cases: breast-feeding, premeno­ teacher trainer attend the first sessions pause, postpill, adolescence. For the time given by a new trainee. There are some being, however, the expansion of the pro­ questionnaires prepared to evaluate the gram isnot impaired by the lack of research.

60 tional and cultural backgrounds. The Mexico Center was supported by a bishop and seven priests representing the Church hierarchy. The laymen and priests who founded the National Billings Center (NBC) have Natural family planning in Mexico began been committed to the teaching of the OM with the teaching of the ovulation method for a number of years. They were respond­ (OM) in 1970. Development has taken ing to calls by the Latin American Episcopal place by degrees, first through information Conference to work in the area of family sessions, then through teacl,,ig programs pastoral care. The bishops, Catholic and instructor training. Coordination and groups, and parishes were informed of the implementation of these programs at the services that could be provided by the national level followed together with con- NBC. In order to legalize the newly trol and evaluation. There are 280 part- founded organization with the civil time volunteer instructors certified by the authorities of the country, notarized National Billings Center. They work in 116 statutes were registered with the corre­ centers at diocesan and parish levels. sponding ministries on June 6, 1980, in the In 1970, after the visit of Drs. John and name of the National Billings Center for Evelyn Billings, NFP began to spread in Natural Family Planning, a nonprofit civil Mexico through promotion of the ovula- association with educational objectives. tion method (OM). In 1972 information on The initial activity of the board of direc­ the method was spread by persons of dif- tors of the NBC was to present to the ferent educational, cultural, and occupa- Mexican Bishops Conference a statement tional levels through various localities in of objectives and plan for services. An offer the Mexican Republic. In 1976, under the was made to train personnel to establish aegis of Archbishop Antonio L6pez Av~ia diocesan and parish centers in each of of Durango Diocese, Father jes us M. Perez Mexico's dioceses. The Mexican Bishops organized a program for the instruction of Conference gave its recognition on teachers of the Billings Method. October 5, 1980, through the Episcopal In the sane year, in Mexico City, tne Commission for the Lay Apostolate, signed director of the Mexican Center of Gynecol- by its president, His Excellency Bishop ogy and Obstetrics, a private health, Adolfo Suirez. His Excellency Antonio research, and teaching institution, commis- Lpez Avina, Archbishop of Durango, and sioned the laboratory director of the in- members of the Episcopal Commission for stitution, Mrs. Maria Aurora GuzmAn V., to the Family were dppointed representatives prepare a program to teach the Billings to the NBC. A request was made for incor­ method through four-week courses to pa- poration as a member of the World Organ­ tients who showed intolerance to contra- ization of the Ovulation Method Billings ceptives or who desired to regulate births (WOOMB) International. The request was by a natural method. accepted on November 3, 1980, as In 1979, the first national ovulation WOOMB of Mexico. method meeting was convened in Mexico The structural organization of the NBC is City, which agreed to fund a center for being developed and implemented through coordination and evaluation of information, departments for coordination of teaching, teaching, and training in the orthodoxy of research, regional centers, program plan­ the ovulation method in accordance with ning, and evaluation. the lines of the Church's social teachings. The coordination of the teaching depart­ The National Billings Center for Family ment selects the learning programs for Planning was founded on May 31, 1979. It adults, youth, instructors, and universities. was staffed by 45 persons, some of whom The research department reviews and were professionals in the medical field, selects bibliographic material to enrich The majority came from different educa- programs in the moral, scientific, and

61 teaching areas. The department for tion of users was undertaken in Mexico regional centers implants and evaluates City. Out of a total of 1,2,20 couples from regional programs undertaken by the Arch- different educational and socioeconomic diocese of Mexico, the pastoral zones of levels, more than 90 percent had either the Northeast, West, Center, Southeast, avoided pregnancy of spaced births over Northwest, and South of the Mexican this three-year period. Of the couples who Republic, with their respective responsible had learned to use OM in order to become persons. The department for program oval- pregnant, 92 percent continued to use OM uation will begin its functions in 1984 by to date. evaluating promotion, irfoimation, train- After two. months of application, 94 per­ ing, and the actual :niplemcntation of cent of the users had become autonomous. programs. Some 16 percent had become trained in­ The cost of teaching each couple in structors and opened new centers. Some urban areas is US$20.00 and in rural and 78 percent had become promoters of the suburban areas US$0.80. method through the educational support During the period 1980-1983, an evalua- given them and through their own initiative.

teachers; and the nreparation of teaching eu materials. frrty-five courses on the ovulation method have been given. Both husband and wife attend. Course content includes the biology of reproduction and how to use the OM; communication between the The Centro de Promocion Familiar y couple and psychological aspects of the Regulacid~n Natural de la Natalidad, method; communication between parents (Ceprofarena, Center of Family Promotion and children; information on artificial con­ and Natural Family Planning) is a nonprofit traception; and the witness of couples organization legally recognized under using OM. More than 5,000 have attended Peruvian laws as a service institution. It is these courses. We have also held four affiliated with WOOM1B International and courses especially for instructors; special has as its objective the promotion of the courses for health workers such as nurses spiritual, moral, and material va"ues of the and obstetricians; and outreach meetings married couple. It also helps couples in school associations, mothers' centers, resolve their fertility problems through nursing schools, parishes, and other ap­ natural family planning, especially the propriate institutions. Training courses Billings ovulation method. have been held in the provinces of Chim­ Training in the Billings ovulation bote, Ayachucho, Chincha, Ica, Puno, method began in Peru in 1974 in Trujillo, a Tacna, Arequipa, Aucayacu, Huacho, city in the north. It began in a pueblojotven Cerro Azul, and Nazca. (a marginal zone of the city with poor Teacher training courses include more economic resources) called Nueva Esper- scientific information on the method, anza. At the beginning of 1977 dissemina- teaching methodology, difficult cases, and tion of the method began in Lima in a the philosophical and moral principles of pueblo tet called Ciudad de Dios. Since Humanae Vitae. The instructors meet then various steps have been taken to ex- periodically to exchange work experience tend the method. This has been done and coordinate future action. through conferences, introductory A permanent consultation center was courses, and the media; the teaching and established in Ciudad de Dios more than follow-up of couples in permanent consul- five years ago. In addition to outreach, tation centers; the training of competent presentations to the couple on individual,

62 couple, and family development, and in- Most of the pregnancies resulted from struction in the ovulation method, medical couples' taking a chance on a day of low consultation is provided. Complete clinical fertility. cards are kept on every woman with scal atektiono gyc olg ac th Results in the pueblo joven of Nueva special attention to gynecological care. The Esperanza after seven years are as follows; woman's charts are also kept. The office is open once a week on Saturdays from 4 to 6 p.m. The principles of the method are ex- Number Percentage plained every week to assistant instructors, Couples using the since experience has shown that frequent method 540 100 repetition is necessary to clear up all Total number of doubts. pregnancies 50 9 We have the following statistics from Couples who did not this center after five years: have children 480 89 Number Percentage No information Numbers of couples available 10 2 taught 582 100 It is planned to establish permanent con­ Lost to follow-up 62 11 sultation centers in different parts of Lima Discontinued OM 53 9 and the country to decentralize the ser­ Continuing users 467 80 vices. Our objective is also to install a net­ work of offices in parishes with instructors From the 467 continuing users: trained in the ovulation method and with Couples who did not proper medical facilities. The Ministry of have children 434 93 Health has offered to provide the medical Couples who planned equipment. Funds to pay the personnel are and achieved now being solicited. pregnancy 5 1 The Catholic Church supports and col­ Unplanned laborates in the dissemination of the pregnancies 28 6 method through its various facilities.

63 Asia/Oceania

"4

. ." .. ...

A group session during a national NFP seminar in Korea

64 Asia/Oceania perhaps more than any other region shows how, after an initial im­ plantation phase, various programs are tackling the challenge of program develop­ ment and evaluation. The various Australian programs have developed clear central standards in both the selection and training of teachers as well as basic criteria for operating quality services. The majority of NFP programs in India have been initiated by the Catholic Church with extensive outside funding from a pri­ vate Catholic funding agency, Misereor of Germany. They illustrate some of the basic characteristics of successful programs serv­ ing a large proportion of users of non- Christian background. The Korean program is a dynamic Catho­ lic Church program integrated into parish and family life services. It is also effectively supported by the professionals from the national Catholic medical school. In most places the input of public funds remains minimal, if not insignificant. Where=s the programs of New Zealand and Australia with support from their respec­ tive governments have grown into quality NFP services catering to an increasing pro­ portion of the general population, other countries, such as Korea and India, still de­ pend primarily on church and religious initiatives. Many of the national NFP programs have developed natio ial guidelines for the train­ ing of NFP teachers and the development of NFP services. The development has been gradual, but there remains much room for improvement.

65 Australian Oouncil of Natural Family Planning

JOHN P. GALLAGHER

John P. Gallagher, M.D., general practi­ tioner; president of the Australian Coun­ cil ofNFP

Australia, the island continent, lies in the of other Protestant denominations. The per southwestern Pacific region with the Indian capita gross national product in 1981 was Ocean on its western and southern borders $11,190. and the Pacific Ocean to its east. With about There is no official government policy on 7.7 million square kilometers, Australia is family planning, and services are freely about the size of the 48 contiguous states of the availablefrom go'ernnent centers and pri­ United States. About two-fiftbs of the country tate clinics. It is estimated that 72 percent of lies in the tropical zone north of the Tropic of women aged 15 to 419 who were in marital or Capricorn; the rest is in the temperate zone. consensual unions in 1980 were using Most of Australia's 15 million inhabitants live contraceptio:. in cities on the coasts, whereas the vast arid interior is nearly unpopulated. This is reflected in thefiguresfor urban population­ 86 percent-and population density-a lou' two persons per square kilometer. 77e Australian Council of Natural The vital rates are a crude birth rate of 15.4 Family Planning, Inc. (ACNFP) was per thousand and a crude death rate of 7.4per forned in 1975 to coordinate the activities thousand, balancing out to a rate of natural of the 75 Australian NFP centers and the increase of 0.8 percent per year. At this rate, training of teachers. The objects of the the population doubling time is 82 years and Council are to promote Christian mar­ the projection to the year 2000 is for 18.1 riage and family life and the proper million persons. teaching of natural family planning. The life expectancy of Australians is 73 The NFP services are conducted by years, with females' expectation more than six volunteers with supportfrom medical and years greater than that of males (76.9 years profeqsional consultants. Funds are de­ for females versus 70.5for males). The infant rived mainly from the government and mortality rate is 11 per thousand. About a diocesan sources but are insufficient to quarter of the population is under the age of maintain and expand the work of the 15, and about 13 percent of the people are 60 centers. years old or over. To standardize teacher training and Mo! Australians are of European origin, services, the ACNFP has produced a set of About 95 percent are of British descent, eand 3 guidelines for t e selection, training, and percent arc, of other European heritac,,. The accreditation of teachers, compiled a com­ Australian aborigines make up about '.5 per- prehetsive teacher training manual, and cent ofthepopulation.The official language is drawn up a code of ethics for teachers. English. Christianityis the major religion in Members of the Council taught 6,500 new the country; 27.7 percent are Anglican, 25per- clients in 1982-83 and provided NFP in­ cent are Roman Catholic, and 25 percent are formation to another 32,000 individuals

66 (by, ua, of schools, lectures,seminars,and agency in the eyes of the community, the so forth). Church hierarchy, and the federal and state The Australian NFP centers are finaan- governments of Australia. cially accountable to the Australian The objectives of the Australian Council Catholic Social Welfare Commission, a of Natural Family Planning at.-, in brief, to body responsible to the Australian bier- promote and foster the ide-s of Christian archy, thich disbursesthe monies received marriage and family life; "o promote an( from the Australian government. These foster an understandin- jf human sexual;iy grantsaregiven onl)' to centersapproved and the love relationship in marriage; to by the bishop of the diocese. 7he bishops establish NFP centers throughout Australia and the Commission can thus control the which are staffed by competent teachers philosophy,, goals, standards,anid e.pan- and backed by good client referral systems sion of diocesan N74 organizations. should further help be requited; and to en­ Tbe Australian Council is at present courage scientific research into and the faced with the problem of maintaininga evaluation of NFP methods and services. continuingstream of new teachersand the The services conducted by members of need to obtain more, tunds for a paid the Council are the following: secretariat. 1. Individualized NFP instruction and supervision service to couples (Those receiving NFP services in Australia belong NFP National Program Development mainly to the middle- and upper middle­ Our national NFP program development class strata of Australian society. Non- could be said to have started in the late Catholic clientele now make up almost 40 1950s with the inclusion of NFIP teaching percent of the total, a different picture in marriage guidance clinics in Melbourne, from that eight years ago when less than 15 Brisbane, and Sydney. Drs. D. Dooley, J. percent were not Catholics. Clientele of Simpson, J. Billings, R. Galbally, and L. first-generation Italian, Maltese, Spanish. McMahon were the pioneers in this field. and Lebanese migrant parentage are weli By the end of 1970, two years after the represented. Services have not yet reached promulgation of ltumanae Vitae, each of the Vietnamese or Aboriginal sections of the eight archdioceses in Australia had an society because of lack of resources and NFP organization, most as part of their language and cultural difficulties.) Catholic Family Welfare Service. By 1974 2. NFP information lectures to small most rural dioceses had an NFP service, groups, schools, and members of the thus covering most of the provincial cities social, health, and community welfare of Australia. agencies As early as 1973 there were moves to set 3. I.ectures to premarriage instruction up a national body to serve as a forum and classes, nursing mothers' associations, and to coordinate the activities of the Aus- community health agencies tralian NFP centers and the training of 4. Provision of resource personnel for teachers. The Australian Council of Natural parent education and human development Family Planning was formed in July 1975 programs in Catholic and non-Catholic and incorporated in 1977. Most of the schools. members affiliated with the Victorian The services are provided mainly by Council of Natural Family Planning even- volunteers. Only six persons receive full­ tually resigned from the newly formed time renumeration; 36 are paid on a part­ Australian Council in mid-1976 to attach time basis. Teachers are entitled to, and themselves to the World Organization of most claim, small out-of-pocket expenses the Ovulation Method-Billings (WOOMB) for such costs as travel and baby-sitting, in with headquarters in Melbourne, thereby order to attend the clinics. The outside halving the original membership of the funding received by the members of the Australian Council. Nevertheless, the Australian Council in 1980-84 came from Australian Council has flourished and has the following sources (figures in Australian attained a high status as a voluntary helping dollars):

67 Australian federal government $400,000 NFP text, handouz, and chart material. In State governments 50,000 addition, the ACNFP produced an informa­ Archdiocesan and diocesan 100,000 tion film on NFP ("Caring About Fertility") Client fees, donations 90,000 and a large set of overhead transparencies Profit on sale of client materials 1 on human sexuality, NFP, and artificial Fertility"). Total $650,000 contraception ("You and Your a This equals about US$565,500 ($121,000 Candidates for teacher training attend per annum) and is quite inadequate to pay teacher training course by invitation only. for the cost of training and retraining First a center leader or some other person, vouch teachers, the rent of premises, secretarial such as a priest or a doctor, wio can a services, and the maintenance and expan- for their good character, recommends suit­ sion of services desired by the state NFP woman or couple with the qualities of organizations. able for NFP teaching. A representative a The membership of the Australian Coun- the local teacher training body conducts cil for the year 1982-83 includes 75 preliminary interview to inform them centers-that is, organized units staffed by about the training program and to assess trained teachers functioning at a venue their degree of commitment to continue recognized by the community as a place practicing and teaching NFP. If the inter­ become for NFP information, instruction, and view is positive, they are invited to is a supervision. Nineteen affiliates are also teachers. Six months of NFP charting limited members. They are individual persons in- prerequisite for acceptance. With or un­ volved in or having an interest in natural funds, the training of an unsuitable and family planning promotion and teaching. committed person is a waste of time In addition, 315 teachers (264 trained money. teachers and 51 trainees), 45 doctors and Objectives of Teacher Training Course other professionals (consultants, members The aim of the course is to help trainee of committees, lecturers, and others) and teachers acquire a complete knowledge of 57 support staff (secretaries, receptionists, fertility awareness, its scientific back­ priests, and administrators) are members of ground, and its application in the various the Council. methods of natural family planning; to in­ Nine doctors regularly teach and lecture culcate in them the skills of communica­ the at NFP centers, 25 doctors serve as tion so that they may impart effectively resource personnel or consultants, and 12 information to clients; and to develop the of doctors serve on executive committees of sensitivity and understanding required NFP organizations. the teacher-client (helping) relationship. Trainees are required to attend three NFP Education, Training, live-in weekends for the formal instruction and Service Development content of the course. This section in­ In Australia, the responsibility for cludes the following: the history and teacher training and service development philosophy of natural family planning, lies with each state or regional NFP morality and the Church's teaching on organization. In response to the need for birth regulation, human sexuality, the and and desirability of uniformity in the stand- teacher-client relationship, anatomy ards of teacher training and accreditation physiology, the scientific basis for NFP throughout Australia, the executive of the methods, the application of NFP methods Council produced a set of guidelines for in all phases of reproductive life, the teacher training programs, compiled a evaluation of methods and services, training manual, produced a set of guide- artificial methods of contraception, and, lines for setting up and running NFP finally, NFP center promotion and centers, and developed a code of ethics for administration. teachers. All these were approved and The method of formal instruction is by adopted by the membership in 1979-80. lecture, audiovisual presentation, films, An ultimate aim is to standardize all client role plays, reference texts, and so forth.

68 The time involved is about 40 hours. As yet, no procedure has been estab­ In between the periods of formal instruc- lished for evaluating the effectiveness of tion, the trainee is attached to an NFP teachers, especially those who work alone center to observe clicnt interviews con- at some country centers. The ACNFP ducted by experienced teachers. The newsletter is teacher-oriented and is a trainee is required to keep a log of the cases means of updating a teacher's knowledge and the lesson learned, and skills. Written assignments have to be com- Service Delivery Statistics The services of pleted throughout the period of training, the ACNFP are available to all who need Before accreditation the trainee has to them irrespective of status or religion. A demonstrate his or her ability to give an new client is defined as a couple or person initial client interview and instruction, to who has had more than one personal inter­ supervise the management of a client, and view and received information on NFP to conduct a telephone or correspondence methods with the intention of personal service. Most trainees undergo about 12 practice. The numbers of new clients for months of clinic experience before being the last three years are as follows: 1980-81: accredited as teachers. 8,000; 1981-82: 6,400; 1982-83: 6,500. In The total cost of training a teacher is be- 1982-83 teachers conducted 22,000 inter­ tween $300 and $400. Most of this cost is views. The number of people who re­ subsidized by funds from the government, ceived NFP information through lectures, the parent NFP body, and the local parish seminars, group discussions, schools, and or diocese. prcmarriage talks in the year 1982-83 was The ACNFP, Inc., requires accredited 39,600. teachers to update their knowledge and A recent retrospective survey by ques­ skills by regular attendance at teacher train- tionnaire of Australian NFP centers con­ ing courses, in-service courses, and NFP ducted in 1982 revealed the following conferences. Because Australia is a country client profile. Though a high percentage of of vast proportions, some country teachers responses fAl into the "unknown" cate­ may have the opportunity to attend only gory, a general picture is presented below one such course or conference per year. of age, marital status, and motivation of An accredited teacher trained by an NFP NFP clients. teacher training body approved by the Age rou Percentage ACNFP may teach in any center affiliated gg4 with the ACNFP. 21-3011-20 53.54.3 For 1982-83, the number of teachers ac- 31-40 26.6 tively involved in teaching according to 41-50 3.1 the latest count was 264. There are 51 trainees, 20 fewer than for 1981-82. There 51-60 0.8 is always a small number who leave the MaritalUnknown status Percentage11.7 teaching force because of planned preg­ nancy, family commitments, or moves to Married 73.0 areas with no established NFP service. Engaged 9.5 There are no full-time teachers (that is, Single 5.8 teachers who work 40 hours per week). De facto (consensual union) 0.6 There are 23 teachers who are reniuner- Unknown 11.1 ated on a part-time hourly basis or by the Motivation to attend NFP clinic Percentage session. The rest of the teaching force pro- To avoid pregnancy 67.2 vides an average of four hours per month To achieve pregnancy 17.1 over 11 months as unpaid volunteers ex- For menopausal counseling 3.8 cept for out-of-pocket expenses. Con- For other reasons (e.g., breast-feeding, tinuing education is provided through sex selection) 2.9 teacher training in-service courses and the Reasons unknown (not recorded) 9.0 quarterly newsletter. The sympto-thermal (ST) method or a

69 modified nucus method is chosen by most (including NFP services) by the Australian clients, government commenced in 1973. The In the matter of method and service government at the time invited the Catho­ evaluation, no further studies following lic bishops of Australia to nominate a that of Johnston, Roberts, and Spencer national body to be responsible for the (1974-76) have been conducted. No recent distribution and administration of the evaluation has been undertaken on funds. Since there was no national NFP method effectiveness and continuity rates body at the time, the bishops gave this task because of lack of finance. Informal evi- to the then National Catholic Welfare Com­ dence points to a minimal method failure mittee, which is now the Australian Catho­ rate and an overall pregnancy rate much lic Social Welfare Commission (ACSWC). lower with the use of a multi-marker The chairman of this Commission is Bishop method than with the use of the tempera- Perkins, and its National Director is Sister ture or mucus method alone. The intro- Agatha Rogers, R.S.M., M.B.E. duction of a last early safe day based on a According to a formula which has altered rhythm calculation also appears to have little in the last six years, each center is reduced the method failure rate. allocated a share of the total grant based on No accurate estimate of the time taken to past and estimated clinic workload and ex­ reach autonomy in the use of the methods penses. The Commission receives an annual taught can be given. Autonomy is reached financial statement and budget estimate when a couple have decided they can con- from each NFP center in Australia, annual fidently identify the fertile phase and statistics in regard to new and continuing comply with the rules of the method. The clients, total number of interviews, and impression is that this period varies from 6 other community activities (outreach) of to 12 months for women with norma! the center. From these statistics, the Corn­ cycles depending upon the type and ade- mission, through Sister Agatha Rogers, quacy of the mucus symptom. presents an annual submission for funding Clients return to centers until they to the Australian government on behalf of become autonomous. They are taught and the NFP centers. She is the only contact supervised individually. Should any medi- between the NFP centers and the Australian cal, marital, or social problem arise, the government, and her submission is unac­ couple can be referred to the appropriate companied by any lobbying by individuals professionals. The teachers are not trained involved at the grass-roots levels of the as marriage or family counselors. NFP movement. The Commission has no The only estimate we can make of the NFP representation, either on the Commis­ cost per client to attain autonomy is to sion or on its NFP subcommittee, because calculate a figure from funds received per of the way the Commission is structured. annum from all sources divided by the In 1977 the president of the ACNFP met number of new clients per annum, a figure with government officers to explore and which is by no means accurate. Our esti- discuss the possibility of being funded as mate is $40 per client compared with $90 an autonomous NFP body. The govern­ or more for clients who were taught and ment preferred to deal with no other body supervised by professionals. Any fees paid than the ACSWC, a position which still re­ by clients are not recoverable from medical mains today. insurance funds as are fees charged by The ACSWC will rccognize and fund medical practitioners and the Family Plan- only those NFP centers that are approved ning Association clinics, by the bishop of the diocese. In this way, The number of clients who may become the bishops of Australia and the ACSWC teachers is estimated to be about 1.0 to 1.5 have the power to control the philosophy, percent per year. goals, standard, and expansion of diocesan NFP organizations. This power may never Program Evaluation and Accountability be exercised, we hope, except in some The funding of family planning services exceptional circumstance which would be

70 difficult to envisage. The bishops of Aus- The Council has a teacher training manual, tralia actively encourage and support the issues a quarterly newsletter, and has pro­ NFP movement but leave its development duced an NFP information film and a set of and expansion to the NFP organizations. overhead transparencies and accompany­ All the state and major regional NFP ing texts for community education in organizations have a director or board or human sexuality, natural family planning committee which is appointed or elected methods, and artificial contraception. to be responsible for the coordination of Our greatest challenge now is to maintain the activities and administration of their our status by a determined effort to obtain local community NFP program with regard and train a continuing stream of new teach­ to NFP information and client instruction ers and resource personnel to meet future and supervision. demand for information and instruction, and to lobby the government for more funds to provide for a paid secretariat. Accomplishments and Neither of these will be easy in the face of Development Needs the present depression and unemployment. The ACNFP is a large voluntary organiza- The efficacy and efficiency of the NFP tion providing a "family ministry," teach- methods taught and the services provided ing and supporting thousands of couples in by members of the Council need to be re­ the use of natural methods, and giving wit- evaluated. A test kit to delineate the fertile ness to the ideals of Chri;tian marriage and phase of the cycle with a high degree of family life to thousands more each year. precision would be valuable. The most Where there is friendship, good will, and promising, in our view, are a urinary estro­ unity of purpose among the membership, gen-progesterone detection kit and a saliva goals can be achieved. The Council, which glucose detection tape. These tests will be is composed of so many autonomous agen- most helpful to women with very irregular cies, has made great progress toward stand- cycles, to those who are breast-feeding, ardization of teacher training, clinic and to premenopausal women. Such test services, and client educational material kits would make NFP more acceptable in because these tasks were unanimously en- our society. Research into the psychosocial trusted to the executive and the standing aspects of natural family planning is also committees. Goals were set and achieved, needed.

The NFP Movement in India

KATHLEEN DORAIRAJ

Kathleen Dorairaj,M.D., director of the Family' Life Center of the Indian Social Institute;president of the NaturalFamily Planning Association of India, New Delhi,India

71 India's population of 730 million is the service channels had been establishedpri­ second largest in the world, exceeded only by marily through thefacilitiesof the Catho­ thepopulationof China. The country occupies lic Church. An emphasis was placed on about 3.3 million square kilometers of the offering the service to the poor. A simpli­ Indian subcontinent in South Asia. India is fied ovulation method has gained widest about one third the size of the United States, acceptance. NFP services are integrated and the population density-225personsper into family welfare and counseling squarekilometers-is nine times greaterthan centers, community health ant education that of the United States. The vital rates in- centers, and family life e,,'ucation pro­ lude a crude birth rate of 35 per thousand grams. Significant numbers of Hindus and a crude death rate of 15 per thousand, and Muslims are served in some pro­ resulting in an annual rate of natural in- grams. At present there are 55 organized, crease of about two percent. At this rate, the well-staffed NFP programsand a number population would double in 33 years, and a of small programs. The most progressive projection to the year 2000 shows a popula- are in Kerala. This papergives details of tion of 966 million persons. NFP projects, state by state. To achieve India is predominantly rural, with only further development, NFPprograms need about22 percent of the people living in urban a large influx of trainedpersonnel. areas. About 40 percent of the population is under the age of 15, whereas 5.3 percent is in Growth and Development the older age groups, 60 years and over. Life Historically, the natural family planning a group expectancy is 50 yearsforthe population as a movement in India was initiated by ideol­ whole, and India is one of thefew placesin the of persons with a strongly religious to world where the life expectancy of men (52.6 ogy. A national organization was formed in the years) is greater than that of women (51.6 promote natural f,-nily planning among years). The infant mortality rate is about 122 early 1970s, but the work even of per thousand. Catholics was minimal, mainly because The Indianpopulation is characterizedby the conservative view of the Catholic great diversity. Indo-Aryan groups constitute Church leaders. In the mid-1970s, the NFP 72 percent of the populatioa;Dravidians,25 movement gained momentum and focused percent; and Mongoloids, 3 percent. The of- on training a large task force of volunteer to ficia! language is Hindi, and English is the promoters to offer services mainly there associate official language. Many other lan- Catholic couples. By the end of 1976, guages are spoken throughout the country, was a network of 48 autc:'omous NFP ser­ About 83 percent of the people areHindus, 11 vice channels in the country. percent are Muslims, 3 percent are Christians, As the primary motive was to offer plan­ and 2 percent areSikhs. Per capitag-oss na- Catholic couples an alternative family tionalproduct was $253 in 1981, accordingto ning method, the movement spread mainly an estimate made by the World Bank. through the infrastructure of the Catholic Governmental supportforfamily planning Church in India. Significantly, th,: move­ activities is a long-established tradition in ment shifted its focus to reach one segment India. The government was the first in the of Catholics-the poor. This shift was a world-beginning in 1952-to support a na- result of the experience gained in pro­ tional family planning program. Tbe sixth moting NFP and the realization that NFP five-yearplan, adoptedin 1981, has asan oh- was both effective and acceptable to the jective the increasein acceptorsfrom 22.5per- poor. Voluntary acceptance was found to cent of all eligible couples to 36.6 percent depend on the communication process by 1985. and the simplicity of the approach, as well as on a sensitivity to the needs of the poor. Voluntary developmental agencies that A nationalorganizationwasformed in work with poor people now promote the early 1970s to promote NFP in India. natural family planning for nondemo­ By the end of 1976 a network of 48 NFP graphic motives, eit'er through family life

72 projects and pr( ams or as part of com- reversibility, ease of use, and lack of side munity health, women's development, or effects. Moreover, in a country such as other social development programs. India, where there is an urgency to reach Altiough the motive for NFP is not popula- out to impoverished groups to help im­ tion control, successfiul use of NFP will prove the quality of their lives, the focus directly affect family fertility behavior and mrust be on methods that can be used effec­ thus contribute to a reduction in fertility. tively without close supervision and The voluntary groups hav- as a powerful methods that can be integrated into other guiding force their concern for the poor; developmental programs with minimal they are therefore eager to try any human- input. istic approach that is acceptable to the large Experience in teaching the Billings majority of the poor. They are not rigid ovulation method to poor women and and closed to alternative approaches, and couples in the Action Research Project of very often they adapt their approaches to New Delhi's Indian Social Institute has led the needs of the people in the local area. to a modification of the method. The India is a country with a great diversity spccific oictive was to improve the ac­ of ethnic and cultural groups, so the NFP ceptability of NFP among the poor with needs of the people may vary considerably low motivation and to reduce the need for fiom area to area. Among the poor, those close supervision and follow-up. It was who are most motivated to limit their fain- also felt to be important to give the poor fly size and have aspirations for their the potential to help themselves. The children may be reluctant to accept the modified method is, in fact, a fertility available methods of family planning for awareness education program, and it is be­ physical, psychological, and religious ing used to give women and couples the reasons. They may be unaware of methods potential to control fertility for nondemo­ other than sterilization, or they may have graphic reasons. Acceptability has im­ tried other methods and had problems proved considerably, mainly because the using them. modifications reduce the duration of absti­ At present, the NFP method that has nence require. This is possible when gained widest acceptance among the poor identification of the fertile period is more has been a modification of the ovulation precise. Abstinence for shorter periods is method developed by Billings. More than less of a problem despite low motivation 150,000 poor women are using a cervical among some poor couples. mucus method effectively either to space or to limit their children. As a rule, this Service Delivery method is promoted in areas with ready ac- Table I shows the distribution of ser­ ceptors, usually areas with a concentration vices promoting natural family planning in of Catholic couples, such as Tamril Nadu, the states of India. These projects are Kerala, Karnataka, and Goa. There are also autonomous and have geographical scattered programs in Andhra Pradesh, spreads from one to four districts with a West Benga1, and Maharashtra. large number of centers and subcenters. The only successful experience in pro- Some use the infrastructure of other suc­ moting the sympto-thermal method among cessful programs to reach out to people. the poor is in the slums of Calcutta, but the NFP services are also offered through effects have to be studied in light of the ef- family welfare and family counseling fort invested and with regard to the replica- centers or through informal channels by bility of the project. integrating fertility awareness teaching into The acceptance of a method of family community health and adult education. planning among the urban and rural poor They are also offered in marriage prepara­ may depend less on its effectiveness (effec- tion or family life education programs. tiveness may be more important in other There is a marked concentration of such cultural situations) than on its simplicity, integrated programs in South India, low financial and psychological costs, especially in Kerala and Tamil Nadu. Inte­

73 grated family life programs have emerged sible parenthood through natural family in South India and in other areas where the planning. priority group is Catholics, but the priority Health institutions in the voluntary sec­ group for NFP services is not necessarily tor offer NF- services, and some hospitals identical to that of family life movements have an intensive postpartum natural fain­ and programs. In the areas where the poor ily planning program. In a rural-based are the priority group and the vast majority hospital in Choondal under the Trichur are Hindus, Muslims, and tribal people, program, the postpartum program has in family life programs designed by the elite four years reached out to 6,054 poor for the elite are irrelevant, women during the lying-in period. Accord­ Haryana, Punjab, and Hhnachal Pradesh ing to Indian custom, a woman returns to in the North Zone of India have had no her mother's home for her first delivery, so programs or projects at all. In other states that all the women who are having their throughout India-Jammu and Kashmir, first baby and who may be motivated to ac­ Bihar, Madhya Pradesh, Uttar Pradesh, cept NF1P are lost to follow-up when they Rajasthan, Gujarat, Maharashtra, and return to their husbands' home 40 to 90 Orissa-the projects are scarce or limited days after delivery, often without visiting compared to the size and the needs of the the postnatal clinic. The other postnatal ac­ areas. The dearth of programs is due mainly ceptors are local women of parity two or to the lack of personnel to plan, organize, higher, and they are available to follow-up and implement the programs or to the low since they return to the postnatal clinic and motivation of the voluntary groups in later to the well-baby clinic. The effec­ these areas to promote natural family plan- tivcness of this kind of postpartum pro­ ning when the obvious need of the area is gram has not been assessed, but the social development, number of women reached has been re­ Out of the 87 programs (Table 1)initi- markably high. ated between 1976 and 1979, 11 have been In the Changanacherry, Trichur, Vera­ discontinued because of the lack of person- poly, Kanjirapally, Kothaniangalun, Erna­ nel or because of poor results. The latter kulam, Quilon, Trivandrum, Palai. Calicut, have been attributed to inappropriate and Irinjalakuda programs, the approach is design and communication strategies that through motivational, vALue-oriented group do not suit the needs of the people. There sessions. Motivated couples are instructed is a potential for developing more need- in the use of natural family planning either based programs in the areas that have given at the subcenter or in their homes by ex­ up projects and in areas where programs tension educators. The literacy rate is high have yet to be initiated but where the infra- in Kerala, so the instructors must be literate structure of other successful social devel- and highly motivated men and women. opment programs is in place. Because of cultural barriers, female ex;.-n­ sion educators may teach only the wife, Regional and Local Programs and male educators must teach the hus­ Table 2 presents the effects of the pro- band. A higher level of education is one of grams according to the area characteristics, the characteristics of motivated couples; the approach, the method of NFP pro- they are more receptive ,o change in family moted, and the number of accept rs and and fertility behavior. Houses may be dropouts. There are currently 55 organ- situated at a con:-derable distance from ized, ongoing projects with large teams of each other in Kerala, so the extension personnel. The most progressive are in the worker must work long hours and walk state of Kerala, where the programs are from house to house to reach each couple well organized and have a large number of individually. It has been found that the ex­ acceptors. Family development progranms tension approach is more effective than for youth, in the form of premarriage waiting for couples to come to the center courses and family life education, use an for instruction after they have attended an integrated approach to promote respon- initial motivational group session.

74 In Emakulam, the availability of NFP ser- were Hindus, 40.4 percent were Chris­ vices is publicized through a "mailed tians, and 1.1 percent were Muslims. A.- ', coupon system," whereby couples are in- half (52.5 percent) earned less than 200 formed about an NFP center or extension rutees a month. Out of 1,120 couples service. The potential acceptor chooses a recruited in the Vellore project i,-1981-82, suitable time and date and mails the 35 percent were under 25 years of age and coupon back to the project administrative 35 percent were 25 to 29; 90 percent cinter. Follow-up services ensure that earned less than 300 rupees a month. Of couples are visited by field workers. the acceptors, 60 percent were Hindus, In Quilon, the center has no organized and only 35 percent were Christians. In the backup project, so a duAl approach was Tuticorin project, 699 of the 2,973 accep­ used. A small priority group of fisher-fo!k tors are using the method to limit family who liv2d in communities along the coast size, whereas 1,866 are spacers and 418 are was selected and visited by field workers. using NFP to achieve pregnancy. This proj­ Those who wanted NFP instruction were ect has used the mass media effectively, taught in their huts and were told where reaching out to the masses through radio they could go for further instruction and programs. motivational sessions if they wanted to In Karnataka, the projects have varied become acceptors and users of natural motives. The Bangalore project's priority family planning, group is the poor in the slums. Although it In Tellicherry, the ,nfrastructure of the is part of a family welfare center that offers social development programs and the a number of family services, its target nutritional package program called the group is the poor. The Mangalore project Maternal and Child Health Program is used uses church infrastructure and is part of the to reach clients. The "Health for a Million" family apostolate but also uses the exten­ Program in Trivandrum is a project of inte- sion approach to reach out to the poor grated health and NFP; it reaches out to regardless of caste and creed. The project communities of fisher-folk. in Mysore is rural-based and the motive is In Palai and Calicut, the NFP program is development. it initially used the infra­ also integrated with a community health structure of the maternal and child health program. Community health workers teach (MCH) programs to promote NFP, but the NFP in the homes of women, together with project was redesigned to meet the needs education about health and nutrition, of the people and has shifted to extension In the state of Tamil Nadu, the 12 educators, who visit women in their homes. autonomous projects are affiliated with the In the Karwar and Bellary projects, NFP Tamil Nadu Family Development Center, is only one aspect of the family apostolate which was instrumental in helping to and is promoted as responsible parenthood organize the programs. NFP is promoted through the family life program. The through the infrastructure of the Catholic Belgaum project is of recent origin, Church and is only one facet of the family although small NFP centers have existed in apostolate. In the Tamil Nadu projects, the the area since 1976. This project is still i objective is family development, and NFP the experimental stage; it has a small team is only one of many family programs, in- of project personnel, but it is using the cluding family life education, premarriage infrastructure of health and family welfare. courses, and family economy. Services arc In the state of Andhra Pradesh, where not limited to Catholics; the poor of all the people are relatively backward corn­ beliefs are reached through the extension pared with those in Kerala, Tamil Nadu, approach. During the 1978-82 period, the and Karnataka, the projects are of recent 12 projects recruited 30,291 NFP acceptors origin except for the NFP service cenLer who said they intended to limit or space established at Vijaywada in 1974. This their children, project was initiated as a hospital-based In Thanjavur, 455 couples were in- service but is now integrated with other structed in 1980-81; of these 58.5 percent family life and social services. The Hyderabad project is integrated with com- followed by NFP instruction in parish sub­ munity health and operates an extension centers. The project, although basically service in the slums. Its work is mainly service-oriented, has a research element. In with poor Muslim women. the state of Maharashtra, the two projects The Guntur project is also integrated in Bombay and Poona cover essentially the with health. The Warrangal project began poor living in urban slums but are part of the as a hospital-based center integrated with the family life services offered by The health, but it is now rural-based and inte- centers implementing the project. grated with social development, especially main reason for shifting focus to the poor con­ women's development and child health, in the slums in Bombay with a high The Malgonda project initiated after 1981, centration of Catholic population was the covers very undeveloped remote areas in low acceptability of NFP by Catholics, classes the state and serves villages with a large especially the upper and middle size. The majority of scheduled castes (formerly who had limited their family are known as untouchables). There are 115 in- youth of upper and middle classes habited villages with 342,256 households, reached through premarriage courses and One cluster of villages is selected at a time, value-oriented family life education courses. and NFP education, with a motive to help There is no formal NFP project in women space their children, is integrated Ahmednagar, but there is a service network with women's development and health through the community development pro­ education. Group sessions and participa- grams. A proposal has been made to inte­ tory evaluation are the methods used to in- grate NFP formally into the existing health volve poor women who have very low programs, which until recently were closed motivation for family planning. Every to NFP and openly promoted sterilization. village has two local women selected and The need for NFP has come from the trained as NFP educators. masses, who are the beneficiaries of the The Cuddapah project is also of recent program. origin and covers the district of Cuddapah, In Gujarat, the Baroda program, initiated another less developed area with a large in 1980, is mainly rural-based. In one urban percentage of "untouchables." Because slum in Barod-, city couples are ap­ family planning is such a sensitive subject, proached directly by field workers, but in the project is integrated with women's the rural areas, family planning is a very development and the motive is purely sensitive issue and therefore has to be health- and development-oriented. The introduced through the health infrastruc- NFP team of 19 field workers and 9 coor- ture. The NFP project does not use the dinators has covered 15 villages. Although local health workers but has its own field the extension approach is used to motivate workers to implement the project. This en­ and recruit acceptors, subcenters in the sures that time is given for NFP instruction. villages are used as a backup measure. The The use of community health workers to Eluru project also serves a very undevel- promote NFP has not been found to be suc­ oped region in the state. It, too, is of recent cessful because health pc-sonnel tend to origin and is therefore in the early stages of regard NFP as a marginal program corn­ program development. In Vishakapatnam, pared with their own health care programs. NFP is offered only through unofficial In Ahmedabad, the government has channels-community health and a post- shown an interest in NFP, but there is no partum service in the voluntary health backup support from voluntary groups to sector. convince the government about the valid- In Goa, the project uses te infrastruc- ity of NFP. Moreover, the governmental ture of the Catholic Church and is there- population policies are themselves antag­ fore integrated as one of the programs of onistic to the promotion of NFP. the family life services center catering to In the state of Madhya Pradesh, the back- Catholics of all classes. The approach is wardness of the area and the marginality of motivational seminars in parish centers, the masses of people have been the main

76 incentives for the volunteer groups to con- purely extension, and the project is not centrate on adult literacy and health, proj. integrated with any other program. The ects that they considered to have higher objective is to study the effectiveness of a priority. Enthusiasm has waned because of method suited to the needs of the people. the poor effects of programs that were not A cluster sample of slums is selected, and designed on the basis of the needs and per- women are reached by person-to-person ceptions of the people. The Sager project channels of communication. Field workers was discontinued mainly because no pro- with similar social and cultural back­ gram director was available; another proj- grounds and similar family life experiences ect also hac difficulty in finding persons to are chosen for the work. There is a regular carry on the work. There is an obvious pattern of follov -up visits to homes for a need for NFP in these areas, but programs period of 12 months. designed on the basis of people's participa- In Bihar, the Patna and Muzaffarpur proj­ tion will be more successful than programs ects have reached out to a large number of with a "top-down" model, which has no poor rural and urban women with a team faith in people. of trained field workers who have similar One district of Madhya Pradcsh promotes backgrounds. The acceptability has been NFP as part of a feminist movement. These very high. Continuation has been disap. efforts have already spurred a number of pointing because a lack of personnel pre­ women's groups working for the status of vented follow-up, but the high acceptability women to promote fertility awareness as a is remarkable considering that the clients means of women's development, are not considered "ready acceptors" of In Uttar Pradesh, there is a microlevel family planning or NFP. rural program in Allahabad district inte- In West Bengal, in addition to the Cal­ grated with the health system. The Allaha- cutta slum project of the Missionaries of bad official project, which was initiated in Charity of Mother Teresa, voluntary agen­ the mid-1970s, has been reduced to a cies have projects in the rural areas. The hospital-based center mainly because of a Family Life Commission of Calcutta has a lack of administrative personnel. The -. ject in the suburban --,.d rural areas on Lucknow program has shifted its focus to the fringe of this overpopulated city. In the the rural poor in one district and has been Krishnagar project, natural family planning more successful there than in its urban- has been accepted and is used effectively oriented pilot project. In Jhansi, the effects by women and men living in the Indo- of a rural-based project are encouraging, Bangladesh border villages. The NFP proj­ and a more widespread program integrated ect has grown into a wide-based community with adult literacy and women's develop- health and development program. In the ment is needed in the area. Baraipur project, the extension approach In Rajasthan, the project has focused on has been used to reach the rural poor. Bhil tribals, and more than 8,000 of them There are satellite centers in Jalp Jguri and have been reached. Follow-up has been Raiganj in West Bengal, Jamshedpur, and difficult in these cases, but of 1,042 women Rourkala in Bihar, and Dibrugarh and Tura who were followed up, the effectiveness in Assam. has been high (11 unplanned pregnancies). In Orissa, one of India's least developed NFP education is also integrated with the areas, there are three projects in Beriiam­ health, maternal and child health, and adult pur, Balasore, and Cuttack-Bhubanashwar. literacy programs of voluntary organiza- The Berhampur project is a successful tions in some areas of Rajasthan. wide-ranging program that reaches out to In Delhi, the action-research projects illiterate tribal people through an informa­ have selected as their priority group the tion adult literacy program. The initial urban poor who have migrated from rural approach, through health workers, was areas of neighboring states and who are liv- relatively unsuccessful. ing in squatter sttlements and slums on In the union territory of Pondicherry in the fringes of the city. The approach is South India, the objective of the project

77 has been to promote and teach NFP to lay those who doubt that poor women can the foundation for a self-supporting peo- learn to use NFP effectively. ple's movement. The focus has been not The success of the present NFP projects on quantitative program inputs and out- in India can be attributed to the efforts of puts but on community involvement. program directors and field workers, the In the underdeveloped northeast, the key persons in such a program. The effec­ population size is small and the tribes there tiveness of NFP as a method depends on its value high fertility. Any attempt to pro- acceptability to the poor. In a country as mote fertility control will meet with op- large as India, where programs are scarce position. NFP education has a low priority in areas with low literacy and large popula­ compared with other value-oriented family tions, there is an obvious need to build on programs, although fertility awareness present successful projects and to offer education is readily accepted by people more NFP programs through the voluntary who place a high value on health, sector, either through social development In the Andaman and Nicobar Islands, and health or through women's programs. NFP is promoted through a widespread The work already accomplished in India community health program. highlights the need for manpower devel­ opment-personnel with the skills to plan, design, and organize need-based people's Accomplishments and Recommendations programs that impart to the poor and According to a report published by the disadvantaged the knowledge to help Indo-German Social Service Society en- themselves. titled Natural Family Planningin India, A national professional association, the 1981, a total of 96,641 couples had ac- Natural Family Pl nning Association of cepted natural family planning. Of these, India, has organized regional-level training 81 percent were poor, earning less than courses to cater to this need, in coopera­ 400 rupees per month, and only 5 percent tion with member family life associations earned more than 600 rupees per month. and the Indian Social Institute. Other Forty-five percent of the couples were organizations that have contributed to using the method to limit family size, 4 training a arge task force of NFP personnel percent were using it for spacing, and 14 are the state-level Tamil Nadu Family percent were using it to achieve pregnancy. Development Center, the regional-level Of those who were using NFP to control Natural Family Planning Training Associa­ fertility, 61 percent were rural couples and tion, Patna, and . private organization, the 27 percent lived in urban slums. Center for Research, Education, Service, Natural family planning is still a marginal and Training for Family Life Education program in India in the sense that it has not (CREST) in Bangalore. been accepted by many population experts The masses in India view fertility as a or by a large number of action groups and natural physiological process that does not development agencies, including some require a medical solution. Fertility that are related to the Catholic Church. The behavior, even among the poor, is rational, opposition to NFP comes from, among and fertility control methods that are sen­ others, those who feel that population con- si-.,ve to the needs of the people will meet trol programs are unnecessary and from with wide acceptability.

78 Table 1 Distribution of NFP Services in India, by States and Union Territories, by Population Size, Total Fertility Rati and Female Literacy Rate

State or Union Population, 1981 Total fertility rate Female literacy rate, 1981 Number of NFP Territory, (in millions) Rural Urban Rural Urban Programs

North Zone Delhi 6.20 6.0 3.2 32.07 54.17 1 Rajasthan 34.10 5.7 4.4 5.41 34.24 1 Jammu and Kashmir 5.98 5.2 2.8 N.A. N.A. I Central Zone Madhya Pradesh 52.13 6.3 4.3 8.99 42.30 7+1** Uttar Pradesh 110.86 6.9 4.8 9.86 35.82 3o Northeast Zone Assam 19.90 4.2 3.1 N.A. N.A. 10 ° Meghalaya 1.33 N.A. N.A. 23.64 57.40 1 Manipur 1.43 3.6 2.5 26.61 39.63 10 Nagaland .77 N.A. N.A. 30.13 56.72 10 Eastern Zone Bihar 69.82 N.A. N.A. 10.16 39.57 2+2+2* OJrissa 26.27 4.7 4.1 18.46 42.55 1 +2* West Bengal 54.49 N.A. N.A. 22.01 55.26 5+20 Andaman and Nicobar Islands N.A. 5.0 3.1 36.70 56.85 1 Western Zone Gujarat 33.96 5.5 4.0 24.12 51.03 1 Maharashtra 62.69 4.3 3.7 24.74 54.48 2 + 1" Goa, Daman and Diua 1.08 3.3 2.4 42.38 56.40 1 Southern Zone Andhra Pradesh 53.40 4.8 3.7 14.10 40.66 7+1* Karnataka 37.00 4.1 2.8 20.04 47.52 5+2* Kerala 25.40 3.4 3.1 62.99 70.97 17+2* Pondicherrya .06 3.6 2.3 34.47 52.46 1 Tamil Nadu 48.30 4.2 3.0 25.07 52.81 12

Notes " NFP services offered through informal channels. a Union Territories. N.A. Not available. NFP project discontinued.

Table 2 Distribution of Program Effects, by Characteristics of Area, Program Approach, Number of Acceptors Dropouts, and Unplanned Pregnancies Reported: India

Area Area Approach Method Period ofim- Number of Numlcr of Iumber of Status of characteristics promoted plementation acceptors/ dropouts ',nplanned project users pregnancies North Zone Delhi Urban/Rural Extension Modified 36 months 5,752 N.A. 9 Action/Research mucus A!mer-Jaipur Tribal belt Extem i Ovulation 24 months 1,042 N.A. I I Service (Rajasthan) Lucknow Rural hos- Extension integrated Ovulation + 12 months 3,073 N.A. N.A. Service pital-based with community modified health mucus

79 Area Area Approach Method Period of lim- Number of Number of Number of Status of characteristics promoted plementation acceptors/ dropouts unplanned project users pregnancies

AlIahabad' Urban hos- Center Ovulation N.A. N.A. N.A. N.A. Service pital-based Jhansi Rural Extension Ovulation + N.A. 1,255 N.A. N.A. Service modified mucus Central Zone Sagar Rural" Extension integrated Ovulation 12 months 204 N.A. N.A. Service with health and M.C.H. Ujjal2in Rural' Extension integrated Ovulation 12 months 42 NA. N.A. Service with health Khandwa-* Rural* Extension integrated Ovulation 12 months N.A. N.A. N.A. Service with health Jagdalpur' Rural' Extension integrated Ovulation 12 months 302 N.A. 22 Service with MCH program Eastem Zone Patna Urban slums Extension develop- Simplified 36 months 13,641 7,325 517 Service ment programs mucus Muzaffarpur 246 villages Extension develop- Simplified 24 months 15,401 4,368 262 Service ment programs mucus Daltanganj' Rural (Tribal) Integrated with Ovulation 12 months 20 N.A. N.A. Service women's development Bhogalpur' Rural Integrated with Ovulation N.A. NA. N.A. N.A. Service health Krishnagar Rural Extension and inte- Ovulation + 36 months 2,869 N.A. N.A. Service grated with health simplified mucus Darjeeling' Rural and Family Apostolate Ovulation N.A. N.A. N.A. N.A. Service Tribal Jalpaguri" Rural (Tribal) Lxtension integrated Ovulation 12 months 231 N.A. N.A. Service with M.C.H. Calcutta Rural/Urban Extension Sympto- 7 years N.A. N.A. N.A. Service/Research thermal Baraipur Rural Extension Ovulation 36 months 1,140 N.A. N.A. Service Berhampur Rural and Extension integrated Modified 12 months 295 N.A. 4 Service Tribal with health and mucus adult literacy Balasore Rural and Extension and Ovulation 24 months 986 N.A. N.A. Service Tribal Development Cuttack- Rural and Center Ovulation 12 months 115 N.A. N.A. Service Bhubaneshwar Tribal Andaman and Rural Integrated with Modified N.A. 571 N.A. N.A. Service Nicobar health and M.C.H. mucus Western Zone Poona Urban/Hindu Extension with Ovulation 36 months 517 N.A. N.A. Service Catholic Family Apostolate Bombay Urban/Hindu Center, extension, Modified 12 months 1,170 N.A. N.A. Service Catholic Family Apostolate mucus Ahmednagar Rural/Hindu Extension integrated Modified 12 months N.A. N.A. N.A. Service with health mucus Baroda Rural/Hindu Extension integrated Modified 18 months 578 24 18 Service with health and mucus M.C.H. South Hyderabad '..A. Integrated with Ovulation 36 months 639 N.A. N.A. Service community health

80 Area Area Approach Method Period of im- Number of Number of Number of Status of characteristics promoted plementation acceptors/ dropouts unplanned project users pregnancies

Cuddapah N.A. Integrated Ovulation 12 months 326 N.A. N.A. Service with women's development Eluru 4.A. Integrated with Ovulation 6 months N.A. N.A. N.A. Service development Nalgonda N.A. Integrated Modified 6 months 500 N.A. N.A. Service with women's mucus development Guntur N.A. Integrated with Ovulation 24 months 366 N.A. N.A. Senice health Vijayawada N.A. Family Apostolate Ovulation/ 36 months 3,650 . N.A. RA. and community simplified development mucus Vishakapatnam N.A. Integrated with Ovulation 12 months N.A. N.A. N.A. NA. health and com­ munity development Warrangal N.A. Family Apostolate Ovulation 36 months 1,623 N.A. N.A. N.A. and health Balla y N.A. Family Apostolate Ovulation 36 months 1,623 N.A. N.A. Service Bangalore N.A. Family Apostolate Ovulation 36 months 4,183 N.A. N.A. Service Mysore N.A. Development Ovulation 36 months 3,849 60 4 Service program Karwar N.A. Family Apostolate Ovulation 24 months 628 N.A. N.A. Service Beigaum N.A. Family Apostolate Ovulation 12 months N.A. N.A. N.A. Service Mangalore N.A. Family Apostolate Ovulation 36 months 1,835 N.A. N.A. Service Chickmangalur N.A. Family Apostolate Ovulation 6 months N.A. N.A. N.A. Service Vljayapuran N.A. Family Apostolate Ovulation 36 months 9,833 N.A. N.A. Service Calicut N.A. Integrated with Modified 30 months 4,102 148 33 Service community health mucus Quilon N.A. Family Apostolate Ovulation 36 months 566 N.A. N.A. Service Verapoly N.A. Fanily life services Ovulation 24 months 820 N.A. 12 Service Alleppey N.A. N.A. Ovulation 36 months 195 N.A. N.A. Service Tiruvalla N.A. Integrated with Ovulation 24 months N.A. N.A. N.A. Service development Trivandrum A.D. N.A. Integrated with Ovulation 36 months 4,227 N.A. N.A. Service community health Ballery N.A. Integrated with Ovulation 6 months N.A. N.A. N.A. Service tribal development Trivandrum N.A. Integrated with Ovulation 6 months N.A. N.A. N.A. Service M.C.H. program Emakulam N.A. Family Apostolate/ Ovulation + 24 months 1,987 217 Nil Service women's develop- modified ment and health mucus Trichur N.A. Family Apostolate Ovulation + 36 months 4,102 1,813 73 Service and health modified mucus Changanacherry N.A. Family Apostolate Ovulation 36 months 1,430 N.A. N.A. N.A. Tellicherry' N.A. Integrated develop- Ovulation + 12 months 250 N.A. Nil N.A. ment and health modified mucus Pala N.A. Integrated with Ovulation -i36 months 2,700 N.A. Nil N.A. community health modified mucus Kothamangalam N.A. Family Apostolate Ovulation ...... nths 725 N.A. N.A. N.A. Palaghat N.A. lntegratcd with Ovulation + 24 months 2,326 N.A. N.A. N.A. development modified mucus Kanjirapally N.A. Family Apostolate Ovulation 2,1mo,..' 956 36 5 N.A. Irinjalakuda N.A. Family Apostolate Ovulation 24 months 2,347 N.A. N.A. N.A.

81 Area Area Approach Method Period of im- Number of Number of Number of Status of characteristics promoted plementation acceptors/ dropouts unplanned project users pregnancies

Goa Urban/Rural Integrated with Ovulation 36 months 318 N.A. N.A. Service family life services Madras" Urban Integrated with Ovulation 36 months 630 N.A. N.A. Service/Research family life services Salem' Urban/Rural Integrated with Ovulation 24 months 1,090 N.A. N.A. Service family life services + extension Coimbatore ° Urban/Rural Integrated with Ovulation 24 months 1,372 N.A. N.A. Service family life services + extension Tiruchinapalli Urban/Rural Integrated with Ovulation 24 months 1,727 N.A. N.A. Service family life services + extension Thanjavur' Urban/Rural Integrated with Ovulation 36 months 943 + 20 1 Service family life services 455' + extension Ootacamund' Urban/Rural Integrated with Ovulation 24 months 953 N.A. N.A. Service family life services + extension Madurai' Urban/Rural Integrated with Ovulation 24 months 1,882 N.A. N.A. N.A. family life services + extension Tuticorin Urban/Rural Integrated with Ovulation 36 months 2,973 N.A. N.A. Service family life services + extension Palyamkottai' Urban/Rural Integrated with Ovulation 24 months 1,097 N.A. N.A. Service family life services + extension Kottar' Urban/Rural Integrated with Ovulation 24 months 3,951 N.A. N.A. Service family life services + extension Kumbakonam Urban/Rural Integrated with Ovulation 24 months 3,255 N.A. N.A. Service family life services + extension Vellore" Urban/Rural Integrated with Ovulation 36 months 953+ 18 N.A. Service family life services 120* + extension Pondicherry Rural Extension integrated Ovulation 24 months 240 N.A. N.A. Service with community development Total Number of acceptors- 126,941; number of recor,.ed dropouts- 14,029 *Sources: Family Planning Programme in Indlia-IGSSS. Report of the Projects Presented to the Natural Family Planning Association of India.

82 courses from among the couples who are successfully using natural family planning in their own married life, and the training is based upon an apprenticeship within a WOOMB center for six months to one year, during which the formal seminars and confer­ ences are attended. The Ovulation Method Research and A marriage counseling service is con­ Reference Centre of Australia operates a ducted from the headquarters center Family Life Centre which serves the family where medical consultation and spiritual through natural family planning, marriage advice may also be obtained. The medical counseling, educational programs on consultations include the investigation, by human sexuality in secondary schools, an expert natural family planning teacher, marriage preparation courses, collabora- of all pregnancy cycles. A marriage prep­ tive research in reproductive biology, and aration course is provided each month and the publication of a quarterly bulletin. concentrates on the establishment of emo­ Throughout Australia there are 110 affili- tional harmony in marriage, with emphasis ated centers which teach natural family upon the responsibilities accepted by the planning, staffed by accredited teachers husband and wife in making their commit­ who have received a broad training in ment to each other. The sources of some natural family planning and who offer the difficulties in making the necessary ad­ ovulation method as the primary method justments to married life are described and for routine instruction. Forty-five of the become the subjects for consideration in Australian centers are located in the state of workshops. Information is provided about Victoria and are grouped as the Natural fertility regulation by natural family plan­ Family Planning Council of Victoria; ning, as well as the traditional Christian twenty-one of the centers are located in the philosophy of conjugal love and family life. metropolitan area of Melbourne. One sub- The School Program has been directed committee of the Council is working to to year 11 and year 12 students. The full provide information for various ethnic program includes six sessions, the first groups, and teaching literature is provided being an information night for parents, in various languages including Chinese, followed by five sessions each of about French, Greek, Italian, Polish, Spanish, and one and a half hours duration, usually one Vietnamese. Information about the ovula- session per week in successive weeks. The tion method is also available in Braille. A information night is intended to encourage large consultation service is provided by parents to accept their responsibility to telephone and correspondence. question what their children are being In the provision of natural family plan- taught in the field of sex education, to ning, the education of teachers is a matter educate the parents and give them useful of primary concern. This involves an annual terminology, and in particular to help conference with an intensive teacher- establish dialogue between the parents and training program, various in-service train- their children which is likely to be initiated ing seminars, supervised by an educational by the remainder of the program, if it does subcommittee which provides coordina- not already exist. The School Program has tor-supervisors for the various centers. The the general title "Christian Sexuality: teachers' educational programi comprises Creative Love." not only technical instruction but also a In all of the sessions within the schools, study of the ideals which motivate people time is allowed for discussion within small to use natural family planning, including groups and the answering of questions. In­ respect for the human person, responsible struction is assisted by various visual aids parenthood, and the sense of mutual love including films, such as "The First Days of with self-commitment. Trainee teachers Life." During 1983 the School Program are usually invited to enter the training was presented in 21 Melbourne rchools

83 altogether, at some of which the number of Professor Erik Odeblad of the Department students was so large that the program was of Bio-Physics, Umea University, Sweden, presented twice. Fifty-nine trained volun- visited Melbourne in order to establish cor­ teer teachers assisted; the total number of relations between women's observations parents who attended was 864, and the made after instruction in the ovulation total number of students was 2,607. In ad- method, the hormonal parameters and the dition programs of one or two sessions biophysical properties of mucus formed by were given by 20 teachers in 13 schools, the cervix during the cycle. It is intended with an attendance of 152 parents and 362 that this project will be continued through­ students. out the next year. The teachers involved in the School Pro­ gram are additional to those who work in Many of the teachers have been involved the natural family plannin'g centers. They in promotional activities, lectures to have a separate training coti:se of five ses- medical associations, trainee nurses, nurs­ sions which maintains a high standard of ing mothers, and various civic groups. A teaching and a continuing supply of presentation of the scientific work on te..chers. which the guidelines of the ovulation The collaborative research program with method are based was prepared and Professor J.B. Brown of the Royal formed a segment of a very successful Women's Hospital, University of Mel- television documentary "Breakthroughs." bourne, and Professor Henry Burger, Visits by cxperienced teachers were made Prince Henry's Hospital, Monash Uriiver- to rural areas and other states in Australia, sity, Melbourne, which began in 1962, is and during the year eight accredited continuing, and has involved the hormonal teachers shared teaching visits to 18 over­ monitoring of several hundreds of women seas countries altogether, in response to re­ with various physiological and pathologi- quests for assistance to establish or expand cal conditions of the reproductive system. existing natural family planning programs In 1983 the program was expanded when using the ovulation method.

UL { taught the signs and symptoms of fertility toand avoid the wayconception. to time theirBy means sexual ofactivities simple instructions, even illiterate women and The natural family planning program in men in Bangladesh have already learned to Bangladesh was begun by a registered follow this method successfully. If indi­ nurse/midwife in the latter part of 1976. viduals or couples who have used the She had received her training in the ovula- method themselves desire to teach it to tion method from Dr. C. B. Haliburton of others, they are required to attend teacher Tamil Nadu, India. At present, in addition training seminars at which the anatomy to the founder/director, the staff includes a and physiology of fertility and reproduc­ program administrator, three field super- tion are taught in detail. At the end of such visors, two full-time teachers and part-time seminars, the individual's knowledge and teachers numbering 13 married couples comprehension of the specific details, as and 42 individual women or men. Semi- well as the application of principles to real nars in the ovulation method and teacher life situations, are tested. After basic train­ training workshops have been held at the ing, a teacher begins to instruct fellow program center or at the Caritas Seminar villagers in the ovulation method and Hall in Dacca, as well as in the various begins to keep records on users. These villages where interest has been shown. records are periodically checked by a Through individual instruction and group supervisor to pick up possible errors in in­ workshops, individuals and couples are terpretation of physical signs, or in the

84 record keeping itself. Teachers receive on- home visits in the villages. Three teachers going education at workshops which are are Muslim and two are Hindu. Additional held once or twice a year either in Dacca or Muslim and Hindu women are being re­ at some other central location. cruited as teachers for their villages. Full-time teachers and supervisors At present there are 985 couples (260 of receive monthly salaries, and part-time whom are considered autonomous) using teachers are paid for their services in pro- the ovulation method to limit or plan their portion to the number of clients they families. It is difficult to claim any substan­ follow (10 Bangladesh Taka per month per tial impact for the program. It is still a very active client). Young men and women in small undertaking in comparison to the high schools, colleges and in premarriage total needs of Bangladesh Nevertheless we sessions are also instructed in fertility are encouraged by the growing interest in awareness and natural family planning. the method among people of all classes and Various forms of the communications religious groups and the support of media are being employed to make the woikers in other voluntary agencies. ovulation method better known and ac- In a country with such a low rate of eco­ cepted as a legitimate and highly effective nomic development, few people can afford method of family planning. But our best to volunteer the time and energy to teach public relations isdone by couples who for NFP. A system oi rc-nuneration according years i'ave used the method successfully. to the number of clients has been worked In fact, the major part of our promotional out for part-time teachers. Communication work is done through personal contacts and transportaton are particular dif­ and one-to-one teaching and motivation. ficulties. Follow-up often requires hours of However, informational and instructional visiting house to house, walking from one booklets and pamphlets have been written village to another. Since this makes on­ in Bengali and are available from program going supervision of clients and new teachers. A monthly newsletter is sent out teachers difficult, emphasis will be placed from the center to teachers and other as much as possible on regionalization. interested parties. Long-range plans include the establish­ The aims and objectives of the program ment of a National Natural Family Planning are to cooperate with the government's ef. Association with representation from each forts to control population growth through of the regional areas which could generally education in NFP; to provide education in be referred to as Dinajpur, Khulna, Barisal, responsible parenthood to premarriage Mymensingh, and Chittagong, in addition and married couples; to motivate members to Dacca. Teachers and supervisors in all of all classes and creeds to accept periodic these areas will have been trained by the abstinence as a means to avoid pregnancy; program's founder/director, Sister M. to offer natural methods as an altert.ative to Imelda, so that a standardized system for women who discontinue other methods teaching, data collection, and reporting and to disseminate information on NFP will be possible. through the media; and to promote a Because of the r.ed for cooperation be­ respect for life and fertility as a gift. tween husband and wife, it is preferred In addition to the national center in that couples learn the ovulation method to­ Dacca there are subcenters in the following gether. In areas where women and men districts: Jamalpur, Mymensingh, Kushtia, prefer to come together in separate groups Khulna, Barisal, Noakhali, Pabna, Rajshahi, for instruction, that is arranged. In our and Rangpur. The majority of the subcen- teacher training courses we ask as far as ters date from 1980. They are usually possible for husbands and wives to receive located at dispensaries conducted by other training and work together in their villages. Catholic groups. The NFP teachers are In a survey of 448 clients of 16 teachers, available for consultation and keep their it was found that 66 percent were literate records at these locations. The majority of and 66 percent Christian. Muslims ac­ contacts, however, are made through counted for 27 percent. Nearly 80 percent

85 lived in rural areas. Just over 60 percent three-day seminars at a parish or village were in the age group 21 to 30 years. Seven school are covered by the parish or our percent wanted to achieve pregnancy, 52 progiam. percent to space, and 41 percent to limit their families. We feel that a good beginning has been The cost to clients for using the ovula- made. We wish both to help Bangladeshis tion method is very little. Most village peo- appreciate the need for responsible parent­ ple do not purchase the booklet which hood and present a progiam which corn­ costs only Taka 2.00. The charts are pro- municates a value for life and tht dignity of vided free of charge. Expenses for two- and the individual.

The genesis of the prograin can be traced back to Mauritius in 1963 with the creation of c'Action Familiale of Mauritius. Sister Paulette joined l'Action Faniliale in 1964. She took a keen interest in all aspects of NFP, receiving her training from Drs. Frangois and Michtle Guy and other meml.hers of the team. Sister Paulette left Mauritius in 1967 and joined the Mis­

- sionaries of Charity under Mother Teresa the same yer. Thus the nucleus was set for the propagation of the method in the CalcuttaI slums. With the approval of Mother Teresa and her active interest and enthusiasm, Sister Paulette oroanized the program. It took almost a year for her to fully implement her plans. The target l)opulation in the pro­ grUm included a total of 120 urban and rural centers in and around Calcutta. In­ itially, 699 couples were included in the program in 1971, which over the years in­ creased to 43,293 in 1982. The minimum age of women was 16 Mother Teresa years. About 70 percent were between 20 and 29 years of age, whereas 50 percent of the male partners were aged 30-39 years. The population consisted of Hindus, Mus­ lims, and Christians. Their proportions This summary describes the NFP pro- varied from year to year. The final distribu­ gram of Mother Teresa's Missionaries of tion by religious affiliation at the end of Charity in and around Calcutta. The pro- 1982 was 26,158 Hindus (60.4 percent), gram actually oegan in 1971, although 10,223 Muslims (23.6 percent), and 6,912 some base line activities had been initiated Christians (16.0 percent). Seventy percent as early as 1967. The objective of the NFP of the females and 13 percent of the males program was to impart a sense of human had no formal schooling; 26 percent of the dignity to the couple through the ex- females and 79 percent of the males had perience of a deep oneness in a free rela- only two years or less of schooling. tionship that would radiate love, peace, Twenty-six percent of the couples had two and joy in the family. children and 25 percent had three at the

86 time of enrollment. Eighty percent of the of the period. If necessary the husband or women were housewives by occupation, the educators assisted in the proper record­ Sister Paulette trained the sisters and ar- ing of the temperature on a piece of paper. ranged for their fanily visits. They initially These were brought to the local centers decided to implement the sympto-thermal weekly for check-up and records. The method of NFP. The thermometer was couples were instructed to abstain from used for recording the basal body tempera- sex until three days after the thermal shift. ture of the women. The Catholic Marriage For reasons of simplicity, the sympto­ Advisory Council (CMAC) in England sup- thermal method was abandoned for the plied thermometers and literature and modified Billings (OM) method in 1978. other materials in the English language. In The modification used was abstinence in 1973, the Gandhian Institute of studies at the entire pre-ovulatory phase. Varanasi, India, led by Dr. Amritananda During the initial "unregistered" phase, Das did excellent work in the sympto- it was observed whether the couples were thermal method of NFP. They highlighted able to follow the method properly and dif­ its virtue and a)propriate place in the ferentiate the fertile from the nonfertile Indian context as a way of life according to phases. Only when they were able to do Gandhian philosophy. During the three- this were they permitted to enter the year period between 1967 and 1970 Sister "registered" category. Paulette, along with her trained sisters and The couples were divided into three educators, was ahle to develop a great deal categories. The new couples were con­ of symtlpathetic cooperation and involve- sidered unregistered until they had com­ ment with the members of different fami- pleted four months of training. After that lies. Couples were motivated to aidopt the they were categorized as r%.gistered if they method and followed it conscientiously. were able and willing to follow the The Sisters of the Missionaries of Charity method. After the couple had used the were trained in th, sympto-thermal method successfully for three years, they method and were instructed on techniques were considered autonomous and they did of educating couples. The sisters and cdu- not riced :o visit the centers in the slum cators visited the couples once a week and areas for a check-up unless they had prob­ taught them the methods to be followed. lems. They received a certificate recog­ In order to achieve cooperation from the nized by the state gov *rnment exempting poor couples, some services had to be them from the government sterilization rendered. These included check-ups and program. They were well trained to look treament for minor ailments of family after themselves and follow the method in members and care for pregnant mothers, the correct way. newborn infants, and childrcn. NFP has A group of educators was selected from become a work within the framework of these autonomous couples who in turn the constitution of the Missionaries of trainco couples among the neighboring Charity, which has proved useful for the population, checking and reporting any success of the program. l)regnancis among them. While working Funds for implementation were pro- as educators they received Rs200 per vided entirely by the Missionaries of Char- month. About five percent of these ity. In 1975 the expenses amounted to educators dropped out mainly because of Rs84,324.00. illness. The educators are supervised by The couples (both husband and wife) the Missionary of Charity Sisters. In 1982 a were trained by the educators in simple total of 110 educators recruited from terms in the local language. They were Aso among the "autonomous" couples were taught to record the basal body tempera- working in the program. Thus a little less ture by placing the thermometer (supplied than one percent of the autonomous to them against a payment of approximately couples became educators. The educa­ US$.30) tinder the tongue before getting tinal component of the method reportedly out of bed every morning from the first day worked well.

87 sympto-thermal method was introduced into four centers -t that time. K orec) There are 194 teachers working in 77 centers. Half are salaried, 20 percent receive a part-tine salary, and the re­ mainder are volunteers. A national two-day The ovulation method (OM) was first live-in seminar is held every year for taught in the pastoral care center of St. teachers. It usually covers the spiritual, Columban Hospital in Mokpo, a small town psychological, and scientific aspects of on the south coast. We had limited family life. materials, no experience, and no money. Dioceses conduct their own teacher Our teaching was monitored by Drs. John training workshops with help from the and Lyn Bil!ings by mail from thei: coordinating office in Seoul. The format is research center in Australia. usually an afternoon seminar one day a In 1974 Bishop Stewart established NFP week for six weeks, with consultation and centers in all Catholic hospitals, clinics, and supervision on a follow-up basis for one to parishes in his diocese of Chunchon. two years. The main requirement for Clients were mainly from rural and teacher training is that the candidate be an working-class families. There was a great experienced user. Normally we require demand for services. In May 1975 the teachcrs to be Catholic, but we also have Catholic Hospitals Association with Protestant and Buddhist teachers who ac­ representatives from all the dioceses met in cept our philosophy. All teachers are first Seoul to launch the Korea Happy Family instructed in the OM and then the ST Movement (KHFM) as a national organiza- method. Four centers teach ST and the re­ tion. Centers were established in all maining 73 teach OM. We use the like-to­ Catholic hospitals and clinics throughout like system: factory workers teach factory the country. The centers in each diocese workers and so forth. Nurses and school had a priest-director and a qualified NFP teachers want more sophisticated instruc­ couple. The coordinating office is situated tion. Most of the teachers are high school in the Catholic Medical College in Seoul. graduates, a few are college graduates, and The goal of the KHFM is to make NFP some are registered nurses. available to every couple in Korea and to teach fertility awareness to young people Statistics 1980-82 as a holistic approach to human develop- 1980 1981 19f. ment. Couples are helped to grow in love Number of couples who and understanding, mutual sharing, and learned NFP 8,619 9,374 9,619 forgiveness. Mother and child care, pre- Surveyed 6,6/8 5,688 6,725 ventive medicine, and counseling are com- Not surveyed 1,941 3,686 2,894 of the KHFM, especially in hospital Satisfied with ponents practicing NFP 4,816 4,544 4,827 and clinic-based programs. I rural areas Reverted to other methods the parish-based teacher makes many refer- and/or gave up NFP 1,535 796 1,553 rals for diseases detected in the early stages. Husband abroad in a The total budgi, for 1980-82 was as foreign country 150 follows: Pregnancy 227 248 95 Tot-al Overseas Diocese The number of pregnancies dropped of Budget Fundin9 Self-Support from 248 to 95 during the nine months !980 W67,400,000 W18,080,000 W49,320,000 1982. We found we needed to concentrate 1981 W77,250,000 W28,570,000 W48,680,000 on teaching OM during breast-feeding. 1982 W64,810,000 W18,000,000 W46,810,000 There is a marked difference in the con­ Major expenses .'re salaries, printed fidence of women when the couple learn materials, and workshops. the method Logether compared with that In 1978 Korea was one of six countries of young women who learned the method in the evaluation of the WHO Family Fer- in a female group before marriage. Approx­ tility Education Resource Package. The imately 50 percent of clients are Catholic;

88 the rest are of another Christian denomina- all administration of its program. Teachers tion, Buddhist, or of no religion. They are and centers are visited on a regular basis by usually young couples with one child. the national coordinator. An annual survey We introduce fertility awareness in high of the work of each diocese with a progress schools, colleges, and universities through- report is taken every year. A quarterly out the country on a twice-yearly basis, newsletter is circulated throughout the NFP is part of the curriculum for medical country. It costs US$10-15 for a client to and nursing students of the Catholic become autonomous. Medical College in Seoul. Female students W*e consider the Church-related struc­ chart their own cycles. Five nursing col- ture of the program a big help in promoting leges have our program as part of the cur- KHFM. Our greatest needs are financial and riculum for public health, material resources. We would like to see Each diocese is accountable for the over- more biomedical and psychosocial research.

Klaus ran a workshop in Karachi and evaluated some of the teachers. An NFP clinic was set up at Holy Family Hospital in Karachi. The majority of village clients for NFP are from the lower economic group and Following visits of Drs. John and Evelyn are Christians; in the cities many clients Billings to Karachi and Lahore in 1974, Fr. come from the middle class, and in Luke Turon, M.D., acted as a contact for Faisalabad the majority are Muslim women. those interested in NFP. Two doctors, one Husbands only rarely come for instruction. in Faisalabad and one in Sarghoda, began The goal of the program is to teach NFP teaching the method in -ddition to several to groups of married couples who can sup­ religious sisters working in rural dispen- port one another and 'oread NFP use to saries. In 1977 the Bishops' Conference of society. The ovulation method is taught Pakistan approved a grant from Caritas almost exclusively. Only in Karachi is there Pakistan for Rs25,000 to promote NFP. regular traininj and evaluation of teachers. In 1978 a religious sister and a Muslim Few statistics 2ve been collected. The working in a govemiment hospital in centers are all independent in funding and Lahore attended a workshop on the ovula- setting objectives. Some help is given by tion method (OM) in Australia. Sr. Elizabeth supplying literature, but no reports are re­ Ann Yates began teaching couples in north quired. Pakistan and opened an NFP clinic in St. Many cultural attitudes in Pakistan Raphaei's Hospital, Faisalabad. Dr. Saad militate against any type of family plan­ Rana gave lectures to medical and nursing ning. Added to this are the objections that students and published an OM instruction NFP requires periods of abstinence and sheet in Urdu. better communication between husband In 1980 Misereor gave a three-year grant and wife. More research needs to be done of Rs39,000 per year with which office into the psychosocial aspects of the equipment and audiovisual materials were culture, especially the joint family system purchased. In September 1981 Dr. Hanna and its relation to NFP.

89 Europe

14IN 4

An English family in Oxford Europe is the area of the world with the oldest NFP tradition. It was here in the mid-1930s that the temperature method . - , was first introduced as a significant ad­ vance over calendar rhythm. 2'5:i;'q;, :,,.The ­ natural family planning services associated with the Catholic Marriage Ad­ visory Council in England and the Centre de Liaison des Equipes de Recherche in France became significant models for family life promotion NFP programs. In the -- 4, mid-1960s essential elements of their .organization and services were dissemi­ e -"nated throughout the French- and English­ speaking world. These are also the groups whose experience in NFP teaching has IT-i been most extensively analyzed. Together with the experienced younger NFP pro­ grams from the developing world, they made a major contribution to the WHO Family Fertility Education and Resource Package of the mid-I 970s. The combination of volunteer NFP teachers with a strong centratized national leadership is best illustrated in both the French and Irish national programs. Both eventually obtained government subsidies, especially for taining. The oldest pro­ grams of France, England, and Ireland also illustrate the importance of compleme,.­ tary family life services. They provide such services, in addition to NFP, ts marriage enrichment, marriage counseling, marriage preparation, family life education, and sex education in the schools. As in the other zones we can foresee significant progress over the next few years as regional c--l laboration and coordination of training and [ service standards are improved.

91 Drs. Jean and Frangoise Mutricy

Centre de Liaison des Equipes de Recherche

JEAN MUTRICY

Jean Mutricy, M.D., former president of CLER (1970-80) and current vice-presi­ dent of CLER responsible for interna­ tional relations; practicing surgeon; delegate of CLER, Paris,France

France,a country in western Europe located France is just under a hundred persons per between the Atlantic Ocean and t:. Mediter- square kilometer, and a lih,.e more than three­ ranean Sea, occupies about 546,000 square quarters (78 percent) of the people live in kilometers and has a population of 54 million urban areas. persons. Its crude birth rate is I" per thousand, Twenty-three percent of the population is and its crude death rate is 10 Per thousand. under the age of 15, and a relatively high pro­ The annual rate of natural increase, 0.5 per- oortion (17.5 percent) is 60 or over. The life cent, implies a slow doubling time-it would expectancy of 74 years shows a differential be­ take 151 yearsfor the population to double at tween males andfemales ofabout seven and a current rates. A projection to the year 2000, halfyears. Males can expect to live 70.6years, also at current rates, shows a population of whercas females have a life expectancy at 56.7 million. The population density of birth of 78. 1years. The infant mortality rate

92 is10 deathsper 1,000 live births. Growth and Development The population is a mixture of European CLER was created in June 1961 as a and Mediterranean groups. The official result of a national meeting of the Centers language of the country is French, although for Marriage Preparation on the theme of some minorities (Basques and Alsatian Ger- family planning. Teams of couples, physi­ mans,for example)speak their own languages. cians, and priests, independently working Most of the French population are Roman on natural family planning, decidef to con­ Catholics. solidate their efforts and to create a Per capitagross nationalproduct in 19,l national secretariat, which was called was $12,130. The per capita income estimate "Centre de Liaison des Equipes de Re. for 1980 was $8,980. cherche" (CLER), or Coordination Center The Frenchgovernment'sposition onfamily for Research Teams. Its founders were Drs. planning is officially a pronatalistone, but Charles and Elisabeth Rendu, Drs. Francois family planningservices arewidely available, and Michele Guy, Father de Lestapis, and The World Fertility Survey conducted in Father d'Heilly. France found that 79 percent of married In July 1961 a liaison bulletin began women of reproductiveages (20 to 44) were publication. Initially called "Fiches using contraceptionin 1978. Documentaires du CLER," this bulletin eventually became the magazine Amour et Famille(Love and Family). In April 1962 CLER was officially granted its legal status Centre de Liaison des Equipes de Re- according to the Journal Officiel as an in­ cherche (CLER) was found.."in 1961 to stitutional organization under the Law of recruit working teams of couples, physi- 1901. The following year, the Catholic cians,andpriestsdedicatedto the cause of Episcopal Conference of France linked naturalfamilyplanning.At an early stage CLER to its Family Life Department. of development, CLER expanded its ac- By 1963, 53 of 90 departments had one tivities to marriage counseling and to or several teams of CLER. Their objective educationon emotionalgrowth and sexu- was to assist couples who had problems ality for youth. Contacts wC'-e developed with family planning. This help was pro­ with numerous foreign programs, and vided by trained couple instructors and is couples from CLER participatedactively known as "couple-to-couple assistance." in the InternationalFairfieldStudy (USA). In the same year, a program of natural fam­ CLER also participated in prepa: ;tory ily planning was initiated in Mauritius, and meetings for the foundation of the IFFLP Drs. Francois and Mich~le Guy participated andsent its delegatesto attendthe TFFLPs in the creation of I'Action Familiale of congresses in Cali and Dublin. Mauritius. Even at that early date, groups CLER is a recognized public associa- and individuals from numerous foreign tion.Its nationalsecretariatin (-',riscoor- countries had already been in touch with dinates the work of its local teo s, who CLER. In 1965, 400 members of CLER work in 76 departments (provi-vos) in responded to a survey from the Pontifical France.CLER edits a magazineand pub- Commission working on artificial contra­ lishes teaching materials designed for ception issues. In 1966, CLER experienced instructors and conjugal counselors, a crisis as some of its members expressed a Trainingof personnel consists of an offi- desire to have a more flexible movement in cial trainingprogram conducted during a non-Christian setting. They withdrew eight consecutivedays. In spite of the diffi- from CLER and formed another associa­ culties encountered because of the avail- tion-"Couple et Famille." CLER then had ability of artificial contraception, CLER to train new teams and start again, during has continued to believe in the promising the difficu't time when the popularity of future of naturalfamilyplanninganahas chemical contraception was growing. organizeda session on continuingeduca- In (967 Dr. Charles Rendu published a tionfor instructorsin thisfield. book based on the experience of the

93 member couples of CLER. The t!lle was cycle (NFP). The objectives established by L'Eglise Nous a-t-elle Trompes? (Has the its founders were not abandoned. In 1977 ChurcbMisguided Us?). The promulgation a delegation representing CLER and led by of the papal encyclical Humanae Vitae the Rendus pa,,icipated in IFFLP's First clarified the problem posed by the issue of International Congress in Call. Three years contraception, but it disappointed the later, CLER participated in the Second great majority of the French people and it International Congress of IFFLP in Dublin was not received as CLER would have and sent a representative delegation to the wished it to be. Most French couples sided Bishops' Synod on the Family in Rome. with the ideas of contraception, and the ac- At this time a certain disenchantment tion cf CLER, which contradicted this with the use of artificial contraception and notion, was perceived as outdated. In spite a renewed interest in natural family plan­ of this opinion, CLER remained active and ning began to be felt in France. CLER inten­ continues to work in the :hree areas of sified its instructors' training programs and natural family planning, marriage and renewed with real success its public counseling, and education of youth in meetings on creating awareness of the use sexuality and love. In fact, it seemed im- of the methods of self-observation of the possible to separate family planning from female cycle. education about love. Throughout these years, CLER has con­ In 1969 the first eight-day training ses- tinued to undes,1take the training of nar­ sion was held at the Foyer de Charit6 de la riage counselors and of teachers for the Part Dieu at Poissy, a retreat center outside educat-on of youth on sexuality and love. Paris. The following year, on the occasion This approach toward the young has been of Dr. Claude Lanct6t's visit to Poissy, the very successful since its official introduc­ Idea was born to create an international tion. The members of CLER trained in this federation to unite the various associations area have spent many hours in information in a number of countries who aspired to sessions. They continue to meet with work on natural family planning and family groups of young people (18,500 altogether life education. At this time also, more than in 1982). The same year CLER's counselors 300 couples of CLER participated in the and instructors met with some 70,000 International Fairfield Study (USA) on adults. natural family planning. The idea of The founders of CLER decided that they creating an' international federation was would create a "coordination center for restudied at Call in 1972, and finally the In- research teams." The :imprecision of this ternational Federation for Family Life Pro- title has been providential, because it has motion (IFFLP) was founded officially in not limited CLER's scope of research activi­ Washington, D.C., two years later. ties to family planning. Interest has been During this time in France, the pro- extended to many other domains dealing abortion campaign was at its peak. Even with family life, ensuring thereby a truly though CLER and other associations made comprehen3ive family life promotion all possible efforts to enlighten the public, approach. a law permitting abortion was passed hi It is difficult to determine precise figures 1975. Public opinion continued to be very on natural family planning users because favorable toward conraception, and the ac- the statistics are prepared for the ministry, tivities of CLER seemed marginal. which does not require details on this ac­ Meanwhile, CLER improved its pro- tivity. We can estimate a percentage of new grams on training, and the sessions at natural family planning users at approxi­ Poissy had more and more influence on mately two-thirds of the total. With respect participants. Even though natural family to its administration, CLER is a nonprofit planning did not seem to interest the organization, functioning in agreement majority of the public, CLER continued to with the French Law of 1901. It is govern­ train instructors to be well versed in the ed by a board of directors composed of 15 methods of self-observation of the female members elected by its general assembly.

.94 This board designates a body consisting of course G. 20 hours for instructors charged the president, three vice-presidents, the with giving family planning information to secretary, and the treasurer. CLER's head- adults and young persons; and a longer quarters are in Paris, where the national course of 400 hours for the training of mar­ secretariat of the association is located. riage counselors. France is divided into regions under the The training sessions usually last eight responsibili.y of regional coordinators days at Poissy, with additional weekend who supenise the activities of the local sessions on such techniques as how to con­ teams in collaboration with the national duct meetings. Knowledge is tested by secretariat, written and oral examinations, including NFP (sympto-thermal) chart interpretation. Training and Service A certificate is granted only after the candi­ The local teams are the basic work units. date has passed an assessment on psycho­ Under the direction of team coordinators, logical aptitude. The short-term training their members are assigned to the various requires at least a year and often 18 months. activities of CLER. The national working The training program for the other level groups (called commissions) meet in Paris. of marriage counseling offers three ses­ One of them is in charge of the publication sions at Poissy and weekend sessions on of the monthly magazine Amour et Famill. listening techniques. This training is very This magazine has presently some 3,000 much oriented toward the psychology of subscribers, and more than 20,000 copies relationships and to helping in personality were sold to the public in 1982. Through development. This extensive training pro­ this publication CLER reaches an audience gram consists of 400 hours of theoretical larger than just its members. Another com- courses. It isoften spread out over a period mission is in charge of research on sexology of three years or more. This is considered and on medical ethics. Another coor- indispensable for the psychological devel­ dinates activities on research in natural opment of the car.didate marriage coun­ family planning and takes part in the prep- selor. As for the NFP teacher training aration of technical documents. The Youth programs, there are also continuing tests Commission is in charge of the training of on knowledge and interviews on psycho­ more specialized teachers for education in logical aptitude. Continuing education ses­ sexuality and love. Another commission sions for instructors and counselors are coordinates all of CLER's trainers to ini- provided and organized within the training prove its various educational programs. sessions at Poissy. CLER's trainers must be effective at three levels: (1) that of "know how"-for exam- Evaluation pie, the running of meetings, speaking in The number of marriage counselors at public, and training people to listen; CLER is stable at around 320, which means (2)that of general knowledge, such as that the newly trained personnel replace anatomy, physiology of human reproduc- those who depart. As for NFP teachers, tion, psychology, and sociology; and their -.umber increased from 291 in 1980 (3)that of personality development, by par- to 350 in 1982. It is not possible, at present, ticipation in studies and discussion groups, to provide exact figures on the caseloads or group dynamics, and psycho-dramatics. clientele characteristics of natural family For the last 10 years, CLER has been of- planning teachers, but we must underline ficially recognized by the Ministry of the renewed interest that the French public Health as a training organization. Its pro- has manifested toward it. grams conform to the stipulations of tLe One of CLER's physician members, Dr. ministry and address specific issues, par- Ren6 Ecochard, has proposed to dedicate ticularly the teaching of a Christian vision his complete sabbatical year to the upgrad. of sexuality. ing and continued education of couple in­ In agreement with the ministry's regula- structors in natural family planning. This tions, there are two types of training: a proposal, presented in September 1983,

95 has received an immediate and over- at Poissy. These eight consecutive days of whelming response, with more than 250 intensive training twice a year, in July and requests received over a short time. The in September, bring together each time 180 enrollment costs to finance expenses for persons at six levels of training. Among this program are practically covered at this these persons we have always had partici­ date. This program on the further improve- pants from foreign countries. Through ment of the NFP teachers will include a these sessions our aims are to provide small section on theory and a major section quality training but with a sense of Man and on chart interpretation for both the cer- Christian ethics. The general atmosphere at vical mucus and the sympto-thermal Poissy is such that many members of CLER methods. This experience is too recent to come back voluntarily for follow-up ses­ have any results available, but its existence sions on continuing education. is in itself proof of a change in the public Another very important activity has opinion, been the work of the Youth Commission, The area of publicity is left to the which has organized training sessions on initiative of local teams. education on sexuality and love for adoles­ Recognized as a public association, a cents and for adults intere, ted in this sub­ member of the Superior Council for Infor- ject (parents, educators, professcrs, and mation and Education on Sexuality, as well others). In addition, an annual session deals as officially recognized by the Ministry of especially with the important topic of Health as a trainirg institution, CLER "Education on the Body and to Relation­ receives a subsidy for administrative costs. ships" which receives regularly a very Its other sources of income are member- favorable response. ship dues, contributions, the participation The greatest achievement of CLER has of its members, and, for its training pro- been to continue to believe in the im­ gram costs, enrollment fees and a subsidy portance and promise of natural family from the Caisse National d'Allocation plannhig. After 20 years of relatively un­ Familiale. The budget of the national productive efforts in this field, following secretariat of CLER was F 1,165,000 in 1980 the rapid expansion of artificial contracep­ and reached F1,630,000 in 1982. To this tion, an evolution in public opinion figure one can add the budgets of the local especially manifested in the press by teams. It must be noted that the subsidies feminist movements, proves the justifica­ of the government continue to represent tion of our perseverance. an important part of the resources of the The most important of our needs are cer­ organization and that it would be most tainly to sustain public opinion and to desirable to develop additional sources of achieve a change of mentality on the part financial support. of the medical profession toward a greater acceptance of natural family planning. It seems to us that CLER could benefit from Accomplishments the scientific results contributed by the As one tries to determine what has been research done in natural family planning, of greatest importance to CLER in the past and from research accomplished in the years, one thinks immediately of the funda- psychosocial area, from the individual as mental role played by its training sessions well as the tamily perspectives.

96 Oatholic Marriage Advisory Oouncil of Ireland

ANDREW KENNEDY

Andrew Kennedy, priest; national direc­ tor of CatholicMarriageAdvisory Coun­ cil ofIreland;delegatefor CMA C-Ireland

Ireland occupies more than 70,000 square for the provision of information instruction, kilometers of an island just west of Great advice, and consultation in relation to Britain in the Atlantic Ocean. Th" population methods of family planning that do not in­ of 3.5 million persons is predominantly Irish volve the use of contraceptives. with an Anglo-Irish minority. Ireland's crude birth rate is 21 per thousand, and its crude The Catholic MarriageAdvisory Coun­ death rate is 9, resulting in an annualrate of cil of Ireland (CMAC) aims to help people natural increase of 1.2 percent. The popula- initiate, sustain, and enrich their mar­ tion would double in 60years atpresent rates, riage and family relationships. This in­ and the projectionfor the year 2000 is about volves family life education, a marriage 4.1 million persons. counselingservice, and a family planning Populationdensity is just over 300persons service, which representsabout 10-12 per­ persquarekilometer, andnearly60percentof cent of the annual workload. The service, thepeople live in urbanareas. Young people- mainly Church-inspired, is staffed by those under the age of 15-constitute 31 per- trainedvolunteers andis offered in urban cent of thepopulation,and 15.3 pecent are60 and rural settings ar about 100 service or older. Life expectancy at birth is 73 years. delivery points. It is funded by the Church The infant mortality rate is 11.2 deaths per and government and, in the approxi­ thousand births. mately 20 years of its existence, the focus The English languagepredominatesin Ire- has moved away from a medical model land, although Irish (Gaelic) is spokeni by a toward a relationshipmodel. minority. Ninety-four percent of the people The service engages 400 trained areRoman Catholic,andabout 5 percent are teachers, who are supported and super­ Anglican. The per capitogross nationalprod- vised by about 40 tutors and two full-time uct was estimatedat $5,350 in 1981. tutor consultants. The board of directors The trend is toward smaller families in of CMAC is drawn from the membership Ireland,although the birth rate is still high. and is accountableto the Churchandgov­ The 1980 totalfertility rate was 3.4 children ernment in the allocation of funds (cur­ perfamily. In the last two decades, people's rentlv IRL 50.000 per annum). aspirationshave moved towardsome kind of Teachers, tutors; and tutor consultants family limitation. are selected and trained.The emphasis in Governmentpolicy towardfamily planning training is to help staff membe's offer a

waspromulgated in the Health (Family Plan- quali , service to enable couples to ning) Act of 1979, which states that: "The become autonomous in their fertility Ministcrfor Healthshall(a) secure The orderly management I-serice training is a re­ organisationoffamily planningservices, and quirement. Help is needed in developing (b) provide a comprehensive naturalfamily realistic evaluation procedures for the planningservice, i.e., a comprehensive service service

97 National NFP Program Development membership. Our relationship with the was The Catholic Marriage Advisory government is satisfactory. Funding mid-1981, when gov­ Council's NFP program is part of an inte- very limited before NFP began. Since grated service to marriage, which also in- ernment-! funding for that time, about IR£125,000 hasyer been cludes premarriage education and marriage spet the ant i na negotiated each year. counseling services on a large scale, post- spent. The grant is in Dublin, and the marriage education on a small scale, and The central office is branches are located education in schools on a medium scale. 50 satellite centers or throughout the country . Altogether there CMAC'sNFP represents annual w.orkload.about 10-12 In thispercent regard, of aare aboutgout 100 servicestgery delivery points.t. CMACs anualworload Inthisregrd, CMAC has cooperative relationships (but visorywe are similarCouncil to inthe theCatholic United Marriage Kingdom .d- noCA formal as affiliation) cooerative with hospitals,ltosis health(bt (U.K.), from which we were founded in boards, and the body responsible for post­ 1962. The program is Church-inspired, graduate training of doctors. Relationships The CMAC began in 1962 and was estab- are also maintained with general practi­ lished branch by L..anch from London. tioners and public health nurses. There were 4 branches by 1966, 12 by NFP Education, Training, 1970, 30 by 1975, and 50 by 1982. An and Service Development independent Council was established in There is a selection procedure for all per­ Ireland in 1975, but links with CMAC sons joining CMAC. Each candidate must (U.K.) are still maintained to mutual have a warm and open personality; be sen­ benefit. sitive, perceptive, credible, and trainable; CMAC clients come from a broad spec- and have the ability to accept and be con­ trum of backgrounds in both urban and cerned for others. Training strives to rural areas. Teachers are mainly married develop these qualities further and the women, most of them nurses, counselors, skills needed to use them effectively. or doctors. Our program originally It is the aim of initial training to give the adopted a focus that was primarily trainees an understanding of the marriage medical. After reflecting on our experience relationship, especially in the areas of fer­ and sharing with other groups interna- tility and sexuality, as well as a knowledge tionally, we carne to see that this approach of all methods of family planning and was inadequate because of its medical, especially of natural methods in current female, and problem focus. Accordingly, use. The training is designed to develop we have set about moving the emphasis and foster knowledge, skills, and attitudes from medical to human, from female to appropriate to the service and to assist the couple, and from a problem to a normal trainee in becoming an effective helper in arena. We are now training all our family fertility management and an effective planning personnel in counseling skills. teacher. In aiming to help couples integrate NFP Specifically, the training course includes into their relationship, we try to enable the following topics: anatomy and physiol­ them to become autonomous in the man- ogy, man and woman in relation to fertility, agement of their own shared fertility and, the menstrual cycle, the temperature meth­ as a corollary, to free them from depen- od of NFP, the cervical mucus method of dency on technology, medical or otherwise. NFP, the sympto-thermal method, chart in­ The service providd is more than a terpretation, alternative methods of NFP method; it has a rel-i iship ,rnphasis. We fertility management, record-keeping, teach the basal body temperature (BBT), emotional development, human sexuality, sympto-thermal, and ovulation methods. marital interaction, self-awareness and self­ They are taught in the English language. disclosure, a philosophy of NFP, morality Our funds come from the government and family planning. tea.ching and evaluat­ and the Church. We have 50 branches ing skills, helping skills, and the place of throughout the country and a represen- faith in the life and service of the individual. tative board of directors drawn from the The teaching process used is that of in­

98 Children in County Clare, Ireland

put followed by small group discussion. In ongoing assessment of the trainee by the the small group there is clarification of the tutors in theory and skills learned and feel­ material taught, discussion of feelings and ings and attitudes expressed. At the end of attitudes where appropriate, and applica- the first part of training, a written examina­ tion to the work situation of the learning tion tests the theory related to NFP. An oral that has taken place. Each small group con- assessment, conducted after three to six sists of six to eight trainees led by a tutor. months of supervised teaching, focuses on The first part of the course takes place the ability of the trainee to teach NFP effec­ over two residential weekends and six full tvely and to understand and relate to the days within an eight-month peiod. This is dynamics of the couple's relationship. The followed by three to six months of super- cost, of initial training is approximately vised teaching. IR£300 per teacher. Teacher evaluation takes two forms. All CMAC personnel inust have 20 hours Throughout the training period there is an of in-service training each year. This is of­

99 fered in the form of two-day sessions probably the most popular, followed by (about 10 hours) and five to eight evening the ovulation method and BBT. We do not sessions. In-service training aims to have figures available on the cost per user develop further the skills learned during of training to autonomy. the initial training and to cover other The vast majority of acceptors use NFP aspects of NFP teaching, such as special cir- for spacing pregnancies; a sizable minority cumstances that may be encountered. use it for limiting their families; and a small A well-trained group of tutors is minority practice NFP for planning a preg­ necessary to implement such a training nancy. Precise figures are not available. program. Potential tutors are drawn from The continuation and pregnancy rates are the body of teachers. In addition to the not known to us. The autonomous couple qualities needed for selection for the train- rate is also not Known, and no criteria have ing program, a flair for leadership and an yet been devised to identify autonomous interest in teaching and group work are couples. No pattern has yet been discerned considered important attitudes for those as to the percentage of users who become invited to become tutors. A potential tutor teachers. must be a confident and experienced teacher of NFP. Training takes place over Program Evaluation and Accountability three residential weekends, usually at The program is accountable in the ad­ monthly or bimonthly intervals. An on- ministration of funds to the board of direc­ going assessment of the tutor trainees is tors, the government, and the hierarchy; in made, and at the end of the period suitable achieving target objectives to the bo lid of persons are invited to become tutors. directors; and in adhering to stated goals Tutors are required to attend two residen- and philosophy to the board of directors tial weekends of in-service training per year. and the hierarchy. We have outreach ac­ Two full-time tutor consultants attached tivities in each diocese. To recruit clients, to the NFP department are responsible for we advertise the availability of our service. tutor training, both initial and in-service. We offer them the opportunity for follow­ They design and implement the tutor train- up and encourage them, but the initiative is irg programs, supervise and assess trainee left with them. teachers, and make recommendations to We do not yet have a strategy for eval­ the director regarding the suitability of uating teacher effectiveness, cost effective­ potential tutors. ness, overall impact on the community or CMAC has 400 teachers, none of whom national fertility programs, the relative im­ works full-time. All are part-time voltn- portance of family life and NFP compo­ teers. They are encouraged to claim reim- nents, pregnancy and dropout statistics, bursement for expenses, but most do not. use-effectiveness of learning and con­ We have no accurate figures of continua- tinuing users, or the acceptability of natural tion or dropout rates of teachers, but we methods. suspect that the reasons for dropping out Accomplishments and of the program include such things as fam- Development Needs ly obligations and moving away. We are making a serious effort to offer a Service Delivery professional NFP service to people. Our The number of users, both new and con- greatest challenge is to make a greater im­ tinuing, shown in our records from all pact on the community, especially in the branches for the last four years is as matter of attitudes. Many see the debate follows: 7,825 in 1979; 9,164 in 1980; only at the level of method and have no 7,738 in 1981; and 6,145 in 1982. The only perception of a philosophy of NFP. criteria for becoming a nw user are a will- Our greatest needs are more tutors, bet­ ingness and desire to be trained in NFP. All ter tutor training, more full-time personnel; three NFP methods are taught, but we have more finance; better literature; and better no figures on the preferences of clients for publicity of a suitable kind. methods. The sympto-thermal method is We see the need for better methods of

100 administration and operating the program, are evident in this report. We need more especially in the area of record keeping. infovmation on why people do or do not The effective use of better methods would choose NFP, their motivations, and their help us considerably and would reduce the experience with abstinence. Demographic number of gaps in our knowledge, which research, too, is obv'ously important.

Austria

The Institut f.ir Ehe und Familie (IEF, In­ stitute for Marriage and Family) was founded in 1973 by the Austrian Episcopal Conference. One department was estab­ lished for natural family planning. The bishops commissioned the first director, Father Alois Jaeger, and Dr. Josef Roetzer to establish and develop NFP in Austria. Some preliminary work had been done earlier beginning with a medical con ference in 1965 in Vorarlberg. Because the encyclical, Humanae Vitae, met with Dr.Josef Roetzer and his daughter, widespread rejection in German-speaking Elizabeth Roetzer Europe, progress was difficult. in-between A special training program for NFP edu- classes with six to eight weeks gain personal cators was initiated in June 1976 with a to allow the coup'es time to training; meeting in Vorarlberg for the diocese of experience; a weekend of further to teach Feldkirch and bordering areas of Switzer- and for those couples wishing of intensive land and Southern Germany. Participants NFP, additional weekends is offered also came from the Soath Tyrol, Italy. training. Individual counseling regional Since then the Vorarlberg center has of. before and after classes. Leaders of in con­ fered training weekends with Dr. Roetzer organizations and educators remain for 80 to 120 participants twice a year. A tact with Dr. Roetzer for continuing study group called "Natural Conception education. to scien­ Regulation" was founded in 1982 within One program of IEF is devoted of Dr. the Family Life Bureau of the diocese, and tific research under the auspices pro­ by May 1983, 46 seminars were given to Roetzer with Dr. Kucera, associate Obstet­ 1,135 participants. The "Model Vorarl- fessor at the University Hospital of berg" was the first systematic NFP rics and Gynecology in Vienna. Spiritual organization in German-speaking Europe. assistance is given by Prof. Karl Hoermann, of Independent NFP groups in other Aus- professor of moral theology, University NFP; trian dioceses and bordering areas have Vienna. Regu!ar seminars are held on twice a developed since 1980, in Kiirnten/Carinthia, a counseling service is provided is Steiermark/Styria, the Tyrol, Biberach, week free of charge; teacher training on Germany, and in Switzerland. From June conducted by Dr. Roetzer; and a library 1982 to October 1983, classes were held in NFP is being built up. Research is planned southern Germany for 1,300 participants. in conjunction with the university. Roetzer has conducted The basic training model created y IEF Since 1951 Dr. and Dr. Roetzer consists of three ialf-day counseling and research through the Mar­

101 prospec­ riage Advisory Service Roetmer in Voeckla- the 1979-83 preliminary study carried on bruck. Services include personal counseling tive. The latter survey will be to dicover "the and counseling through correspondence into the indefinite future of NFP under (30 to 50 letters and charts a day). The Ser- reliability and liveability Couples are free to vice has prepared worksheets and learning everyday conditions." except calen­ aids. Dr. Roetzer's book Natuerliche choose any natural method either to avoid or Geburtenregelung (Natural. Birth Regula- dar rhythm and decide is not ion) has been translated into English, achieve pregnancy. Pregnancy but as "an Dutch, Japanese, and Croatian. Slides and treated as a "dropout statistic" Only those transparencies have been designed for interruption in exposure." to a contraceptive both introductory and advanced classes, couples who switch cooperation are Dr. Roetzer has also collaborated with method or decline further the Family Life Mission of Ingrid and considered true dropouts. are expected to Walter Trobisch to relate NFP to the Final results of this study and infer­ general ccncept of Christian marriage and provide information on fertility pregnancies to bring NFP to the Protestant Church. tility, unplanned pregnancy, of the Dr. Roetzer has conducted two studies while experimenting in the margins to the use of of clients from Austriq Germany, and fertile period, pregnancies due Switzerland who send in their charts by barrier methods, and planned pregnancies mail. The 1975-77 study was retrospective, as well as continuation rates after pregnancy.

Periodical Group of the Society of St. Paul and the Associazione Don Giuseppe Zilli (former director of Famiglia Cristiana). The center avails itself of a scientific board, which includes sociologists, psychologists, 01SF theologians, philosophers, journalists, and physicians. The aim of CISF is the study, research, The promotion of NFP, with some ex- and promotion of family life on an interna­ ceptions, was limited to Catholic couples tional and national level. Its activities in­ until a few years ago. Very little attention clude the training of marriage counselors, was given to family planning in the univer- training of teams to prepare couples for sity medical curricula. Hardly any mention marriage, organization of seminars, and the was made of NFP. Doctors have extremely publication of materials including the negative judgments on NFP. magazine La Famiglia Oggi (The Family In 1974 the Italian government intro- Today). duced legislation to establish Consultori A major contribution of CISF has been Familiari, centers for "social and psycho- the training of 1,500 counselors, social logical counseling" as well as for dis- worker3, psychologists, priests, religious tribution of contraceptives. They became sisters, and physicians in marriage counsel­ primarily family planning centers dis- ing. About 21 courses were held in 12 dif­ tributing the pill and IUD to women. The ferent regions in northern, central, and Church then set up its own Consultori southern Italy. Many who underwent train­ Familiari to provide counseling and ing are now working in private and public also NFP. Consultori Familiari. Some of these courses One of the agencies that was active at the were sponsored by the Bishops' Con­ outset is the Centro Internazionale Studi ference or the Consultori Familiari in the Famiglia (CISF), a foundation of the region. In these courses NFP was amply

102 covered. The first objective was to train by the Drs. Billings. CISF has now pub­ the counselors in the "client-centered" lished a "kir" for NFP education entitled (Carl Rogers) approach and then to equip Educazione ai Metodi Naturali. It was the~m with the knowledge of NFP. The sub- written bj two gynecologists and includes ject was approached from medical, a section on mora! aspects written by psychological, and troral perspectives. All a priest. methods were presented and then natural The kit consists of a guide book with 40 methods (mucus method, basal body tem- colored illustrations, 86 colored slides, and perature method, and sympto-thermal a cassette. The kit is being promoted all method) were explained in detail, with in- over Italy and is available for translations in struction on charting and educating other languages. couples in NFP. CISF is also interested in research in NFP, which the Ministry of Health does not prtisiniti trainingofthe stiae te support. An example is the recent policy of participants to undergo further specific the local health authorities in Milan, which NFP training. This is why CISF is now plan- had allocated funds for a university depart­ couping .S coursest n NFP tehe avn ment to carry out some research in the field couples. Short courses on NFP were given of NFP. Unfortunately, because of the eco­ to social workers,engaedmrriead studentcoplesin teachers, arios and fomici cuts in public funds, so far the funds engaged and married couples in various have not been made available. parts of Lombardy (the Milan area). After this extensive work CISF feels There has been in Italy a need for aids for ready to organize specialized courses for the training of couples in NFP. The parent training NFP teachers. CISF hopes also to group of CISF, Farniglia Cristiana, was the finance both biomedical and psychosocial first to promote and publish in Italy books research in NFP.

majority are Catholic. In addition to providing teaching of the Billings ovulation method to clients, the

Center conducts training courses. Teachers NFPSRC are taught all natural methods, but particu­ lar emphasis is on the ovulation method. The Center maintains ari u--to-date bibli­ The Natural Family Planning Study and ography on NFP and on contraception as Research Center (NFPSRC) is part of the well and provides translations of books, Catholic University of the Sacred Heart. manuals, and articles into Italian for clients Work began in the field of NFP in 1975 and teachers. The Center has undertaken with the establishment of a Marriage research on cervical mucus and hormonal Counseling Center. In 1980 a distinct correiations, and it coordinates work on Natural Family Planning Study and the ovulation method in Italy through Research Center emerged working ex- periodic meetings of regional supervisors, clusively in NFP. Both the Marriage the promotion of in-service courses and Counseling Center and the NFPSRC helped congresses, and correspondence with to set up 15 regional centers throughout satellite centers. Italy with subsidiary centers. They now The Center also provides a medical con­ teach NFP, primarily the Billings ovulation sultan. clinic for difficult cases and orfers a method, in hospitals, family counseling two-year integrated course on "The centers, parishes, and private homes, both Regulation of Human Fertility" at the in urban and rural areas. The clients belong university level. Candidates for the teacher to various socioeconomic classes; the training program are selected by personal

103 interview from among volunteers attend- Organizational support is provided by ing lectures on NFP, in particular the ovula- the Catholic University of the Sacred Heart, tion method, and from clients who are which has set an annual budget of about confident of NFP efficacy in solving prob- Italian L130 million. Affiliated centers are lems of fertility regulation and who have supported by local volunteers. Some have the right moral qualities and cornmunica- refused public monies to "preserve the tion abilities. The teacher training program spirit of NFP." Financial support is some­ comprises technical instruction in NFP, a times supplied by dicceses for couples to practicum of two years, and study of the attend teacher training courses. More per­ ideals that motivate the NFP user. Ongoing sonnel and material resources are needed, education is a condition of accreditation. but funds would not be accepted if tied to Regional seminars are held two to three conditions. The program would greatly times a year, national seminars once a year. benefit from scientific, biomedical, and Currently 350 teachers are affiliated with psychjsocial research. the program, mainly part-time and volun- The Center has also assisted in organiz­ teer. The conilnuation rate is as high as 99 ing NFP centers in Belgium, Spain, and percent. The goal of the program is to France. Orientation courses are also given bring the individual person and the couple to nursing and medical students, mid­ to a total vision of man and a deeper com- wives, doctors, and missionaries. the prehension of the dlignity of human life and Following a preliminary survey, the truc nature of conjugal love, the trans- Center designed and distributed data col­ niission of life. and responsible procrea- lection forms to all regional ovulation tion. The Center tries to promote dialogue, method centers, and results are expected reciprocal respect, self-discipline, and love to be computerized in 1984. This will give for the child. Teaching is considered thor- details on number and characteristics of ough when it couples respect for human users, satisfaction with NFP, pregnancy Nfe with accurate information and proper and dropout statistics, and previous family understanding, planning use.

Julian's, a private Catholic hospital serving mainly a middle- and upper middle-class clientele. The second center opened in 1963 in Paola, a blue-collar district. Other For many years the only agency in Malta centers were opened at Quormi (1965), for the teaching and promotion of family Gozo (1965), B'Kara (1966), Rabat (1970), planning was the Canz Movement, founded and Zejtun (1977). in 1956. It is a church-based family NFP was always presented in conjuction organization whose aims are to educate with premarriage courses. NFP was ex­ young people and engaged and married plaif-d to audiences through the Cana couples in Christian values of family lifc Movement; then individual counseling was and to offer premarriage and marriage given to couples in the NFP centers. At first counsciing services. NFP was taught by a team of doctors who The NFP program was started in 1956 volunteered their time. By 1977 there were and consisted mainly of lectures by doc- 25 of these volunteers, but after a doctors' tors in premarriage courses on calendar- strike against governmental health policies, rhythm and the temperature method. The several left the island, leaving only one Floriana Center has remained the national gynecologist, six general practitioners, and center, but as a result of demand the first one psychiatrist. district center was opened in 1961 at St. In 1961 the Cana Movement began em­

104 ploying trained marriage counselors who representatives from each commission of were also trained as family planning the movement. The NFP program is the teachers. At present 16 marriage coun- responsibility of the NFP coordinator. selors also instruct in NFP. In 1975 the The training program for NFP teachers Billings ovulation method was introduced. consists of a six-session course conducted It was combined with the temperature and by one of our doctors and the NFP coor­ to a lesser degree the calendar method. dinator. Each newly certified teacher is at­ Hence, we adopted the ST method. tached to a tutor (a doctor or experienced After 1976 the Cana Movement started teacher) for several months. Once every in training NFP teachers and introduced NFP month all teachers attend a meeting are courses both on a national level and on a which specific cases and difficult charts af­ district and parochial basis. NFP teachers discussed. Currently 6 teachers arc with are recruited from women, preferably filiated with the NFP progiam, along The those in the 25-35 age group who are mar- 16 marriage counselors and 6 doctors. ried and have children. They should have a NFP coordinator is salaried and works part­ secondary level of elucation and he users time. All others are part-time volunteers. themselves. Our goal is to have one teacher Only one teacher has temporarily dropped attached to each of our 60 parishes, out for pregn,-ncy. Tutors informally the The NFP course consists of six sessions, evaluate the teachers' work whenever one every two weeks. Courses are held in need is felt. small groups of about 10 couples. Referral The numbers of user couples trained is available for moral, psychological, during the past four years are as follows: psychiatric, and gynecological cases. 483 in 1980, 564 in 1981, 521 in 1982, and Clients for the most part are Maltese and 483 up to August 1983. New users are come from all socioeconomic classes. Most mostly engaged couples; a small percen­ come from the !ower classes. The middle tage are married couples who are dissatis­ class is the next most frequently repre- fled with other methods. We have no sented group. Almost all are Catholic. reliable statistics on the method selected The Cana Movement has no fixed source by the users or continuation rates but are in of income, and services and courses are the process of making a scientific survey. It free of charge. Our main support comes is estimated that the cost of .materials for from fund-raising activities. Until 1980 the each user is M£2.82. We estimate that 5 Cana Movement received an annual grant percent of our acceptors are planning a of M£600 from the Ministry for Social Ser- pregnancy, 85 percent are spacing births, vice but then it was discontinued. In 1981 and 10 percent are limiting their families. the government opened the state family The NFP program is accountable pri­ clinic which provides all forms of family marily to the Cana Movement's administra­ planning except abortion, which is illegal tion. This includes accountability for in Malta. administration of funds. Ultimately it is ac­ Our budget for 1980-84 is as follows: countable to the diocese and archbishop Projected Income with regard to stated goals and philosophy. Fund raising M£2 1,000 Outreach and recruitment of clients is car­ Sale of books ME 5,900 ried out mainly through the parishes and Sale of thermometers ME 4,000 the local newspapers. Our monthly maga­ Donations ME 3,600 zine, FamiliaKana, has a wide circulation, TOTAL M£34,500 and the Cana booklet on NFP has been re­ Pro.Eected Expenditures printed four times since 1976. Salaries (office staff) M£19,100 We are still in the process of developing Office equipment and supplies M£18,700 strategies for evaluation. Our experience a TOTAL M£37,800 has shown that once NFP has become The main administrative body is the Way of life for the couple, they find that sex­ Cana Council, which is made up of the their interpersonal relationship, both director, president, secretary, and ual and otherwise, greatly improves. Our 105 material resources and person­ greatest challenge is lack of factual data and need more conducting scientific, statistics. We need to train more teachers nel capable of and psychosocial research. and to open at least four new centers. We biomedical,

The initial central team in Lisbon con­ ducted its own training ihrough reading and discussion and by attending the formal training sessions held by CLER in Poissy, France, from the very first session in 1969. cane In 1965 following a visit by the French The formation of regional centers training national marriage preparation chaplain and about through a series of weekend most a physician couple from Grenoble, the Ser- sessions, at the end of which the for a vico de Entreajuda e Documentagao Con- motivated couples were recruited in liaison jugal (SEDC, or Conjugal Interhelp and continuing education program Center. The Documentation Service) began with a with the Lisbon National its group of six couples and a priest from Catholic Nursing Association created a special Lisbon who agreed to study NFP together own complementary service with and other in­ and to learn as they maintained contacts training program for nurses woman with the French groups. From this begin- terested persons. A former to be its ning gradually knowledge and experience member of the service was asked grew. Both rural and city groups asked to coordinator. been held learn about NFP, and their experience was National training courses have general in­ shared especially in parishes and schools. for the last five years. An initial is The service eventually became linked formation and education certificate supplemented with the Catholic Physicians Association given, which can then be certificate. through its medical members and had its with a specialized NFP teacher's is coor­ proceedings and activities published in the The NFP teacher's certifying exam NFP training association's magazine, Medical Action. dinated nationally with the Similarly, the Catholic Nursing Association program of the Catholic Nursing Associa­ an also becmune progressively involved. tion. A woman physician has created The work is carried out essentially NFP senice at the National Miserecordia through church channels with the invita- Hospital of Lisbon with well-structured for health tions for courses usually made by a priest, a NFP teacher training courses the bishop, a sister, or a couple. Courses are of- assistants. This NFP program is within pro­ feted in nearly all 19 dioceses in the coun- context of a general family planning must be try. There are seven active service centers gram (excluding abortion) which SEDC col­ in both urban and rural settings, and all are offered to the whole population. linked with the national office in Lisbon. In laborates in the NFP service only. strict t'c --ral parishes all couples practice NFP. The service does not maintain about All services are offered free of charge at the records. It is estimated that currently 400 national and regional levels, but voluntary 50 NFP teachers taught approximately year. contributions are accepted. women users during the past

106 in-service training, administration, and United is paid for, in the main, by a gov­ ernment grant amounting in the last finat­ cial year to £25,000 and by a grant of about Kingd o m£1,000 from the National Catholic Fund. The initial course for NFP instructors provides 18 hours of instruction and prac­ CM AC tical work. Training takes place over three entire days with an interval of one to two weeks between each training day. Instruc­ tion is given in the anatomy and physi­ the mucothermic The Catholic Marriage Advisory Council ology of reproduction, Role playing is used (CMAC) was founded in 1946 as a marriage method, and charting. ability. Psychological counseling organization. An NFP service to develop teaching their management are has been offered since its foundation, difficulties and sessions. Trainees com­ Beginning in London, the service has discussed in group and are subject to on­ spread to 79 centers throughout the United plete a test paper p-actical sessions. Kingdom. Centers are mostly in the larger going assessment during for a probationary townis and have close ties with the local Plans are under way service followed by Catholic church. period of instructor a final certificate of Most NFP clients are in the professional further csting before cost of the in­ and middle classes and the majority are qualification is issued. The is about ;£25 Catholics. Instruction was given first in the itial training of instructors course materials). There calendar method and then in basal body each (inclusive of teachers, all of temperature by doctors and nurses. In are just over 100 active part-time volunteers. 1976 it was decided that NFP instruction whom are unpaid, number trained have should be given mainly by nonmedical About half the total decision has been made teachers, and in the following year the first dropped out, but a more carefully during group was taught the mucothermic method to screen trainees this unsatisfactory of Professor John Marshall. recruitment to reduce Instructors ideally are recruited from figure. The program is accountable to the users of NFP. They must have been mar- National Executive Committee and, ried for at least three years and be under CMAC expenditure of government funds, the age of 50. They can be members of any for the Department of Health and Social religious creed or none. Wherever pos- to the Security. sible, husband and wife teams are an honor­ recruited. To meet the need to orient The NFP service of CMAC has Elizabeth health service personnel, family planning ary medical consultant, Dr. Mrs. Jean nurses have been accepted for NFP training Clubb, and a national tutor, of courses so they can offer NFP to clients in Johnson. In addition, an dministrator family planning clinics, even though they the CMAC medical services has recently themselves are not users. been appointed. All are responsible, CMAC Instruction y meail is also provided by through the chief executive, to the The NFP Professor Marshall for clients living a long national executive committee. ad­ way from a center. Eight hundred new serVice is represented on the medical consltant, clients per year are taught this way. In a visony committee by the medical administrator. survey of 108 couples in 2109 cycles using tile national tutor, and the courses the ST method and recording both pre-and The nationad tutor sets up training has postovulatory acts of intercourse, -an to ifstoUCtxs. Training of tutors will overall failure rate of 7 percent was 1ecently been instituted ais well. Tutors train­ achieved with a method failure rate of offer regional suppoit, and in-serv:ice 3.9 percent. irng to instructors. be The headquarters service of instruction, Evduation techniques have yet to

107 the devised. Lack of staff and funds have liaison and comrmunication between to NFP prevented the collection of adequate two groups. A major contribution of slide-tape statistics. The greatest accomplishment is has been the development illustrate the that NFP doctors and tutors have been in- programs by Dr. Clubb. They of fertility dur­ vited in both London and the region to of- basic ST method, the return for the pre­ fer introductory sessions on NFP to health ing breavit-feeding, anid NFP service personnel and famrily planning menopausal woman. and nurses undertaking training and in-service Needs include more instruMctors administrative updatin.g. A recent CMAC working party tutors with the necessary, paper on the relationship of the N1P ser- backup, including publicity. Scientific, would be most vice to the remedial counseling service has method-related research provided guidelines for the furthering of beneficial.

family planning teachers. It was not until 1982 that this need was met. The National Association of Natural Family Planning Teachers was founded in October 1982 natural famn­ Ki' n(-0 Mand isopen to any certificated ily planning teacher anu any other person who is in sympathy with the objectives of go "the association. The principal aims of the 'association, which is a registered charity, are to promote the availability of NFP and to In 19-16 the Catholic Marriage Advisory education :ad setvicc to all persons of competence in NFP Council (CMAC) was founded in London maintain standards standards. and underton, as part of the work of mar- in line with international riagc counseling, the tcechng of natural The first annual general assembly a com­ family planning. 7The ve-v nature of its meeting in October 1983 elected origin and name indicates that most of mittee consisting of a president, chairman, and CMLAC's clientele are Catholic, but the time vice chairman, secretary, treasurer, headquarters arrived when it was generally accepted that four general members. The Birming­ n ,tural family planning was no longer ex- of the association is NtP Centre, Elizabeth elusively Catholic. It was, therefore, in ham Maternity Hospital, Queen There are response to increasing demand from pa- Medical Centre, Birmingham. its own tients, doctors, and nurses for a service in eight region..l centers, each with Cardiff, natural family planning, that the NFP coordinator. They are Bristol, Live.­ center was set up in the department of ob- Coventry, Glasgow, Nottingham, stetrics and gynecology in Birmingham pool, Newcastle, and Sheffield. 'r5rming­ and Maternity Hospital in 1975. This was in ac- ham, Bristol, Nottingham, Liverpool, There cordance with the policy of the Depart- Sheffield are also teaching centers. at ment of Health and Social Security to are six additional teaching centers of eight provide free family planning services. The universities or hospitals and a total three center has three functions: training, central service delivery centers with research, and service to patients. or four subsidiary centers each. received from the After much discussion, the teachers Financial aid is Authority, which pays expressed the opinion that current Birmingham Health fees and expenses and organizations did not fulfill their aspira- lecturer and tutor grant of £500. A good tions completely, so they requested estab- donates an annual between district health lishment of a national association of natural relationship exists

108 authorities and NFP clinics. The former recruited from satisfied users. provide lecture theaters and equipment The standard of the t-aching program is and pay students' course fees. stringently monitored by the committee of NFP clients are referred from the public the National Association. They , turn are health system and family planning clinics, accountable to the members of the Central NFP orientation is given to all government Midwives Board for the standard of family planning personnel. Clients are also teaching for nurses and midwives and to recruited through church-related activities the Dean of Postgraduate Medical Educa­ in parishes and marriage preparation tion of the universities for doctors. courses. The association provides all Funds are administered by the treasurer methods of NFP, teaching mainly in of the association with the appro ,al of the English but also in some Asian languages. committee. Course programs are continu­ There is participation in well woman ally reviewed, changed, md updated in the clinics, infertility clinics, and preconcep- light of constructive evaluation from tion clinics. A Ilome visiting service is students and according to new develop­ available in many areas, and user and sup- ments. Full accountability for course pro­ port groups function in most places. grams is the direct responsibility of the Centers for teaching naturA fa'nily plan- committee. Asystem for evaluating teacher ning by members of the National Association effectiveness has been developed through of NFP Teachers are spread throughout the chart anaysis and monitoring of clients United Kingdom. At the present time it is behavioral adaptation. not possible to give the number of new Our greatest accomplishments have users trained for the period 1980-83 nor to been the establishment of the chair in estimate cost. natura! family planning within the Queen The criterion for new users is simply a Eliabeth Medical Centre, University of wish to iearn about fertility awarcness with Birmingham, and establishment of teacher a view to using this knowledge to pl.n training courses first at the center and later their families in a natural way. Clients are in university hospitals outside the Birming­ taught all methods and then, with the help hamw area. Facilities for research projects of the teachers, select the method that is and trials at the center have also been best for them. Seventy-five percent choose acquired. the multiple index (syrnpto-thermal with Our greatest ciadlenge is to ensure mat cervical mucus); 10 percent choose the natural methods are offered by trained cer­ ovulation method only, and 15 percent tified teachers in every family planning choose BBT only. Approximately 50 per- clinic as an equal altemative. Our needs in­ cent of clients are spacing their families, 25 clude more doctors, greater material percent are limiting, and 25 percent are resources, publicity through the media, planning pregnancies. Teachers are often and a permanent administrative staff.

109 Prcgram Issues

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1101 T;T /•...... / 4

Woe in Martu LAnn F

110 Since the first part of the book provides specific examples of national NFP pro­ grams, this second part of the monograph focuses on the concepts, processes, and main issues of NFP program development. The various subsections or chapters were specifically structured around the three major themes of: 1. Program development 2. Education, training, and services 3. Ev2luation and accountability. Papers were commissioned from NFP experts on key issues such as the sociology of NFP programs, the production of the major training and resource package of the World Health Organization, and the demo­ graphic analysis and impact of NFP programs. Perhaps most significant are the major commentaries from the participants and the summary of program issues which at­ tempt to draw a picture of the develop­ ment challenge of the next 20 years. The major issues appear to be how to up­ grade and expand NFP services ensuring accountability without losing some of the cultural rootedness which the pioneer volunteer programs maintained. The challenge for many programs will, no doubt, be how to combine a creative mix of volunteer teachers with the profes­ sional support of a full-time staff of co­ ordinators and administrators. Solutions are likely to vary from country to country as NFP services expand into the wider government, church, and medical spheres. Since the major development issue is how to ir..;oduce quality natural family planning information and services into ex­ isting community systems, the editors hope that this book will serve as a practical guide.

111 Developrner4 of National Natural Family Planning Prcg raOms

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Sr. Solange Mnard of Cameroon with an African participant at NF? workshop

112 MARIE-PAULE DOYLE Marie-Paule Doyle, M.S. W., executive director of Serena Canada; founding president of IFFLP (1974), Ottawa, Canada

are too dif­ This paper outlines some key issues on the people who will be meeting the development of national NFP pro- ficult to please. Others feel more comfort­ may grams. The first step is to define the objec- able in a small program although they is tives of theprogram.The second stage is to revise their objectives once the work choose a model. The NFP movement under way. Some may feel they are being presents two contrastingmodes: (1) from pressured by the International Federation which the bottom up, and(2)from the top down. for Family Life Promotion (IFFLP), a Choosing a leader is also critical,as are takes a broad view and communicates sharing power and responsibility. Com- feeling of urgency not yet perceived at the munication needs to be developed with local level. grass-roots,church, and government con- If these feelings or other similar ones ex­ stituencies. A discussion of funding for ist, they will more than likely have an im­ NFPprogramsconcludes thepaper. pact on the choice of objectives. There will be a great deal of difference between offi­ the local Ten years ago, there were few national cial objectives and those which they natural family planning programs. We now group considers realistic and which have many more national programs, and agree to implement. piogram several are scheduled for implementation When the time comes to assess in the next few years. This congress should performance, I wonder which objectives Since be the ideal time to reflect on the more or will be used as a point of departure. or less conscious decisions that are giving this question will become crucial sooner ensure shape to the newcomers. In this paper I later, I would encourage groups to was asked to address three sets of ques- that their stand is known before becoming and tions: (1) purpose and functions of a na- enmeshed in an ambitious program is tional NFP organization; (2) funding and large-scale financing if a large program national program accountability; and not what they wish. (3) national program growth and redefini- After choosing objectives, the next stage tion of goals. is choosing a model. There are two main Purpose and Functions of development models for a national natural a Natona NFP Organization family planning program. One works from The first stage, and certainly the most bottom to top, the other from top to important, is choosing objectives. Progres bottom. cannot be made without a clear idea of The model that lays a base before setting what is to be accomplished. Time should higher level structures in place is depen­ be taken to plan and to clarify objectives, dent on the existence of local centers In my experience, there is often con- already operating in parallel fashion siderable difference between the plan on without too much communication be­ paper as presented to others, and the inner, tween them. They gradually feel the need personal plan that one accepts and finds to unify and coordinate their activities. The motivating, national structure caps an existing group­ Do all family planning program directors ing, which agrees to exchange a little here really want to establish national pro- autonomy for greater coordination and im­ grams? I doubt it. Some may think it's too proved possibilities of widening the scope much work; that they will never find the of their activities. funds; that communication with other Development of this model is a tour de parts of their countries is too difficult; that force on the part of its organizers; nothing

113 i,more difficult tli n convincing a group of represented, or representatives of pro­ pioneers to work harmoniously. Personali- grams with whom one feels most comfort­ ties -ire strong, precedents have already able and who are familiar with the 17ld. been established, and negotiation is seen as There is no easy answer. Both choices en­ a waste of time. It often takes a second tail problems, bu. it seems to me there are generation or the advent of a "common more problems when leaders have no co­ enemy" to achieve unification, workers and do not share power and The second model works from the top responsibilities. Their programs are very down, from an individual or group in vulnerable because they are dependent on authority attempting to serve an entire the presence of one person and are fre­ countuy. The challenge of this model is quently restricted to that person's twof,old: to find in each area local, in- viewpoint. volved, and tenacious workers who will A dynamic program finds ways for deal­ successfully implement the stages of the ing with important iisues as they arise. master plan; and to decentralize power suf- These may be issues Such as philosophy, ficiently so that the entire weight of the rccruiting and training standards, service program does not rest on the shoulders of standards, relations with church or state, one person or on too small a group of or financial autonomy. Some groups have people. national commissions on paoticular sub­ The next stage is choosing a leader. ject,, .)thers submit hese issues to adminis­ Development of a national natural family trators who in turn consult educators. The planning program is very often the respon- more communication and interaction there sibility of one iinIdividual. The knowledge, is in decision-making between the national abilities, dynamism, scope, involvement, team and local groups, the more dynamic and perseverance of that person will make and well-integrated is the organization. the difference between a dynamic progrm Natural family planning programs are and one that will never take wing. You frequently relatively unknown or mis­ already know a great deal about the understood locally. No one among us characteristics of a program if you know should feel uneasy or think he or she is the the person in charge. A program closely only one leading an unsung program. We tied ro church structures will frequently be are all in the same boat, from the least ex directed by a priest or nun. Physicians will perienced to the veterans. We still have v establish clinics, and researchers will set up long way to go. Our priests and seminari­ research centers before thinking about ser- ans do not understand much of our work vice units. Couples will appreciate the and think they have discharged their duty couple-to-couple approach and presenta- to inform themselves and support us by tions in the home, or they will use com- saying to the faithful: "In family planning, munity facilities. All these decisions, follow your conscience." Our moralists crucial in the establishment of a national have fallen on hard times lately. Our program, will probably never be discussed universities have been dazzled by the since the director will think that the modus promise of contraception; our health and operandi he has chosen is the only suitable welfare professionals are ignorant of recent one. At a congress such as this, it is possible natural method developments; our journal­ to compare the experience in one's own ists are prejudiced and erect barriers be­ country with what happens in other coun- twcen us and the public. tries and to question what is taken for There is a lot to be done in encouraging granted. local cooperation. Many national programs Another challenge in establishing na- are work; g in the dark without being tional programs is sharing power and aware of, or enjoying, their success. The responsibilities. Again there are two basic encouraging thing at the international level options: an influential board of directors is that progress accomplished in one place composed of responsible lay people or is useful elsewhere. Furthermore, since clergy in schools and dispensaries, and prophets are not honored in their own representaiives of the regions to be countries, the message .soften better

li accepted elsewhere. A national program needs money, but not A national natural family planning pro- just any money, not from just anyone, not gram is expected * )develop lines of com- at just any old time, and not just any municdtion with government authorities in amount. Money can build or destroy an its own country and with other church organization, depending on the adminis­ organizations working with families. Al- trator's ability. Ideally and ultimately, a though it is quite easy to envisage dialogue national program sho-uld derive its core with eccl(e-siastical authorities when a na- funding from more than one source. It tional program is Catholic in origin, it is fre- should fund itself in part, and it should qucntly much more difficult to find a place regard projects only aLsa supplement. in the sun among state programs. But What is core funding? It involves expen­ should the attempt be abandoned before it dituies essential for the maintenance of a isbegun? national secretariat: salaries and benefits, Program experiences range from most rent, office expenses, t;'avel, and con­ positive to most negative, and this matter ference expenses. These expenditures are of tie intcrrclation between programs and essential for the survival of the organiza­ state authorities is one of the most contro- tion, but ironically they are the most dif­ versial we carn broach here. it is crucial for ficult to have covered by a funding agency. many of us, however, since on our All funding agencies are justifiably afraid response depends access to public funds that cterual delpcndency m,y be estab­ for our programs, our influence on docu- lishcd. The basic requirements f a na­ rnentarion produced by the state, and tional program will not disappear in time, establishment of public services offering so the piogram needs a stable funding natural methods to a population larger than Source. Core operating funds should be we can ever reach. Is cooperation with the sought from multiple Sources. To depend state possible or desirable? At what cost? only on one Source isthe big mistake that Promoting research is another function leads to catestropce when, for one reason of a national organization working with o atastrphe wen, fro r natural methods. It is a function beyond of financial autonomy is essen­ the means of most of us. We have neither A degree organization. Most of the ftuds nor the personnel to do 'big- tial for any national this autonomy is a. result of time research," and as we are service- the time financial participation and sales oriented, research is not one of our members' priorities. Our inability to p)rovide data on to the public. It is utopian to think that any our work, however, means that we are not national organization can survive on its alone, but relative autonomy being talken seriously. In the absence of own funds crises. Project funding should "big-time research," perhatps we should averts many revenues. These projects consider "small-time research." only complement That is the option chosen by programs are often supplementary lorkdone in ad­ that decide to accumulate information and dition to a rigorous timetable. Sometimes to analyze it without waiting for things to they do not even fit into organizations' be done on a large scale or for big-name priorities. They cannot ensure financial specialists to tell them how to do it. And stability; they do not last long enough, and is too risky. The adminis­ we have in our groups some who are well their renewal a n:,ational program must balance informed on returning fertility during trator of breast-feeding, others who are familiar his funding sources (core, internal, and with the practical effectiveness of the project) so asailto not ifin hs organifua­ method they teach, still others who are in- tion's financial future. programs have only terested in psychological or pedagogical Natural method had access to major family matters, and many more. very recently The sums Fundi g and National planning funding sources. with Program Accountability available arc minimal in comparison Natural A national program needs money. funding agency total expenditures. Noting this does not advance cience, but famil. planning methods are valid and denying it dries not advanct- mhe program. viable and meet the needs of a sizable por­ 115 tion of the popIation. Natural methods are important to review results obtained and to educative and help to develop individuals' reassess whether needs have changed. Pro­ personal resources. Why are they not then grams with good annual statistics are in a a natural choice for international develop- Detter position to follow the evolution of ment agencies? All of us from developed their program regarding client numbers countries should press our national and in- and origin, and teacher numbers and char­ temational authorities to grant a fair share acteristics. Ongoing programs can always to NFP programs. benefit from adjustment. Some of you may think money is not to The most obvious adjustments, how­ be refused whenever it is offered. In my ever, are needed when program conditions opinion, it is very dangerous for an alter. These adjustments may be occa­ organization to accept a great deal of sioned by legislative change, by establish­ money before it is ready to carry out a large- ment of a family planning grant program, scale project. Collective wisdom must be or by the fact that for the first time, natural developed so ihat we can determine when methods are being offered to couples in a national program has sufficient infrastruc- state-financed clinics. These major changes ture to receive a substantial sum. require considerable adjustment of oro­ When Service de Regulation des gram objectives and strategies. Naissances (Serena) expanded from one Many programs hesitate to abandon their province to nine others in Canada, our an- orientation as a movement to develop as a nual budget increased by 300 percent. We service. When they examine the impact of had 15 years' experience arid more than such a shift, they find multiple possible 200 trained teacher couples. Our adminis- disadvntages, including: a less firm philo­ trative structure was in place, and yet we sophic orientation arising from the service found it very difficult to absorb so much reaching a larger ciientele, which may have money overnight. New programs, how- more di-erse basic options; a more profes­ ever, are being asked to accomplish this sional than apostolic orientation, since quasi-impossible exer ise. This is a con- often the establishment of more service cern. Is it really hmpossible to respect pro- points will almost inevitably entail. hiring grams' development rhythm by putting full-time professionals who may supplant reasonable sums of*money at their disposal part-time volunteers; loss of administrative instead of chunks on which they may control, since as a result of an appreciable choke? financial injection, the program requires Financial stability is the dream of all of us people with different abilities who will but an impossible d-ean for most. Because replace program pioneers on more or less the programs are not self-sufficient, we short notice; and uncertainty as to future never know what the future will be. In our results, since the jury is still out on whether planning we need to develop three scen- natural method teaching is as valid in a ser­ arios: what to do if we receive less tunds, if vice (public) context as in an apostolic we succeed in gettin more funds, and (private) one. third, what to do if funds remain stable. We are really at the crossroads with the This kind of exercise is especially impor- development of our programs. Some will tant when we have .taiff or are planning to want to forge ahead and accelerate devel­ add staff. opment of a national program by covering Natlonai Porc.g'm i',Jrwth their country with service points, ensuring and ~ >.dellton oGGoals co-workers in every sphere of authority, A responsive organization must intermit- and using large sums of money. Others will tently reassess its goals and objectives, prefer to mark time and observe the efforts Reas's:essment of goals and objectives and results of others before proceeding. seems to be the obvious thing to do when a Who is right? It is very difficult to say since program is not developing as hoped. But the first group may break their backs by that is not the only time when this reorien- assuming too heavy a load, while the tation exercise is usefu!. second may wait a long time in vain for an At the end of each activity period, it is opportunity that will not come again.

116 Experiential Learning and the Professional in NFP

THOMASINA SMITH BoRKMAN

Thomasina Smith Borkman, Ph.D., associate professor of sociology, George Mason University, Fairfax, VA, USA; leadingexpert in self-help groups

NFP services are growing beyond their not expand to a large number of places originalpart-time volunteer-based begin- without existing institutional networks, ures the experiential nings. The expansion of high-q:.iityNFP but if essential fe, of a Jew people in services to more people and countries is component are lost, only the challenge now. 7his paper invites you any loc.nitv t:ri be reached.Furthermore, are designed ac­ to consider some directions NFP services if thesg NFP programs professional can take and their implications, cording to the conventional would be so Certain assumptions which, in fact, are or medical model, the services that the advan­ value jtdgments, underlie this sociologi- expensive and ineffective would be lost. cal analvsis. These are: NFP should be tage of the network and nonprofes­ made avaiable at low cost to many in- New kinds of programs to be designed terestedpeople in many countrieswithin a sional occupations need experts to play reasonable time period; the services that enable experiential institutional should be of highquality,accountableand their irreplaceablerole in the respectful of the diverse values of the peo- context. this challengefor NFP ple involved; and finally, the methods Thispaper raises leaders. should be groundedin biomedicalscience. and institutional In sociologicalterms, NFPis a social in­ novationand like any innovationneeds to become known and respected. As ;artof Natural Family Planning services are a this process of expansion, NFP leaders relatively new social innovation having need to promote the acceptanceand credi- been created durirg the past 25-30 years. bilitv of NFP among established leaders During this time, several kinds of groups­ and institutions. Three orientationshave with medical, religious, and experienced­ their own provided the primary leadershipin devel- user orientations-have evolved oping NFP services up to now: (1) NFP approaches to teaching NFP to women or teachers and users with experiential couples. Many of these efforts have been knowledge qfi NFP, (2) the medical profes- ad hoc, part-time, and volunteer-based. sion, and (3) religious groups, especially Many have been too informal and irregular Catbolics. NFP services currently combine to be entitled service programs. Some these orientationsin a variety oj mixtures groups are free-standing and independent, in different programsandcountries. Each whereas others operate inside such institu­ of these orientations offers both advan- tionalized delivery systems as medical care tages and disadvantages to scrvice systems or Catholic marriage and family delivery. The experiential is not presently programs. given le.2itimacy while the religious and Dr. Claude Lanct(t (1982) recently sum­ med.cal are. marized the status of these NFP services. Theparadoxof NFPis thatservices can- It appears clear that NFP has achieved

117 , new staius of respectability and time, volunteer activity. Moreover, pub­ .ct it is still very close to licly authorized services have to be is); ts origins being still in accountable and have external means to mayj, iaccs mcthod specific, women measure quality. Also, publicly authorized oriintc and mostly by peer instruc- services cannot usually be restricted and tors. Th; cha)llege of the next decade available to persons of certain religious or will ie : c:,(),,nd the movement into etnical value positions while excluding offt.-, qua~ty services ro a much persons with other values. ia'g,. r nn-iicr of potcntikd clients. Third, the methods should continue to be The chal:rge of expanding high-quality grounded both in biomedical science and NFP se!rvices to more people and places is in the experiential knowledge (Borkman acccepwd ihere! as the issue of interest. This 1976, 1979, 1980) of successful users. This congrc:;- i: ansimportant occasion, .nd I in- assumption refers to the knowledge base vite you to consider some major directions of NFP services and to what kind of exper­ that the development of NFP services is tise is needed to direct NFP proirams. Two likely to take batsed on the history of these kinds of knowledge are distinguished here. services and tle apparently available op- Both seem essential for effe.ytive NFP ser­ tions The implicarions of following these vices: (1) the application cl biomedical directions will be spelled out. This socio- research findings on human reproduction logc,,1 analysis suggests that there are ma- and fertility, and (2) expt riential knowl­ jor pitfalls to expansion if NFP services are edge gained by practicing NFP or teaching simply nodclcd after existing medical, NFP to users. educational, or religious delivery systems. 1. The essential bic;nedical scientific Some suggcstions are offered to avoid knowledge is applied information taken these pitfalls. from research findings. It is important to Certain ,ssumlptions have been made encourage biomedica! research on repro­ that were uSed as criteria in conducting this duction and refinement of the methods, sociological analysis. These assumptions but as a separate activity from NFP service are als, in fact, several value judgments. programs. Medical professionals per se are Current sociology recognizes that certain Pot necessary to provide NFP services. The value judgments are necessarily involved applied research material is neither highly in .ociology and any scientific work technical nor extremely complex. t has (Gouldrncr 1962, 1968; Foss 1977). Often been well dc monstrated that nonliterates these value judgments are implicit, not ex- and educated people alike from many plicit. Certain explicit value judgments cultural backgrounds can be taught the ap­ underlie this analysis, and they represent plied biomedical knowledge and can use it the criteria or parameters in terms of which effectively in practicing NFP. Therefore, tile analysis was conducted neither the teaching of NFP nor the direct­ be controlled by There arc three basic assumptions: ing of programs needs to professionals on First, NFP should be made available to physicians or other health specialized knowl­ many interested people in many countries the basis of technical or other medical pro­ within a reasonablc period of time. This edge. The physician or assumption focuses on the idea th-,t the fessional is needed on a consultant basis, condi­ capacity for wide diffusion of services however, for problematic medical biomedical should guide the direction of their tions -tnd to review the applied development, knowledge base of NFP services. Second, the NFP services that are devel- 2. The essential kind of knowledge for oped 5;: uld bc low-cost, high-quality, ac- an effective NFP program is experiential countable to their constituencies, and knowledge of NFP. This refers to trusted respectfiul of the values of the people in- information gained by personal, lived ex­ 'olved, Once NFP services come into the perience (Borkman 1976, 1979, 1980) that public domain, whether they are mandated many teacher users and long-term NFP by church, medical, or government policy, users obtain through their practice of NFP. the services can no longer be solely a part- The experiential knowledge of NFP ir­

118 i~& cludes the pr-ctic-A apj: ication of the and accountable is another ingredient of a biomedical inforrnation to everyday til.fc regular orogram; r'.e administrator func­ plus the em,.otionad awA relational ispc,:!s of tion represents the program to the relevant the -abstinencc, sexuality, and communica- communities. A regular program may rely tion between the , Th necessity/of on part-time, unpaid volunteer effort for expericntial knowio.tige is recognized by most of its service provision, but the iden­ many NIP seovie programs that require tifiable, continuous presence is provided teacher, to b, users. by the administrator. A second necessary clement is the con­ Elements in a Pub'dly ceptualization of the NFP program in AccounzIe INIP, t ogir,m terms of its nature (an educational ap­ From a sociklogical perspeclive, NFlP is a proach, a religious or a medical one); the social ;nnov aion, and, ?,!cc any inw:viun, values attached to it; what groups (medical, it nc.cd.-; to b'comic knovn ant! iCsp,.cted. experienced user, or religious) will control Social innovation refers rtu O-r prac- it; how it is viewed in relation to other tices that are new to the invo1\'cd inrdvidu- family planning methods; and how the als or organizations; it doe,; not mezan new program articulates vtt other local health, in the sense of never prcvioisl" occurring family planning, marriage and family, and throughout human history (Borkman educational services. 1979). What is needed to translate this Third, the functions of NFP teacher, social innovation into i-cspected and effec- supervisor of teachers, and program tive program ser-vic,-; that c;.u be diffused administrator need to develop into Jdenti­ to many people and countries? The ser- fiable occupations. ()ccupations are job vices n ed to become regular programs, positions that define responsibilities, have quality control and accountability duties, and privileges, and that have standards, develop new NFP occupations, selection criteria, standards for training, and become accepted by relevant leaders experience, performance, and idclogies. and institutions. Some people call this pro- Ideology refers to the set of ideas that oc­ fessionalizing an NFP program. cupational members develop about the As can be seen, the term "professional" nature of their work, its linkages with other is problemratic because it has many mean- occupations, ethical standards, vhat the ings and is used in different ways by peo- occupation contributes to its clients and to pie. Some of what people discuss under the society, and so foril (Frcidson 1973). term "professional' I Will discuss under These issues pertain to the fact that in the headings of: regular program, quality many places the spreal of NFP services is control, and accountability standards and hindered by the lack of trained, committed NFP occupations. There is another mean- NFP instructors. These instructors would ing to the term "professionalize" that is a be trained to work regularly in NFP pro­ danger for NFP programs. I will discuss it gramns and have the 'occupational quali­ later. ties" of confidence, commitment to follow Since NFP is changing from a local op- program guidelines and procedures, will­ tion to a service mandated by public policy ingness to submit to adnim;nistrative control in some countries, NFP services will need for the good of providing regular services, to be regularprograms that arc publicly and familiarity with paper work, ter­ accountable and have some means of minology, and organizational practices of showing the quality of their services. Regu- agencies so that they could operate as lar programs are defined here is legally and "professional" -as contrasted with ''ama­ financially responsible services that are teur." I am deliberately using descriptive regularly available and have a continuous, terms about what is needed for occupa­ identifiable presence in the community. A tional performance rather than using the regular program is contrasted with a part- terminology of professionAs. Some of time, ad hoc "fold-up" group that may rely what is meant by "professionalizing" NFP only on volunteer effort. A program ad- is to call for the above qualities in contrast ministrator who is publicly responsible with the qualities found among many cur­

119 . .- -- , . /! . ­

- rs, i;,ho :.e not systematically religious orientation, such as Serena ,'.:tmincd or tested in any way Canada. Physicians who often have to de .1K~'itf,: -ve!'ftheir knowledge and religious values have led some groups, sl':i.!s; "T'', Ar, or uri;ii volunteers whose cither voluntary associations of primarily eotT;Amfi ies in their zeal about experiential users like the World Organiza­ itvl..uc:.I,;a. s effective teachers); tion of tht Ovulation Method Billings who0 m:y f;0[ 'w,- 1,,::cupationally committed (WOOMB) or more medically based clinics to pmviding -, in an NFP program by with so-me emphasis on research, like Dr. submiting to ii,administrative pro- Roctzer in Austria. Religiously oriented cedurts; who ri oa,be familiar with the progrm-n- are often within the context of practices and "culture" of agencies. Catholic marriage and family programs like Fou;th, externA quality control and ac- Ireland's, but these programs have strong co m.iliry standards for NFP progamns input from health professionals and ex­ need to be developed and agreed upon. periential users who teach NFP. Thcse standards are mainly for outsiders- The three orientations a-re important the -e .;vant local communities who give because each seems to contribute some­ t- legti- acy to a program tha't is vital for thing vita] to the philosophy and knovl­ its diffusion. These program elements edge of NFP as it iscurrently constituted. It include such a:.spects as standards of seems that effective NFP services combine follow-tp, confidentiality requirements, some aspects of all three orientations. As record lcping requirements, guidelines discussed earlier, the biomedical, scientific 'or supervising teachers, and so forah, grounding of NFP methods is absolutely There are major dawgt.Ts in defining and critical, arid their appropriate application implementing quality and ,ccountability ensures that NFP is reliable and ,fective as standards. The most frequent error in a family planning method. Similarly, the developed countries with high educational experiential knowledge for teaching NFP levels is to equate standardization, the writ- to newcomers and for informing issues of ten form, or activities done by a profes- NFP service delivery seema critical from sional group as prima facie evidence of past history. The extreine case would be quality and accountability, using males without personal experience Fifth, obtaining acceptance from the of NFP who learned it from books and lec­ relevant leaders and institutions is critical tures ais teachers; one would expect many for obtaining funds, for attracting clients, dropouts and unsuccessful users. The reli­ and for becoming a regular program. All of gious dimension as world view isseen here the preceding tour elements contribute to as key in providing a value framework the legitimating of NFP prograns. within which NFP is interpreted. Values are often articulated in NFP by religious Thre.e Orientations Found groups, but this need not be tie case. In In CurrentNFP Services this paper, religion is being defined in two Three orientations have provided senses: first, as the world view in which primary leadership in developing NFP ser- human values guide choices and behavior; vices up to now: (1) NFP teachers and and second, as an institutional entity which users with experiential knowledge of NFP; encompasses a network of organizations, (2) the medical profession; and (3) religious occupations, and administration. Many groups, especially Catholics. NFP services secular or nonsectarian value-oriented c~rently combine th~e.,: orien~ons ni a groups, however, also could and do pro­ variety of mixtures in diff:rent rog cuns vide a value framework within which NFP and cot . There axe experientialists can be interpreted. For example, the femi­ with stroag religi !- o'.oiciations 1cadipg nist health m.vement and alternative iving voluntary associjtile like John Kipplcy's groups like Summertown (Shivanandan Couple to Couple League. There are other 1979) are examples of value-oriented cxperientially controled voluntary xsso- groups. ciations that are mooderate in medical and in Each of the three orientations also

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represents a direction that N'P can expeicn,,iu IV :- publicly ac.,_u iC deveiop as service programs. What are the regPia. li Et.,,.ic) itwould be i'ffio'r rawor strengths and weaknesses of each to "devc)(,p qut'fJtiJ.ty atr-d accoutn­ orientation0 as a form of service delivery for t:ility standards for local programs that Strtng-ts and weak rsses vr den- v ,-", i A' "..rtrqp ai"_;w ) , a varicty of tified relaitiv e t.othec valte e go~ ,:r.'td ­ l::.:;:',:(5"t.;c kndarir~l Iclo / v eccis were the c:r or a ::.-Si-. ,Titint , in the modern The S th I -h&- )u' riiatloo worM, rd itnav be difficult to incor­ lies in its c nar crtinuousarticulation,n­ porate it f.uiilifuly into irstutionala.ed

of (lht , _viucs o NFP. meo:dical ,-irWestern religious service pro Relgiou i-wt.uv rwcould also F.,cihiiate grams. Overiall, klie experientia! orientation the expansin of NFP swrviccs b,, designing results in great value diversity of NFP pro­ progranms linked with their existing institu- grams, but Serious conilict ed.. arisc in the tional networks (as is Leing done by the struggle to develop ivguia:._r progams with U.S. Catholic Diocesan Development new occupations, quality, and accoun­ Plao)L The weaknesses of the religioai-, tability standards and ko obtain. legitimacy orientation are tha:t: (1) some religious fboNFP progr:.,-s. The resulting NFP ser­ groups are intote:ant of value s-ystems vices, however, woukl likeslv be low-cost, other than their own; (2) some religious contain mmy volunteer users, and be groups would not offer s.rvices to persons widely available to ma-y people. with value systems different from theirs; The strkngtlhs of the medical orientation (3) some religious services impose their are also scvcra. Thley include the fllow­ marriage or family services as a condition ing: (1) updating NFP methods woifld be of participation in NFP; (4) some, reigious facilitated by .he relatively c!ose links of power structures and organiz:tions do no,, hionh.adical resc,irchcrs and clinician.; pro­ legitimize experiential user knowledge ar..dviding serices; (2) e;istingrmod,,s of may not be respectful of it or incorporate it qualty :ud -ccountability c In ,,:.atively appropriately into their service progix-n; easily applied to NFP; (3)c : ing models and (5) religiously b;:1ed se-rvices woui be of hiow to develop regular prog

121

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44 ~K~ I. n'tw3c Sh (,mti ll alcoholism as a stripped away in favor of redcf'ming it in Concurrently, the value crilnC und,' th &' ii iust ic' ,vatern to technical terms. cultural tic c-r-t ( 1t of alcoholism as a diversity of NFP among different dise,.,e t ~,~. :nlc within the medical ;nd religious groups could be diminished. likely be trc',ient svo',:n I selected this illustra- The medicalization of NFP would tri, (,A ;,Id'aion because there are accompanied by its professionalization, seem to occur together. i p)rialt.- p .r to which I will return, since tile two between the trc rn..,rte of alcohohr.i, and Sociologists define tihe term "to profes­ which tile provis.n (4 N!:I' i,.Tvices. sionalize" as the process through social (-r cept S JtvCsalre cady medicalized, Occupational groups attempt upward aInd i'rtilitv is regarti d wii Jn a pathology mobility, that is, to increase their prestige. asnd orientation by the indi,.at profession. This remuneration, autonomy from clients, (Wileoti:y approach is antihlicneal to the values of control over their work territory oc­ N'I. Ahere fertWi. isviewed as a natural 196-4). In the professionai%;., process, Hfe nroccss not ti.be artificially sup- cupations usually emtdate prestigiolis, PiL' ,cd. *rherc is alwadv an example of the autonomous pr,.icss'ons like the medical Starr 1982). Il.Cdicalizatlin 4,)f, t---the idcl pCr- profession ('f~eid ,;n 1970; 'siinncl who redefine NHI: and liael it frorin Although the ideologies of professionaliz­ .withi their mi.cal orictiationr 'fertility ing occupations often center around altru­ awareness vth a bNarrir ncthocd." istic ethics of service, objectivity and Cocioh,iea:i analysis ,)f(:!ses of medical- impartiality, and a client service orienta­ iZaiOll point out tlhalWhCn the medical tion, sociological analyses of these occupa­ are profeC"ioi takes over a condition, they tional groups reveal that their bhaviors o ideologics corccptualize it to fit their world view often contradictory their J.cobs 1976). Occupational (Conrad and Schneider 1980). Tie world (Gerstl and impos. view of scicntiflic medicine contains the group'; often restrict r-cruitment by and tencn,'v to strip oindiithns of their ing stand;rds of formal education number in hunar and religious vAwu connotations training that serve to limit the or and to replace these with technical con- the occupation. Restrictive recniAtment to exclusiv­ notations. .-ric Cassell, himnself an M.D., is standards of training also lead tnc of man,'who argue that medicine is in- ity in who is allowed into the occupation. .heretlviral hut knowledge of this fact Part-time or volunteer workers may be dis­ training in at­ is denicd with the b,.ief that couraged front obtaining high slary the physiciaix docs not make ethical tempts to uphold uniform and insti­ decisions, he only makes technical levels. Many standards supposedly quality decisions. Such concern for morality tutd to establish and maintAn and cer­ is not a gcncralization of expertise but control lead to expensive training are never an accepted part of the physician's tification mechanisms that objec­ role, and is so recognized by the demonstrated to accompish their ways, the occupa­ society th()ugh largely in a covert tive. Thus, it-a .;arkvof at the manner. But he and the patient protect tional groups are self-serving and client themselves frn the ,twcsonleimpli- expense of service to clients cations of that resporisihility by hiding interests. behind the belief that d(octors only Tile profissionalization of NFP has pit­ make technical decisions. (Casscll falls that could lead to serious problems. i973: 57). Two particular dangers are (1) diminishing since it is If NFP \venc t) become the territory of the experiential-user knowledge in written form and ,i the icguhr mcdic-al establishment-with not easily codified models of oc­ the exception of tl )Se phlyicians who su)- not respected in professional and (2) discouraging the training port NFIi fi)r its

122

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6;4 4 of volurteers in NFP programrs can keep standardized nlrner. Costs down ard e.. huc.vin nigh, which is The foll,,ing recommeidiuons suggest inyiportanr to ,.iag couples, wherea4s how V4P services can make a successful the of "NIf,.i o ,1 tr'ansition from "art-tame,fold-up., would drive co,,- . and t.iari x-cs:-al e,n ide-: 1 :..ic '.rlt h and.! ;staffed with ir:Ain'd instructw,whether wea,ncsscs of the hr,:e one:-,ions as,er- paid or unpaid. vice delivcry systems, what can wc con- 1. lwi.c pe-son who have a commit­ elude? The paradox of NIP is that services inert in each of the ork-ntations to help in cmnot expand to a largr: v,,,, of places planning and development. 1t is important without u.sing existing inmia aiuonal net- to have adequate represe:tation of the works (medicl or religious), but if these three orientations, not iust tokenism. networks lose the experiential component Careful attention should be paid to choos­ of NFP, then only a few people in each toe, anr k:s:periential eapu who will not be locaity will be reached. Furthermore, if intimidated by the authority of health per­ these NFP programs and occupations are sonnel or w'hg.ious represcntatives. designed according to the conventional 2. Prepare a straightfo-ward and explicit professional or medical models, the set- outlinc of values and criteria regarding NFP vices could be so expensive and ineffective prograrms simila" to mine at the beginning that the advantage of the network would of this presentation (or in even more be lost. The temptation would be to pro- detail). The first step to awareness is to fessionalize NFP occupations if conven- become cognizant of the values and criteria tional models are followed. Similarly, the for a progran within which one wishes to current model of the medical profession, if operate. applied to NFP prograns, could medicalize 3. Invite a sympathetic but independent NFP and distort its integrity. New kinas of outside observer to help assess whether programs and nonprofessional occupations the approach is consistent with its own need to be designed that enable experien- values if a group is in doubt about its direc­ tial experts to play their irreplaceable role tion or process. There are probably many in NFP and that t reserve the values at- experienced persons who would provide tached to NFF. free consultation in exchange for helping to develop a novel value-oriented service Suggested Recommc.ndatlons program for NFP. I have considered some of the potential 4. Try developing two Solutios to any advantages and disadvantages of following problem you face rather th.n one. As the extremes of each of the three orienta- appropriate, select contrasting types of tions (religious, medical, or experiential) solutions: for examplc, if appropriate, an as a model of NFP programs and services, inexpensive rickshaw solution and a more The approach will need to be novel in expensive limousine solution if you have order to retain the combination of needed fulids; or a solution depending totally on ingredients from all three orientations: the voluntecr 't:iff along with a solution religious respect for human values, the ap- depending on p:iid :t-ff and minimum vol­ plied biomedical knowledge of ferzility unteer heip. This approach may reduce at­ awareness and reproduction, and the ex- tachmcnt to a sing,4.'le soluion, and it may periential learning of tran:ilating the hin- opcn up more possibilities. medical knowledge to evcryday life within 5. Look for other arcas of human ser­ the value franework of the involved in- vices that face sirnilar probiu-ns and cx­ dividuabs. Exactly how le accomplish this amine the wa',; thcy conceptualizce isuues in any pragmatic situation is irnpo,;sible to and the solution!: at whk.h they arrived. say; indeed, the important message i, ptob. For example, the alcoholism treatment ably to maintain the spihit of tie ctrngths field has agencies termed "social model' from the three orientations, not to rigidly or "social-experiential model" (Borkman or systematically apply sonie formula in a 196.2) prgrams that faiced similar dilem­

123

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W.y,-p~. . ,.arne .;n~"Ersvior nenta.!Impac~t Inshe CA:xpcrleC,,IX :- c lir ( )ncrcai,,, d tl. , 'y:,o r ofl ;xin cur~rent concern about sta, ., ' Fp c- lvd of oc' 1 c ." bccrv,- f: areas of self-interest. T ,J o' at ? apprenticshIp :;Id occup1tion and clioic phasizes on-the-job l 1wa2-i minimizes special training 76f- InI c yncr.rc and Mal schooling, i 5Tr, me in kok i he especially lih, the u xtil uv- vop.lInit t. newvv with th,.e experintial lctuig that is the lagirIruiZe irgmsOalsace :h cx- strength of currnt NFP inistructors and is ccuions .jvl nAc' tc :ia vit aPart in keeping with fostering( many volunCer .ciential ur is jo(. givlring I.-tcr-' -'Od C.re or instructors. of se:rvice Ci,Jore Consider new technoloies th;at could be religious dcliver)' sysiet'ts. ecxasti NIF 1:1 the exploited for didactic training in the. ap- you now in the of developing new NFP occupa­ biomedical aspects. An example is the challenge plied that lit within existing use of video cassettes for training ;essions. tions and programs Trainitg could be designed to be as low medics] care oz religious deliv, systems the integrity of NFP. cost as possible and to make it widely ,vaii- vithou. comniromising able in many places. 7. Adopt an "NFI impact Statement." I Reyerences am suggesting a new kaid of systematic B.iunmn, lit a~ona. analysis of selected conscquences of afy 196 x{rienti! Knowledge: ANew Concept for proposed procedure, policy, or practice on the An-Isis of Setf-HIep Groups. Social the client, the programl, or va!ues. The idea Service Rev'ie' 50:445-56.

124 1979 A Socil Science !,.--pective of Research GerstIl, Joel and Glenn Jacobs, cos. IBsues fr N iural Family Planning. Interna- 1976 Professions for the People: The Politics of tional !fe,iL-t of Natural Family Planning Skill. New Yoik. Scenokman. 3331 -5. Alvin W. Gouldner, VaW.cFre of Natural 1962 Anti-Minotaur: The Myth of a 1980 "A Social-Expericntal Perspective -16. tie soc io a Thl e i- Os3:103 Fam ily' Planning."' Paper presented at Congress of the Inter- Second hvcrnational natlonal Federation for Family Life Promo- 1968 The Sociologist as Partis;n: Sociology and zion, Na'a.n, Ircl ad, Sept. 24. The Welfare State. Ar:vr-can .ociologist 3:103-16. 1982 A Soctal-EpcrieotialModel in Programsfor Alcoho/sm Recck;>'-v: A Researcb Report on Ivan et al.,eds. a Neu, "catm'ent Design. Washington: Illich, Naional Instiute for ,lcohol Abuse and 1977 Disabling Professions. London: Marion Alcoholi;n-,. )HHS Pubicstioo No. tADM) Boyacs.

83-1259. Lanctgt, Claude A.

Cassel, Eric J. 1982 "Natural Family Planning! An Overview." 1973 M 3krn.ad Escaping Moral DeCsions. Paper presented at the Germat Agency for HastirngsCenwer Studies 1, No. 2:53-62. Technical Cooperation Workshop on Cur­ to Population Problkms, Conrad, F-ale:,airi Joseph \W. Sch,,eider.Wahbr-iebaenOc.2.rent Approaches - Oct. 2;. Fron; B.d Wachtberg-Niedbachen, 1980 De-,vance .tid erdicalization: ness to Shckoes;. St. Loui.r: C.V. Mosby. Shivanandan, Mary.

Sev New York: Rawson \Wade, 13-15. Kurt, Lynn LPelr and C.P. 1979 Natural Wolf,Finstcrbusch, ed:;. 198: Social "miract ,issnienrMetbods. evl Star, Paul. 19821 Toe Social Transfor,;cotion of American Medicine. New Yotk: B?.sicBooks.

Foss, Denis C. 1977 Tha V',O Cnt:,of:.fsy in Socioloe'. San Wilensky, ltarold L. Awer­ Franci.co: jossCy-Bs. 1964 Thc Profcsionaliintion o., Everyonc? cati,!o;rr7 of Sociolog'I,LXX:137-58. Fdedsdoo, 2..iice . 1970 /"ro.;.isiba" ',v'tc,1e.N2w York: Dodd, Zoia, Irving K. Mcad & Co. !97'7 "Hfatmim and Disabling Mdic.lizion" In Disbiin.' l'r-ofesso;.r..ediied by Ivan Illich et al. London: Marion Boyars. 1973 The Pofcssio-s ad TLir Prospects. Bcverly Hide: 5ngc.

i .7-. te:*s z.; F,# r_. aegUrl ! NoVe~bCr 1977, is s .oinsored by " . ,-the Cazholc Church, and we are directly accountabl:e t.oit. It is funded through C2'-,hoiic Social Service, and we also rcive Title X ronies from the Urted STEIPIHEN U E Sl..tws goverqmens, for the edlucadon ,and training of NFP teachers in the public sec­ Siepben 13ric, A.C.S. W, ,;¢a' direc- tor. I am arso sectctary of the corumirtee for of Ceubolic Social S&ew.fces, Diocese of for standards for New England Natural Providence, R.L, USA; direr/o, of NFP of Family Planning, Inc., an organization Rhode Ishlad representing the NFP interest of the six northeastern states. Nine of the 11 dioceses Before reacting to several poilt irl Mrs. in the New England region are members of Doyle's excelklt paper, I wc-uld like to say our regional association. a little about my own wor .My Vwife Sheila Mrs. Doyle has given us several models ,uid I direct Natural Fafniiy Planning of of natural family planning national Rhode lsarad, a program of Cathoe'c Social development, from top down to bottom serAces in Rhode island. The program, up. I personally favor development from

125 the bottom up for several reasons. First, because of the size and power of govern­ there is far less likelihood of losing the real- ment. Often we feel we cannot cope with life perspective of day-to-day married life the strong advocacy postioi they take for Ihat comes from instruction and follow-up artiiicial cortraceptionl and othcr practices of natural family planning services with we cannot condone. This can mAke us feel couples. For exannple, it seems to me that very armbivalcnt towr:,nrd their money, as in some cases priests have lost a sense of Mrs. Dola v".3 sucstcd. real married iife by the way they character- In oik r to deal with this uniqu. rela­ ize spontaneity and its value iri a conjugal tionshi'I - ith government, suggest relationship. I have often felt that if they sewr.il poitiorjs that church-s.onsored lived with a woman, their views on sexual NFP t-

126 teaching prog!rasn<. Political administra- and their fertile signs did more to "sell" tions change, and they are particularly sen- NFP than any indoctrination we could sitive 1o polifical forces that surround have done. them. Further, it is probably best that we keep our main funding base in the organ- In ancient Greece, there was a mythical ization that shares our values. In other character called Procrustes. It seemed that words, always own at arst 5 1 percent of Procrustes had a house by the side of the our own NP company's stock. road, and he grabbed everyone passing by Lastly, I think we need to have a basic the house -nid put his victims on his bed. If openness of ri-nd ,NFP wiil flower when theywere too short for the bed, they were we love people and accept them where stietched to fit, and if they were too long they are. We can also accept programs a:id for the bed, their feet werc cut off. Pro­ agencies where they are as well. Several crustes has a lesson for us. Perhaps what years ago, when we trained 19 women we can do is to get rid of the bed on which from, governmen t family planning agencies we try to make people fit our point of view to teach NFlP, we had no idea of the impact and bring in a banquet table around which this training would havC. tcause we we can share our gifts and strengths in didn't know their own life circumstances, sharing the message of NFP with our we asked them. as a follow-up measure, to brothers and sisters. chart their own cycles or the cyles of a I will be happy to provide copies of our friend. All of them freely chose to chart standards for programs in the New England their own cycles. We found out later that region as well as my own program of state­ three of them were trying to become preg- ment of philosopy and purpose to any nant. Their new awareness of themselves country representative who requests them.

KATHLEEN DORAIRAJ ports family planning but has had a fL.: fledged national family planning program Kathleen Dorairal, 41.D. director of tWe integrated with the health infrastructure Frnil)' Life Center Of the Indiatn Soial since 1950. And yet, after 33 years of fam­ Instiite: presidenft oJ the National Fan- ily planning programs and substantial ilI1Plalnning Associaition of India, New investments of human and financial Delhi, India resources, the program effects have been poot. Fewer than 25 percent of the married It is imporant to consider fertility couples in the reproductive ages have ac­ behavior and family planning programs cepted the family planning methods pro­ within the broader socioeconomic conitext motcd. In the 10 years between the 1971 of a country. In the case of India, where the and 1981 censuses, the population in­ level of socioeconomic development is creaLsed by 136 million persons, and the an­ low, programs must be d.csigned that are nual growth rate increased slightly, from sensitive to the nwed.s and concerns of the 2.20 percent in the 1960s to 2.23 percent poor, whose motivationis and ratior.Hilty in du; ing the decade of the 1970s. The the area of childbearting must be con- government has mounted a 'multi­ sidered. If such concerns are n,,-lected, pronged attack," involving governmental fertility reduction programs will not be agencies, the private sector, mass media successful. Family planning and the reduC- communication campaigns, and monetary tion of fertility are not ends in themselves incentives, togeth(r with a focus on the but only one means of enhancing human promotion of theoretically more effective welfare. Fe-tility behavior cannot be family planning methods. isolated frdim other aspects of social and The Indian experience points up the economic development. rcl,tionship between development and The government of India not only sup- population. The upper classes and upper­

127 middle classes, who have benefited most nutritional requirements of each child. If from socioecornmic development since more children survive, fewer pregnancies iendcn.,.cc, now have only two or and births are required. Women need not three cildre- and accept a method of spend their reproductive years in com­ family im-itatio,- when the desired family pulsory, repetitive motherhood, and so size- s reacheJ. They have high aspirations NFP contributes to the health and welfare NFP can also for themselves and their children, and they of women as well as children. place a high priority on education as a tool improve the quality of family life because it for social mobility. Thus, they are moti- improves communication between vated to accept family planning and to in- spouses. Women, especially poor women, vest their personal resources in fewer who learn to use NFP acquire knowledge children. The poor, h'"Wever, have not about their own bodies that gives them the shared in tihie fruits of India's socio- means to control fertility. economic development. Poverty and Natural family planning involves iden­ malnutrition continue to contribute to in- tification of the fertile and infertile phases fUat deaths, and parents need to have of a woman's menstrual cycle and requires enough children to ensure that some will sexual abstinence during the fertile period survive Yo care for them in their old age. to avoid pregnancy. Family planning pro­ They are therefore "below the threshold ponents in India are often antagonistic levl' for acceptance of official methods of toward NFP because many of them believe fertility control. They are especially not that NFP is synonymous with the outdated receptive to the primary method promoted calendar-rhythm method. A large number by the Indian government program, that is,of them are not even receptive to learning sterilization, about the more modem approaches to It is in this context that natural methods NFP. Most family planning experts are men of family planning become an important who perceive that women, especially poor alernative. NFIP is acceptable to poor women, will not be able to identify the fer­ coupl!es because it is not permanent and tile period. They believe that the poor are because it permits them to space their prolific because they are irrational and children and thus focus on the health and unable to abstain from sexual intercourse.

put us in contact with Mrs. EDGAR PAZ-GONZALES in Latin America M. Wilson of WOOMB-USA, who invited for the Family of Edgar Paz-Gonzales, A.D., obstetrician us to the first Congress took place in Guate­ and gynecologist;founder and chairman the Americas which VE3MO-Billings (Asociacion mala in July 1980. of A attended the Venezolana pc.ra Aplicaci&7 del Mtodo The 14 Venezuelans who initiate a national NFP de Ovulacidn Billings), Caracas, congress agreed to exclusively the Venezuela program to implement Billings method. Its main attraction to the majority of Venezueln physicians, in­ its novelty. Many priests, educators, and physicians cluding gynecologists, was necessary to particularly, have worked in favor of Upon ou, return it became would direct natural family planning in Venezuela for a create an organization that Anonprofit long time (in my case for over 21 years). and support the NFP program. Octo­ Many publications and works on NFP have community association was founded Venezo­ been presented before the Venezuelan ber 12, 1980, named Asociaci6n Ovulaci6n Billings Society of Obstetrics and Gynecology. lana del M6todo de la con­ We distributed Dr. Billing's book, (AVEMO BILLINGS). It was legally Mitodo de la Ovulaci6 n (Ovulation stituted and registered with a constitution Method). The Christian Family Movement and published bylaws.

128 The members of our board of directors center, we offer instruction and follow-up were selected from the foundin?. roup and aim to keep proper records and with His Excellency Archibishop of Valen- statistics. cia, Msgr. Luis Eduardo Henriques, desig- In July 1982 the first national meeting of nated as national counselor. Va'encia is the instructors of the Billings method took third most important city in the country place. Delegates fron arnost the entire and is the site of major industrial develop- country participated. ment. Thereafter the board of AVEMO Our program has expanded from Caracas, Billings created the Centro Nacional and a the capital, to other important cities and working team to undertake the promotion dioceses such as Valencia, Acarigua, of the Billings method through presenta- Porlamar, Ciudad Guayana, Puerto Aya­ tion of talks, confecnccs, and publications cucho, Los Taques, La Cuaia, Matufin, San and to infom adrniiatrators and educators Carlos, San Crist6b:d, ad Barquisimeto. through seminars, workshops, and other We will soon establish centers in the re­ activities, maining dioceses. The program functions The Ministry of Health and Social in urban, suburban, and rural areas, in Assistance in our country, the official body private residences, parishes, and church responsible for the national health and facilities. The services provide assistance to well-being of Venezuelans, conducts a pro- all classes of clientele coming to the dif­ gram entitled "Family Planning," which ferent centers without regard to race, recommends only artificial methods of creed, or social status. To date the instruc­ contraception and disregards the natural tots have been recruited from couples methods. Almost the entire nedicad profes- eigaged in apostolic movements and reli­ sion accepts and approves of this program. gious members of various orders through­ We decided that it would be more produc- out the country. tive to solicit the support and assistance of Our primary objectives are promotion the Catholic Church for AVEMO. and expansion of services to the entire The bishops received our presentation country, securing funds, and improving well and invited us to present it to the con- the training of instructors. We have con­ ferences of clcrgy in difference dioceses. centrated on teaching the Billings Method Later with the assistance of clergy, in Spanish but have some experience religious orders, and secular apostolic teaching in the indigenous language in mis­ movements, we proceeded with seminars sionary zones. of three days' duration for the training of We have not obtained any official finan­ instructors of the Billings method. cial assistance to this date, although we We then founded Centros Diocesanos have contacted various public administra­ Billings (Billings Diocesan Centers) to tion staff and overseas institutions. We de­ undertake the expansion of the movement pend entirely on the collaboration of a few to their respective dioceses and, with the private individuals and organizations and assistance of the national center, we pro- on Volunteer staff. Because of the newness ceedeI with the creation of centers to of our program and ;ack of accumulated provide services in the parishes and other data, we have difficulty in providing valid locations within easy reach of the public, statistics on couples using NFP, percentage Services to the public were then initiated. of dropouts, cost effectiveness, and preg­ With a minimum of personnel in each nancy rates.

129 gram and canrot get NFP training because the prograun is limited to married couples. DCUSs-.ion How do you set up o non-Catholic service in a developing country that has only a Catholic program? Some private sector providers solve the by having no selection The need to naike natural family plan- problem of values for clients but insisting on strong ning available to all was discussed under criteria criteria for teachers. Religious af­ three i-wi.n topics: expansion of service, selection may be less important than the ac­ leadership, and fu.ding. filiation periodic abstinence in the Expansion of Servioe Two issues were ceptance of life and the motivation to high~igh'cd in thc discussion: the relation- teacher's own of the praictice with ship between pri;'vte NFP organizations share knowledge not uncommon for all teachers with an explicit v:lu: vstem and the more others. It is program to be Catholic while pluralistic public sctor programs; aind the in a private or more u;;ers are non-Catholic. differece bcte,.r -,Pas a social move- 50 percent of some providers, non- merint ,uid NF;1 a's merely one kind of family In the experience be more strict in their value planning scrvice. Catholics can than Catholics. Some organizations do not aim to make orientations Many clients come to NFP for health NFP available to all potential clients or to reasons. Several participants believe that all try to staff ;ll delivery points. Rather, they have the right to learn about their bodies see themselve.s{ as a reference source for the to use the knowledge to limit their fer- best teaching, traini.,, and literature in the and You do not refuse to teach physics field. They ,-1so try to train couples to tility. NFP might make a bomb. An of s.ccc ful integr because a student be models that information their relationship. Asian participant noted periodic abstinence into planning Many/ IFP ]cac.:r,, -' 'estion whether it is about artificial methods of family b tis readily available possible.to rc::ich ih ,,_ whole country and at to young people, so it makes good sense to teach unmarrieds the samec time passm NFP Values, about NFP as well. par- Thu dis well. i\ key qncstion i'." many conference The distinction between NFP as a move- ticiparits, who V,'ii, to make NFP available ment and a service was defined in several to alfl, is what iiiii.r1s they Should take Some NFP providers call themselves towards clients' values and behavior. What ways. a movement and have a clear philosophy policy should NFP programs have toward and ideals, but they have no problem pro­ single people (not sexually active), engaged "ding services to individuals who lack couples, and coha'hitjrs? It was suggested such a commitment. The core group of that NFP values 'n presented as an essential volunteers is the guiding force for the successful practice of committed NFP.ingredient For example, teachers should point behind the service. Others see the move­ incorporating the whole works best in a stable, com- ment as broader, out that NFP depends on the aspect of family life education, in which an mitted relatioshipon ndship depnd servic provided NFP service is provided. love and responsibility between partners. One program director has found that a Leadership An important issue in develop­ Priests couple expresses the values of NFP more ment of NFP programs is leadership. by successful practice of periodic ab- and sisters start many programs, especially work stinence than by spelling out the values in remote areas. They are willing to in words. in places where others cannot or will not A pavticipant from the public sector ob- go. The challenge is both good leadership served that many potential clients want and how to pass on leadership. N.FP. only as a contraceptive, and these Participants generally felt that the role of people are automatically turned off by mar- priests and religious (defined as both men riage enrichment courses. Some people- and women celibates who have dedicated for example, singles-come to an NFP pro- themselves to the Catholic Church), like

130 that of doctors, should be as facilitators, effective nor very acceptable. Information Once a program has been initiated, they on start-up costs, number of autonomous should have the humility to step down. users, number of unplanned pregnancies, This does not mean there is no place for and continuation rates is needed. There is religious. One medical provider has found little halrd data on acceptability of NFP. It is that some clients may still prefer to talk to important to know if a couple with an un­ nuns for reasons of confidentiality, planned pregnancy comes back to NFP There are great contrasts between pro- later on. grams in various countries. In one devel- One private Catholic funding agency oped country, medical and church groups funds NFIP not just for demographic or are not being reached at all. In an African economic development goals but for nation, leadership is based on a hierarchy achievement of family and self-fulfillment with the initiator a bishop, the president a goals. At the same time funding agencies doctor, and service provided by the need hard facts and technical know-how couples. for funding. Funding Funding is important in the ex- There is the problem of meeting the pansion of service and raises many ques- challenge imposed by the sudden infusion tions with regard to program philosophy or withdrawal of funds. Each program and accountability. An African participant should answer ,he question: Is the project stressed that developing countries are culturally appropriate? Do we have the caught between two conflicting sets of staff? Assistance can be provided in kind. expectations: NFP motivators com- from A program director from Africa does not religious groups, and funders have their think NFP providers shoulc. always think own ideas. Nlany religious NFP providers of someone else to provide the funding. He do not accept the referral clause that some described his own organization's income­ international funding agencies may require. generating projects, which included real This clause mandates referral of dissatisfied estate rental and for-profit business. Volun­ clients who request methods of contracep- teer services are a form of funding coming tion not provided by the NFlP service to from inside the organization. One partici­ other family planning scrvicL.; or health pant stressed the importance of taking ac­ personnel. On the othei hand, govern- count of the whole picture. The problem ments are reluctant to fund single-nethod of funding can be mitigated by inserting programs. Both groups, it was suggested, NFP into existing church, government, or would accept referral of clients to a family medical delivety systems or into a literacy doctor. prografli. One participant from a developed coun- The problems of funding vary from try urged that NFP personnel should press country to country. In one poor Latin for accountability of the funds their coun- American country, some couples cannot try gives to the United Nations Fund for afford to pay for the service. But paying for Population Activities. [low much goes for NFP adds to the motivation to use it suc­ natural family planning? cessfully. Therefore, couples are expected Contrasting yet similar views on funding to pay, but if they cannot afford it, the pro­ were presented by a private European gram subsidizes the couple. In a European funding agency director and a United country the service has to be free because States government reprcsentative. Some other family planning services are pro­ agencies see nothing wrong in incorporat- vided free. ing a philosophy of family life promotion Funds, it was pointed out, are needed into an NFIP program, but this value system not just to run NFP programs but to unify should not be mndatory. Some interna- the NFP movement nationally or regionally tional organizations have been reluctant to (which one participant recommended as fund NFP because they perceive NFP as the the second level of development). It is ex­ ineffective calendar rhythm method. Fur- pensive to bring people together. Who ther, they consider NFP to be neither cost- pays those expenses?

131 N P Education, Training, and Service Development

-. ­

,- - . . ,° . .I YII1A

Sr. Paulette, Mlissionary of Charity, counseling woman on NFP In Calcutta

132 ANNA FLYNN

Anna Flynn, M.D., obstetrician and gynecologist; currently Research Fellow in PerinatalMonitoring at University of Birmingham; founder/directorof Birm­ insgham NFP Centre and Association of NiFP Teachers, U.K.

This paperattempts to look at the prob- and contraceptive technology began its lems facing NFP pro, rams in the 1980s flourishing developments. andoutlines a suggest2dplan of action at In contrast to the highly technical nature both a local and a nationallevel to ireet of the artificial contraceptives, natural this challenge. rr ethods depend principally on educaing The most critical./actor in any NFP pcople to detect their own fertility. They delivery service is the quality and corn- entail a delivery system different from that petence oj the NFP teachers. 7 'erefore,to of artificial contraception. Th.e develop­ achieve a high-qualityNFP service, a pro- mcnt of NFP services started when private gram mrust ensure that adequatetraining pioneering groups began to be established courses a-re available. ihis requiresstan- to help couples in the use of the natural dardsfor curriculum content for use not methods. These groups often received only in local or area programs but also financial and moral support from the nationally and internationally. Outlines Church at the local or diocesan evel and for such courses based on the WHO/BLA T were closely associated with other socio­ Family Fe'rtilityEducation Resource Pack.- moral programs within the Church frame­ age and that of the U.S. curriculum out- work, such as marriage counseling and lines a-re ofered as a help for programs farmily life education. In general, with a few desirousof initiatingorupdatingtraining notable exceptions, the NFP services were programs. Continued NFP education is delivered by lay volunteers who received also important because of rapid develop- local training only. Accountability was to ments in science an2d education. This the local church group. Thus; a myriad of paper o(fers suggestionsfor the implemen- NFP movements, each with its own train­ tationof continued education. ing and delivery sy:,ter, sprang up in different countries. There was very litle rapport even between neighboring coun­ Historically, the cyclical fertility of the tries, and no effort was made at interna­ female has been recognized, but it has been tional expansion. traditionally associated with menstruation. While NFP remained very much a move­ The twentieth century saw the develop- ment at the grasF-roots level, the con­ ment of scientific methods to identify the traceptive services had developed rapidly fertile time in the cycle. Scientifically based in the intervening years from being private methods of natural family planning by clinics to becoming fully integrated into planned sexual intercourse or abstinence the general medical services of each coun­ during the fertile phase allowed couples to try. They were staffed by well-remuner­ plan their families. ated professionals, and they operated at The same scientific discoveries that pro- national and international levels. duced the development of natural methods These developments served to isolate also made it possible to eliminate corn- the NFP programs, which came to be seen pletely the fertility phase in the cycle. I as quasi-religious rather than health­ refer, of course, to the introduction of the oriented and which were generally dis­ oral contraceptive pill, which seemed the credited by the medical profession, by the answer to family planning problems. Con- official family planning (ccntraceptive) traceptive clinics quickly sprang up to services, and often by government health "deliver" the pill and other contraceptives, services. All of this led to a lack of con­

133 fidncc in N ' byD the p!Cic by dewvcop!ng mn intemational NFP oh'umi. tihc In 0hc ittn. hal ° of t 19",70'. howeve', In addition, these organizatiohi ; were and NFP v, ,,lio.nrtovcd -aiore rapidy, with driving fcxce for the inplantati no only 'vit.in thc NP net- pansion of NFP in devclopirig coe!-atries. s?.<:A of wo 1;but lso in the reaiors:hio between Since 1977 rh'y hcve sowed the Am rican co.-n­ NkP and the officia. co1,traceptPe services. NFP in African and Latin a.ssemblies of Con.cem with the possible sid.. cff;cts of tries. Thronb'.k the gcncni and arificiail techniques cx~sed tsc public to these internztional organiz-Ations and take a second look a: natur.-i methods of through cth r ir.ernitoria semn.ars medical, family planni',e. The l.st decade, there- workshops, expcrts from the and fore, h-:; sce!n :.,.icad, expansion of NFP social, beha'vioral, psychological, bodieas prorpn'Li.5s 'an. .'annrvicc . in both the devel- educational disciplines, scientfic Orgarijz. iorn, the .p' a.d the developing world, such as the 'World I-Iealdi the In some parts of the developed world, British Life Assurance Trust (BLAT), :nd Human Ser­ NlFP hau; expanded out of the church J.5. Department of Hcath a few, have been at­ centers into exi,;ting medical servics. In vices, to name but England, the original NFP movement tracted to offer their expertise. (Catholic Marriage Advisory Counci!) of- All of this has led to a better understmd­ different ferd NFP services in 0he 1950s and 1960s itg of the scientific basis of the as a clnrch-based organization. The NFP NFP methodologies, their acceptability, of an center in Birvningham, founded in 1975, is their efficiency, and the importance for the based in the Obstetrical and Gynaecologi- appropriate educational technology cal Department of the University Hospital. more effective delivery of NFP. Thus, out move­ There it offers training courses in NFP of the snal individual grss-roots 30 leading to an official certificate recognized ments that constituted NFP programns by the medical services, with lecturers and years ago, a professional, multidisciplinary, course tutor faes remunerated by the Area international service has developed, recog­ and Health Authority. It also has a service clinic nized by official govcrnmentA bodies posi­ in the hospital running parallel to the con- health services ais having something the corn­ traceptive clinics. Although it maintains a tive to contribute to the health of the mor.1 very close liaison with the diocese and its munity, quite independent of parishes and Catholic schools, its accounta- and ethical values it also offers to some. to bility is to the University and area health This growth poses a serious challenge services. NFP movements and programs worldwide. of us A further development from the center The important question for each one over the last two years was the establish- in the NFP field is whether we are prepared the ment of regional centers, similar to that in to meet this challenge. I believe that decades Birmingham, at Liverpool, Bristol, New- future of NFP over the next two we give. castle-on-Tyne, Sheffield, anid Nottingham. will be determined by the response These centers have developed within the medical networks but as yet are often The Challenge of NEP partly financed by the diocese and main- Developments in the 1980s we tain a close liaison with each other and In order to meet the challenge, to Birmingham through the National Associa- should proceed in an orderly fashion tion for NFP Teachers. Other countries in take stock, plan action, and take action. Europe are also developing along similar All good business people take stock not lines, once in a lifetime, but yearly or more often. The founding of the international NFP If they do not, they are left with out-of-date organizations, World Organization of the items that constitute a liabi!ity. In our NFP Ovulation Method Billings (WOOMB) and programs we should also take stock of the International Federation for Family Life demand ior our services and of our Promotion (IFFLP) in the 1970s served to resource potential. Our first question coordinate and stimulate further the small should be: Who are the people likely to NFP programrs at diocesan or national level look for NFP services? To put it another

134 way: What do we know abou,. our user awareness component of NFP, are an im­ poputltion? What are theit characterist'cs? portant orientation service, since they ale Their cxpectatior;? Their problems? likely referral sources to NFP services later. Where are they fir,,,d? Hew can the) find Finally, home visits and teaching may be us? Thse-ca,,fundamnvtal Q-Uestions to be necessary to re-ach certain families who are answered iuxre we !.V-gin to p!:.n our either unahle or unwilling to attend a clinic. service progra.n. We now ask ourselves the next question: Let me give au exanple. Historically, Having identified the user population, NFP serv.ceS ver; v',ry muu'i church- what reCources do we have to mee their associated, and many pgran-s sti;l have needs in regard to NFP? There are various their clinics, pcl;iuiel. f ccs, and in- types of resources, including pcsornel, structors on the pr:tty of the church to finance, clinics and training centers, and which they -_e attacheo. Changing atti- backup support service!; for referral of tudes to cont rcepti and a return to clients and related activities. nature la'.v" ni dv t':rcasing numbers of people intcrested in natural family plan- Personnel ning, not b.c-cause of any moral reasons but Probably the most effective part of an for medical u/d!n; cultural reasons. Will NFP service is its personnel. Many different they be prepared to seek out a church- persons will be involved in an NFP pro­ associated clinic? Or will they mistrust the grin, but they fail into three main cate­ clinic as a means of religious indoctrina- gories: administrtion and organization, tion? Are these people better served instructors or teachers, and pt')lic rela­ through the medical network? Such clients tions and fund raising. usually come from contraceptive clinics With regard to administration and and fed more at ease in the health-clinic organization, each program should have an situation. Referral is easier, the location organizing committee to coordinate all and booking system are already well those involved in offering NFP services. known, and only a minimum of adjustment This committee is also responsible for the is ieqtired or. the part of the client, standards of service, training programs, NFP offers opportunities other than just and the fertility acceptance philosophy of avoiding pregnancy. It can be used to NFP. For this reason, several disciplines achieve a pregnancy and therefore is suit- should be represented to evaluate stan­ able for infertility arid preconceptional dards and monitor progress. A salaried ad­ clinics. These arc normally situated in a ministrator/coordinator is desirable, hospital outpatient or other specialized although this is not always a reality for clinic. Breast-feeding mothers are naturally many programs. A salaried secretary, either attracted to NFP, but the best place to con- part-time or full-time, is essential. tact them is in the maternity unit of the The well-trained, competent NFP hospital or La Leche League. Premeno- teacher is the linchpin of any NFP service. pausal clinics are fashionable nowadays, The importance of the NFP teacher was and they too can be fruitful soil for the im- emphasized by Dr. W. D. Clarke, Director plantation of NFP. Thus, the public and of BLAT, when, at the International Semi­ private health-care delivery systems may nar on Natural Family Planning held in be necessary to help the NFP services max- Dublin in 1980, he stated, "Teachers are imize the potential user population. the crucial factor (to NFP) because, in my Well-women clinics and women's edu- experience, a good one can make evei. a cational centers and certain feminist bad method work, but a bad one can ruin groups are developing in Europe and the best methods and plans." America. They are often interested in the Teachers should be able to offer all NFP fertility awareness component or in t,FP methodologies to clients. For several itself and are another group of potential reasons clients may prefer to use a single users. Inputs into medical schools, nursing indicator of fertility or to select and com­ schools, teacher training colleges, schools, bine several indicators in a multiple-index and colleges, mainly through the fertility approach. The teacher should be able to

135 help them select but should not attempt to Time is one of the most important com­ service, aid influence them to use a particular method modities for NFP delivery always con­ because she (the teacher) has found it use- volunteer workers ca-nnot the­ ful personally. tribute the necessary dine. Moreover, that are In larger programs and as more teacb.ers progran cannot impose standards remunera­ are trained, it becomes possible to too rigorous since there is not "specialize" in teaching NFP to particular tion for services. Programs with volunteer seek and accept groups-e.g., postpartum, infertility, pre- staff may be reloctmt to they menopausal, and postpill-thus offering a funding from public bodies because exp.:cted. more efficient serv ice to these particular are not able to offer the services it is bet­ groups of clic:nts. Thik,; L a pity, and, in my opinion, the The programs should have at least one ter to accept the challenge and improve demand. public relations officer who coordinates services to meet the of profes­ the relationship of the center to the public. On the other hand, a good mix with the Very often tis is combined with the work sionals and paraprofessionals the best for the of the administrator or the secretary or volunteers may achieve their other members of the central program. program. The professionals, to justify Public relations efforts require training on salaries, will have to give excellent service, zeal of the the different methods of reaching the whereas often the apostolic incentive to public. The mass media are the best adver- volunteers is an even greater It is most impor­ tisemcent, ad people need to be trained in make the program work. in­ public spadking and other media skills in tant that all NFP workers-whether of the order to use mass media efficiently. A very volved in the day-to-day running important public relations task is orienta- center, in orientation of the public to NFP, the client level-are tion talks for those likely to be referral or in NFP delivery at developments in sotircs for NFP clients-hospitals, clinics, kept abreast of the latest work and in medical schools, church groups, priests, NIP, both in basic scientific NFP. seminaries, religious congregations, and better methods for delivering school governors. Clinics and Training Centers clientele. Con­ Finance NFP has a rich and varied to have the As the pcogram becomes better known, sequently, one should aim as possible to sources of funding begin to emerge. In clinics as widely dispersed NFP for moral general in today's world, in order to attract cater to those looking for as well as those funds, donors must be convinced that the reasons (church clinics) that the program Ias the necessary trained person- with health reasons. It is important in both location nel and that it is responsible and account- clinic sites be accessible able for the funds given. Professionalism is and hours of service, attractive for clients, great advantage the key word-nobody has either the cash and well staffed. There is a health or or the inclination to give hard-earnec in being located in an official requi­ money to what seems to be an amateurish hospital clinic, since all the above program without definite goals and with- sites are practically ensured. may staff out trained personnel. Although many NFP teachers respon­ Assistance is not limited to financial sup- the clinic, one person should be and account­ port. Hell) may be obtained for training- sible for its efficient running To avoid for example, a hospital or university may able for this to the center. system is provide lCcture space, equipnent, photo- overloading the clinic, a booking should stating facilities, or lecturers' and tutors' advisable, and at least 30 minutes fees. Occasionally a teacher who works in be allowed for each new client. is NFP delivery within the ftunily planning A network of domiciliary NFP teachers clients clinic will be remunerated ,as a professional. very useful for the follow-up of the A close liaison Funding demands the accountability of a in or near their homes. between the clinic quality service. It is often difficult to sus- should be maintained the clinic having tain high quality with an all-volunteer staff, and these teachers, with

136 the overall responsihility for tlh cik.. n cessky to modify the plans. NF) scrce This helps to ensure quzli tore,. , ie deof iopmcnt can occur 'Lnd be responsive teachers in the netwoik and is imprt.ant in to the renuircments of the (-.ers only if the ascertaining when a couple have beconme program continually talues stock, pl;ns ac­ autolornous users. tion, uid takes action in an everrecurring Any NFP program must offer some train- cycle. ing, both orientation courses for public relations and basic NFP teacher training. Education and Triahdng This necessitates a site for training courses, for NFP instructors and much will depend on how the pro- To develop training programs of a high gram is set up, its goals or end points, and caliber, two types of training are necessary: its personnel and financial resources. (1) hasic NFP teacher training courses, and Where there are several small NFP pro- (2) tutor training courses. Teacher training grains, a central training center, well courses are essential to any program and equipped and in almost continuous use, are usually developed locally by the pro­ may be a more economical solution than gram. The tutor is the person who trains several smali, poorly c:quipped training the teachers. Normally each small program centers. The central training center could does not have a well-defined tutors' course then have a training team recruited from (although most have in-service days to help the smaller programs. This ensures quality develop tutors). There should be one, control for the training program. however, at least at a national level, in Having looked at the demand for ser- which all satellite programs participate and vices and at our resource potential, we can to which they have access. A national now begin to plan. There are many kinds tutors' training course helps to ensure of planning objectives-short-term, quality control for all basic courses in the medium-range, and long-term-and a pro- region. gram requires all three kinds. Each objec­ tive should be clearly defined. Usually one Basic NFP Teachers' Training Courses plans mote than one can realistically Historically, NFP was taught in a achieve, and for this reason, it is important woman-to-woman or couple-to-couple to identify priorities in the planning and to system, where very often the instructing set time limits for achievement, woman or couple had a large personal Accountability and budgeting are essen- input and drew heavily on personal experi­ tial so that plans can be developed in an ence. Sometimes a fanatical zeal in pro­ orderly fashion, always aiming for the roting NFP for either moral or cultural overll long-term plan. Budget items in- reasons was expressed. There was no elude staff, training, finance, and locations, assessment of the standards or quality of among others. Ideally one should budget instruction given, but it certainly varied for a three- to five-year expansion goal. considerably. Although a program may have very few The development of a more professional current resources, a well-planned future approach to family planning in general, program is probably the best way to attract usually within the health services, and the funding. Therefore, a clear exposition of growing realization that the critical variable the potential demand and a plan that seeks for successful Ni'P is the trained, comnpe­ to remedy the lack of resources suggest a tcnt teacher prompted the initiation in the program that is accountable and respon- mid-1970s of more formal training for NFP sible. "Think Big" is a good slogan for NFP delivery. programs. Curriculum objectives for training NFP Finally, one arrives at the action stage, as teachers were formulated in the United defined by the demand, the potential States in 1974 by Mary Martin for the resources, and the plans, both long- an'. Human Life and Natural Family Planning short-term. In the course of taking action, Foundation under contract with the U.S. one must take into account any additional government. These were shared in 1975 information being discovered and any with the World Health Organization

137 to (WHO) for the further ,developmefnt of a more knowledge than a user in order re­ standardized cuOrriculum for NFP woild- give her confiderce and ability; she of wide. WHO worked wiii BLAT to develop quires an opportunity during the course and its the Family Fertility Education Resource her training to talk about sexuality teaching Package which contain;. four modules: control; she must have supervised which she is (1) fertility awa,.cness, (2. ovulaticn meth- practice, using materials with support od, (3) sympto-thermal method, and (4) liv- familiar; she needs an adequate problems; ing with NFP (sexuality and responsibility), system for consultation vbout educational In addition, it includes an educvional and she needs training in handbook. methods. Because of these requirements, The important common factors in the self-instructional methods for training are two programs are described below: inadequate, and a group system including I. Fe:tility awarenes,; includes a discus- both men and women is the idcal. sion of basic anatomy and physiology, making this module particularly well suited Selection of Candidates for NFP Training to schools or for persons who wish to What are the characteristics of a good know more about their bodca; but who NFP teacher? All training agencies must ask may not necessarily plan to use NFP. this question in the interest of being 2. All current NFP methodologies are in- economical in their efforts. We all know cluded, thus emphasizing the importance certain attributes or qualities that certainly of training NFP teachers to impart :.' seem to make for success, such as motiva­ methods so that the client may have a tion, commitment, empathy, or the ability choice. to learn. It is not always possible, however, 3. The importance of modern teaching to identify all of these attributes in a per­ techniques in the curriculum is stressed in son, even when we know what the desired the training objcctivc.i m ,dulc (Martin) and qualities are. How often is it our experi­ the educationa handbook (WHO/BLAT). ence that the ideal candidate eventually The teacher not only must have the turns out to be a poor teacher? The oppo­ necessary background knowledge but site can also occur. must be able to communicate it to the Ideally, the NFP teacher should have client, some personal experience in monitoring 4. Living with NFP is an important her own fertility and a fertillty acceptance module that is missing from the American attitude. Some training programs offer a curriculum, although without doubt it is pretest to all their candidates. Even then implied in the training objectives, one still has the problem of differential A somewhat later development in NFP learning rates: the slow learners feel inade­ than that of methodologies was the realiza- quate, while the quick learners get bored tion that the successful use of natural or frustrated. There are several pedagogical methods required that the couple be able techniques to overcome these problems, not only to define the woman's fertile and tutors for these courses should be period but also to handle their sexual trained specifically to deal with such behavior during the fertiic phase according situations. to their desire to avoid or achieve preg- When NFP demand and interest were nancy during that cycle. It is most for- low, the small number of candidates who tuitous that the resource package managed wi-,ned to become teachers allowed for lit­ to incorporate this realization. It guides the tle or no selection. Increasing demand is trainee-teachers toward their major role of now forcing teaching programs to get helping clients to become autonomous and some return for their outlay in training. suggests ways of approaching this Nevertheless, there will always be some "delicate" subject. dropouts, and if they are a Aiigh percentage The WHO/BLAT project highlighted cer- of trainees, the training prograri should tain basic aspects of what constitutes a reexamine itself. good training program for NFP teachers. In From my short experience, I find that summary, it points out that a teacher needs the quality of the training offered is prob­

138 ably thte most ciric l variable in determin- In the Birmingham Training Program ing the continuation of the NFP teacher. Assessment, the diploma is recognized by Another very important element is follow- the Central Midv ives Board for nurses, up and support from the center, including heAth visitors, midwives, and lay people in-service training through chart analysis, and by our postgraduate dean at the assessment of pregnancy cha-ts, special University for postgraduate training for physiological situmtions, data collection, doctors. All the regional training courses and involvement it,research projects. sponsored by Birmingham (there have been five over the past two years) also enjoy the Assessment of the NFP Teacher same facilities for the diploma, provided Ideally, the successful teacher is one they are organized, directed, and examined who can teach the clients to chart correctly by the Birmingham training team. and understand the indicators of fertility; The fact that the NFP training courses are to determine correctly the fertile days in recognized by official bodies like the Cen­ the cycle; to adjust sexua! behavior accord- tral Midwives Board and the University ing to their family plaming intentions gives them increased standing and credi­ (avoid, space, or limit pregnancy); and to bility with both professionals and the iecognize any departure from the normal general public. It aLo helps to ensure high in the cycle and to seek expert help if it is quality in the training courses and in the required. The teacher should also have the assessments. latest information with regard to research and NFP delivery. Before the teacher is given responsibility Continued Education for NFP Teachers for clients, however, it is wise to have a Several activities ensure continued qualifying examination. This may take education for NFP teachers. First, in­ various forms, but it should include a test service days are held at the center several of comprehension of the basic knowledge times a year, and attendance at one of these necessary to teach clients NFP, including each year is obligatory to continue on the all the current indicators of fertility. After a Register of Certificated Teachers. Regional practicum of teaching NFP under supervi- meetings are also held at each of Birming­ sion, the trainee should demonstrate the ham's six satellite centers at least once a ability and sensitivity to understa.d diffi- month. Chart analysis arid various diffi­ culties, either physiologically or psycho- culties are discussed. The Association of logically and scxually, that couples may Natural Family Planning Teachers, a na­ have in the practice of natural methods and tional organization for England, Wales, and the ability to maintain confidentiality. The Scotland, serves as a coordinating body for ability to teach the basic methodologies to NFP teachers for all areaas. It also serves as a clients should also be demonstrated. A final link between the teachers and the health certificate should be issued to those who and family planning services and other NFP pass the basic qualifying examination. This groups. Finally, a newsletter is produced is important for three reasons: it gives the that is the official communication of the teacher the confidence she needs to know association. It keeps teachers informed that she is qualified and capable of about newer techniques, research, and teaching; it is a safeguard for clients and other items of interest. gives them confidence in their teacher's These are the critical areas in which an competence; and official health services NFP program needs to take stock, plan, may demand a diploma before employing and take action to ensure quality educa­ an NFP teacher. tion, training, and service.

139 Family Feiliy Education Resource Package

W. DONALD CLARKE

W. Donald Clarke, Ph.D., director of BLAT (British Life Assurance Trust); pro­ dvcer for WHO of the Family Fertility Education Resource Package, London, England

Dr. Clarke affirms that the quality of and student and when the teacher has NFPservices depends on the qualityof the taken the trouble to understand what sort teacher. NFP requires a teacher who ac- of person the student is and how he or she tively involves the client in the learning can be motivated to learn. It is possible for process, especiadly as most NFP learners a teacher who relies upon a didactic, are adult. This approachis also appropri- authoritarian style to be successful in some atejbr those who trainNF' teachers.Cn- situations, such as where the learners ex­ linuing education, practice teaching, pect, and want to be told, what to do and gradualprogression in handling difficult how to benave without having to think for cases among 'N1clients are,rcopnne.,fh themselves. strategies. The 11- /Il!A 7' FIamily l'ertil- It is much more likely, however, that the ' u'Education esouer It'l'ackig isan im- successful teacher will be the one who re­ portant aid to A7 !' t/'enA' is dtscrihed quires her learners to be active participants in the rest oJtbe pa er in the learning process and who spends do to Dr. Flynn's a;.ilvsis (4 the SitU.Riom r- more times listening to them than they garding tcachcr tr.aining and N1F iscx- her. (Not for nothing has it been said that so that he tremcly perceptive and accurat. She has man has two ears and one mouth Un­ identified con-ctly that tie luality of any can listen twice as much as he speaks!) teachers service is first an1d foremost dependent fortunately, the majority of NFP didactic upon the quality of the teachers. Good seem to be of the authoritarian, train­ teachers need three things: a sound type and lacking in any professional teach in knowledge of the subject that they are ing. Consequently, they tend to themselves teaching; the type of personality that the manner or style that they or makes them acceptable xi a person to their were taught either at school or in college clearly an­ students; and the availability of sound, in church. Their attitude I have the reliable support services that can provide nounces, "I know I am right. you this them not only with technical and logistic knowledge. It is my task to give learner to services but also with access to continuing knowledge. It is your task as the as the author­ education for themselves, listen to me, to recognize me It is a illusion to think that there is just ity, and to do what I say." one model of a good teacher. On the con- It often seems to the outside observer trary, good teachers come in all shapes and that the major concern of such teachers is sizes with different personalities and to get another notch on their guns or teaching styles. Learning takes place most another medal by getting a learner to pass effectively and efficiently when there is a the test and thus prove what good teachers match between the personalities of teacher they are. Such an approach is almost exact­

140 ly opposite of what is required in NFP with NFP, the ce-vical mucus method, or teaching. NFP teaching is about human the sympto-thermal method. Unlike some behavior and human attitudes just as much other publications, the resource package as it is about knowledge and skills. To makes no claim to be the right or only way change behavior or attitudes requires a far of doing something. On the contrary, it en­ less dominating approach and a much courages teachers to adopt those parts they greater willingness to see the task from the feel are appropriate to their situation, to point of view of the learner, adapt those parrs that they feel nee1d modi­ Most NFP learners are adult learners. fying to fit their situation, and to reject They are not school children or high everything else. The only aspect of the school, college, or university students. package that has any semblance of a claim NFP teachers will get nowhere until they to authority is the educition handbook recognize aid come to terms with this because if piofcssional educators ire asked basic fact. The characteristics of adult how NIT should be taught, then this is learners are the following: they have to be their answer. highly motivated to want to learn; they will The resource package represents a major learn only what they feel they need to advance in the teaching of natural family learn; they want to be guided, not judged; planning. Based on a five-year study con­ they learn best in an informal setting; and ducted in six countries by the World they need to be given the chance to absorb Health Organization, it contains only those what they have been taught. resources that have proved helpful for The strange, unrecognized thing about teachers. It is as scientifically accurate and this description is that it also applies to NFP rigorous as it is possible to be, but at the teachers when they themselves are learn- same time it is presented in such an in­ ing to teach. So it is a lesson that has to be teresting and artistic manner as to make it learned by those who train NFP teachers! easy for both teachers and learners to grasp Dr. Flynn's call for a continuing education the necessary concepts. Provision for NFP teachers should be The primary target audience is all those listened to by those who have the power to people involved in teaching and learning establish it. Teachers need the chance to NFP, but so great is the clarity of the ex­ practice their art in informal settings where planation that it is also likely to appeal to they, too, can make mistakes and learn nurse trainers and teachers of school chil­ from them. Let them learn first how to dren, who will be able to select those teach the easy cases among the women, for items, such as the physiological and aria­ example, with regular cycles, a fair amount tomical ones, that are highly relevant to of intelligence, and a reasonably high level their work. of motivation. Then let the teachei's come The kit contains the following items: back and learn how to deal with the more Anne mid Graham This 11-page booklet difficult instances, such as those presented showing a short story in the form of a car­ by the nonliterate or premenopausal. What toon strip is designed to stimulate discus­ is needed is a planned system of teacher sion with learners on the importance of training and continuing education. communication within a relationship. Also It is to be hoped that the WHO/BLAT included are three sets of questions related Family Fertility Education Resource Pack- to the cartoon story, each set being for age will provide one vital component of a learners of different ability, and two short planned systematic education. It has taken cartoon strips on attitudes to abstinence years of careful work to develop, with from sexual intercourse. This booklet meetings of experts, field tests in six coun- forms part of the "Living with Natural tries, further meetings of international ex- Family Planning" module. perts, and a large financial investment in Living with Natural Family Planning This publication. it offers suggestions, guid- module examines different aspects of the ance, and practical help in the form of individual and joint responsibilities of the visual aids to all NFP teachers who deal man and the woman that are necessary for with the topics of fertility awareness, living the successful use of natural family Flan­

141 ning methods. With the help of cartoons to determine the fertility of the woman. and diagrams, it deals with periodic Common anomalies in the results are abstinence, the expression of sexuality, shown and explained. The CM module also ansid communication. As with the other has fully explained practice charts. modules, all the visual aids are to be found Throughout the package, abstract con­ together in a compendium. cepts and complex charting are made Ferti!ty Awareness This module uses easier to follow by using step-by-step labeled anatomical drawings to provide diagrams which include manipu!ation of some basic intormnation about the male and charts, pencils, and menstrual cycle female reproductive anatomy and physiol- wheels. The various components of ST and ogy that are rited to fertility. It covers CM charts and instructions on how to fill both maJe and female reproductive sys- one in are systematically presented and terns, the pituitary gland and the brain, and fully explained on the text side of the card. the mens.rual cycle, which is shown by a Particular Staes of a Woman's Repro­ segmlented wheel with a color scheme that ductive Life This section explains what is runs ithroughout the package. happening in a woman's body at particular life and how it mucusC.-ervical (CM) Mucus Method The cervical stages of her reproductive method in this package is a may alter hr body temperature and cer­ variatn ofAth, Billings ovulation method vical mucus. The stages are: immediately in which the days of relative fertility are after the menarche, postpartum, discon­ identified by self-observation of cervical tinuing hormonal contraceptive, and pre­ mucus throughout the menstrual cycle, menopuse. The effect long cycles have on Subjects covered are tlr mucus symptoms interpreting fertility is also shown. and observation, charting and interpreta- Education Handbook This 63-page hand­ tion, the peak day rule, and use of tile CM book explaining in detail the Resource method to avoid or achieve pregnancy. Package contains sections on the choice of Tie fertile 2nd infertile types of mucus are family planning methods, design and con­ clearly shown by photographs. tents of the package, and how to use it. It ,.T!Eto-Ternal Method The sympto- has a full compendium of objectives, key thermal (ST) method identifies the days of concepts, and visual aids and a glossary of fertility and infertility by changes in basal terms used in the package. The handbook body temperature in combination with also gives directions for planning a course other signs, symptoms, and/o-, calcula- using the package, teaching techniques, tions. Step-by-step diagrams sh( w how to the role of the teacher, and how teachers observe and record the t..mperature themselves can be trained. readings on an ST chart. NFP teaching isat a crossroads, a point at Handouts and Charts Both the CM method which decisions have to be made. There and the ST method modules have hanid- are a number of inspired teachers about, outs that ex.plain in concise textual and and they have been successful; in fact, visual form how to fill in the charts after rather like the statement in Dr. Flynn's making the relevant observations. Handout paper, they have even managed to make sheets arc suitable for photocopying. Alter- difficult methods work. But a,.the moment native ways of charting by direct use of there are no signs that this inspired few can thcrmometer and lined paper are also generate enough teachers to match the shown.The ST module covers the uses of need. In other words, current teaching the method, the relative fertility during the methods are not really independent of menstrual cycle, diagnosing probable their inventors; so the choice has to be pregnancy, changes in the cervix, the either to have a small cadre of inadequate recording of intercourse, temperature, teachers almost immediately or to try to mucts, and other signs and symptoms. develop, at first more slowly, a large Practice ST charts show specimen results number of teachers independently of the of body temperature, cervical mucus, and inventor of a method who rely more on a other signs and symptoms that can be used compromise between teaching methods.

142 Comments

This research involves M&UREEN BALL research project. the trainee in a public relations exercise, the people in other service Maureen Ball, national coordinator of see'king out can be helpful if clients need ibe New Zealand Association.of NFP agencies who referral. Successful trainees are then The Nev, Zealand Association of Natural accredited. as Family Planning has 125 active trained Both men and women are trained those teachers who are partially remunerated. A teachers. They are selected from family plan­ basic training course takes approximately who are pleased with natural others. Men 12 months. Candidates must be users who ning and would like to help they are are able to function efficiently in a clinic, work with a female teacher when for and they must subscribe to the aims and teaching couples. They are available would objectives of the Association. Each can- consultation when a male client do not didate is selected by the national coor- prefer to talk to a man alone. Men few dinator before a training course. teach female clients by themselves. A a Trainees attend a three-day residential doctors, who are ;nterested in providing local NFP seminar with expenses paid. For best medical back-up service to their training results no more than 20 and no fewer than teachers, attend sessions in our 10 are trained as a group. Lectures, group courses. We have no trainees from our discussion, and role-playing are used to Polynesian or Maori communities. office in present the following topics: anatomy and In the national coordinator's of physiology; hormonal influence during a Auckland, we have up-to-date records NFP menstrual cycle (acted out as a dramna); the the workload and status of every ac­ concept of "combined fertility"; teaching teacher in the country. To maintain arid interviewing; special circumstances creditation teachers must attend four study (for ex .ample, breast-feeding or premeno- days per year and complete a residential A pause); and motivation. Self-administered postgraduate course every three years. expenses. tests are used for comprehension exercises. government grant covers their After six weeks trainees complete a writ- Teachers who take leaves of absence for ten exam. They then commence role-play family or other reasons are given refresher work under supervision in mock clinics to courses on their return. with gain teaching and interviewing skills. We maintain a friendly relationship We do Pregnancy investigation is included in this the Family Planning Association. part of training as a role-play exercise. not have the money or resources to pro­ When the supervisor is convinced that the mote our service aggressively but supply items. trainee has gained enough role-play tx- local newapapers with news an perience, he or she starts teaching under The annual NFP conference provides other supervision. The supervisor is present at all opportunity to invite members of workers to interviews at this stage and will try to ar- agencies, doctors, and health and range for the trainee to see a wide range of join us and share both our education brings clients, our fellowship. This conference A second three-day residential seminar together about 120 NFP teachers from all (usually approximately 10 months after the over the country. Before the conference first) consolidates the basic training, the 14 area leaders meet and report on Trainees then complete their final exam developments and events in their own paper, which includes a comprehensive areas. These area leaders are elected each case history of a real client-couple and a year by their local teachers. They are

143 The responsible for the four local study days man's fertility, to his sperm survival. per year, and they keep the national co- "waiting time" finishes when the male ordinator informed of developments in partner is able to show the female partner The the area. that those symptoms led to ovulation. Good communication among teachers temperature chart confirms that ovulation throughout the country is essential to has taken place. maintain morale. Some teachers in country Over 50 percent of our clients are not centers would be very isolated and cut off Catholics, and most come from a mainly if it were not for our communication net- middle-class, educated socioeconomic work. Our quarteiy newsletter, sent to all group. Our biggest group of clients are accredited teachers, provides an oppor- breast-feeding women. The next largest are tunity for continuing education as well as a those discontinuing the pill or injectable forum for shring news and views. Infor- Depo-Provera. Many of them are planning mation is also channeled through area to have another baby but want time for the leadets. effects of the chemicals to wear off. We Our NFP tcachers, both men and have not yet worked out a satisfactory data women, work inclinics by appointment. collection system on continuation rates. We teach "symptoms" only to a couple Our third largest group, many referred by who have a full" l.!east-fed baby during the doctors, are trying to achieve pregnancy. time that the mother has no signs of return- We teach fertility awareness in secon­ ing fertility or is not cycling. As soon as the dary, mainly Catholic, schools. We have breast.feeding situation changes and/or just introduced further trairiing for our NFP signs of fertility appear, we teach the clinic workers to become educators. Some sympto-therma method (i.e., symptoms accredited NFP teachers receive intensive and temperature), with cervical palpation training in public speaking, group leader­ for those who are interested, ship, and classroom techniques. In the Our approach to teaching stresses the future, only NFP teachers with an edu­ "combined fertility" of the couple. When a cator's certificate will work in this area on male and female ceacher work together, behalf of our Association. the male explains the male partner's role Our greatest needs are to expand our ser­ and the techniques of temperature taking vices to all cultures and socioeconomic and recording. The femle teaches the groups; to promote our services better; fem:Ale client about mucus symptoms as a and to improve data collection processes. sign of days of possible sperm survival in We also need more research on reliable fer­ the preovulatory phase. Emphasis is placed tility indicators and development of such on the "waiting time," which starts with products as a urine test kit to detect the ap­ the onset of mucus symptoms due to the proach of ovulation.

vices but also for the continuation of -IOM~AS IrLGERS education through the development of natural family planning edu­ Thomnas Hilgers, M.D., obstetrician and cationindependent programs. The philosophy of the promotes the development of gynecologist; associate professor of program srogea tpro gams fo newontura Department of Ob/Gyn, Creighton strong education programs for new natural University; director of NFP Education teachers throughout the Center, Omaha, Nebraska, family planning andUSA Researcb country. The Creighton Model is built upon six different certificate programs. The basic The Creighton University Model is programs involve the training of new unique because it allows not only for the natural family planning teachers (natural development of a program of excellence in family planning practitioners and natural the delivery of natural family planning ser- family planning instructors). The advanced

144 the programs hivolve the further training of oped through the research efforts of Plan­ NFP practitioners so that they may either Creighton University Natural Family establish or participate in natural family ning Education and Research Center. The ex­ planning edtucation (natural family plan- program began in 1978 and has already ning educators and natural family planning hibited a major impact on the development the supervisors). The NFP educator is specific- of natural family planning services in ally trained in the natural family planning United States. Several NFP practitioner and core curriculum that has been developed 2t instructor training programs have been Creighton University School of Medicine. conducted in the United States, and many In addition to these programs, two more are in the planning stages. The specialized certificate programs are also Creighton program offers a new and foun­ available. One involves the training of unique opportunity to build a solid of physicians (natural family planning medical dation for the future development consultants) to enable them to participate natural family planning services. in the future training of natural family plan- The program at Creighton University, ning teachers. The final program is the under the auspices of the Creighton Uni­ most recent; it allows for a sound theoreti- versity Natural Family Planning Education the cal base to be given to priests and non- and Research Center, is accredited by Plan­ Catholic clergy, so that they may be more American Academy of Natural Family knowledgably involved in the natural fam- ning. In addition, its certificants are eligible ily planning movement, to pursue certification by the American The Creighton Model has been devel- Academy of Natural Family Planning.

ANDREw KIURA method in her own life, and she must con­ tinue charting and forwarding her charts to Andrew Kiura, M.D., surgeon;founding FLCAK at least every three months. member and currentpresidentof Family The candidate for training must not have Life Counselling Association of Kenya, any other volunteer activity in the com­ and its voting delegate to IFFLP; cur- munity because of the time required for rently associatedwith the Kenya Medical NFP training and teaching. The candidate Research Institute; elected member of must be committed to continuing educa­ IFFLP African Zonal Council; with his tion and must attend follow-up courses to wife, Jane, member of the Pontifical stay up to date in NFP knowledge. She Councilfor the Family must also have a commitment to continue promoting and teaching NFP. Married The Family Life Counseling Association women must have the consent and support years of schooling is of Kenya (FLCAK) conducts training pro- or their husbands. Ten as an grams for teachers and tutors and imposes the absolute minimum for acceptance candi­ strict criteria for the selection of trainees. NFP teacher trainee. Finally, each which may Teacher trainees must be married women, date must have a local sponsor, organi­ married couples, or religious sisters. The be a hospital, parish, or community it ensures ideal choice is considered to be the married zation. This is important because to the com­ couple. The woman must be between 24 that the teacher is acceptable community and 45 years of age, and she must have munity and will return to tie received. been charting her menstrual cycles before and make use of the training training for at least six cycles, two of which To make sure that the criteria are met, must have been ovulatory. She should have candidates undergo a selection process, a good knowledge of the rules of the NFP which consists of a written paper to test method she intend , to train in, and she knowledge of NFP and an interview, in must be confident )f the efficacy and ad- which the trainee's chart is also discussed. vantages of NFP. She must use only an NFP The interview seeks to assess the trainee's

145 attitudes toward NFP. tutor's course. In addition to further Although Dr. Flynn recommends that knowledge of NFP, the tutors' program in­ the teachers be able to teach all methods of cludes, among other topics, counseling, aids, pro­ NFP, we have found that our program must ethics, leadership, making visual management. be flexible. Teachers who will work in gram design, and program and the tutor rural settings usually offer only the ovula- Both the teacher trainee prac­ tion method, which is easier to use and trainee courses contain supervised more acceptable for rural populations. In tical work, both real and simulated. of teacher training programs urban areas, teachers are trained to offer all Two types first, an intensive training methods of NFP. It is important that allare offered. The to nurses and doctors teachers in one country use a common course, is offered start NFP programs in the methodology of teaching, charting (sym- who intend to The course lasts four to bols), and record keeping. Clients who various hospitals. on the level of move from one area of the country to six weeks, depending experience in NFP, and is another become confused if their new education and sessions. The certificate teacher emphasizes a different methodol- given in all-day who complete the course ogy. A national association of NFP awirded to those them from the compulsory teachers, such as th? one in England, will exempt family planning course at the would help to standardize teaching eight-week and this is a development that national hospital. methods, The other type of training program is for nonmedical personnel who The tutor is even more important than primarily meet the teacher selection criteria. They the teacher in the overall program, because this is the person responsible for the mustwrsos attend threehc one-weekr eddrn residentialh wrsos hc r eddrn h proper trainingproer ofofteaher.raiin teachers. Well-trainedeilraied school holidays in April, August, and i wors hops for the program to Dc em er h e tiin opr tutors makeoffr it possible hgh-uoitysericean tosprad December. The timing of t'ae workshops offer high-quality service and to spread allows the participation of school teachers, much faster throughout the country. who constitute the majority of the trainees this course. The workshops are carried FLCAK is placing q great deal of emphasis in on tutor training. Although teachers areintscoreThwrkopaecrid on t thrnin tou cers aveb out at the diocesan level by a team of tutors. traited at the regional or tiocesan level by The training materials used in the the tutorthe he training of tutors is done at courses are primarily the WHO Fanily Fer­ the national level. tiity Education Resource Package. FLCAK Criteria for acceptance into the tutors' participated in the research and trials that program include at least three years' ex- led to the development of this package. We perience teaching NFP; ability to com- have some complaints with it: we believe municate in English or Swahili; sound that it does not emphasize the prolife knowledge of mad belief in NFP; organizing aspect of NFP adequately and it tends to and counseling skills; commitment to real evade the philosophical and moral issues improvement of marriage; availability to inherent in sexuality. We also think that conduct NFP workshops; and sponsorship the presentation of the ovulation method is by some organization. Couples are pre- not detailed enough, but we have been ferred as tutors, but if only one partner is a able to modify certain portions to accom­ candidate, there must be evidence of full modate our own needs. We also have support of the spouse. adapted Dr. Mary Martin's NFP instructors' Selection is made through both oral and training modules (the American curriculum written testing during the interview for the outline) for use in our training programs.

146 NOTKER KLAi\N stresses that the successful use of NFP methods depends essentially on the joint Notker Klann, directcr of section on decisi.'n made by both the man and the counseling and coordinator of the woman. Different az;pects of this Jecislon National NFP Program for German are discussed, and the possible difficulties Bishops Family Life Program (Zen- that may result are addressed. The aim is to tralstellePastoral),West Germany show future instructors that NFP methods depend on both the awareness of fertility and the corresponding understanding of of both partners. It is The Working Group for Natural Family the sexual behavior that abstinence may Planning at the Central Agency for Pastoral pointed out clearly change in a couple's Questions of the German Bishops' Confer- require a fundamental which may lead to positive ence (Arbeitsgruppe Natiirliche Familien- sexual behavior, reactions and behaviors. plannung bei der Zentrastelle Pastoral der as well as negative NFP Deutschcn Bischofskonferenz) was the first A couple's moti-ati.'ons for learning The NFP organization in the Federal Republic must be clarified with the instructor. of Germany. Working closely with Dr. expression of sexuality must be explored to its Anna Flynn of Birmingham, the Group in a wide context with regard cultural organized and carried out a training course physical, psychological, and exchange of for persons who wished to become NFP aspects. This requires an teachers and for resource persons in the views and emotions and an understanding and of moral, areas of preparation for marriage, family of roles within society and adult education, and youth services, religious, and ethical values. in training The course was financed by donations and The teaching methods used demonstra­ by support from the Catholic Church. NFP instructors include both may The course was designed to include both tion and teaching by experience. This one-to-one informational and practical components. be done in small groups or with be prepared Informational units focus on knowledge of counseling. The trainee must of knowl­ fertility awareness, methods of family plan- to take the experience and level point ning, and living with NFP. The fertility edge of his or her clients as a starting the art awareness unit teaches basic anatomy and for NFP instruction. In this context, physiology as it relates to fertility, since of listening is of special importance. theoretically understanding the biology of reproduction At the conclusion of the pass enables the trainee to comprehend the oriented course units, the trainee must are tested basis for natural family planning. Topics in- a written examination. Trainees elude male and female reproductive on hormonal control systems, symptoms periodic organs; hormonal control systems; the ef- of fertility, application of in­ fects of estrogen and progesterone and abstinence, and sexuality. Those who experts in their significance for NFP; indicators of dif- tend to work as educational ferent phases of the menstrual cycle (main adult education, youth work, and prepara­ theo­ symptoms, less major symptoms, combin- tion for marriage complete only the a ing different symptoms); and "double retical part of the course, which takes in ad­ check" ais a procedure. total of 21 hours of class instruction The unit on methods of family planning dition to the considerable time expended offers general information on artificial con- on personal study of the course materials. NFP traceptives and their relationship to the Those who are training to become part of natural methods of birth control. In this instructors proceed to the practical must in­ way, the instructor is able to help couples the course. Each future instructor an activity make responsible decisions about the troduce three couples to NFP, abilities. choice of methods, taking into account that helps to develop teaching on their particular situations and motivations The trainee is required to write a report and their fmaily planning intentions, each couple that contains all the important the The unit that focuses on living with NFP information necessary to asses,,;

147 teaching process. This information forms cially for the purpose of analyzing the data. the basis for an oral examination that is At the same time, medical research conducted after at least three couples have relating to subjectively measured ovulation been instructed. A teacher trainee must at- and its comparison with objectively tend at least three regional meetings, par- measured ovulation was completed in ticipate in two supervisory meetings, 1983 by Dr. Freundl of Dusseldorf. In addi­ spend at least 27 hours working as a tion, results from a psychological examina­ teacher, and complete a final 12-hour col- tion administered to those who took part loqulum. The theoreical and practical in the training course will be analyzed. The components combined require 72 hours of findings are expected to supply informa­ instruction and practice. tion about the personality traits of NFP Following successful completion of all users and about the effects of NFP practice requirements, the candidate receives a cer- on the relationship of the couple. tificate of qualification as an NFP instructor. The results of scientific investigations There is not yet an autonomous organiza- pertaining to NFP are very rarely published tion of those who have finished the training in medical journals in the Federal Republic course. The Working Group forms the in- of Germany, so the average level of knowl­ formational network for all these teachers. edge among physicians about NFP is very Continuing education is an important re- low. The training course has succeeded in quirement for all instructors, and each one stimulating interest among practicing gyne­ must declare a willingness to participate in cologists and scientists. Three dissertations continuing education activities. A written on various aspects of NFP have been corn­ statement to this effect is completed. pleted, and they will be published in the The Working Group on Natural Family near future. Medicine and the medical pro­ Planning has been asked by its commis- fession are held in high esteem in the sioning institution to present a report on Federal Republic of Germany, so it is par­ experiences in the training course. For this ticularly important to promote medical purpose, the registered cycles of the par- research in the field of NFP and to focus on ticipants in the course as well as those of postgraduate education for physicians. the couples who have been introduced to Moreover, research in psychology and NFP will be used. This analysis has not yet sociology is necessary to learn more about been undertaken, but about 2,400 cycles couples who practice this method and are available for investigation, and a com- perhaps to contribute to the development puter program has been developed espe- of materiols to publicize NFP.

CLARA LOCKHART fanily with emphasis on natural family planning. This was later elevated to an Clara Lockhart, Ph.D., national coor- episcopal commission with a national dinatorforfamily life (includingNFP) in coordinator, a diocesan or couple coordi­ Dominican Republic; academic dean at nator (for eight dioceses in all), couples the UniversityDominicana representing marriage and family move­ ments, coordinators for responsible parent­ The Church is the oni'y institution dedi- hood, and a young person. cated to natural family planning in the The Equipo N.cional de Pastoral Familiar Dominican Republic. Services are offered (National Team for Family Life) was estab­ to 8,921 couples or 0.7 percent of fertile lished by this commission to bring about women. In 1978 the Departamento de Pas- uniformity in the expansion of the work. toral Familiar (Department for Family Life) Composed of committed professionals was created by the Dominican Republic's such as physicians, nurses, psychologists, Episcopal Conference to assist and coor- counselors, sociologists, and educators, dinate at a national level the services to the the national team's principal objectives are:

148 (1) to plan, elaborate, and evaluate ac- NFP acceptors are practicing Catholics, tivities and programs a the national level; Protestants, arid Jehovah's Witnesses. At (2) to standardize the work undertaken in present there are 8,921 users in the pro­ each diocese; (3) to represent the commis- gram of whom 1 percent wish to achieve sion; and (4) to develop and supervise the pregnancy, 5 percent wish to limit births, national program on family planning by and the remdning 94 percent wish to space the Billings ovulation method, dispersing births. In most cases when the user can the latest scientific knowledge through ap- identify with clarity the fertile phase and propriate media. the couple achieve a level of satisfaction Each diocese created its own family life with periodic abstinence in harmony with pastoral team with a similar structure and a their family pianning intention, the woman local diocesan coordinator to represent leaves the program. She comes back ory them at the national team. when she experiences changes in her cycle The Commission for Fertility Regulation or when her circumstances change. The within the national team has the following user may feel confident after five or six aims: to provide couples with knowledge cycles, but she is still given long-t nn of natural family planning and to help them follow-up until her autonomy is proven. establish a new style of life centered on Most dropouts take place in the first or conjugal love, mutual knowledge, and second cycle. The most frequent cause is communication so they may create an disagreement between husband and wife awareness of co-responsibility in the pro- on periodic abstinence. For this reason creation of children. records are set up only after the second or The first NFP centers arose from the third cycle, thus giving the couple the need to have an office site for counseling status of "registered" in the program. couples. At present there are only 14 In general 4.7 percent of the users centers, since the core of the work consists become instructors. They must be fertile of going to where the users live to instruct couples and users of the ovulation method. them through local meetings, workshops, During their follow-up term they arc given and home visits according to needs. This is special training as instructors. If the train­ especially true in farming areas and in the ing takes place in rural areas, it will be hills where transportation is difficult. followed by a second anci third phase after Caritas and other private institutions of- the first course. In the city one intensive fer medical consultation facilities for the training workshop is given to instructors of teaching and follow-up of the couples. the ovulation method. The objectives and They either provide gynecological con- context vary according to the socioeco­ sultation or refer clients to an appropriate nomic level of the participants. The general center. The diocesan teams for fertility objectives are: (1) to master the scientific regulation are composed of professionals, aspects of the ovulation method; (2) to priests, and couple instructors trained in learn educational techniques; and (3) to the ovulation method. The first centers gain group skills for working with people. were created in 1975, and the headquarters The content is, first, theological and was established in 1978 in the capital of ecclesial based on the documents of the Santo Domingo. Church on the family and, second, biologi­ The service is geared toward the poor, of cal and psychosocial. The latter topics whom there are several categories: the include anatomy and physiology, the inter­ poor farmer, the urban migrant, the hill pretation of the ovulation method, human farmer, and those in need of total sexuality, psychological differences be­ assistance. twcen men and women, the psychological Couples are motivated through radio advantages of the ovulation method, the and television programs and publicity Dominican family and the contribution of brochures to attend workshops on the the ovulation method to the integration of ovulation method. An instructor is as- the couple, and supervisory practice. signed to them for teaching and follow-up. The continuing training classes are basic

149 for both leriAng and evaluation. Evalua- To ensure quality control in teaching, we tion is both written and oral. The trainee is demand: (1) highly qualified personnel in evaluated on eamuninations and also on the the teams for fertility regulation-doctors, supervised practicum in teaching couples. nurses, psychologists, priests, and teachers Enthustom for the ovulation method, con- of the ovulation method; (2) development fidence in its effectiveness, and experience of a program of 32 to 40 hours; (3) reevalua­ as a couple are also required. Once these tion of informational materials; (4) periodic conditions have been met, a 'certificate is evaluation of the program by the national Issued by the Episcopal Commission for team; and (5) teaching supervision through the Family Life, which accredits the trainee as instructor meetings with the head of an instructor of the ovulation method. department of fertility regulation.

MARY CATHERINE lRTIN awareness or knowledge that a couple may use in combination with other methods of Mary Catherine Martin, Ph.D., M.S.N., family planning is not accurate and should NFP education and development consul- not be identified as NFP, Fertility aware­ tantto IFFLP ness is, in fact, knowledge; fertility accep­ tance-that is, living with knowledge of The concept of fertility acceptance must fertility potential and integrating sexual be emphasized as a learning principle when behavior in harmony with procreative in­ offering NFP services to couples. NFP pro- tention-is natural family planning. vides :he means for a couple to avoid or This concept is important to emphasize achieve pregnancy. The couple's decision at this time precisely because of the interest is based upon knowledge of the woman's being shown in NFP by ministries c health cycle and their procreative intention. They and governments for whom contra "tion use periodic abstinence to avoid preg- or fertility suppression has been a_ ac­ nancy or engage in intercourse to achieve cepted and common practice. Erik Erikson, pregnancy. a noted anthropological psychologist, in a The growth of the couple in their 1980 article in the InternationalJournalof relationship through the development of Psycho-Analysis has suggested that, be­ intimate and loving dialogue has been iden- cause of the precision in contraceptive tifled as a long-term motivator in the suc- technology, a new form of psychological cessful pr.ctice of NFP. In addition the repression may be developing among couple experience confidence in identify- couples who use family planning system­ ing the fertile and infertile phases of the aticaly. Erikson states that some couples cycle and learn to discuss their family plan- who consciously choose to use family ning intcntiocs. planning methods may not realize that they In the Western world, modern contra- are choosing not to be parents. If this hap­ ception hs been widely practiced for the pens, says Erikson, repression of the pro­ past 20 years. The underlying philosophy creative drive and need may occur and the of most methods of contraception is based individual or couple may require profes­ upor some tfnn of fertility suppression by sional counseling to deal ,rfectively with temporary or p-.rmanent means. this state. As NFP set-vices expand, it is important Fertility acceptance is the preferred to emphasize that the fundamental peda- pedagogical and attitudinal concept to pro­ gogical philosopy of learning to live within mote when teaching couples NFP because the procreative potential of the couple is it properly reflects the philosophy of learn­ one of fertility acc:eptance. Fertility accep- ing to live with and to integrate periodic tance reflects the couple's ability to live abstinence into the couple's sexual positively with the knowledge of fertility, behavior within the framework of their To suggest that NFP is simply fertility procreative potential.

150 supervised teaching and clinical pracdce at Discussion the local level are essential. Another view was that regional training is good for train­ ing tutors (those who train teachers) but not for field teachers. Many consider it a to select a few teachers and All agreed that the competent, trained good idea tutors. Concern was also ex­ teacher is the key to a good natural family make them traiee teachers be equipped planning program. The discussion centered pressed thlat skills as well as interview on the selection process for teacher with counseling techniques. trainees, the methods of training, the face difficulties in send­ nature and content of teaching materials, Many programs to a new location. Several sug­ and the context in which the teaching ing teachers made to ease this situation. takes place. gestions were of the teacher with an organ­ Selection of Teacher Trainees There was Identification local sponsorship both can be little disagreement on the importance of ization and a trainee should come the selection process for new teachers and helpful. Preferably the community that has indicated a on the necessity of designing programs to from a mistake to send someone to a meet both urban and rural needs. In both need. It is there is no community sup­ the developed and developing world, birth place where possibility of follrw-up for a attendants and midwives should be con- port and no new teacher. sidered ais potential trainees, in Africa, There was less agreement on whether In a well-developed program teams for support and teachers should be current NFP users. teachers wvork in In the experience of another Some programs consider this essential. evaluation. from Latin America, it Others are willing to waive this require- program director that there is a request ment in the public sector provided the sometimes happens is. trained and sent back prospective NFP teacher knows the fertility for NFP, a person but the teacher does indicators and can chart her own or a to the community, receive local support. friend's cycle. There was also some diver- not gencc of views on the degree of commit- Going to a community and establishing a ment to a prolife attitude that should be center is another approach. It is possible to or three expected on the part of teachers and go to a community and pick two clients. Representatives from some pioneers. Some will continue while others teachers will national NFP programs said they would may drop out. Some NFP refuse to teach NFP to anyone who indi- never mwke a team. A well-established found that cated they might terminate an unplanned North American program has be pregnancy; others would accept such users second-generation leadership tends to program works in the hope that NFP practice might per- more stable. This national Another suade them to change their position. with teams of at least two couples. for pro­ Teacher Training Sho'ild the trainee be program has developed guidelines teacher. Med­ trained locally or sent away to a regional, viding support for an isolated programs national, or international teacher training ical and educational NFP backup center? Participants disagreed on the prac- for the isolated teacher are important. factors, ticc of sending teachers away for training. Because of distance or other always pos­ Some Latin American teacher trainees are face-to-face teaching is not being trained in the United States, for cx- sible. In such cases self-teaching materials England ample, because high standards of training can be used. Dr. John Marshall in self-teaching are not available locally. After a core of has had some success with courses. teachers has been developed, then local materials in his correspondence way even teacher training programs in Latin America Some people prefer to learn that cen­ will be started. when they have access to a teaching Even if a teacher receives basic training ter. In Australia there are correspondence and all teachers are away from the home site, it was felt that courses in every state,

151 trained to be correspondence course A distinction was then made between a teachers. core model with the essential factors and a Discussion participants wanted to know curriculum. (A curriculum can be defined how many hours of teacher training are as all of those teaching/learning activities essential. According to the World Health that constitute the teaching program.) The Organization, which developed and tested core for NFP teacher training programs the Family Fertility Education Resource should be the same, but modification of Package, the amount of time required to the curricula wi!l always be needed to suit train teachers using these materials varied the needs of the individual 1--arner. Differ­ greatly, ranging from about 11 hours in the ent curricula may even be needed for the Philippines to ,49hours in Colombia. A pro- same city, one for church-based programs, gram in Europe finds that 27 hours is the one for family planning programs, and minimum for basic teacher training; this another for university programs. does not include instruction in special As NFP programs expand into the public circumstances. Another European program sector, one participant considers it very im­ provides 50 hours of training but includes portant to define NFP within the context of "special circumstances" and family coun- periodic abstinence. Such a deftnition seling in the course. determines ho,, the irisnuction and coun­ The supervised practicum is usually seling serviccz. are designed. It does not spread out over several months before cer- take much time to teach physiology, but it tification. The question was raised if any requires a great deal of time to help couples programs are training teachers without incorporate periodic abstinence into their supervised practicum. In one country relationship. trainees teach clients on their own 2nd There was soen discussion about defini­ then bring the clients' charts to the tion of terms. Fertility awareness was de­ supervisor. fined as knowledge. It is up to the client to -hat to do with this knowledge. Teaching Content With regard to teaching decide family planning, however, includes content, some programs teach all fertility Natural Knowledge of fertility indicators but leave the decision up to the periodic abstinence. with use of bairier methods is client as to which ones are used. Others combined There were conflicting opinions teach primarily the ovulation method and not NFP. to approach this issue: "The NFP believe that all fertility indicators should be on how issue is one of normal sexuality with ab­ taught but not all NFP methods. The New absti­ Zealand program concentrates less on the stinence. It's difficult to go from no cyclic fertility of the woman than on the nence to a great deal of abstinence." "To to accept or address use of the con­ combined fertility of both the man and refuse withdrawal within the context of the woman. dom and to deny reality." "You have to In response to a question on uniform NFP is for a couple to move gradu­ teach,., training standards and materials, a [allow leeway] "Yes, learning takes time to U.S. participant noted that there are maniy ally to NFP." If your goal is to get to NFP different types of te-acher-training pro- occur. abstinence), then toleration but grams in the United States. Another partici- (periodic of the use of other meth­ pant with experience in many countries not endorsement be within the NFP framework." said there was no standard across the board ods may participants but that NFP teacher training materials The Teaching Context Many approach in were becoming fairly uniform. favored the couple-to-couple said An African from a country with a multi- teaching NFP. One program director well with a spe­ ethnic society mai-intained that uniform such training works very planning a materials may be inappropriate for differ- cial group of engaged couples see some extra­ ent cultural groups within the samine coun- wedding together. You can really try. Modification will always be necessary. ordinary reactions in couples, which He asked why uniformity was being so inspire the teacher. find the small­ strongly recommended. Several program directors

152 group learning situation the best. Couples the status of women prevents the wife speak out more in a group. Many teachers from participating in decision making. comeHealth outorganization of such foundgroups. that Thesmall-group World Couples in some cultures will have to Healh ogan~atinfundthatsmal-gouppractice NFP in the context of an extended ontx o tended teachingcotnbination was effective. of small-group Some programsteaching anduse familypac system.te NtNot only do the couples have to be motivated to use NFP, but their individual instruction. Some confine the relatives also have to be motivated to give instruction of general physiology to groups of couples but reserve other matters for a can make more decisions is a couple and private session. Another approach is to develop a style of life that will promote the have a group session first. Then, after development of both patnrs. Changing charting a cycle, the couples return for Social patrerns often bring new oppor- individual instsction. national program, iound that. tunities. It might be that training in NFP An African increases the couple's .3bility to choose ises tope'sreimlg thecose when government funding was accepted, wisely and to persevere in making the most the couple-to-couple approach was no of these new opportunities. the program longer possible. Instead, developed special courses for husbands in A number of NFP programs encourage the evening, participation in Marriage Encounter, a mar­ Some feel that the couple approach is riage enrichment program. Couples who not suitable for all cultures, especially a have experienced this type of marriage en­ Muslim country or where the extended richment appear to be more receptive to family system prevails. In the Muslim con- NFP. Autonomous NFP couples are sur­ text many cultural attitudes prevent any prised that they can learn more about niari­ type of family planning. Added to this are tal conununicaion through such pr,.,grams. the objections that NFP requires periods of Many NFP programs find that the couple abstinence and depends on better corn- successfully practicing NFP is the best ad­ munication between husband and wife. vertisement for the method Such couples Such communication is seen as a threat to become a resource 2nd have a multiplier the existing type of relationship, in which effect in attracting new users.

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NFP instructor Suzannre WidMet a~t the en­ trance to the Dia~gnostic Center, Hosphtal Clinic, UnIversidad Cat6lica de Chile

154 NFP Program Evaluation and Accountabilil/

RON H. GRAY and ROBERT KAMBIC

Ron H. Gray, M.D., professor Dept. of Population Dynamics with join! ap­ pointment in Dept. of Epidemiology and International Health, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD., USA: Robert Kambic, M.P.H., research coordinator for IFFLP/USAID-African NFP Program with Johns Iopkins University technical assistanceteam, Baltimore,MD, USA

Thefirstpartof this paperdescribesthe consider the types of program evaluation, four major types of program evaluation the data required, and the statistical in any family planning program. These measures to be used. We appreciate that are process, outcome, impact, and cost- this does not address the humanistic effectiveness evaluation. Adequate rec- aspects of NFP, but it is, nevertheless, of ords are essential data for evaluation, importance to consider the broader pro­ Besides user characteristics, statistical grammatic issuej. measures include volume, coverage, qual­ ity, and effectiveness indicators. The sec- Types of Program Evaluation ond half of the paper examines factors There are four major types of.program thatare criticalin evaluation ofNFPpro- evaluation (Gorosh 1982 and Fisher 1983): grams.NFP is an educationalratherthan Process Evaluation is a management­ a biomedical technology. Since education oriented assessment directed toward im­ occurs over time, defini:ions need to be provement of program operations. It made when a learning user becomes a might be an output measure of the extent registeredclient, discontinues,or becomes to which a program is meeting predeter­ autonomous. Classification of planned mined objectives such as the number of and unplannedpregnancies also need to couples registered, or it might be used to be clearly defined. Sampleformsfor regis- monitor major areas of the program by in­ tration, follow-up, and discontinuation depth analysis of a partict.iar process such arepresented as training. The objective of an NFP program is to Outcome Evaluation is an achievement­ provide services for couples wishing to use oriented measure of the effectiveness of NFP in order to plan or prevent pregnancy. the program among users of services. In Thus, the "client" is rightly the focus of family planning, outcome is usually meas­ interest. The extent to which the program ured by the number of new users, the con­ provides such services efficiently, how- tinuity of use, and discontinuations for ever, is also a matter of legitimate concern pregnancies or other reasons. The most since it affects the quality of client care. common procedure is the estimation of The evaluation of NFP programs is ulti- use-effectiveness by life-table procedures, mately an important means of improving which provide continuation and discon­ services to clients. In this paper we will tinuation rates expressed per 100 woman­

155 years, Another outcome measure is the system is the individual records for each couple-years of protection against preg- couple. These are primarily designed for nancy provided by the program. This is the client management, local decision making number of years an average couple will be or administration, and monitoring. The protected from pregnancy by family plan- record forms must be simple, brief, and ap­ ning use. propriate to the skills and the concerns or Impact Evaluation is an achievement- responsibilities of the personnel using oriented measure of the effect of the pro- them day-to-day. The additional demands gram on the overall population. In family for speciai research or evaluation must be planning this is usually an estimate of the kept to a minimum. If records are too demographic impact of a program as meas- lengthy or complex or if they appear to be ured by the number of births averted or irrelevant, they will not be properly main­ oAeclines in birth rates. Itis difficult to tained. Records are needed for entry of a measure demographic impact because the couple into a program and for monitoring information needed is complex and hard to client progress (Figures 1 and 2). There is, obtain, because one cannot predict what additionally, a need for discontinuation fertility might have been in the absence of records, which will be considered in the the program, and because women using next section. the program may be merely substituting The individual records are used to pro­ NFP for other methods of family planning. duce aggregatestatistics to evaluate larger Cost-Effectiveness Evaluation is a measure components of the program, such as of the relationship between program costs monthly activity reports. Aggregate and achievement. In this regard, cost- statistics, also called service statistics, can effectiveness is largely a managerial tool be abstracted from the individual records "for determining how to deliver family and entered onto simple, clearly labeled, planning services less expensively" and logical summary forms. These statistics (Sirageldin 1983). It is an assessment of the provide the program directors with infor­ economic efficiency of the program de- mation such as how many clients are enter­ rived from estimation of the costs of ing NFP instruction each month, how categories of program input. Such inputs many are under the supervision of the in­ are the training of teachers, couple recruit- structor, how many have discontinued, ment and teaching, which are broken and how many have become autonomous. down into expenditure components such Special additional records are needed for as personnel, facilities, supplies, and ser- cost-effectiveness analysis, particularly in vice activities such as administration, the assessment of time expenditures. A couple services, and travel. In order to simple !og of time spent by personnel on allocate costs to these activities, it is different program activities can be con­ necessary to have some measure of time structed for this purpose. spent on each activity, such as time spent in teaching or on travel. Then these costs Statistical Mesures must be expressed in relation to such out- Numerous statistical indicators can be puts as new acceptors or such outcomes as developed for progiam evaluation: couple-years of protection. User characteristics by age, parity, marital Cost-effectiveness studies are an aspect status, and so forth can be used as descrip­ of Operations Research. They are complex tive statistics of couples entering the and require a special evaluation effort progrim. beyond the scope of normal programmav ic Volume indicators, such as the numbers evaluation, of new clients registered, in training or auto.nrmous, and the number of discon­ Data Required for Evaluation tinuaticns by category, summarize the Both qualitative and quantitative data are overall program activity. needed, but the focus here will be on quan- Coverage indicators, such as the percent­ titative measures. The basis for any data age of the population covered by services

156 or percentage of ,arget reached, measure conceptions outside the apparent "fertile the degree of program acbievement period." These are diffic lt to define unless QualitV indicators, such as client satisfac- charts are available fcr the conception tion xad knowledge or duration of training, cycle, acts of iwercourse are recoided, and are important to assess the effectiveness of conception can be attrilut;;d to a specific the educational and other processes. act of intercourse. In many cases the cate­ Outcome or effectiveness indicators Use- gorization of a pregnancy will be ambigu­ effectiveness is one of the most important ous. There is also a problem of "competing meaqilres of both program and method biases." The client may be reticent to ad­ performance. It is known that the use- mit that rules were broken, and the NFP effectiveness of contraceptives varies over teacher may be reluctat to attribute a time, in part because less effective users pregnancy to a mt-chod lailure. Moreover, tend to discontinue early, leaving a clients may retrospectively classify a selected population of more effective or pregnancy as "planned" to avoid embar­ motivated users as the predominant group rassment over an unplanned conception. over time. To overcome these problems, Nevertheless, from the programmatic lifc-table techniques have been developed point of view, the final evaluation depends to estimate continuation or discontinua- on the total number of pregnancies tegard­ elon rates over time, and such life-tables are less of their origin. If the method is considered to be the most valid procedure theoretically perfect, but the couple can to evaluate use-effectiveness of family use it only imperfectly, then program­ planning (Tietze and Lewit 1973). matically the method may be of limited To construct a life-table, one needs to value. For example, if one had a theoreti­ know ,.he number of subjects commencing cally perfect method of contraception but NFP charting and their date of entry, the large numbers of users failed to use the date of d-scontinuation, the date of last method properly, it would have relatively obsci-vation for losses to follow-up, and limited progranimatic value, as compared the number of subjects continuing use at to another method which might have the end of the observation period. The data lower theoretical efficacy but be used for estimating use-effectiveness may be more consistently. derived from individual client records Routine client records can be easily which 3hould be constructed so as to make maintained during the teaching/learning information retrieval as easy as possible. phase, but it is difficult to obtain such in­ To facilitate this, it is best to use a special formation on autonomous users who are discontinuation form such as shown in self-sufficient and not "nder supervision. Figure 3. Information on reasons for Since autonomous clients may be the ma­ discontinuation is complex ard requires jority of NFP usets, and autonomous use is careful definitions of different reasons for one of the main programmatic advantages stopping the method. These definitions of NFP, special studies are needed for this must be clear, unambiguous, and mutually group. Probably the most efficient study exclusive. If, for example, a woman approach is to identify autonomous users discontinues for multiple reasons, rules from teachers' records and to conduct must be established for deciding which special follow-up surveys to identify con­ should be classified as the primary reason. tinuing and discontinuing couples. These The definitions of discontinuation relevant surveys, however, are an added evaluation to NFP are given later in this paper, effort beyond the routine program statis­ The definition of the circumstances of tics and ent?il significant costs and pregnancy is of particular relevance to organizational problems. NFP. Pregnancies should be categorized It is difficult to me-sure the demo­ into user-related pregnancies due to break- graphic impact of a family planning pro­ ing of rules; pregnancy due to inisunder- gram, but as an intermediate step, one can standing of instructions, or teaching errors; estimate the couple-years of protection and method-related pregnancies due to (CYP), which is simply the contraceptive

157 protection time afforded by method use. two persons' cooperation rather than the For NFP, the couple-years of protection consent of just one party. Our definitions c.n be calculated from the number of new attempt to take these considerations into users and the discontinuation rates over account. time (Gorosh and Wolfers 1979). Although There is a point in a program at which of limited scope, CYP is a useful measure clients will be given the opportunity to with which to estimate the "effective- make an informed decision as to whether ness" component in a cost-effectiveness or not they want to use NFP. At about the analysis. same time, the client will provide personal Cost-effectiveness measures Cost- history information to the program (Fig­ effectiveness estimation is complex and ure 1). Once the personal information has the methodology is beyond the scope of been provided and the client has made an this presentation. Cost-effectiveness is, informed decision to use NFP, the client however, an important aspect of evalua- crosses a boundary from nonregistered to tion, particularly in the case of NFP where registered status, and is defined as regis­ the high start-up costs of teaching are offset tered or admitted to the program. Programs by the longcr-term economics of autono- should keep as a basic service statistic a mous users who practice the method with- count of all clients who register for NFP out ongoing supply or service costs. use (Lanct6t 1981 and Kambic 198 1). NFP is becoming more widely accepted A second key point in NFP service comes by ntonai and international agencies such when the registered client first begins to as USAID and WHO (Sirageldin 1981). To chart. Another threshold has been crossed. maintain existing support and to expand For some clients this may occur on or even NFP, it is inportant to examine objectively before their day of registration. For other its cost-effectiveness in relation to the costs clients, who are presently pregnant or un­ and effectiveness of other methods. It is decided about NFP use, it may be several proba. V that NFP will prove to be cost- months before they begin to chart their effective when one properly determines first cycle. Once the client starts to chart, the long-term low costs of autonomous she should be in relatively frequent conta%,, users. T o establish this, however, there with her NFP instructor until she reaches must first be rigorous evaluation of costs autonomy or discontinues. and use-effectiveness both during training The number of clients first starting to and autonomous use. chart added to the number of clients pres­ ently charting under the supervision of an Boic Defl:-ntons ior instructor is another service statistic to be NFP Progi-am Evalatlon kept. We call this total the number of The definition of what is being measured "learning users" in the program. is basic to any science. So as not to com- Those users who do not discontinue the pare apples and oranges, NFP programs NFP methods will eventually reach a point should have a clear idea of what they want where they are able to use a method when they ask for statistics. One program's without follow-up instruction. We call this "acceptors" may be another's "registered type of user autonomous. In order to clients" and sill another's "users." Pro- classify a user as autonomous, the follow­ grams should provide their definitions in ing conditions should be met (Lanct6t and any written reports and papers. Martin 1981): Because NFP service is an educational 1. The learning user will correctly chart rather than a biomedical technology, the her daily fertile indicators. acceptance and use of NFP by clients is a 2. The learning user will consistently gradual process that happens over time. identify the fertile and infertile days of her This is different from methods of family cycle. planning in which a single event, such as an 3. The learning user will adjust with at lUD insertion, will chanige a client from least relative satisfaction to the periodic nonuser to user status. NFP also requires abstinence required by NFP.

158 FIGURE 1 REGISTRATION FORM

Identification Client's Name Client's Address Office Phone Home Phone

Day Month Year

Identif-cation Number Fi F-1 F-1 EL]L R Project District Teacher Client

1. How old were you at your last birthday? (in years) L]ZI

2. Are you: i. Married 3. Single 2.Engaged 4. Divorced/separated 5. Other- specify

3. If married, how many years have you been married? r-IZ (Code 0, if less than 1 year)

4. If married, how old was your spouse at his last birthday? El El (in years)

5. Hlow many living children do you have? (If more than 9, Code 9) a.-oy a. Boys 2. Boys (If more than 9, Code 9) b. Girls b. Girls F]

6. When did your last pregnancy end? (Code 0 if never pregnant) Year (Code I if pregnant now) Month

7. What isyour religion? 1. None 4. Protestant/other Christian 2. Traditional 5. Muslim 3. Catholic 6. Hindu 7. Other- specify

8. How many school years have you completed? 0. 0 5. 9-10 1. 1-2 6. 11-12 2. 3-4 7. 13-14 3. 5-6 8. 15+ 4. 7-8

159 9. Why do you want to chart your fertility signs? .-. i. To have a child 5. Have a child of other sex 2 To space 3. To limit 6. Other - specify 4. For self-knowledge 7. N/A

Cycle and Breast-feeding liformation

I0. Are you breast-feeding now? --- 1. No 2. Partial (Baby gets food and breast-feeding) 3. Total (Baby gets only breast milk) 4. N/A

11. When did your last periodmenses begin? F] M E"L]D-D[] (Code 0 if no menstruation since last birth) Day Month Year

Family Planning Practice

12. a. Among the following methods, which method are you using now? EI

b. If you are not using any method, name which was the most recent method you used. l 0. None 5. Breast-feeding 1.Pill 6. NFP 2. IUD 7. Withdrawal 3. Injection 8. Abstinence 4. Barrier 9. Other - specify

13. When did you stop using the most recent method? -] --- l I Month Year

14. Where did you hear about the NFP program? 11 1. Doctor 6. Media-specify 2. Other health worker 3. Motivator/field worker 7. Friend/relatives - specify­ 4. User 5. Clergy 8. Other - specify

Family Planning Intention

15. When do you want your next pregnancy to begin? years 0. No more pregnancies desired 4. After two years but before three 1. Trying to become pregnant now 5. After three years 2. Within a year from now 6. It doesn't matter 3. After one year but before two years 7. Don't know

16. Does your spouse share this Intention? 1.No 2. Yes 3. Don't know 4. N/A

17. If you are trying to become pregnant now, how many months have you been trying?

160 FIGURE 2 FoLLow-uP FORM

Identification Woman's Name

Today's Date Day DEZDMonth 1 ElDYearF

Identification Number El ED M W ElDE Prolect District Teacher Client

Charting 1. Follow-up form number? M

2. This follow-up visit is at: Il 1. Client's home 2. NFP clinic/center 3. Elsewhere/specify

3. When did you begin charting? ED D El11] (Fill in 99, 99, 99 if client did not start charting) Day Month Year

4. How many months has it been since you began charting? F-- R]

5. How many complete cycles have you charted? F E---­

6. Who ismainly responsible for keeping your chart? F'i 1. Self (client) 5. Client memory 2. Spouse 6. No record kept 3. Instructor 7. N/A 4. Other/friend

7. Client record shows she is charting: (Mark all that apply)

I. Mucus 4. Calendar [i RL 2. Temperature 5. Other minor signs (breast tenderness, etc.) [l ] 3. Cervix 6. No record [][

8. The chart shows: LI 1. Not every day charted-not enough information to .nterpret 2. Every day charted-not enough information to interpret 3. Every day charted-enough information to interpret 4. Days necessary to interpret the fertile time are charted

9. Is there any difficulty in identifying the relatively preovulatory infertile, the fertile, F­ and the completely postovulatory infertile time? I. No difficulty 2. Client has difficulty (specify) 3. Teacher has difficulty (specify) 4. Both have difficulty (specify)

161 10. Intercourse is recorded: I 1. At least the last intercourse in the preovu!atory, "sate days" 2. At least the first intercourse In the postovuiatory, "safe days" 3. Both I and 2 above 4. All (including fertile period) 5. Incomplete record 6. No record

11. a. Do you or your spouse have any difficulties with abstinence? l--. 1. No 3. Always difficulty difficulty 2. Occasional 4. Unt.ertaln 4....I b. W ho h as the diffi culty ? 1. Woman 3. Both 2. Spouse 4. Uncertain

12. During th, ienle phase do you? L­ 1. Abstain 2. Have intercourse without contraceptives 3. Have intercourse with a barrier 4. Have intercourse with withdrawal or have other genital contact 5. No comment from client

13. Do you intend to avoid pregnancy for the next three (3) months? Fi1 1. No 2. Yes 3. Don't know

you? 14. Has your spouse received any instruction in NFP either alore or with 0. None 3. Three or more 1. One 4. N/A 2. Two

15. If the couple wants to avoid pregnancy, are they following the rules? l"-i 1. No, they don't understand the method 2. No, they are taking risks 3. No, they are using barrier methods 4. Yes 5. Don't know If no, specify how the rules are being broken and why

Autonomous

16. a. Is the client autonomous? El 1. No. 2. Yes b. If yes, give month and year classified autonomous lJF.J F1J L Month Year

Discontinuation

17. Has the client discontinued NFP use? 1, No. 2. Yes *Ifyes, fill out a discontinuation form

162 FIGURE 3 DISCONTINUATION FORM

Identification Women's Name

Today's Dte l DayE l Month--1I LiiYear F]

Identification Number El Eli El [ F]F] El Project District Tea.her Client

Discontinuation 1. Date of discontinuation EEl DlF1 D-'E Day Month Year

2. Kind of discontinuation F-] I. Lost to follow-up 2. Health related 3. Personal 4. Pregnant

3. Complete afollow-up form for the pregnancy cycle or for the last cycle prior to discontinuation. D­

4. Lost to follow-up -] 1. Whereabouts unknown 2. Left area

5. Health/medical Fl 1. Menopause 2. Medical condition/medicine or drugs that prevent charting - specify

3. Hysterectomy 4. Deceased 5. Other - specify

6. Personal [--R I. Privacy-does not want to be followed 2. Social/family pressure 3. Lack of confidence in NFP 4. Method too complicated 5. Excessive abstinence 6. Prefers other method 7. No need 8. Other - specify

Pregnancy Analysis - Client

7. Date of last menstrual period [ l [--E1[ ] Day Month Year

163 8. Client became pregnant and this was confirmed by: I I. Test (immunological) 2. NFP chart 3. Physical exam 4. Other - specify

9. Is a photocopy of the original pregin cy chart attached? E-' I. Not available (If not available, attach comments on pregnancy from the user and teacher) 2. Yes

[I 10. Client states pregnancy is due to: 1. Both client and spouse decided to try to conceive 2. Client and/or spouse took risks 3. Client did not think she was fertile

[I I1.Will the client ever use NFP in future? i. Definitely not 2. Probably not 3. Probably yes 4. Definitely yes

Pregnancy Analysis - Instructor

12. In the judgment of the Instructor the pregnancy is due to: 1.Misunderstandirpg by the client 2. Incorrect of insufficient information given by the instructor 3. Conscious departure from rules-no barrier use 4. Conscious departure from the rules-barrier use 5. Method related (must have a chart) 6. Unresolved 7. Planned pregnancy (User had no intention to avoid this cycle)

1 "1 13. a. Conception is a result of intercourse on cycle day (Code 0 don't know) b. In the apparent I. Preovulatory infertile time 2. Fertile time 3. Postovulatory infertile time 4. Unknown

Review by Supervisor

Mont11 M : 14. Reviewed by supervisor on Day Month Year

15. Supervisor's comments F-1 1. Agree with discontinuation analysis 2. Disagree with discontinuation analysis - specify

NOTE: THESE THR FORMS AM ABBEVIATED

164 4. The learning user will demonstrate an avoid pregnancy should be asked at ability to recognize any change in the basic registration and can be categorized as cycle pattern which should alert her to follows: no more pregnancies desired; seek additional instruction (for example, before becoming pregnant wants to wait at postpartum amenorrhea, breast-feeding, least one year, two years, or three years; premenopause, cycle disruption), wants to become pregnant in the next year; The program should determine the is trying to become piegnant now. number of clients becoming autonomous The intention should be checked from each month. time to time by the teacher, especially if the Once a client couple is registered, they client's chart shows intercourse during the either become autonomous or discontinue, fertile period. The teacher should make a The first category of discontinuation is note in the record if the intention of the "never started charting." Those are the client changes. clients who register but never take the next If a client does becrme pregnant while step of starting to chart NFP. Such couples trying to avoid pre.tancy, or before the are important indicators of program accep- end of the desi- a spacing interval, the tance. If the rate of noncharters is high, we teacher should hiterview the client, review want to know why and examine such the pregnancy chart and NFP record, and things as teaching technique, informed complete a discontinuation form. consent procedures, and profiles of those The teacher miy f~id that the client who do not chart. It is important to men- states that the pregnancy occurred because: tion that those who do not chart will not be both the man and the woman decided to included in effectiveness and continuation try to conceive; the man did not cooperate; life-table statistics because they never the client ignored her fertility signs; or the begin NFP use. client did not think she was fertile. Once a client begins to chart, there are a With the above information the teachers number of reasons for discontinuing use of can classify the unplanned pregnancy as NFP: pregnancy, loss to follow-up, per- one of the following: sonal reasons, and medical reasons. Let us 1. Client education-related: the client first exanine pregnancies and natural fam- could not correctly apply the NFP rules ily planning use. because she was either poorly taught or in­ When looking at NFP programs and correctly learned the method. methods, both profes:,ionals and family 2. Client ust-related: the client correctly planning users want to know the answer to under,;tood the method and rules but did this question: "When NFP is used to avoid not follow them because of choice (de­ pregnancy, how well does it work for the cided to conceive), or pressure by the average user?" spouse or partner, or because the couple Unplanned pregnancies are defined as ignored the rules or "took a chance." "conceptions by a woman who is on 3. Method-related: the client under­ record as intending to use NFP to avoid or stood the method and applied the correct delay a pregnancy." The client who wants rules but became pregnant. no more pregnancies is called a "limiter." 4. Unresolved: no category can be ap­ If the client wants only to delay pregnancy plied to the unplanned pregnancy. for a period of time, she is called a Pregnancies that are not unplanned can "spacer." The important element in this be classified as client-planed, clients were definition is that although the client has trying to conceive; and client-open, clients gone on record as wanting to space or were open to pregnancy but not actively delay pregnancy for a certain time interval, trying. she nevertheless becomes pregnant before In addition to pregnancy, there are other the end of this time interval (Brennan and types of discontinuations: Klaus 1982, Lanct6t and Parenteau-Carreau 1. Lost to follow-up: a client will be lost 1973). to follow-up if she can no longer be con­ The client's intention to space or to tacted by the program.

165 the client Gorosh, M.E. 2. Medcal discontinuation: 4: Management of a medical condi- 1982 Family Planning i,grams stops charting because and Evaluation. J.A. Ross (ed.), International tion that mrkes it impossible to chart. Eni3,clopedia of Population 1:225-28. New 3. No further need: the client no longer York: The Free Press, Macmilan Publishing Co. needs family planning services because, for Gorosh, J.E., and 1). Wolfers. example, of hysterectomy or menopause. reason 1979 "Standard Couple Years of Protection." In: 4. of Measuring the Impact of fo Personal discontinuation: any raon 7 Methodologi, for stopping the use of N P that is not ac- Family Planning Programs on Fertility. New counted for in the above reasons. York: United Nations, 34-47. NFP has become more widely accepted promote NFP, Kambic, R. but in order to establish and Assur- 1981 FeasithilityStudy to Determine Quality must be evaluated in a manner for Natural coparbleprogri~rns tousat evaluaterfor mnethmanae Needs and Techniques comparable to that for other methods of Famil Planning. Washington, D.C.: U.S. family planning. This implies a greater Department of Health and Human Services, degree of rigor and accountability for NFP Public Health Service. the method may be made more so that M.C. Martin. and accessible. Of par- Lanctt, C.A., and videly available Natural Famili Planning Services Program ticular importance is the need to assess the 1981 EvaluationGuide. Washington, D.C.: Intema­ acceptability of NFP programs in terms of tional Federation for Family Life Promotion. registrants and learning users, the use­ C.A., and S.Parenteau-Carreau. effectiveness of NFP methods during both Lancttt, and the cost- 1973 "Studies of the Effectiveness of Temperature learning and autonomy, Methods of Family Planning." In: Proceedings femivn effectiveness of NFP programs. of a Research Conference on Natural Family Planning. edited by W.A. Uricchio and M.K. Williams. Washington, D.C.: Human Life Foundation.

References Sirageldin, I.,D. Salkever, and R.Osborn, eds. 1983 Etvaluating Population Program: Proceed­ ings of the Internationel Workshop on Cost- Brennan, J.J., and 1H.Klaus. Eftctir'eness and Cost-Bcnefit Analysis of 1982 Terminology and Core Curricula in Natural P'opulation Planning Programs. New York: Family Planning. Fertility and Sterility 38, St. Martin's Press. No. 1:117-18.

Tietze, L., and S. Lewit. Fisher, A., J. Laing, and J. Stoeckel. 1973 Recommended Procedures for the Statistical 1983 ttandbook for Family Planning Operation Evaluation of International Contraception. Research Design. New York: The Population Studies in Family Planning 4:35-42. Council.

166 Research on Natural Family Planning inthe Philippines

JOHN E. LAING

John E. Laing, Ph.D., Population Council associate and adviser; visiting professor of iemography at University of Philip­ pines, Population Institute, Manila, Philippines

The Philippines has one of the highest Rhythm practice varies widely, and its NFP prevalence rates in the developing underlyingprinciplesdo not appearto be worid. The calendar-rhythm method of well understood by users. Religious NFP has been promoted hy the Philippine reasonsappearto play only a limited role Family PlanningProgramsince its incep- in the decision to use NFP. tion, andover theyears a substantialbody Introduction of research data has been accumulated. Among the world's developing coun­ This paperpresents majorfindings from tries, the Philippines has one of the highest past researcb, describes current research, natural family planning (NFP) prevalence anddiscussesfuture researchneeds. rates. World Ferility Survey data on 19 Among the findings presented are the developing countries reveal that, among following: (1) most NFP users have relied the countries studied, the Philippines was on and continue to rely on some form of second only to Peru in current and past use calendar rhythm rather than the more of the calendar-rhythm method. Among modern forms of NFP; (2) there has been exposed (i.e., fecund, nonpregnant) mar­ an upward trend in rhythm practice, ried women in the Philippines, 11.3 per­ despite the family planning program's cent were found by the 1978 Republic of relative emphasis on promoting other the Philippines Fertility Survey (RPFS) to methods; (3) most rhythm users are self- be current users of rhythm, comp~ued with taughtor taught byf,'iends ratherthan by 14.3 percent in Peru and 10.4 percent in specially trainedfamily planningprofes- third-ranking Sri Lanka. sionals; (4) rhythm users' continuation The Philippine family planning program, rates are similar to those of pill users, coordinated by the Commission on Pop­ lower than those of IUD users, and higher ulation (POPCOM), has offered rhythm as than those of condom users; (5) rhythm an official program method since family users' failure rates are considerably planning promotion became official gov­ higher than pill or IUD users' failure ernment policy in 1971. The inclusion of rates, but similar to those of condom this method among family planning ser­ users; and (6) overcll pregnancy rates vices is attributable to the fact that the following acceptance of rhythm are re- Philippine population is predominanitly markably similar to those of pill accep- (about 85 percent) Roman Catholic. Pro­ tors, in spite of the greatereffectiveness of motion of rhythm, however, has generaily pills while in use. Data on the use- been less enthusiastic than that of otlter effectiveness of basal body temperature methods (Special Committee... 1978). In (BBT)and the mucus method indicatethat the early 1970s, pills were the mcst these methods tend to have been practiced strongly promoted method. In the mid­ somewhat more effectively than rhythm. 1970s, emphasis shifted to condoms to in­

167 crease ser/ices to rural couples far from 1931), 36 percent of the rhythm users cited clinics. Sterilization replaced pills and con- doctors, nurses, or midwives as their doms during the late 1970s as the method sources of instruction. A majority o; most favored by program officials and rhythm users (58 percent), however, said workers. in recent years, however, official they had been instructed by friends and interest in NFP has increased sharply, relatives. Only 6 p:rcent cited Outreach spurred by survey findings of the late workers, whose training in contraceptive 1970s indicating widespread popularity of methods is not sufficiently detailed to calendar rhythm and by increasing aware- qualify them as reliable rhythm instructors. ness of more reliable techniques for identi- Even among rhythm acceptors at clinics, fying the safe and unsafe periods, many received their instruction from non­ Over the years, a considerable body of medical workers who were, in most cases, family planning program-related research insufficiently trained. In the 1974 National in the Philippines has shed light on the Acceptor Survey (Laing et al. 1977), for in­ practice of NFP, primarily calendar stance, only 67.5 percent of the inter­ rhythm. This paper provides an overview viewed rhythm acceptors said that they of the currently available data related to had received rhythm instruction from a NFP practice and effectiveness in the doctor, nutse, or midwife. Almost all the Philippines and discusses the needs and rest had been instructed by part-time "lay" prospects for additional research. motivators whose training was intended motivating Trends In 1hythm Prevalence only to develop skills in The fist nationwide survey to provide couples to try contraception, not to qualify data on contraceptive practice was the them as rhythm instructors. 1968 National Demographic Survey (NDS), Use-Effectiveness among conducted two years before the national Rhythm Acceptors at Clinics program got under way. It indicated that During the 1970s, three nationwide 5.5 percent of married women aged 15-44 surveys, the 1972, 1974, and 1976 National were practicing rhythm (Laing et al. 1973). Acceptor Surveys (NAS), were conducted. By the time of the next national survey in With each successive round, the time 1972 (Barretto 1974), the --.oportion using period of observation and the sample size rhythm had risen to 7 percent despite more increased. As a result, the most reliable vigorous promotion of pills an.d the IUD by rates available come from the 1976 round. program clinics. Six years later, in 1978, Some key continuation rates are shown the RPFS indicated that the proportion us- in Table 2. First-method continuation rates ing rhythm had risen still further, to 8.9 are the percentages of acceptors of the percent. specified method who are still using that Table 1 shows the trend in prevalence method at the end of the specified time for each of the most widely used methods period (12 or 36 months). All-method con­ according to the three national surveys. In tinuation rates include as "continuing" 1968 and 1978 rhythm prevalence was ex- those cases who have changed methods ceeded only by withdrawal prevalence. In and still use any method at the end of the 1972 rhythm and pills were tied as the specified time period. It can be seen that most widely used methods. During the the highest continuation rates were con­ 1968-78 period, the proportion of married sistently found for IUD acceptors and the women 15-44 who said that they had ever lowest for condom acceptors. The rates for tried the rhythm method rose from 9 to 23 pill and rhythm users were very similar. percent. Though relatively short-term rates were Rhythm users have relied more on non- slightly higher for pill acceptors than for program sources than on program person- rhythm acceptors, longer-term rates were nel for instruction in the rhythm method. about equal. For instance, in a survey in 1.980 of wives Accidental pregnancy (failure) rates, living in areas covered by the National both life-table and Pearl pregnancy rates, Family Planning Outreach Program (Laing are presented in Table 3. The life-table

168 rates indicate the percentage of acceptors gram ,as increasingly recruiting less­ who became pregnant while using the motivated couples to try the methods it specified method within the indicated time was promoting most heavily, the rhythm period. They show that rhythm users had acceptors, continuing to be largely self­ the highest cumulative rates at both 12 and selected, maintained earlier levels of 36 months, followed by condoms, pills, motivation. and the IUD, in that order. The rhythm­ condom comparison may be misleading, Use-Effectiveness among however, since more condom than rhythm Rhythm Users In General users drop out early and therefore cease to In 1977 the Philippine Family Planning be counted when they become pregnant Program shifted its emphasis from pro­ accidentally. The Pearl rates are more ap- viding services through clinics to a village­ propriate, since they include in the based Outreach Project. With this program denominator only woman-months of use. shift, the research focus on clinic acceptors The Pearl rates indicate that the probability shifted to a focus on "eligible couples" in of failure among rhythm users (20.2 preg- Outreach areas. As a result, the National Ac­ nancies per 100 woman-years of use) is no ceptor Surveys were supplanted, in 1978 greater than the probability of failure and 1980, by Community Outreach Sur­ among condom users (21.3). veys (COS). Because of the nature of the In life-table analysis of pregnancy rates, sample, a new procedure was developed the joint effects of continuation and failure for collecting and analyzing data on use­ rates may be seen in measures of "ex- effectiveness. tended use-effectiveness." One such Each respondent was asked about her measure is the "over-all" pregnancy rate contraceptive practice during each of the (Table 4)-that is, the percentage of accep- 30 months preceding the interview. Those tors who became pregnant within a speci- who reported pregnancies during this fled period of time following acceptance, period were asked whether they had been regardless of whether they were using any using a method at the time of conception. method at the time of conception or Method-specific monthly continuation and whether the pregnancy was desired. Con- failure rates were computed from the dom acceptors had the highest pregnancy responses and converted into annual con­ rates and IUD acceptors by far the lowest. tinuation rates and Pearl pregnancy rates. Pill rates were lower than rhythm rates in Since the continuation rates were not the short term, but by the end of the third duration-specific, they are not comparable year after acceptance, the cumulative pill to the 12-month life-table rates, which rate was equal to the cumulative rhythm refer specifically to the first 12 months rate. This is a startling finding since it in- after acceptance. dicates that fertility is so much higher The 12-month continuation rates and among pill users after discontinuation that Pearl pregnancy rates for each of the the advantage of the pill's low failure rate reversible methods with at least 50 while in use is completely canceled out woman-years of observation are shown in within three years after acceptance. It Table 6. Among the four methods, the rank should be borne in mind, however, that order of rhythm appears to have improved pill acceptors tend to be younger than despite the fact that nearly two-thirds of rhythm acceptors and are therefore more the rhythm users in the COS said that they likely to become pregnant. had learned the method from nonmedical Trends over time are shown in Table 5, sources. The rhythm continuation rate was which presents continuation and preg- well below that of the IUD but somewhat nancy rates of acceptors in 1970-72 and higher than the pill rate. The rhythm failure acceptors in 1975. Continuation rates rate was higher than the pill failure rate declined and overall pregnancy rates in- but not nearly as high as the condom creased for all methods except rhythm. failure rate. These findings suggest that, while the pro- The 1980 COS also showed that 5 per­

169 cent tried combinations of methods-3.4 began operations in four pilot provinces, percent used rhythm plus withdrawal, 1.2 using a nonclinical approach to promote as train­ percent rhythm plus condoms, and 0.7 the use of BBT. Parishes were used Volunteer percent condoms plus withdrawal. The ing an administrative centers. were recruited use-effectiveness data for the first two couples from rural areas They were categories of combined use are shown in and trained as BBT instructors. sent back Table 6 (there were not enough cases in the then provided with supplies and in their villages. third category for inclusion), together with to instruct other couples to data on withdrawal alone, which was the This project subsequently expanded the momen­ most prevalent method among the COS cover nine provinces but lost year or two respondents. The estimated continuation tum and enthusiasm of its first 1976. Late in and failure rates of rhythm plus condoms and ceased operations about in the four were almost identical to the corresponding 1971 a survey was conducted RPC perfor­ rates of rhythm alone, but rhythm plus pilot provinces to evaluate the of these withdrawal appears to have been a strik- mance (Laing 1972). Analysis ingly more effective combination. It was as surveys revealed a six-month all-methcd likely to be continued -s the hID and as continuation rate of 66 and a six-month Correspond­ use-effective in preventing accidental overall pregnancy rate of 19. 1973a) pregnancy a,;the pill. Withdrawal alone, in ing rates from the 1972 NA* (Laing 7i and contrast, was somewhat less likely than for rhythm acceptors at clinics were 1974 NAS rhythm :lone to be continued for a year 26 respectively and from the and sornewbat more likely to result in ac- (Laing 1978) were 77 and 18 percent program ap­ cidcntal prcgnaiiicy, but it was clearly respectively. Thus, the RPC the superior to condoms in both regards, peared to be less successful than clinical program in terms of continuation terms of pregnancy. Use-Ef'ectlvenss of BBT but about the same in however, During the late 1960s and early 1970s, The differences are not great, as much to dif­ the Asian Social Institute (ASI) operated 24 and may be attributable of the clinics in urban areas of the Philippines that ferences in the 'haracteristics differences in the offered both calendar rhythm and the basal populations studied as to since the body temperature (BBT) method. In 1971 a methods provided. Furthermore, period follow-up survey of acceptors at the Manila rates refer to such a short time ca , be taken as clinic wAs conducted for the purpose of following acceptance, they effects. obtaining data on use-effectiveness (Laing only suggestive of longe:-term 1971). Of the 142 respondents, 72 said they had used BBT, 60 said they had used Nature of NFP Practice calendar rhythm, and If' said they had As noted above, the most widely prac­ is used both. The 10 respoadents who had ticcd form of NFP in the Philippines used both were combined with those who calendar rhythm. In a recent survey of 308 of the said they had used P13BT only, yielding a rhythm users in the Bicol Region all but sample of 82 BBT users. The 12-month Philippines (Bicol University 1983), was continuation and pregnancy rates of the one of the respondents said that she two groups are summarized in Table 7. The using calendar rhythm. The one exception continuation rates for BBT were con- claimed to be using the mucus method. of sidepably lower than those for calendar Only five percent said they had heard had rhythm, but the failure rates and overall BBT, and seven percent said they pregnancy rates were about equal. Thus, heard of the mucus method. Comparable despite the theoretical advantage of BBT data at the national level are not available, over calendar rhythm, there was no evi- but it is known that there are so few agen­ dence of a practical difference in this cies offering instruction in more advanced instance. NFP methods that only a negligible propor­ In 1971 another organization, the tion of NFP users could have been exposed Responsible Parenthood Council (RPC), to them.

170 There cs,of course, considerable variation being "10-10-10" (ten safe days, ten unsafe in the practice of calendar rhythm. A vari- days, ten safe days) or variations like ety of evidence points to the widespread "8-10-9" or "9-9-9," which are ap­ use of crude formulas that do not take into propriate for couples with at least fairly per­ account '- -iations in cycle length. The regular 27-to-30-day cycles. Thirty-six very fact tnat most rhythm users claim to cent of the respondents, however, re­ have received instruction from friends and ported more conservative formulas, like relatives suggests that many do not take Days 1-20 or Days 1-15. (The latter may not variation of cycle length into ?,ccount. Fur- be as inaccurate as it might at first appear, thermore, the Bicol study. cited ahcve since some couples start counting from the notes that none of the respondents toik first day after menstrual bleeding, in which such variation Lito account inspite of the case it would be equivalent to the former.) fact that 21 percent reported irregular The findings from the Bicol survey and cycles. Focus-group discussions involving the focus-group discussions can be viewed rhythm users living in rural areas near as merely exploratory. Much more infor­ Marfila also revealed a general ack of mation is needed on the variations in awareness of the need to tailor fonnulas to rhythm practice. Relevant data from larger­ the.Lndividual couple (Verzosa ec ,d.1980). scale studies, such as the 1976 National Ac­ The formulas reported call for absti- ceptor Survey and the Community Out­ nence periods ranging from about eight reach Surveys, are limited to responses to days to more than three weeks. In the q-stions about the time during the focus-group discussions, for instance, most menstrual cycle when the wom-n is most formulas identified the "safe" days as five iikely to conceive. Even in the 1976 NAS, to ten days before and after the start of where most of the rhythm acceptors had menstruation (Verzosa et al. 1980). It is not been instructed by clinic personnel, only clear from the research report how the date 21 percent of all respondents and 39 per­ of the next period was estimated, but in cent of rhythm users said they thought it most cases it was probably a simple matter was between 7 and 21 days before or after of assuming that it would be either on the the beginning of the period (Laing and same date of the succeeding calendar Alcantara 1980). month or exactly four weeks following the In the 1980 COS, the question was beginning of the last period. It is widely changed to make it more directly relevant believed that cycles are "regular" if they to the respondents' own experience: fall on the same calendar date each month, "When do you think is the best time for a a belief that disregards the variations in couple to avoid sex in order to prevent length of calendar months. pregnancy: during the wife's menstrual Some couples count only the days after period, right after the period, midway bc­ menstruation as safe, especially if they tween periods, or irrmmediately before the know the woman has irregular cycles, next period? Among current rhythm users, Some others do just the opposite, abstain- 34 percent gave the correct answer (mid­ ing on all but the estimated last five days of way between periods), 38 percent said the cycle. This practice is reinforced by the right after the period, 24 percent said im­ widespread taboo on sexual intercouse mediately before the next period, and 2.5 during the days of menstrual bleeding. By percent said during the period. Such the time bleeding has stopped, couples responses indicate widespread ignorance who follow the conservative "five days of ovulation and its timing. before, five days after" formula assume that there is already a risk of pregnancy and Reasons for Preferring Rhythm. therefore try to restrict sex to the last five In the 1974 National Acceptor Survey days-that is, about Day 23 to 25 onwards. (Laing et a. 1977), respondents were asked In the Bicol survey (Bicol University to compare the four program methods. 68 1983) the reported formulas tended to be Rhythm was preferred to condoms by less conservative, the most common ones percent and to the IUD by 69 percent. Pills

171 were preferred to !hythm by 58 percent, fectiveness (9 percent) were mentioned but when the respondents were limited to much less frequently. Effectiveness was those who had tried both methods, rhythm usually cited in a defensive manner--"It's wzs preferred by 53 percent. (Among those effective enough"--rather than as a cate­ who had tried both rhythm and the IUD, goric assertion that rhythm is highly effec­ however, the IL"D was preferred by 54 per- tive. Only 1.6 percent said their main cent.) Clearly, the rhythm method was a reason for practicing rhythm was that it very popular method in spite of the fact was not immoral or sinful. that the progrm had been placing much heavier emphasis on the promotion of Problems with the pills. When asked why they preferred Calendar-Rhythm Method rhythn over the other methods, respon- Owing to its high failure rate, the dents were most likely to cite medical calendar-rhythm method of NFP is inap­ safety (absence cf side effects, pain, or propriate as a method for most couples health dangers) and convenience (no need seriously interested in limiting family size. to get supplies, have insertion, or interrupt The main dfficulty, especially for the hus­ the sex act). Some also cited effectiveness band, appears to be abstaining throughout and husband's support, especially in con- the entire "unsafe" period. This difficulty trast to condoms. Interestingly, almost of abstaining is exacerbated by the conser­ none mentioned religious or moral reasons, vative formulas often adopted, which The focus-group discussions (Verzosa et result in excessively prolonged periods of al. 1980) revealed a similar pattern of abstinence, with only a few days each responses--lack of side effects and lack of month available for sexual intercourse. interference with the sex act were the most Such an onerous schedule invites chance­ common responses. A few respondents in taking. In the 1978 COS (Laing 1979a), 36 this study also mentioned compatibility percent of rhythm users admitted to taking with religious teachings. It is doubtful, chances at least occasionally. however, that this finding reflects growing The burden of prolonged abstinence awa2reness or concern with Church teach- would be reduced for some couples by ing. The 1980 Community Outreach Sur- better instruction in the calculation of the vey included the following question: "Do safe and unsafe days-especially the you think your religion approves or disap- monitoring of cycle length and the tailor­ proves of modern family plannhig methods ing of the formula to individual circum­ like the pills, IUDs, condoms, or steriliza- stances. Even for women with perfectly tion?" Of the Catholic respondents, 8 per- regular cycles, however, the minimum cent said they didn't know the Church's abstinence period of eight days would be stand; 74 percent said they thought the excessive for some. A frequently cited Church approved of such methods; and problem (Verzosa et al. 1980) is that only 15 percent said they thought the husbands are especially likely to lose con­ Church disapproved. Eight years before, trol after drinking. This problem would respondents in the 1972 National Acceptor continue even if the abstinence period Survey had given similar responses to a could be reduced. Furthermore, the re­ similar question: 25 percent had indicated quired abstinence period woula L-)tinue that they did not know the Church posi- to be relatively long for wives ith ir­ tion; 61 percent had thought it approved; regular cycles. and 14 percent had thought it disapproved There is little reacon to doubt that im­ (Laing 1973b). proved education and instruction would The 1980 COS questionnaire asked lead to improved calendar-rhythm use. In respondents what they lik, .1 most about the 1980 COS, for instance, women who their current method. The response men- knew that the time to avoid sex in order to tioned most often by far by rhythm users prevent pregnancy is midway between was that it was not harmful or painful (71 periods reported proportionally fewer ac­ percent). Convenience (15 percent) and ef- cidental pregnancies than did other

172 women. Their Pearl pregnancy rate while and the development of improved tech­ using rhythm was 24.A; in contrast, among niques for estimating the safe and unsafe those who said they thought sex should be days. As a result of these considerations, avoided right after the period, the Pearl together with the difficulty noted above of pregnancy rate was 30.6; and among those asking existing program workers to take on who said they thought sex should be NFP instruction in addition to all their avoided immediately before the next other tasks, POPCOM is presently corn­ period, it was 50.4. mitted to a policy of upgraulng NFP prac­ The main problem with trying to im- tice "though the training of volunteer prove understanding and practice of the workers of commit.nIty-based organiza­ rhythm method appears to lie in finding a tions, particularly religious lay leaders" cost-effective way of doing so. Findings (Commission on Population, 1983). Since from the 1980 CG3 (Lang 1981) indicated POPCOM is only a. coordinating agency, that neither full-time, paid family planning the implementat' )rt of such projects will field workers nor village-based volunteer be contracted out. workers were adequately knowledgeable Three large-scale, three-year projects to provide instruction in calendar rhythm; have been approved. The first (Philippine moreover, such workers would not have Business for Social Progress 1983) will inte­ the large amount of time necessary for pro- grate NFP instruction into the work of 124 viding such instruction without seriously existing community-based organizations in impairing their ability to do the other tasks 244 communities, whose main function Is expected of them. to promote socioeconomic development. These conclusions were borne out by a The second (Archbishop Gabriel M. Reyes recent project in southern Mindanao Memorial Foundation and Philippine (Valera 1982), where 25 paid workers and Cultural Communication Service Corpora­ 94 village-based volunteer workers under- tion 1983) will be focused on one province went special training to qualify them better and will integrate NFP training into the as calendar-rhythm instructors. Their family life component of a community knowledge about the method was tested development program. The program, before and after training. In addition, a which has been pilot-tested in one village, sample of 336 rhythm users in the workers' will be extended to cover the entire prov­ areas of jurisdiction were interviewed six ince. The third project (Philippine Federa­ months Later. The training was found to be tion for Natural Family Planning 1983) will effective in increasing the workers' knowl- train selected couples in four or five edge, but the interviews of the rhythm parishes who will, in turn, instruct other users revealed that only four percent of couples in NFP. them had received rhythm instruction dur- Findings from past and ongoing research ing the six months that had elapsed since suggest that these projects will encounter the workers had been trained. Further- serious difficulty in their efforts to promote more, another test of the workers' knowl- NFP. In the evaluation of the BBT project edge at this time indicated that they had of the Responsible Parenthood Council, It lost most of the knowledge they had was found that many clients instructed by gained during training, community-based volunteer couples (who were themselves BBT users) ccmplaind Prospects for Future Program Efforts that they had difficulty understanding in­ In recent years, the attention of family structions and that they were not vL~ited planning program managers has been in- frequently enough. Clients felt that the creasingly directed toward the need to im- volunteer couples seemed more interested prove NFP instruction and practice in the in recruiting acceptors than in taking time Philippines. This concern has grown out of to instruct and guide them. In addition, an increasing awareness of the high preva- there were shortages of thermometers and lence of this method, the low degree of charts, and many of the clients had diffi­ knowledge about how it should be used, culty using and storing them safely. Ani­

173 mosity rapidly developed between the pregnancy was attributable to method fail­ RPC workers on the one hand and the ure, one to inadequate teaching, and one to other family planning field workers and inaccurate application of instructions. clinic personnel on the other, each side ac- Comparable figures are not available for cusing the other of "client grabbing." The calendar rhythm, but it is certain that more principles of calendar rhythm were ig- failures among calendar-rhythm users are nored, even though the project managers due to both inadequate instruction and were aware that the BBT method was not method failure. With such a high preg­ well suited to estimating the first unsafe nancy rate due to conscious departure day. One-third of the persons listed as ac- from instructions, however, the UST find­ ceptors did not in fact try BBT. Primary ings suggest an absolute limit to the reasons for nonacceptance included preg- effectiveness of the mucus method in the nancy (33 percent), perceived diffiolty Philippines, no matter how low its with the method (22 percent), lack of "method failure" rate. cooperation from spouse (13 percent), no In 1982 and 1983 the Program for the thermometer (9 percent) and postpartum Introduction and Adaptation of Contracep­ amenorrhea (8 percent). tive Technology (Program... 1983) con­ More recently, there have been small- ducted focus-group discussions with scale efforts to instruct couples in the groups of mucus method users, dropouts, mucus method. The best-known of these and instructors in and near Manila and in efforts is the WHO multicenter trial, in Central Mindanao. The findings revealed which the University of Santo Tomas (UST) that the method, as understood and prac­ in Manila was a participating center (World ticed, was a simplification of the correct Heath Organization 1981). The data on procedure. For instance, several clients uwe-effectiveness indicated that the UST were unaware of the peak day and its im­ s2mple had the lowest accidental preg- portance, and many of the rest had diffi­ nancy rate among the five centers. The culty identifying it. Some users recognized Pearl rate was 13.8 pregnancies per 100 only wet and dry days, without differen­ woman-years of use for the effectiveness tiating among variations in consistency phase (excluding the three-month initial during wet days. They simply viewed all teaching phase). Including the teaching dry days as safe and all wet days as unsafe, phase, the Pearl rate was 17.9. Both of without regard to ^he pattern over time. these rates are well below the Pearl rate of The instructors appeared to understand 22.9 found for rhythm users in the 1976 the importance of patterns over time, the NAS during the first year after acceptance peak day, and variations in types of mucus; (Laing and Alcantara 1980), indicating that it appears, however, that this information the mucus method was used somewhat was not being communicated adequately more effectively than the calendar-rhythm despite frequent home visits (at least method. The difference is not very $reat, weekly for several months). Though however, considering the presumed clients were instructed to abstain for the superiority of the method and the greater duration of the first teaching month so that care taken in instruction in the UST study seminal fluid would not become confused (the calendar-rhythm acceptors had not with cervical mucus, most did not comply. undergone a "teaching phase" of three to Charting had been practiced by most six months) and in follow-'Jp (each subject clients in the early months, but most was seen monthly in the UST study). In stopped keeping charts within the first contrast, most of the calendar-rhythm ac- year. Almost all failures were attributed to ceptors were not followed up at all, and the husband's desire for sex during the un­ many did not visit the clinic even once safe period. after accetance. Difficulties with abstinence and lack of Of 23 failures in the UST study, 20 (87 cooperation from the husband are counter­ percent) were a result of conscious depar- balanced for some couples by advantages. ture from the rules. Only one accidental In her analysis of data from a study of suc­

174 cessful, long-term NFP users in Iligan City, don on NFP practice has already been Espernza Aranas-Dowling (1979) reported gathered in past research efforts, there are that the respondents cited several advan- still many gaps. Several research projects tages of abstinence, including heightened already under way or expected to start pleasure from love-making, greater sen- before the end of 1983 are intended to help sitivity of spouses to each other's needs, in- fill these gaps. In addition to the three creased understanding about sexuality, large-scale NFP action projects described and increased self-confidence resulting above, two other projects, designed pri­ from their ability to control their urges. It marily for research purposes, are presently must be borne in mind, however, that under way. these advantages were reported by couples The above-mentioned study, testing the who had been able to learn and use the use of parish-based volunteer workers to method successfully for at least a year. instruct couples in calendar-rhythm or the The Population Center Foundation is mucus method, is expected to provide presently sponsoring a study designed to qualitative data on the operational prob­ test the relative effectiveness of calendar lems of implementing such a program as rhythm and the mucus method as taught well as comparative quantitative data on by parish-based volunteer workers in two the use-effectiveness of the two types of provinces in the southern Philippines. In- NFP. It will attempt to improve on past formal progress reports from the project studies of NFP use-effectiveness by distin­ areas indicate considerable difficulty in guishing between different types of failure finding potential acceptors of either (method failure, inadequate instructions, method who are willing to undergo in- incorrect application of instructions, and struction and able to complete the teaching conscious departure from instructions). phase successfully (de Guzmar. 1983). In A second ongoing study is the 1983 Na­ one area covering about 5,000 couples, tional Demographic Survey (NDS), which only 59 couples, 30 for the mucus method is expected to update the information on and 29 for calendar rhythm, out of a target national prevalence of NFP last obtained in of 100 had been enrolled after completing the 1978 RPFS. It will also deal with such the teaching phase during the first 18 concerns not studied in previous national­ months of project operations. In the other level studies as awareness of different types area, which got a later start, 42 had been of NFP, questions on the timing of use of enrolled in the first six months out of a the current method (for use-effectiveness target of 200. Major reasons for nonenroll- analysis and comparison among methods), ment among those who have undc-'one reason for termination of use, source of in­ initial instruction have been pregnancy, struction, things liked and disliked about amenorrhea, inability to understand or the current method, and the perceived follow instructions (especially charting), duration and timing of the abstinence and lack of cooperation from the spouse. period for a woman with a regular 28-day Instructors report that participants in tain- cycle. ing sessions, which are held in the evening, Three new studies ate just now getting often become sleepy; about half of the under way. The most ambitious is an in­ couples are represented by only one depth survey of a representative sample of spouse (usually the wife); many bring about 700 NFP users in 8 of the country's children with them and are distracted; and 13 regions (Demographic Research and many have difficulty detecting mucus pat- Development Foundation 1983). The sam­ terns, are embarrassed about recording pie will consist of all respondents in the 8 information on sexual contact, or openly regions interviewed in the 1983 NDS who admit to being too lazy to maintain their said that they were currently using NFP. records. They will be I 'llowed up a.ier about eight months and interviewed at length about Needs and Prospects for Future Research their awareness, knowledge, perceptions, Although a good deal of useful informa- attitudes, communications, and practices

175 concerning the different types of NFP. The from interviews and focus-group discus­ questionnaire will be largely unstructured. slons of men currently using NFP. so 2s to encourage the collection of detail- Several operational issues also need ed qualitative data. In addition, data will be study. Given the heavy reliance of NFP on obtained for analysis of short-term use- clear instruction, there is a special need to effectiveness between the NDS and follow- collect more information on the conter. up survey oata. The findings from the and quality of instruction. A corollary is the follow-up survey will be combined with need to assess the training of instructors the NDS data on NFP for a single rnajor and the quality and utilization of informa­ report on NFP in the Philippines. tional support materials (e.g., leaflets, radio The other two studies are tests of pro- broadcasts) that may be employed to aug­ gram strategies. One will tcst the establish- ment instruction. Similarly, charts, calen­ ment and operation of NFP centers in dars, zecord-keeping forms, and other such hospitals in Metro Manila that have not aids need to be evaluated with regard to previously offered family planning, usually ease of use and appropriateness for the for religious reasons. The major objectives couples for whom they are intended. The will be to determine the extent of demand popularity of NFP among Philippine for such services and to document the ef- couples and the increasing commitment of fectiveness of NFP use by the clients of the program resources to upgrading its prac­ centers. The other study, to be conducted tice clearly justify increased commitment in central Mindanao, will test the active of research efforts. promnotion of alendar-rhythm use in com- NoTE: The unabridged paper by Dr. Laing, "Natural bhination with either withrawal or condoms Family Planning in the Philippines" appears (Silva 1983). It will attempt to minimize in Studies in Family Planning, Vol. 15, #2, confusion by presenting a single formula Mar/April 1984. for calculating safe and unsafe days (7 safe days, 14 unsafe days, the rest safe). It will Table I Survey Estimates of Contraceptive Prevalence among Married Women 15-44, by Method- Philippines recommend minimizing the frequency of 1968-78 (Inpercentages) sexual activity during the unsafe days and always using a backup method on those Survey date on days. The effects of this intervention actual practice and use-effectiveness will Rhythm 5.5 7 8.9 Pills 1.3 7 4.8 be assessed after a 12-month intervention IUD .9 2 2.4 period. Condoms a 1 3.8 These studies should greatly increase Steriliation b b 5.3 our understanding of how the various Withdrawal 6.2 4 9.5 forms of NFP are practiced and how they Others 1.6 2 2.3 might be disseminated more effectively. Total 15.5 23 37.1 Some major research needs still remain to Sources: Laing, et a]. 1973 (for 1968); Barretto 1974 (for 1972); be filled, however. One is the need for NSCO, et al. 1979 (for 1978). prospectively collected data. Another im­ a Include& under "other." portant research need is a better under- b Less than Ipercent. standing of the role of the husband, both in staningftih eon tof pctehub and in Table 2 Cumulative Life-Table Continuation Rates of Clinic the initial decision to practice NFP and in Acceptors, by Method: Philippines 1976 National Acceptor the duration and effectiveness of NFP use. Survey (Inpercentages) The main source of research data related to NFP practice hos been from wives. There is Method First-method All-method a need to learn .ore about the point of accepted 12 months 36 months 12 months 36 months view of husbands, particularly those Rhythm 42 19 57 30 husbands who have tried NFP and ,gi,,:nup PilLs 48 17 61 30 IUD 68 39 8151 2654 or those who have not even tried. What lit- Condoms 23 6 tie information is available directly from husbands has been drawn almost entirely Source: Laing 1979b.

176 Use-Effectiveness Rates of Table 3 Cumulative Life-Table Rates and Pearl Table 7 Twelve-Month at ASI Clinics Pregnancy Rates: Philippines, 1976 NAS Calendar and BBT Acceptors in Manila, 1971

Pearl preg- - Calendar Life-table pregnancy rates nancy rates Type of rate BBT Method 12 months 36 months- 60 months First-method continuation 32 47 Rhythm 13.8 22.9 20.2 All-method continuation 41 52 Pills 5.1 9.5 7.8 First-method failure 24 27 IUD 2.4 5.1 2.6 O ,erall pregnancy 40 38 Condoms 10.4 12.9 21.3

Table 4 Cumulative "Overall" Pregnancy Rates: References Philippines, 1976 NAS (In percentages) Aranas-Dowling, Esperanza. 1979 A Study of the Conjugal Interactionof the Overall pregnancy rate Successfui Natural Family Planning Prac­ titioners of lligan, Lanao del Norte. Method 12 months 36 months SEAPPAI Research Report No. 57. Rhythm 36 61 Reyes Memorial Foundation Pills 28 60 Archbishop Gabriel M. Communication Service IUD 13 39 and Philippine Cultural Condoms 40 66 Corporation. 1983 "Far,,!ly/Community Welfare Project." Proj­ ect proposal submitted to and approved by the Commission on Populbtion, May 1983. Table 5 Cumulative 12-Month Continuation Rates R. and Overall Pregnancy Rates of Clinic Barretto, Felisa and Practice of Family Acceptors by Method and Acceptor Cohort: 1974 Knowledge, Attitudes, 1972. Studies in Philippines, 1976 NAS Planning in the Philippines, Family Planning, (5)9:294-9.

Overall Bicol University. First-method All-method evc continuation rate continuation rate pregntancy rate 1983 "MisconceptionsPatc fRyh and Irregularities yBrna in the Method Practice of Rhythm by Barangay Service accepted 1970-72 1975 1970-72 1975 1970-72 1975 Point Officers and Married Couples of Repro­ ductive Age of Albay and Masbatt." Legazol Rhythm 43 42 58 60 36 30 City. (Draft). Pills 54 37 66 54 23 40 IUD 68 61 82 74 10 20 Commission on Population. Condoms 23 18 50 47 32 40 1983 "The Philippine Population Program: New Thrust and Challenges." Draft document re­ viewed by the Board of Commissioners.

Table 6 Annual Continuation Rates and Pearl Preg- de Guzman, Alice. nancy Rates Estimated from 1980 COS Data 1983 Personal communication.

Demographic Research and Development Foundation. Number of Annual Pearl 1983 "A Detailed Investigation of Natural Family woman-years continuation pregnancy Planning Use in the Philippines." Research Method of observation rate rate proposal submitted to and approved by the Population Council. Rhythm 710 51 33 Pills 423 42 19 4 Laing, John E. IUD 165 70 Continuation and Pregnancy Rates among Condoms 114 10 60 1971 Acceptors at Rhythm Clinics in Manila. Rhythm + withdrawal 246 73 17 Manila: Universty of the Philippines Papua­ Rhythm + condru as 71 51 31 Withdrawal alone 767 43 44tion nstltte, (IJPPI).

Source: Lalng 1981. !1972 1971 Evato'atton ofthe RPC Program.UPPI.

177 Life Education, 1973a Use Effectiveness of Family Planning in the Family Planning, Family proposal sub­ Philippines, 1970-72. lhilippineSociological Health and Nutrition." Pr(oject Commission Review (21)2: 137-51. mitted to and approved by the on Population Ouly). 1973b Selected Response Distributions from the Pn;mning. 1972 National Acceptor Survey. UPPI. Philippine Federation for Natur:i Family 1983 "Natural Family Planning Program Delivery." (August). 1978 Estimating the Effects of Contraceptive Use Draft proposal for POPCOM on Fertility: TCchniiqucs and Findings from of the 19'7-1Philippine National Acceptor Program for the Introduction and Adaptation Survcy. Studies in Family Planning9:6. Contraceptive Technology. 1983 "An Exploratory Study on the Use and Mucus Method of 1979a 1978 Commnitiv Outreach Survey'1,: ttigh- Teaching of the Cervical based on lights from jlarital l)istribution ol COG Family lanning." (First repont Nov. Variables. 1I'PI. focus-group discussions conducted in 1982, and second report based on focus­ June 1983.) 1979h Currentlly Relevant Findings and Imptica- group discussion conducted in tions from Family l'lanning Program- Oriented Researcb at the 1I.1'. P1opulation Silva, Dolores. Package on Institute. UPPI. 1983 "Introduction of a Promotional the Use of Combinations of Methods to 1981 Famnily l'laning Outtreach in the Philip- Improve Contraceptive Effectiveness." Research pines, Final Report (in the ommnnunityl Proposal of the Socio-Economic Cotabato Outreach Sturveys. I PPI. (Mimco). Center, Notre Dame University, City, Philippines. Laing, John E., and Adelamar N. Alcantara. Popula­ 1980 Final Report otithe 1976 National Acceptor Special Committee to Review the Philippine Survey. UPI. (Mimco). tion Program. 1978 Final Report. Manila (June). Laing, John E., Trinidad Osteria, and Matthew B. Cor. 1973 Ihilippine Family lhtinning Knouledge, Valera, Jaime B. Attitutdes, and 'ractices: Baseline Data, 1982 Ani Evaluation of the Effects of Strategies 1968. UPPI. Used to Improve Ine Delivery of Rhythm as a Family PlanningMethod. Los Banos: Univer­ L.aing, John F., James F. Phillip, Zelda C. Zahlan, Rica sity of the Philippines. I.orente, and Josctina V. Cahigon. Nora 1977 Final Report on the 1974 NVtional Acceptor Verzosa, Cecilia C., Cecilia L. Pabalan, and Survi'. UPPI. (Mimeo). J. Llamas. 1980 Final Technical Report on Motivational National Census and Statistics Office (NCSO) et al. Research on Rhythm P'ractice.PIACT/Philip­ 1979 Republic of the 1Philippines Fertility Survey,: pines. (Mimeo). First Report. World Health Organization. the Ovula­ Philippine Business for Social Progress. 1981 A Prospec."e Multicentre Trial of Planning. II. 1983 "Developing Capacities of Community Based tion Method of Natural Family Groups ili Organizations to Implement The Effectiveness Phase. Fertility and Family Welfare Programs Including Natural Sterility 36:5.

Comments

MARIE MIGNON MASCAREN9IAS Two studies of NFP in India cannot be ignored by any family planning worker credibility of Marie Mignon Mascarenhas,M.D., direc- because they established the Karna­ tor of CREST; pioneer in NFP in India; NFP in this country. They are the member with her husband of the Pon- taka State Study (KSS), which was carried World tifical Councilfor the Family out from 1977 to 1981, and the

178 and 8 Health Organization (WHO) study of the Christian (51.5 percent were Hindus ovulation method in five countries, of percent were Muslims). which India was one. The WHO study was One of the most important by-products the first to compile data from India. of NFP is the enhancement of the woman's tie method. Bangalore was selected from 20 centers in dignity that results from using knowledge India to conduct this research, with the The woman finds that fertifity an educa­ consent of the Indian Council of Medical is fertility control. Moreover, Research and the Ministry of Health and tional method that integrates the teaching is particu­ Family Planning. Certain highlights from of health, hygiene, and nutrition the study should be mentioned for the larly appealing to both women and men. benefit of NFP workers. The method also encourages breast­ An important finding was that 94 per- feeding and stresses its importance. It cent of the women, many of them illiterate should be noted that the contraceptive ef­ and from different cultures and religious feet of bre-ast-feeding is a physiological backgrounds, learned to distinguish the phenomenon of major importance; in fertile period in the very first cycle. The developing countries it prevents more continuation rates were higher than those pregnancies than all the oher methods of for any other method of spacing used in contraception. to India (see Table 1). Promotion of NFP in India appeals welfare of The method effectiveness was on the groups that value the health ad order of 98 percent, and the use-effective- women md children. Ths,;e include social, organ­ ness of the method in India was 85 percent. educatic ,al, and religious women's are also The study involved 278 couples in India izations. Governmental agencies the most effec­ alone and was done over a period of about being reached, and one of a successful two years. A simultaneous monitoring pro- tive voices for NFP is often that NFP does gram of progesterone assays was done for user. It must be remembered with drugs or every woman seven days after she had not have any companies be in users. claimed to have reached her peak day, as devices to sell, and sales must made to bring detected by the sensation of wetness or Outreach efforts are being closer coopera­ observation of mucus changes. The study the medical profession into To nurses and was the most diligent NFP study ever tion with NFP workers. empha­ undertaken and studied 1,000 parameters medical students, the NFP message and accep­ in five countries. It proved that NFP was sizes the safety, effectiveness, that are met scientifically valid and that it was an applic- tability of the method, criteria It is stressed that able and a practical method for spacing or only with an NFP method. and mor­ limiting pregnancies in developing coun- NFP can reduce infant morbidity to space tries regardless of educational level. tality because it helps women the health The other study, KSS, was conducted their children and contributes to throughout the state of Karnataka; 3,500 of each child. or decry couples were registerd, and a systematic There is no need to criticize has an follow-up, similar to that used in the WHO other types of contraceptives. NFP advantages study, was observed. The KSS found that intrinsic worth, and its medical women's libido was significantly higher in the pre- and postmenstrual phases (i.e., Table 1 Continuation Rates for the corresponding to the infertile period) than Ovulation Method in India at other times during the cycle. Difficulties caused by abstinence were reported by WHO Karnataka only 1.7 to 4.6 percent of the husbands in Study State Study the Karnataka Study. Detailed records on Number of couples entering 278 2790 this aspect of the method were maintained Continuation rate throughout the study. It was found that 97 After six months 84% 93.0% percent of the husbands were cooperative. After one yea, 78% 75.0% 71% 70.8% The majority of these couples were not After two years

179 are sufficient for its promotion, suited to promote NFP as integrated with Community heAlth workers are pre- health education for nutrition and hygiene. sented with the advantages of NFP that Women's groups respond to the very couples gain by not being dependent on powerful argument that women who use doctors, hospitals, or drugstores, The child NFP are not called upon to face any risk or health and welfare services are ideally hazard to health.

KWANG-HO MENG Evaluation of family planning programs has usually been based largely on the more Kwang-bo Meng, M.D., associate pro- pragmatic public health approach. In this fessor of Departmentof PreventiveMedi- type of evaluation, the program objectives cine and Bin-statistics, Catholic College, and the way of measuring the program ef­ Seoul, Korea; delegate of the Korean fects to meet the objectives are considered. Happy FamilyMovement-NFP The goals and objectives of government family planning programs are concerned In a broad sense, evaluat'on of a public primarily with increasing availability of ser­ program is undertaken to determine if the vices and reduction of the birth rate to program is "worthwhile." But program predetermined levels. Selection of pro­ evaluation is often frustrated by confusion gram evaluation topics and measuring the over what is meant by "worthwhile" and effects of the program may not be so dif­ how it can be measured. In fact, the word ficult in these cases. "evaluation" has been defined in the past Evaluation of NFP programs, however, in different ways, depending upon the con- should be different from that of other fam­ text in which it was used and the programs ily planning programs because the goals that were under consideration. and objectives are somewhat different. As In the field of public health, the Dr. Borkman conceptualized some years American Public Health Association has ago in the InternationalReview of Natural defined evaluation as "the process of Family Planning,NFP is a "value-oriented determining the value or amount of success interpersonal behavioral innovation." That in achieving predetermined objectives." In is why NFP has been perceived as either a the field of social science, evaluation con- movement or a social service program in sists of the application of social science many countries. In those countries, the techniques in the appraisal of social action most important goal of the NFP program is programs. Interest centers around the still enriching marriage, improving the assessment of behavioral changes, of couple's relationship, or sanctifying the related attitudes and motivations, and of family, not regulating fertility. Because of the factors influencing them. this goal, a more sociological approach On the other hand, economists often toward evaluation-namely, evaluating define evaluation in terms of a cost-benefit behavioral changes between partners or analysis. The cost of all inputs into the pro- even toward God-is needed in NFP pro­ gram, such as personnel employed and gram evaluation. materials utilized, is estimated and com- In general, I agree with Dr. Gray's pared with the benefits accruing from it. description of evaluation, but I would like The object of evaluation is to maximize the to add my personal experiences. First, benefit per unit cost at every stage of evaluation of the performance of the peo­ operation of the program. pie in managerial positions, including It is thus apparent that evaluation ap- t -achers, is very important. This is because proaches vary in complexity and demand the success of an NFP program depends different degrees of knowledge and skill, largely on who is running the program.

180 Many NFP programs are headed by reli- CYPs in NFP if the number of subjects we gious leaders, such as priests and sisters. observe is the same. Their eagerness to improve the program Behavioral changes before and after the and the amount of time they devote to it acceptance of NFP should be evaluated as a are reflected in the performance level of program outcome. As I indicated earlier, teachers, and thus in program outcome. NFP is a part of family life promotion, and The time they give to the program should therefore, changes in the relationship be­ be recorded and included in the evaluation. tween the husband and wife, the couple's The effectiveness of teachers and the commitment to their children, and even a learning activity of users can be evaluated couple's loyalty to the Church should be by observation of teaching sessions. indicators of program success. Percentage Special forms need to be prepared io increase in church attendance and in those record observations of the evaluators. :'eceiving the Eucharist have been used as Second, I am glad that Dr. Gray did not indexes of program success in one diocese mention the Pearl index in measuring use- of Korea. effectiveness of NFP methods. This index Third, the aim of cost-effectiveness disregards motivations and the variability analysis is, as Dr. Gray pointed out, to of couples with regard to their monthly measure the relationship between program risk of conception. In my opinion, those costs and achievements that cannot be who have not completed charting at least measured properly in monetary terms; ex­ three cycles should not be counted as NFP amples are the work of volunteers and the users, but many studies still include those improvement of family life resulting from couples in the evaluation. This results in a the program. relatively high Pearl index for NFP as a Finally, I would like to mention briefly method of family planning. the necessity for research in the field of Dr. Gray recommended using life-tab!e NFP evaluation. Since the principle of NFP techniques to determine use-effectiveness, is the responsible regulation of birth at­ but we must be cautious in applying this tained through an educated awareness of technique to NFP. As we all know, life- and acceptance of the natural cycle of fer­ table rates can be calculated only up to the tility and infertility, the attainment of the cutoff date; for example, if the interval be- goal is affected by many factors, especially tween start of a program and the cutoff psychological factors. Studies on factors af­ date is 12 months, life-table rates are ob- fecting NFP practice can be very usefil for tainable only up to 12 months at the most. planning and revising programs. For life-table analysis, we must assume In the field of NFP, evaluation efforts that the pattern of NFP practice is constant have concentrated primarily on the bio­ over time, but this is not the case. In NFP medical evaluation of NFP as a family plan­ the continuation rate is much more depen- ning method in terms of use-effectiveness. dent on the degree of motivation than in This, of course, is an important evaluation any other family plannirig method, and the measure of NFP, particularly for outside longer the observation period, the more funding supporters, such as governmental couples who are successfully using NFP. agencies, who see NFP as another fertility Studies show that a couple who becomes regulation method. What we NFP workers, autonomous in NFP use have a higher especially Church-related NFP workers, probability of continuing NFP practice. really need, however, is to see the NFP pro­ The estimated "life expectancy" of NFP gram as different from other family plan­ may, therefore, vary with the duration of ning programs. Its ultimate goal is different, observation. so we need to discuss how to evaluate it Couple years of protection (CYP), on the properly for improving the program per­ other hand, is a good measure of NFP use- formance with respect to the promotion of effectiveness. Since the life expectancy of family life. NFP is longer than that of other contracep- We, of course, have to clarify our goals our tive methods, we even get relatively higher and objectives before we can evaluate

181 objectives program. The problem of identifying spe- the NFP program goals and cific program objectives is a major problem should be. associated with the evaluation of a public In conclusion, evaluation of effective­ program. A second problem is measuring ness in preventing pregnancy is just one the effects of the action program. In the aspect of NFP program evaluation. Two first regard, the Diocesan Development other important aspects of evaluation of Program for Natural Family Planning in the program accomplishment are performance United States is one good example of what analysis and public (client) response.

SHEILAGH O'ROURKE developing countries. This lack of ex­ perience must be taken into account in any Sheilagh O'Rourke, Ph.D., anthropolo- program of data collection in the develop­ gist; coordinator of evaluation project ing world. l'Action Familiale-Haiti (1982-83), Haiti How, then, does one meet the demands for service statistics and for program accountability? First I First, I wouid like to express my admira- evaluation and donor agencies be tion for the astute presentations of Dr. would suggest that demand for data collec­ Gray and Mr. Kambic. As an anthropologist reasonable in their Since most NFP who has spent a year evaluating an NFP tion and accountability. limited formal program in Haiti, however, and as one who program personnel have of gathering and has benefited from discussions with many education, the onus falls on the organiza­ who represent programs elsewhere in the tabulating such data few. These developing world, I would like to add a tion's highly educated have many other few suggestions, educated few already their time (e.g., train­ For many of the NFP programs in devel- diverse demands on promotional oping nations, much of what has been said ing educators, writing demands for too here is presently impractical. Many NFP materials). Thus too many physical and educators-i.e., those who would be ex- much data place tremendous on some of the pected to perform most of the proposed psychological strains valuable people. data collection-are persons with limited organization's most world, the educator literacy. They have little experience in fill- In the developing his job quickly learns ing out forms and keeping written records. who wants to keep income of an NFP In Haiti, for example, as part of the evalua- that even the small on reporting "good tion, a sample of educators was acked to educator depends many training sessions complete the organization's couple rk-gis- numbers" (i.e., of acceptors). Motiva­ tration form, which asked for basic socio- held, high numbers is not confined economic, fertility, and family planning tion for fabricating results or to NFP organ­ data. In most cases, they were unable to do to developing countries world, this pro­ this, or could do so only with assistance. izations. In the developing Moreover, We should note that these educators are blem is just more accentuated. Haiti has led me to persons who are otherwise competent in my experience in organization produces their work. Their clients-mostly nonliter- believe that its NFP planning service ate couples-are well trained in NFP prin- the most reliable family At this particular ciples and practice. statistics in the country. of NFP intema­ Obviously, such educators cannot be ex- stage of the development have really accurate pected to collect extensive, accurate data tionally, it is critical to many couples on their client couples. The ability to fill data on each program. How with the NFP out forms is a learned skill that takes prac- are truly being reached of those couples tice and traii ing, a skill acquired early in message? How many NFP? Problems in industrialized nations but not in most reached are accepting

182 outreach and in attracting new acceptors be obtained by scientific sampling proce­ can be corrected only if the existence and dures. It is not absolutely necessary for parameters of those problems are known, each program to collect aggregate data on and they cannot be known if data are each and every one of its functions. Some fabricated, programs may find it impossible to collect To collect this essential data on new ac- data on every new acceptor, each new ac­ ceptors, one need ask only five questions: ceptor's demographic characteristics, name(s), address, age(s), parity, and date of every educator's workload, total discon­ inscription. One short simple form asking tinuation rates, total pregnancy rates, and only these questions could also have space other items. In this instance, it is preferable for the client's NFP history. Educators to collect quality data on a randomly could note on the form: the date of each selected number of cases (e.g., pregnancy training session that the client attends; the rates, total workload of educators, costs fact that the client has become autono- per client), than to assemble a large quan­ mous in NFP and the date on which this oc- tity of poor data. Again, better educated curs; or the date the client withdraws from personnel or personnel hired specifically instruction for any reason, including for this purpose would be expected to do pregnancy. As long as a client continues the bulk of this work. NFP instruction, subsequent months' data I am aware that many will object to these would be entered on the same form. suggestions because the NFP movement is Such a simplified form would retain all presently an "outsider" striving to gain ac­ the most important data and would also be ceptance, and its statistics, therefore, must suitable for those with limited formal edu- be of the highest possible quality. But I cation. Service statistics could easily be ex- believe that by limiting the data needs, tracted from such simplified forms by tailoring them to the ability levels of the more educated personnel. For exampie, personnel involved, and by using specially the number of new acceptors, each educa- trained personnel in some instances to col­ tor's monthly client caseload, continuation lect randomly sampled rather t-an aggre­ and discontinuation rates, reasons for diF- gate da,.., -,uality statistics can be obtained. continuation, and pregnancy rates could all What I have attempted with these sugges­ be tabulated from one such form. tions is to reconcile the tensions between My third suggestion is that data for any the needs for good data and the abilities of and all of these needs-service statistics, some oiganizations to provide these data. program evaluation, and accountability.-- Quantity is sacrificed for quality.

will be used for staff evaluation. Many ad­ ininistrators are aftaid of accountability be­ cause they fear that their mistakes will be found out. Evaluation should not be pre­ sented as a form of judgment. It is critical not to use records to penalize staff; such a In this discussion the major concerns of practice may motivate educators to falsify participants were the need and feasibility records. The use of in-service training for of evaluation, the process of evaluation, staff evaluation was recommended. including the nature and detail of evalua- Much attention was given to the content tion forms, and the roh, of the outside of an admission form. A list was made of consultant. both essential and desirable information to The process of evaluation itself may alter be obtained. It was agreed that both the the program being evaluated. There is woman and the man should provide the sometimes a fear that evaluation records following information; age, marital status,

183 number of births and n-umber of linvng chil- agencies underscored this. It is difficult to dren, time since last pregnancy, intention obtain funds without minimal statistics, to space or limit, breast-feeding status, pre- which are also important for credibility vious family pltnning use, name and ad- Good management also requires some dress (urbanlrur-a), education, occupation, dcgree of evaluation. and ethnic or religious gioup. NFP programs have not had input into The first eight items were considered the development of such survey question­ essential, the rest,optional. naires as the World Fertility Survey. Statis­ It was noted that the complexity of the tics are also needed to convince the form is related to the type of analysis to be medical profession of the value of NFP. undertaken. The use ot computers may not Pregnancy statistics are especially critical in always be appropiiate. It is necessary to the view of one participant. move gradually from limited to extensive To satisfy potential donors' need for data colleciton. From the beginning of a evaluation, one African participant sug­ program there is a need to build in the pos- gested that the donor agency provide an sibility of expansion. The evaluation proc- evaluator. This was not considered a good ess should be planned together with the idea by other participants. establishment of the program. Too many An Asian participant raised the question forms, however, may cause an obsession of the basic differences in motivation be­ with pieces of paper and the consequent tween funding agencies and their influence neglect of acceptor couples. on the forms chosen for evaluation. Inter­ A participant from Africa noted that national Catholic donors do not have the there can be resistance to filling out forms same motivation as international popula­ and questioned if there were a place in Afri- tion agencies. This difference was not seen can development programs for outside as necessarily crucial. Every kind of fund­ evaluators. It was recognized that forms ing agency needs basic statistics on used in Western countries may be inap- program performance. Moreover, basic propriate and that developing countries evaluation is a way to educate the trainers need simplified record-keeping. The to ask: "What am I doing? Is it worth­ simplification, however, should nt be so while?" There is a need to develop differ­ great as to render the forms useless. An- ent levels of forms. It is primarily a other African program directo.- has found question of degree. that forms, even sinp'. ones, take three or Bringing in an outside evaluator raises four sessions to complete. If too much in- the issue of the role of the consultant. Not formation is asked in one interview, the everyone in NFP understands the role of clients become suspicious. T'ere is also the consultant. The funding agency and the question of where to keep forms. The NFP personnel reed to work out an agree­ World Health Organization has provided ment about what the consultant will do. A funds to its collaborators for security filing potential problem is that local consultants cabinets. may be affiliated to the local multi-method A program director remarked that if tl family planning programs, which are often educator/teacher is to collect statistics, hostile to NFP. There is a need to build then he or she should receive appropriate bridges in the local community. An African training. People need to have an explana- remarked that people in developing coun­ tion of the purpose of evaluation forms. tries are accustomed to the idea of evalua­ The representative of an international tion but are not trained in proper NFP funding agency said it was important to evaluation. distinguish two kinds of data collection: How do you transfer the skills of the (1)data for service programs and (2) data consultant to the program so that the pro­ for research proiccts. Many participants gram becomes autonomous? Most agreed recognized that it is necessary to have that that is the ideal. The United Nations statistics to provide to potential funding has changed the emphasis from technical agencies. The representatives of the donor assistance to technical cooperation. So the

184 role of the consultant is first to provide problem. Postpartum amenorrhe.:4 can con­ technical skills, then to transfer technical tribute to NFP success rates. It k: possible expertise to the local program, and then to to calculate life-table rates with or without act as a broker. But too much must not be women with postpartum amenorrhea, but promised. it is necessary to state what was done in In NFP there is the particular dimension compiling the statistics. The longer the of accounting for the autonomous user. observation period, many believe, the Then there are also "secondary users," better NFP rates look. Once a couple be­ those not taught by a program but who homes autonomous they may contribute learned it from a trained NFP user. They many years of pregnancy-free experience are not always included in current surveys. to life-table analysis. Couples do make a transition to autonomy One participant expressed uneasiness from NFP programs. It is essential to follow with excluding early cycles (the learning autonomous users and obtain data on ex- plhase) in evaluation procedures. He be­ tended effectiveness, lieves also that all cycles without any pos­ The question of when to begin using sibility whatever of pregnancy should be months of couple experience for life-table left out of the exposure period. He also analysis received attention. It was sug- suggested that rates of intercourse per gested that couples be included when they cycle should be included. commence charting. In some countries The issue of quality versus quantity mea­ couples are not registered until they have sures was also addressed. Questions can be charted three cycles. Even if they are not asked about client satisfaction and client counted in official statistics, the relative knowledge. Couple communication fac­ proportion of early dropouts is a good indi- tots and religion have also been found to cator of acceptability. The important factor be important. is that published statistics should include Finally, there was the question of the information about when couples' experi- budget for evaluation. When too much of ence was counted. the funding goes for evaluation, the service A question was asked about including provided to the community can suffer. It is the postpartum amenorrhea period in use- important to clarify the percentage of the effectiveness statistics. This is, obviously, a budget for services versus evaluation.

185 Summary of Program Issues

As NFPprograms begin to expand and * To identify and maintain dev-op­ it, the to integrateinto largersystems of services ment priorities specific to NFP larger for couples and families, many issues sur- process of integration with Jaice. The key issue is how to increase the systems. of number andquality of NFt p1rogramsthat 0 To develop precise definitions intuitively are well funded and staffed u'ith compe- previously undefined and standards, tent and comident NFP teachers and a understood NFP program eval­ groaing staff of administrato,-s. Organi- training procedures for teachers, measures zations also need to consider the iypes of uation and quality control .rid NFP program et'olvirg, the effectiveness of the for both teacher training programs, and the long-term impact of services. agen­ NFP services on the local community and * To identify and define specific various the countrl, as a wvhole. To aclieve cost- cy relationships among the NFP effctive programsa majorchallenge is to organizations and the national with­ design delitery systems combining paid program, so that larger systems utilized and volunteer staff. Tbefol1owing recom- in a country can be properly mendations apply to those programs and monitored. which u'ant to expand. I is recognized * To establish regional and national human that some programswill choose to remain NFP resource centers so that to small and intensive, and technical resources, related the improvement and development the Program Development of better NFP services in both be The salient issue for many NFP programs public and private sector, can is the need to expand services and include available. NFP as an integral part of larger service * To develop leaders who are both systems to couples and families. opden and receptive to the philosophy To meet the challenge of expanding pro- of the grass roots, experiential, user­ the grams, change is required. Systematic plan- oriented NFP programs, and ning and redefinition of goals must be needs of the larger systernc involved. more than undertaken to achieve an orderly transition * To secure funding from a into the larger systems cf services such Ps ore source in order to establish Along the pastoral services of the Church, family firm base of financial support. life education, and health care delivery with this need is the recommenda­ systems, including family planning pro- tion to prepare a variety of budgets grams. and project activities. Critical to NFP programs in this process * To develop program administration of expansion is the setting of priorities, manuals, personnel policies, and job and NFP, as it has grown, has become iden- descriptions to insure upward tified in national programs with family life, lateral job mobility in NFP services. youth and parent education, health care 0 To develop a mechanism for contin­ systems, and the area of human values uing education for NFP teachers, related to sexuality, marriage, and family. program administrators, trainers/ larger Attention should be given to the following tutors and support staff within needs: systems of delivery. The NFP person­

186 nel will require a full orientation to miaYulg LJUUY aL tILt:HauIsutt ICve_, nJ .luuL-U the larger system of care in order to in this recommendation are requirements utilize more fully the resources of the for additional training in program ad­ system and realize better accessibility ministration, planning and budgeting. and quality of NFP services. When the larger system assumes leader­ Governments and other funding agen- ship in the national organization, ex­ cies can provide valuable assistance in the perienced NFP personnel must help to fomi of resources to improve quality NFP identify priorities of NFP. Perhaps, in the program development in both public and initial phases of integration, the priorities private programs. This could include fund- of NFP service delivery need to be overem­ ing for specialized resource personnel who phasized to achieve an acceptable level of could be helpful to all groups involved in attention in a new national structure. In in­ the delivery of NFP within the national stances where the NFP program has achiev­ program structure(s) in the country. ed national status, it must begin to work Assistance in the development of advertis- closely with other NFP programs within ing, informational films, program bro- the country sponsored by family life chures, lit.rature reviews and instructional organizations, health care systems in­ materials would be a valuable cc, tribution cluding family planning, and national pro­ to the standardization and quality of NFP grams concerned with education for youth services as programs expand. NFP exper- and families. tise would be required in the design and The national NFP program should approval of films, teaching materials and establish resource centers for other na­ other -pecialized NFP materials. At the tional organizations to learn about and same time, existing resources for training receive training in NFP. The private NFP in leadership and program administration programs have a role in refining and im­ could be utilized. National and regional proving the delivery techniques of NFP as workshops and seminars for both public well as studying the related areas of family and private NFP experts ci issues related life, conjugal life, anci education for youth to the delivery of NFP cou.d facilitate the and parents. The resource center could process of integration. become a focus for other agencies and The expansion of NFP programs will re- disciplines interested in the study and quire flexibility on the part of both the NFP development of NFP. program and the larger organization into which NFP will be integrated. Specific pro- NFP Service Department gram plans, objectives and goals must be The major issues related to the develop­ stated in measurable terms, so that the ac- ment of NFP service programs are how to complishment can be assessed. As the goals design acce,4ble programs to meet client and objectives are met and redefined, new needs and to provide competent NFP needs will surface. It is important that the teaching staff and sufficient follow-up in­ identity of NFP remain visible and not str iction to enable the learning couple to become lost in the many other priorities appl, the appropriate natural method and already established in the larger, existing begin to integrate periodic abstinence into system of pastoral, family or health care. their relationship. NFP programs have typically started with motivated, experienced, volunteer Design of Service Programs NFP programs teacher couples, who are concerned with which meet the requirements of learning the delivery of NFP within a volunteer net- couples and provide accessibility to both work As NFP programs integrate with initial method instruction and sufficient larger systems of delivery, the spirit and ex- follow-up instruction need to contain the perience of the teacher and service groups following: must be maintained. Experienced NFP * The capability to offer instruction in teachers and program administrators both the cervical mucus and sympto­ should have active roles in the decision- thermal methods of natural family

187 rates for pro­ planning, establish use-effectiveness Linkages to education for youth and gram evaluation. parents, premarriage instruction and Ongoing evaluation of the NFP service family life programs. program is important to determine if the * Regularly scheduled and accessible program is meeting its goals. It is also im­ instruction with teachers available portant that the program review these for follow-up, goals and objectives, at least annually, to " Accessibility by walking or by public delete obsolete objectives and set new transportation, to enable learning ones. This idea of setting goals implies couples to attend the classes. written or intuitively understood program * Continued recruitment and informa- standards. tion sessions for potential clients to build the volume of new clients necessary to maintain a regularly Staffing of Service Programs Several scheduled NFP service, criteria need to be considered in staffing an " Flexible and varied time schedules to NFP service program with competent meet the needs of working women, teachers. These include the following: women with families and children, a IThe use of NFP teachers only for and learning couples. It may be teaching. necessary in some countries and * A distinct NFP servicc staffed by cultures to plan programs that can be competent NFP teachers who can directed to the men and women provide an educational service. separately. * Training of volunteer, motivated, * Sufficient record systems for clients user couples to become information so that the instructor and program and education staff, so that a trained director can contact clients if they teacher does not have to do all NFP­ have not returned for follow-up, and related tasks in a service. can assess program results. * Training of motivated educators, preferably parents, who use natural and work as teachers in the The expansion of NFP services will re- methods system, to provide fertility quire a greater number of competent trained school information at appropriate NFP instructors, so that increasing numbers awareness in the schools. These in­ of learning couples can be given programs grade levels specialists would be a that are expanding with a mix of paid and formation recruiting new clients volunteer teachc couples and support staff valuable aid in men and women it will be necessary to increase the number for NFP, as young programs. of staff to insure proper teaching of a larger enter premarriage volunteer or paid numbers of couples. e Provision of either the NFP teacher in The experience of many NFP programs staff to assist record keeping, and indicates that teaching the fertility aware- registration, duties. ness component, that is, the signs and other administrative of financial and com­ symptoms of fertility, takes a relatively e Establishment or incentives, such as short period of time, i.e., one or two ses- munity awards sions. However, to teach the natural social and family events, trophies, and community methods to avoid pregnancy, it is neces- acknowledgment, for volunteer workers sary to help couples develop confidence in recognition program. identifying the fertile days of the cycle, ap- within a ply the appropriate method rules, and use The expansion of NFP into pubhc agen­ only the infertile times for intercourse. cy organizations, such as ministries of Couples usually begin to become comfort- health, raises the issue of design of the NFP able with periodic abstinence within six to service, since sometimes it would be eight cycles. Some programs will review situated in a service offering all family plan­ charts for at least a year or more to ning methods. The staffing and design of

188 such a service needs to be carefully con- viding NFP services to a target sidered in relationship to the duties to be population. performed. It is suggested that the staff of The need for other organizations, the NFP program develop this service as a just beginning NFP services within a distinct and different service from other multi-method organization, to family planning methods. receive funding for NFP services of­ NFP requires an educational service fered to those in the community that directed primarily to couples. It demands they serve. It must be noted that the initial instructional sessions, with small family planning agencies already group or individual follow-up instruction receiving international and govern­ available at varying times during the day ment funiding might receive priority and evening. It may be preferable for pro- for additional funding for NFP. This fessional staff to specialize in certain areas. type of inequity must be avoided to Teaching NFP requires a positive attitude respect the appropriate and fair -towards recognition of the fertile and infer- distribution of NFP services to all. tl4 days of the cycle, as well as support of The need to state core NFP program the client or couple's decision to use NFP. standards so that funding for NFP The staff could become easily distracted services can be distributed to those from developing an innovative educational programs providing high quality. All service if they had to switch from NFP to agencies should recognize the same provide other methods of family planning. core NFP program standards. How­ Rather the focus needs to be on building a ever, there may be differences in strong educational program based on presentation, depending on the knowledge of the fertile and infertile times overall orientation of the agency or of the cycle and helping couples become program offering the service. confident in their ability to use NFP and in- The need to respect cultural and tegrate abstinence into their lives. religious preferences of people and communities served when funding appropriations are made. Funding of Service Programs * The need for periodic program Expansion of NFP services requires in- evaluation before continued funding creased funding. There is a need to com- occurs. Each program offering NFP bine both full-time paid personnel and services should have stated goals and volunteer personnel, as the NFP program objectives, as well as specific plans of grows towards offering a regularly action. Periodic evaluation determin­ scheduled service to larger numbers of ing the effectiveness of the action clients. The majority of existing national plans is required. Continued funding NFP programs have evolved within the should be based on the ability of the Catholic family life environment and/or NFP service program to meet its secular organizations with a strong goals. Catholic frame of reference. Many of the existing NFP programs in the developing The Clientele Served in the CommuLnity countries have received funding from Various types of organr2i-tions may offer Catholic international and national NFP within a related family lift. service, organizations. rather than a health care or family planning As these existing programs become facility. NFP service programs shouid iden­ more secularized and/or integrated within tify and define the target population within broader systems of services to families, the the community. This is very important in issue of equity of funding from interna- the total orientation and design of the NFP tional agencies becomes paramount. Equi- service program. Educational services are ty in funding implies the following: defined by the combination of the task to * The need for the agency which offers ' be learned and the orientation and needs of NFP only, to receive funding for pro- the learner. In defining the target popula­

189 tion of a NFP program, questions raised in- development from the beginning of the in­ clude: tegration process. " Do the couples come from a variety of socioeconomic and educational NFP Trainerand Teacher Programs levels? There are two central issues related to " Are couples attending the program the development of core national NFP primarily because of a religious value teacher training program standards. First, system or a concern for their health? consensus needs to be developed by the " Are the couples young and still in- national NFP organizations and hiational terested in having a family, or are agencies in which the NFP tstruction is to th.y older couples who do not want be integrated, concerning the overall aims additional children at this time? and specific objectives of the content for " Are the couples unable to read or NFP teacher training. The Family Fertility write? Education Resource Package, prepared by " Do the couples and women live in the World Health Organization, offers a urban areas with relatively easy ac- comprehensive training kit for preparing cess to the instructional service, or NFP teachers and users. Teaching sugges­ do the couples live in rural areas tions, content and visual aids are included where they have to travel long for teaching fertility awareness, sexuality distances for instruction and chart and responsibility, the cervical mucus reviews? method, and the sympto-thermal method. " Are the couples seeking to achieve In addition, there are suggestions for pregnancy or to avoid pregnancy? teaching/learning activities. This kit is recommended as a resource to the existing It is important to realize that, even national training program. Some countries within the same program or organization, that do not have a national training pro­ NFP instruction may require different gram may want to use it after adapting it to types of approach because of the charac- the culture and local language. teristics of those who come to ihe service. The NFP teacher training program in­ When many programs of NFP instruction cludes formal instruction and supervised coexist in a community, it is important to teacher experience. It is usually necessary understand that there will be variations in to have teacher training programs with for­ the teaching approach based upon the mal content of about 7 to 10 days, to pre­ needs of the clientele served and the types sent the essential factors of NFP, some of methods taught. teaching techniques and discussion of at­ Designing an NFP instructional service is titudes and counseling techniques used in different in nature from setting up a clinic support of couples who use the methods. service in which the client is seen once or The supervised practicum varies from twice for a medical evaluation. It is essen- four to six months and depends upon the tial that the staff of the NFP instructional number of available NFP clients in the ser­ service be competent and confident in vice. It is recommended that a new NFP th-ir abilities to teach and follow client teacher trainee teach and prov.Je follow­ couples in the use of NFP. This implies up to at least 10 coupl"" prc .ably in a both a central and extension approach of variety of categories. F -. Anple, it is im­ service accessibility, a distinct effort to portant that NFP teachers learn how to utilize motivated, competent NFP instruc- teach women in special circumstances tors, who do not havc other conflicting job such as breaxt-feeding and couples wishing assignments, as weli as an effort to mix to achieve pregnancy both paid professional and paraprofes- In some 'ountries, providing couples sional persons in th:: delivery of the NFP with informion on breast-feeding, nutri­ service. As NFP educational services tion, and oral re-hyaration for child care become part of a larger system of delivery, can I-.important areas for NFP teacher it is essential to focus on their proper training. This information can be given to

190 couples interested in learning NFP training must be explicit about those signs methods. of fertility that are reliable for certain NFP teachers need to attend continuing phases of the gynecological and repro'duc­ education workshops in order to maintain tive situation of the woman. NFP teachers current teaching skills. Often NFP teachers need to complete a course in the formal have been trained, but then either do not content of NFP with a supervised prac­ practice their teaching skills or do not keep ticum by an experienced NFP teacher dur­ up with current developments. The loca- ing which they teach a certain number of tion for the NFP teacher training piogram couples and follow them. It is recommend­ becomes a key point for recruitment, ed that an isolated teacher without follow-up, and supervision of the teacher recourse to supervision is not desirable, trainees for extended lengths of time. and that most teachers prepared in this Some of the issues to be considered in fashion do not function later as NFP selecting the place include: teachers, because of a lack of confidence in " Convenience for NFP teacher the ability to teach. trainees. Objective evaluation is needed of both * Ability of the NFP tr;,inees to obtain the formal course content and the super­ clinical teaching opportunities with vised teaching experience. This includes supervision by an experienced (a) competency tests related to the objec­ teacher, tive knowledge of the formal instruction, " Convenience of frequent (at least and (b) personal evaluation by the clinic monthly) meetings with the training supervisor of the new teacher's ability to faculty for the new trainees to provide initial and follow-up instruction discuss problems and teaching ap- and to work within the agency offering the proaches and to profit from group NFP service. discussion and additional chart re- It is important that the NFP teacher have view of clients, confidence in NFP. It is preferred that NFP * Convenience for national, multi- teachers use one of the methods them­ disciplinary faculty to be formed and selves. The issue of competence to teach to provide the NFP instructors with NFP correctly and confidently is impor­ training nat addresses the varied tant. It is less costly to recruit NFP teacher fields related to NFP and family life. candidates from a group of persons already Examples of such faculty include using one of the NFP methods. NFP physicians, maternal and infant-care teachers should be enthusiastic, confident, nursing specialists, psychologists, and knowledgeable about NFP in the larger educators, priests and family life system of service in which NFP is being in­ counselors. National experts in these troduced. respectiv fields can be recruited and Commitment on the part of the trainee encouraged to become active in the and the hiring agency are desirable. The NFP faculty team. Experienced NFP new trainee should be committed for a teacher: within the country shoulo period of time (two years) to provide a be utilized as N,,' faculty as well as teaching service in the agency. If the trained to be clinical supervisors dur- trainee works in a national ministry of ing the follow-ur instruction for the health and is subject to transfer, their NFP teacher trainees, teaching skills should be transferable to a new job assignment, whenever possible. NFP Teacher T'-hfiig Commitment on the part of the agency The needs of '>-c learning couple direct employing the NFP teacher implies that the the service orienta k,:n of the agency offer- trainee has attitudes and personality ing natural family planning. This require- characteristics that are supportive to the ment determines the design of programs agency in which he/she will be employed. for teacher training. NF O teachers need to It also implies a commitment on the part of be trained to provide all NFP methods. The the employer to utilize the skills of the new

191 NFP teacher. * The faculty agree on materials, goals The attitude of the NFP teacher trainees and objectives they wish to use to should be conducive to a teaching/learning add to the core NFP teacher training situation. This means they are open to new program. For example, additional situations and accept couples and clients materials related to infant care, nutri­ with a nonjudgmental attitude. It is dif- tion, and re-hydration may be vital ficult to assess this latter quality, but it is for some national programs. Still desirable that the agency recr.it in- others may be interested in further­ dividuaLs with open a.,titudes. .To be a ing particular programs related to teacher implies being open to lemning family life and education for youth more about the field(s) in which one is which support the values of the fami­ teaching and an ability to transmit this in- iy in that country and culture. formation to othets. * The faculty initially include some of International NFP experts are a primary the site supervisors who will be resurce for the national program. They supervising the new NFP teachers in should be utilized as consultants to the ex- their initial teaching experience. The isting faculty and leadership, especially in site supervisors should be skilled in those countries that do not have faculty for teaching techniques particularly training NFP teachers. Arrangements with related to teaching NFP and helping international NFP training consultants couples become autonomous in the should be made so that eventually the practice of NFP. country will be relatively autonomous in Regional NFP teacher training work­ its ability to train NFP teachers. shops have to be carefully planned to in­ Preparation of national faculty, tutors, or clude sufficient national representation so trainers (these terms are used synonymous- that appropriate follow-up of new NFP ly) becomes a third key issue in the con- teachers could occur within the country at sideration of developing national NFP supervised locations. The issue of defining teacher training programs. Some of the tutor or trainer preparation workshops to following points are relevant for considera- facilitate NFP teacher training needs fur­ tion of national faculty for NFP teacher ther definition at this time. training programs: * The faculty include expertise in a variety of topic areas, including Evaluation reproductive biology and physi- Program evaluation for NFP programs ology, the current natural methods, involves severaJ dimensions which include specific teaching experience in the both local and national evaluation program cervical mucus and sympto-thermal standards. The primary issue in program methods, instructional experience evaluation is to establish a monitoring and small group discussion techni- system that gives timely data to the pro­ ques. in addition, experts in family gram administrator and staff to check life educational programs and health routine operation of the service system and services are useful in providing progress toward the goals of the program. enrichment to the basic training pro- Based on the data, the program operations gram for NFP teachers. can be adjusted or the goals amended. Ad­ * The core faculty be chosen for their ditionally the evaluation data can be used skill in teaching or training teachers to set new goals and contribute to in NFP. knowledge about how to deliver NFP ser­ * The faculty be trained on a continu- vices more effectively. ing education basis on how to use the National evaluation looks at the entire Family Fertility Education Resource program while local evaluation examines a Package. Expertise should also be small part of it. However, the same data sought in management and evalua- collection system can be used for both. tion. This monitoring system should be design­

192 ed with care. Standardized definitions and monitoring processes for describing systems invite interprogram comparisons the information collected and used at and exchanges wlch may lead to im- the local program level at simila. provements. intervals. The following are some of the data needs e An external person who can assist in for NFP program evaluation: analyzing the overall information * Number of couples or individuals regarding the problem areas related served. to national NFP program expansion. * Regions or districts of the commur'i 0 Persons trained specifically in data ty served, recording systems, (including the use " Number of couples still using NFP of computers) to analyze the data and after a specified time period, prepare regular reports. " Number of clients who discontinue Analysis of national and individual pro­ NFP. grams should begin with formally stated " Reasons for discontinuation, and implemented NFP program standards. " Characteristics of clients, e.g., age, The evaluation should be able tt, measure parity, education, religion, urban/ the accomplishments attained by those rural, ethnic group. programs. When the goals have been " Number of unplanned pregnancies. achieved, NFP program development then " Information on cost effectiveness, focuses on other areas that need to be ad­ * Number of planned pregnancies that dressed by both local and national result when couples come to the ser- programs. vice to learn how to achieve pregnancy. Process and Outcome Evaluation should * Time it takes to assist couples to be conducted together for the process may reach a stage of autonomy in correct- have to be modified if the service output is ly using NFP. deficient. Process evaluation is directed " Number of information sessions towards improvement of progran opera­ given to related agencies or groups tions. Outcome evaluation measures the ef­ who may serve as a source for fectiveness of the program among users of recruitment of NFP clients, services. Each program should be conduc­ * Amount of time spent on preparation ting these kinds of evaluations on a conti­ of news releases or radio and televi- nuing basis in order to serve their clients sion scripts and the approximate and their communities more efficiently. numbers of persons reached through such media campaigns. Impact Evaluation refers to the long-term * Number of information sessions results of an NFP program. Some of the given to potential clients, and the ac- critieria used to determine the overall im­ tual number of new couples that pact of an NFP program would include tOce enter the program. following: " Amount of time and content for e An increase in the number of supervised instruction or for on-the- organizations showing interest and job training that a supervisor pro- cooperation in the development or vides for the NFP teachers. expansion of NFP efforts. * Amount of time it takes to train NFP a Improved attitudes and knowledge information specialist/promoters, of NFP methods both on the part of To evaluate national programs these data the clientele, health professionals, arc necessary but may not be sufficient. Na- government, the press, and other tional program evaluation implies the same community service groups. kind of effort, but is more complex and * A levelling or a reduction in the usually also involves the following: number of unplanned pregnancies or * A network of program directors in the birth rate, if this is the desire of using the same reporting forms and the program and country providing

193 with groups of clients at­ the service. may be realized This type of impact evaluation is more tending one instruction rather than in­ difficult to obtain in an educational service. dividual instruction. Many other kinds of impact can also be Program administrators should survey with a measured, for example, the number of the autonomous clients periodically mothers or satisfied users who later in- simple questionnaire or interview schedule struct their children or friends in NFP and to determine if they are still using the fertility awareness. Some programs feel method. Once a coup!e becomes autono­ con­ that although NFP does not have as high a moLs in the use of NFP, they may ex­ use-effectiveness rate as some of the "ar- tribute many years of pregnancy-free tificial" methods, over time it may be a bet- perience to the life-table analysis. ter method of family planning because it Couples may decide to have another this meets the cultural needs of the people serv- baby while using NFP methods. At ed and thereby can have an effective long- point they would not be using the method is born term impact. More research is needed on to avoid pregnancy. After the child this issue. and the couple returns to the use of NFP, The strategies used to achieve a pro- they would again be entered into the long­ would gram's goals will also determine to some term statistical analysis process and extent the nature of a program's impact. again contribute to continuing use-effec­ Periodic prograni evaluation should cx- tivcness information. amine the impact of these strategies on the communities served and, if necessary, Conclusion the change the strategies for achieving pro- This monograph clearly demonstrates last 20 gram goals. progress in the NFP field in the ycars. In many countries, with the assis­ special Cost-Effectiveness Evaluation refers to the tance of NFP consultants and pro­ ratio of the actual cost of providing a family development projects, s.,ccessful NFP planning service to the number of clients gramns have been developed. An increasing opezat­ served or the number of continuing users. number of NFP teachers, generally in Most N1P progranis have high start-up ing in avolunteer capacity, have resulted Govern­ costs which often diminish as increasing a national leadership in NFP. and numbers of clients arc served over time. ments, international funding agencies, The longer a couple uses NFP successfully, private organizations have shown greater the less the cost to both program and interest in including natural fanily plan­ client. ning among the family planning choices In family planning cost-effectivenecs offered. Both public and private organiza­ studies, one approach is to relate program tions concerned with health care and fami­ costs to the number of couple-years of pro- lv life have become involved in the serious tection (CYP). CYP is the number of years delivery of NFP information and education that a couple uses the method and does -ot services. We hope this book will be a have an unplanned pregnancy. These types catalyst in the process of expanding NFP of studies arc just beginning to be under- services and integrating them into the taken in NFP programs and few results are larger network of services to couples and available. A more cost-effective service families.

194 Appendix

195 English speaking. Founded 1979. Address: 29 Howe Street, P.O. Box 129, Freetown, Sierra Leone. Tel. 22371.

South Africa (Republic of) National Natural Family Planning Association. English speaking. In developing the list of NFP centers and Founded 1979. Address: Khanya House, P.O. Box 941, Pretoria 0001, South Africa. resource materials for this Appendix, we Tel. 3-6458/9. were guided by the existing network of were guiem and their activities; there- Tanzania Family Life Education and NFP. Service of IFFLP members athe Tanzanian Episcopal Conference. English fore, we recognize that the lists presented speaking (and Swahili). Founded 1976. Ad­ Dar-es-Salaam, Tan­ not comprehensive or complete. dress: P.O. Box 2133, are zania. Tel. 30071/2.

Tunisia Action Familiale. French and Arabic speak­ 27 Rue Les LIST OF NFP CENTERS ing. Founded 1981. Address: Mimosas, 2070 La Marsa, Tunis, Tunisia.

AFRICA Upper Volta Entr'Aide Familiale. French speaking. Burundi Action Familiale du Burundi C.E.D.-Caritas. Founded 1977. Address: B.P. 481, Bobo French-speaking and Kirundi. Founded 1979. Doulasso, Upper Volta. Address: F.P. 2110 Bujumbura, Burundi. Tel. 4055. Zambia Family Life Movement. English speaking. Founded 1977. Address: '.O. Box 31965, Central African Re )ublic Service d'Education a la Lusaka, Zambia. Tel. 212070. Mai.rise de la F'cundite. French speaking. Founded 1982. Address: Dispensaire du Foyer de CharitY, B.P. 335, BANQUI, RCA. THE AMERICAS Tel. 61-11-05. Argentin Secretariado para la Familia. Spanish Congo Foyers Chrtiens. French speaking. Founded * speaking. Founded 1981. Address: Paseo 196( lFirst General Assembly, 1970). Address: Col6n 221 (PB), 1399 Capital Federal Buenos P.O. Box 200, Brazzaville, Republic of Congo. Aires, Argentina. Tel. (0I)-33-3701. Tel. 81-2285. Bolivia Centro de Vida Familiar Arquidiocesano. Kenya Family Life Counseling Association. English -Spanish speaking. Founded 1978. Address: speaking and tribal languages. Founded 1977. Avenida Armentia 512, Casilla 8596, La Paz, Address: Mater Misericordiae Hospital, P.O. Bolivia. Tel. 36-40-57. Box 30325, Nairobi, Kenya. Tel. 5566. Brazil Centro de Pastoral Familiar (CENPAFAM). Madagascar Fivondrovan'ny Tokantrano Kristiania * Portuguese and Spanish speaking. Founded (FTK) Family Life Promotion Movement. 1974. Address: Alameda Franca 889, 01422, French speaking and Malagasy. Founded Sao Paulo, S.P., Brazil. Tel. 28-28-015. 1974. Address: Immeuble Falda, Antanimena, B.P. 1382, 101-Antanarivo, M4adagascar. Canada Serena. English and French speaking. *" Founded 1955. Address: 55 Parkdale, Ottawa, Tel. 26084. Ontario KIYIE5, Canada. Tel. (603) 728-6536. and English Familiale. French Matritius L'Action *t speaking. Founded 1963. Address: Route Chile Comisi6n Nacional de Pastoral Familiar. Span­ Royale, Rose 1-ill, Mauritius. Tel. 43512. * ish speaking. Founded 1981. Address: Ch, Hamilton 11051, Santiago, Chile. Tel. 80280. Span­ Morocco IHeure Joycuse. French speaking (Ara- Universidad Cat6lica (Medical School). hia). Founded 1955. Address: Roe ElJraoui, ish speaking. Founded 1979. Address: Casilla Casablanca, Moro,-. Tel. 2,4-40-37. 144-D, Santiago (Attn: Alfredo Prez), Chile. Tel. 99-58-71/48-76-42. Catholic Secretariat of Nigeria. English speaking. Address: Force Road, 1P.0. Box 95 1, Laospeakige.Adre: Fe . BColombia Carvajal Foundation. Spanish speaking. 46, Lagos, Nigeria. Tel. 25339. t Founded 1962. Address: Apartado Aereo Cali, Colombia. Tel. 52-11-29. Rwanda Action Familiale du Rwanda (Centro Medi- co-Social Gikondo). French speaking (local Centro de Pastoral Familiar para America language). Founded 1978. Address: Boite * Latina. Spanish speaking. Founded 1974. Ad­ Postale 442, Kigali, Rwanda. Tel. 4535. dress: Calle 65 No. 13-50, Mezzanine, Bogota, Colombia. Tel. 211-3217. Seychelles Action "amiliale Seychelles. French and English speaking. Founded 1970. Address: Dominican Republic Comision Episcopal de Pas­ P.O. Box 289, Mont Fleuri, Seychelles. toral Familiar. Spanish speaking. Founded (no Tel. 227819. date available). Address: Apartado Postal 186,

196 Santo Domingo, Dominican Republic. Tel. ASIA/OCEANIA 685-9741.

Ecuador Instituto Ecuatoriano de Accion Familiar (IEDAF). Spanish speaking. Founded 1976. Australia Australian Council of NFP, Inc. Founded Address: Esmeraldas 2811 y Calicuchima, *. 1975 (antecedents to 1953). English speaking. Guayaquil, Ecuador. Address: 1 Robert Street, Willoughby NSW Tel. 028-417-55. (and 2068, Australia. d'Haiti. French speaking Haiti Action Familiale Method Research and Reference Creole). Founded 1971. Address: Rue des * Ovulation of Au:;tralia. English speaking. Casernes No. 65, B.P. 528 (Archcvech6), Port- Centre 1976. Address: 27 Alexandra Parade, au-Prince, Haiti. Tel. 2-3459/2-5181. Founded Fitzroy North 3068, Victoria, Australia. Tel. 03-481.1722. Billings de Planificacion Mexico Centro Nacional *t Natural de la Familia (WOOMB/Mexico). Ilong Kong Catholic Marriage Advisory Council. Spanish speaking. Foundcd 1979. Address: "*'t English speaking (and Chinese). Founded Ave. Paseo Palnas 745-12, Col. Lomas de 1965. Address: 502 Caritas House, 2-8, Caine Chapultcpec, I11000 Mexico City DF, Mexico. Road, Hong Kong. Tel. 9-242-071 Tel. (5) 540-2470. (ext. 259-260).

India Center for Research, Education, Service and U.S.A. Human Life Center. English spe,king. * Training for Family Life Promotion (CREST). T-Founded 1973. Address: Saint John's IJnivcr- English speaking. Founded 1975. Address: 24 sity, Collegeville, Minn. 56321 U.S.:i. Tel. High Street, Bangalore, 560005, India. (612) 363-3313. Natural Family Planning Association of India. The Couple to Couple League Intrnational, English speaking. Founded 1974. Address: 43 *t Inc. English speaking. Founded 1971. Estate, New Delhi. 110003, India. 3614 Glenmorc Avenue, Cincinnati, Lodi Address: Tel. 622-379. Ohio 45211 U.S.A. Tel. (513)661-7612. FTamil Nadu Family Development Centre. Family Planning Inc. * :.nglish speaking (and Ilindi). Founded 1976. New England Natural Nagar, nglish speaking. Founded 0981. Address: ))l Address: 37 Allithusai Road, Aruna Itidia. Cushing Ave., Boston, MA12125 U.S.A. Tel. Post Box 7,2, PutlUr, Tituchirapalli, 6 (617) -,36-8 01) (ext. 311). Tel. 25035. Natural Family PIatnning of Rhode Island, Catholic Social Services. English speaking. Indonesia National Bureau of NFP Services. English Founded (no0 datC availah!c'. Address: 433 speaking. Founded 1970. Address: .Jahan Elmwood Ave., Providence, RI 12907 U.S.A. Ciding Timur 71, jakarta Pusat, Indonesia. Tel. (4011) -167-7200. Tel. (121) 46710. Developnwnt Program for NFP. napanT Diocesan Life Assci7tion. English speakig speaking. Founded 1980. Address: 'lie Family English 1976. ddressI: Yuwa D.C. (BuldJnans ). Found d Tokyo 105, Suite 334, 15112000 K (20)St. U..A.Tel N.W., 77-139.Building, Washington, Shiba 3--i10 Mil ato-ku, 21)0(1 U.S.A. Tel. (2)2) 737-1339. Japan. Tel. (03) -t54-7010/452-5734. Los Angeles Regional Family Planning Coun­ * cil. English speaking. Founded (no date avail- Korea (South) Korea Happy Family Movement Fng­ able). Address: 3250 Wilshire Blvd., Suite * lish speaking (and Korc,,n). Founded 1975. .k20. los Angt'le, CA 0001(0 [.SA Tel. Address: Catholic Medical College, 51)5, (213) 386-561-i. Banpo-dong, Kangnam-ktu, Seoul, Korea. Tel. 593-5141-9. Family ol the Americas Foundation, Inc. *t English spc:tking. Founded 1977 (formerly 1 Natural Fatmily Planning Associa­ WOOMB-t SA, name change 1982). Address: lala.s._i Natitonal 7 of Malaysi;a. Fnglish speaking (and South Tvler Street. Covington, LA 0433 tion 31)8 1983 (previous activities (50-i) 89'2--ii, Malay). Founded U.S.A. Tel. from 1973). Address: 23-F, Mk. 13, Ayen 1am, I anily Life Missitn for North America. Eng- Pcna tig, Malaysia. Tel. 88-1-714. itsh speaking. Founded 1983. Address: 704 1ll Ave. South, Minneapolis, NIN 59415 New Zealand New Zealand Association of Natural U.S.A. *I Family Planning. English speaiking. Founded Nlater lospital, Auckland 3, Creighton University Natural Family Planning 1975. Address: Tel. 689-919. Education and Research Center. English New Zealand. speaking. Foutnded 1978. Address: 601 North Family Life Office. English speak- 3011th Street. Omnala, Nebraska 68131 U.S.A. Pakistan Natural P.O. Box 304, Tel. (402) 449-4715. ing. Founded 1977. Address: Faisalabad, Pakistan.

Catholic Family Life Venezuela Avemo Billings. Spanish speaking. Papua New Guinea National Founded 1974. Ad- Founded 1980). Address: Apartado 70505, Office. English speaking. S92, Goroka, E.i.P., Papua Prados del Este, Caracas, Venezuela. Tel. dress: 1p.o. Box 34i-73-76. New Guinea.

197 Taiwan Catholic lappy Family Service Association. Towarmystiv,o 0powick Rodricielstiva. Eng­ * Eng~lish spcaking (and Chinesc). Founded lish and Polish speakg;,.g. Founded (date not 197h. Address;: 9th fioor, No. 2, ( hitngshan availalble). Address: al Powstacicow Trrans. N. Rd., Sect. 1, Taipei, Taiwan Ill.t. N2S, Warsaw, Poland. Tel 33 1 193. Portugal Movinicn to ie I)fensa da VidaL. Portt;­ - Thailand National Commission for Family Lifc Pro- guese speaking. Founded It) Address: Rul motn ition. Fnglish spcaking. Founded 1 177. Ad- dc lcneficancia - , 10(0 Lisbon, lPortug;ll. dress: 2 Soi Soclsuk, Prachaisongkroh Rd., Tel. 73- -35. langkok 10310 [I'haila:nd. Tel. 277-3354. Servicio de Ent rcaijuda :s 1)Ocimeintaeao Conjugal (SIM)C). Spanish speaking. Ftinded 1905. Address: Rut; R:quel Roque(Ganicro 2-5'E, 15(00 lislon. Portugal. Tel. 78-31-(01. EUROPE Scotland Scottish Associationt o r Naitural Family Austria Narri:tge Advisory Service. English speaking. Planning. English speaking. Founded I 19'9. . Foundcd 1951. Address: Vorstadt 6, A-48-io Address: Cntcster h0IotSc, Ilcirdsden, Vocchlabrtick Austria. Tel. 076/72/336-i. Glasgow, Scot land. lgaiciton Le IlaFIlIAl. Spainish England Catholic sliMairri:ige Advisory Council. Fng­ lIspantla Address: Aparlado t lish spcaking. Founded 19-lo. Address: I' speakig. Founded1e I aI rct'8. ehnA, Spain. d ., Ito d o n \ 113 ,I,IT.K . de Co rr eo 2. , L tnsd'o ..nc R-it. Tel. 0 1-727-01

The National Association of Natt ral Familv Sweden Faniljcframjandet. English and Swedish Planniitg Teachers. English speaking, speaking. Founded 19-0. Address: lPost Office FouMdedl 19)72. Address: NFI' Centre, itir- lBoIx 31(' 5-S-161 03 Iromuna, SWICdn. mingham Maternity Ilo,:pital, Iirmingham Tel. 1)8-373395. B1l5, tI.K. Tel. 0121-.172-137-. * 17,enotcs major NFi centers. Franwc Centre (Ie Liaison ies l-Atipt-s Li Recherche Denotes centers which may provide lists of t (CLFR). French speaking. Founded I 902. t ml Address: 05 lltilevard CieCIchy, 7'5009 materials and price lists upon request. Tel. 8--L-8---l). Paris, France.

Itnstitute Rccherchc stir I'Fnfant ct laCouple SELECTION OF BOOKS (IREC). French speaking. :ounded 1973. Ad- AND PAMPHLETS dress: 10 Place Notlre Dame, .;(8) Grenoblc, France. Tel. ("() -- 10.1- -1. GENERAL: Germany Fanily life Mission. English speaking. * Fo tlCd 19'3. Address: Pltfacl 1)65, Billilgs, Evelyn I.., 7he Biillings lhethiod. Anne I)-76-i( KcliI/Rhecir, Gcrmnsi . Tel. ())tlovanl Pry. ltd. llichlond, Victoria, 0-78-51-7-83-31. At tralia, 198010Randton( Ilotise,NV, 1981).

Ireland Cathiolic \arri:gc Advisory CtLnnCil of Ire- ltr:d", Peter, In! nduct ion to Vatti-al Famill'lMan­ * t land. E+ngilish speaking. :tiun1ded 19-10 (1975 fling (inl Chinese). 5(12 Caritas thuse. 2-8 Ireland). Address: All Ilallows Ct[ltege, l)tili(n ::aitlt ld., IIig Ki il1. 9, Ireland. Tc,. 3756i'9/3 -1151. lradv, Peter, LovIe aind Li'(in Chinese), 5102 Carntas Itah Centro Intcrnizioin:ile Studi ::Ilnligli: (CISF). Ilotse. 2-8 Cai ne Road, I ling Kting. t Italian sptakiig (ant Eiigli'n). Founded 1973. Address: Via Nonte RIosa 21, 201i9 Milanti, Cannata, Mari.a A., and Elduartli Ztmizarreta. llani­ 1 Italy. T,1. -9.82.9-1l. /cacitn Iamili-. 1'diitis0IAulinits,1 Nazca I-t)19Iuenos Aires, Argentina, 1980. Centro Anirisiano Metodi N-ituraii. Italian i2-9, oes, speaking.(Crev iaganFoundedi 15, Vin1982.ircam tc,Address: M ilki tVia, ltBice ',il\. (Car nmo G lspar,ra M al (it), and A rio n M ane lneG im Tel9002/ S99 Antor Co tttal,liito iaCitildc Nova',i R Tel. (02/8599';56. CCl. Pauniio Carlos 29, Sto Panillo 11(i}S1, Center of Sttidy :tnd Rcscarch in NF I, (Ini- Brazil, 1982. * vcrsita Catolica tlei 5, Ctir'e, F.toltt ti'Mcdi­ cinraChiirrgia. Fingliili speaking. AlLdrtss: The Cat hilcIispital Assioci:ati i illndia, attti-al Roma Policlitico ''A. Gcmelli," Largo Agos- IPl/rito, Iacht ml. I'vPlinning fill Entiglish atid tino Gcemlli 8, 0(01068, Rome, hlly, four Indian laiiguages). C.l.C.I. Centre, Tel. (10) 331051. Ashok Place, New Delhi 1 100ll, India.

Poland Khub Intcligencii Katolili cj.English :tnd The Catllic I lspital Associittin of Ihndia,Vapttal Polish speaking. FtuiidCd 19.5. Address: ul I-am/It,lanotlingl' (ill :nglish aid fitur Inldian Kopcrnika 3-i, 00-336 \X'arsza'.vs, Poland. languages), C.B.C.I. Centre, Ashok ilace, New Tel. 27-39-39. Delhi 1Il00lI, India.

198 CAilha it Mairriage ,N(i'ir%d (uinnril i)t Ircln, Eiull- ,'i'i'Shla K., I11L'i.stlti'((g1L mid3 Neifurtd .1( ca/lintl jor ASo',ttthf MilI [phiiws IL'gC, Sltu.ia,. K f'; 8.6it:i East~ M\IMICtt Duin~i 1), lrt'iandl. al-li ls, SAlina, Kans' (-.iOl U.S.A., 190(9.

Centro Iicnmii n iStii P Fiiladlna3 1Z33/13 a't NI1i.lill i, Ia hil'l/,i,,u /)I- //u' .1Iluc(/u'r­ .IM'hli \Atitlla/j, \Via Nmintu Ria .21,. 201.0 tui( *IiI/n/, ( :honlit \l~irriaigc Adlvisory Milani . Iny. Cucl((INI A() NRII SCrLV t 15 Ilnsticn

(;IM1n1n lug, L.. IIt C' 111C, Whit /;lp'lrI-O' S/u Iuid Knw AIbout Natural Itpl/i') M'almil8 ;Iarsltihl. Iihthe liii'lulr/ie lirt .1. (at).hlit Mr. Clitnil Inlfiiiti in lanuplilt. 211) -StAW R.' L Ii. iAgt' ,NdS0Vir' iiithill C1(. NIl' "cricc.

CluIb]), Fliziil ,. Awttppttl l-aiudj PI'/11,1,i. ( rac', NIt'tI i ANI IR,!,WIN[. I I I Ih rcI I)11\l~ I hiiAi', Nit I .it l~w. I. , aidt MNI Mairl n, 'rtlitI' A iu-au'ai' 2201 Nc%\ Ii :td',n~ R I llLht-lmNslurtl FS'.'A, '11. I 'Itt lilt hiilalihiiip mnid Ili Naural CMN2 9)81, I K.. I 1)8 (apit. '.idcl pmi33 li. Panilv I lnninlg PtC'tluill (nIi AnitritA.

Fijailkiiw'ki, \\Ii~l/iinir'rt't Z1/3'i1YtRY/tiip \\'mWahigmn, D.C. 20iS 1'.,, . I191). ll1( 4 ef /i'3't,'ilq/l I ioiuki/u. '131W . M(C John I.IuIh. NIA . M~a.an I Mi.( 1,ilttIClltii)1n1 Z4.1.0\'i1 1it x LUkfs l juli. W:irsi) cx.. SI-11'.:rtuu- IiTh al .1i d ,T/ II' li 1 Poildit. 19113). lI'c I'iill un anI I it Natutrail Faikl Plan­

PtI:uIL;C:IT NIxatiitinui llriANsiltr tdC Alf*.ht'liZAt-TI0. ning FCtk'Alol ) I Amt'rit-;i, \\asIigt In. AI111f1'ltuiuu1( ~ u'nl t'idlpI- Sam/u't. I, -Amin. R1I( dt' lhiiiru . llrzil. 198 NiIHugh. JAint'S AI i/ui'u~ugl(l /'u'r /u3iH' (ll IntttlataiR \I(,\'imutnlu u rasiltiri tltdc Nihctizatai 3, NValuaut u/vIIIilu4 ) t~a ct .1/31allI (3 et 160l< L' inmciri, opcn Ilrogr~iml - NIT,. I i I I K St rccz, .W

t/e .Na/sselii'.N N,linun /-~u,,z///a/. Edtltiis ixailahlc fronm Ow' r:i,.iliait ( ailic ultCumnfcr- XAOCi .Nl1)iLI-Ns, 1 1, l4nt Sitnt'-1IIWnt' IvN.11 MtCC, COltlit' Oai33k fo rmna(, Bmrzil.

Nimminl C athoilit Fantil'' Li ,c (A)Iitc, /'aimudt' M'an­ n in t a it ..Nlr ia A , Ih/u3313 (it,3/ Mall it(acinl *'iuLg (I .Neltur d W I'.PAY IBox 592, (ri i ka, Failiarni. FI-tc itt-cs llanlinas, S N.. Avenidla EP .'., I'aipua NCA.v iica. TIaiiiit'; I1n92 \lcxit-(i 21, [).., NICXIO), I1982, P&Lrt'. Santchez, A! ICtLiI (CtlI. Pi'auif/n 1/3 NaItUral tit, Ili la,,.d/- lictiu/i de Billings. CENIA­

/i3'diumn 33/ ti/anm A'unuuIodiu ,ti, RH i 1: Chile,~ I )cpt . I )st it ri 'aI V (i im i 1gial,lO K rit'gt-'. Hulnt ingtoin. Ni'xx- Y irk. 1l.S A., I]9-2 FSCIJcla tIC Nk'tlititt, AIl-Ahcla Ilntprcsuncs, L~irm1-10, Santiago , ( hilt'. !Il gcrs., T\N'..I Rett'/ur'it/Ut A13,1(n~lvl il P Ihi i 13 .'tp f/a' tilt Y(IflowI i-ian I,(1('Iilngut' ' RuVt icr, .13scI, NI.DI.. Iaiit' I'Iauu/u,g tilt Natural !i/i' IlTSr. ( raXcS MCtl ta -NtitloiiisNUal 1.11rarv, Wcat'. FItn1ing If. lk'vt'l I ( mpa ln', O ltd Miiilk- Ii sc, 226 Ntxx I 11th in Rd., tn-'appan, T NovxxIrwx, I('.S.A Iiirt, Esscs. CA2 98.1. 1'K.. I1981. St'rcnA-C(a:utla1.1315O'mid L ill'. 55 I ark tl t, 1)11aa, IntcClLa, SiSlcr MI., 774 1-1 i/ .aNet l1 lautib't I-'MIi- I )nl:rii, 3.hata K I JllLhiti il r-ncilaij, Naturil F.ittilx I'L1:(nning Pro grami, -15 hcslnri Iliar. 'lCjIgAii n, Iltaka~ SlIMClttS, 1.ailtdrumin:iliId txI Ri rvitk, kili's on/ 1./Ic: IF",Kiiaglnltsh '7h, 'ielttic El ide'uce' /r 11/'.' lo/rt i/rth, /.uttLICrVart (iil'., (Grtl RApitL.s. M] U.S.A.. Kax'anaghija.l-ax\-\, [rant-is lcdj. l'ilauu/,4 [our I1983. I'tllhill till,S-T Wa Scl'.~trtIK ia( iilat, 55; Park- SI'll1\ t tit a 'hants-. (/ia//3',mo~qtoi3/33 34, KNI .N~ssiitilS. tLll: Ax-cnt'.i laa (I)llrii K I-i I FS,II()t'lni kuItlchNlI2lluI'N. C(vadatli 19I3)51)[ 1 ~

Kaixanag-ijazrmy-, Fiatis t;l MI. Ilarirnl-I.ajpilnt' Tamtil N~aidu atil I )t'\ C'll Itti.t' I :crnr, 'Ih'

St'rt'na-CAnTItLa; 55 Iarktl .Nxcntc, (um~ l'hutltlntlt,p blihiat l(tmll. i-, Allit hnrai O)ntario K I -I IES, Cminai. 19--. HLI.. .- ritin N~igat. ' I. IlII -xT1)2.I'Llttl, 'l'inthiapali13(i IIntli~I. I90 Kipplcv', Ji31111 andJ sltcia. theu .-It ' (( 'tit dt'1l 1'Iittling,, *'IitCouplel Im C' p113 I.Cagnt' 'Inhiscli, Ingritd Mnid P1(/1wili Ittwi3.1i .1Ar. l:xpti- Intecrntlioii 1. In1C., P.O. BO9X 1108-1, C:11l- ect' oli Lov' PF'ioiig If RcIZl aInila c'ilnlalt, Ohio -s521 IUS.A., 19-1) 1)I Tapplan. NLuw Jkrscv I'S.A.

199 Vincent, Bernard, AMethode Thermique et Contra- Hilgers, T.W., The licture Dictionary of the Ovula­ ception, Masson et Cie, 6diteurs, 120, boule- tion Method and Other Assorted Teacbing vard Saint-Germain, Paris VI, France, 1967. Aids, Creighton University Natural Family Planning Educatiot, and Research Center, 601 Vollman, R.F., 7he Menstrual Cycle, W.B. Sanders North 30th Street, Omaha, Nebrask-. 68131, Co., Philadelphia, PA, U.S.A., 1977. U.S.A., 1982. Hilgers, Thomas W., K. Diane Daly, S.K. lHilgers, and Wilson, Mercedes, The Olidation Method of Birth A.M. Prebill, The Ovulation Method of Regulation, Family of the Americas Founda- Natured atcnily, Planning-A Standardized, tion, hIc., 308 S. Tyler St., Covington, LA Case Management Approach to Teaching, 70433, U.S.A. Book One, Basic Teaching Skills, Creighton University Natural Family Planning Education Zimmerman, A., et al., Natural Fanil , I'lanning and Research Center, 601 North 30th Street, Nature's W '-Gods Wit', The Human Life Omaha, Ncbrska 68131, U.S.A., 1982. Center, St. John's University, Collegeville, MN 52321, U.S.A., 1980. Human Life Foundation of America, Curriculum Validation Study for Natural Family Plan- Zimmerman, A. (lrench abridged vers;ien), Prnir tote ning Instruction Training, Washington, Voie vNotitelle: le couple Iamour, [a flecon- D.C., U.S.A., 1977. dite, Distrihuc par F. Guy, 16 place Notre Dame, 38000 Grenoble, France. Human Life and Natural Family Planning Founda­ tion, Basal Body Tenmperature Method, Zimmerman, Anthony (English editor), Que Dicen Forms A + B, Module 2, Washington, D.C., las Parejas?--4iaJ'artja el Amor y' let Vida, U.S.A., 1978. ZQue Dicen los M1edios?, t1,1 itom's in Spanish, translatedby CI:VI'AAL, I Calle 65 Human Life and Natural Family Planning Founda- No. 13-51), Mezzanine. Bogota, Colombia, tion, Iertility Awareness, Forms A + B, 1981. Module 1, Washington, D.C., U.S.A., 1978.

Zinnerman (ed.), A Reader in Natural Family Human Life and Natural Family Planning Founda- Planning, Iluman Life Center, St John's Uni- tion, Instructional Objectives, Washington, versity, Collegeville, MN 56121, U.S.A. D.C., U.S.A., 1978.

TRAINING: Human Life and Natural Family Planning Founda­ tion, Overall Performance Training Objec- Australian Council of Natural Family Planning, Inc., tiie, Module 5, Washington, D.C., U.S.A., Guidelines for the Selection, Training and 1978. Accreditation of Natural tamily I'lanning Teachers, Rigney louse, Marist Place, Parra- Human Life and Natural F3mily Planning Founda­ matta 2 150, Sydney, Australia, 198(0. tion, OVulation M,,thod, Forms A + 13,Module Washington, .C., U.S. 1978. Australian Council for NFP, Teacher Traiting 3, Manual, 11.0. Box 183, Fitzroy, Victoria Human Life and Natural Family PI.anning Founda­ 3101I, Australia. tion, ),?npto-Thermal Method, Forms A + B, Module 4, Watshington, D.C., U.S.A., 1978. of Ireland, Catholic Marriage Advisory Council Tutor's 1andbook in Nl4, All liallows Col- Human Life and Natural Family Planning Founda­ lege, Dublin 9, Ireland. tion, Toolfor Assessing Effectii e Components Training, Forms A + B, Wash- Center for Research Education, Service and Training for Instructor ington, D.C., U.S.A., 1978. for Family Life Promotion, Natural l* , Planning Teachers, 14 High St., Bangalore Min, Ly-G., M.C. Martin, and A.H. Wood, Curricu­ 560005, India, 1980. Ion Outline for Instructor Training in Natural Fanily Planning, The Human Life Center for Research, Education, Service and Train- Foundation of !.-nerica, Washington, D.C., ing for Family Life Promotion, Population U.S.A., 1977. E'ducationfor Quality of Life, 14 hligh St., Bangalore 560005, India, 1980). ([ he above Human Life Foundation materials are available from NFP, P.O. Box 10419, Alex- Guznin, Maria A., lInstrucciones para tisarios del andrla, ''A 2231(1, U.S.A.) letodo de /Ia (vtulacio, (Billings), WOOMB de Mexico, Ave. Paseo de las Palmas L'Action Familiale, Liiret de lEducatrice, Route 745-1205, Col. Loma: dc Chapultepec, Royale, Rose Hill. Mauritius. Mexico I I(110 D.F., Mexico. Teacher's Aurora, Mantal Pa,n EMsiatiza y Marshall, John, Family Planning-A Guzinin,Capacitacion Maria de Cenetros, WOOMB-M~xico, Handbook, Catholic Marriage Advisory Coun- Centro Nacional Billings de Planificaci'n cil (CMAC), 15 Lansdowne Rd., London WI I 3AJ, England. Natural de la Familia, A.C.. Ave. Paseo Palmas 745-12, Col. Lomas de Chapultepec, 1100 Menezes, J.A., Natural Approach to Family Plan- Mexico City, D.F., Mexico, 1984. ning, Department of Responsible. Parent­

200 hood, Catholic Hospital Association of India, University Natural Family I'lanning Education CBCI Centre, Ashok Place, Ncv Dclhi and Research Center, Omaha, NE 68131, 110001, India, 19 ). U.S.A., 1980. Menczes, J.A., Natial lFioail /'qiomingin I'ictures, Ililgers,TXI., comp., Relevant Issues in Natural Department of Rcsptonsihic Parenthood, I.aimill' IPlanning, Creighton Univcrsity Catholic IHospitail Associatiofn of India, CBCI Natural Family Planning Education and Re- Centre,dia sk Place, Ncv, Delhi I1001 , search (:enter, 61)1 N. 30th St., Omall, NE India, 9 6H ILS.A., 19h2.

National Association of Natural Family Planning Teachers, A~l l'ractictl .)lanual for Ihlndbo-(erman Social Scr,,icc Socicty, Natural Famtily oatitrs, NFi' ingr , Birniinghand Naternity ilnning (NI') I'rogran, 28, Lodi Road, Ihtspital, ilitngham B IS, England. In.,iitional Area, New I)clhi 11003, India.

National Asso)ciation of Natur;,l Family Planniing International journal cy Fertilit', Vol. 26, 1981, Teachers, Returniq F'rtilit' After Child- No. 3 (Special Issue), 11 papers from Call irtb, ProcCCdings Of the Xlth Congrcss of Congress, June 1977: Fertility anod Sterility, lublin, June 13, NFl John 1'.France, Phi.).: Overview of the Bio- Centre, IBirminghant Natcrni:y IHospital, h gical Aspects of the Fertile Pentiod. Birmingham 1fI15,Englan~d.loiaAsetofieFrieProd SIhcnry G. Burger, M.I)., M.S.: NCuroendocrine

Ovilation. Santamaria, I)ionisio, and Guillcrmo (;ihbt ns, (A,,trol of Iluman Responsathiliidad en liaTrinsynisionth, let Diane Fordnev-Scttlage, N.D,: A Review of Vida, Ediciones Paulinas, S.A., Avenida Cervical Mucus and Sperm Interaction in TaxquenIa 1792, Mexico 21, D.F., Mexico, Ilumans. 1982. Suzanne ParcntCau-Carreai', NI.).: The Sympto-Thermal Methods. Sercna-Canada, I'Ianning Your Iamnily the S-T t~l"itY 55 Parkdalc, Ottawa, Ontario, Canada John J. Billings, Ni.).: Cervical MUcus: The KIY IE,. Biological Marker of Fertility and Infertilit). William 11. Collins, et al.: Biochemnical Indices WOOMB de Nlcxico, Centro Nacional Billings, G14ii de Sctinienio para IntrttreS del ,Ih'tdo of the Fertile Period in Women. de la Ovutacion - Billings, Ave. Pasco de las Anna NI. Flynn, NI.D.: A Survey of Postpartum P.,hltas, 7-45-I215, ( t . l.onas dc Chapul- Fertility Studies with Particular Reference to tepCC, Mexico 1i0()( 1).F.. MtCxico. the Breastfecding Mother. Barbara Anne Gross, B.Pharm., M.Sc.: The World Calth Organiza titt and BIAT (entre for Ilornional and Ecological Correlates of Lac- I Iealthf and ,"lNiedcal Edt'at iii, latmily hIqt il- tat ion Infertility. package jbr ity lFlucatitn--a resource teachers of ,Vaturat Fmil' I'lanning Alfredo I'5rez, M.D.: Natural Family Planning: .Metihods, EMA IHose, tovistackc SLare, Postpartum Period. London WCI.1 I 9JP, England. Franck Rice, I'h.I., etal.: Effcctivencss of the Sympto-Therinal Method of Natural Family RESEARCH /PRlOGRAM DEVELOPMENT Planning: an International Study.

Bt,(que, I)onald .1.(cd.), loinfl I'Ian1iing Inprove- J.A. Johnston, Ph.D.: An Analysis of Con­ ment Tbrough Evaluation. .A 3anmatl oJ inuity-l)iscontinuity in Natural Family Plan- Ilasic 11rinciples, Community and Family ning: an Australian Factor Analysis. Study Center, Univcrsity of Chicago, 1126 (I.imitcd numbers of this special issue are 0 , EAst 59th St.,Chicago, I1.61 ' U.S.A., 19-0. available from IFF.': 1511 K Street NW,Suite 333, Washington, D.C. 211105, U.S.A.) I)iocesan Il)cvcl pltnrt Prograttt-NFl', Diocesant J'hant .br ,'attural FIanily Plantning Develop­ Martin, ment, 1511 K Street, NW., Washington, I)C. Lanctit, Claude A., and Mary C. Natural 20015. IS.A., 1981. Fainily Planning Services I'rogramne Et,alutttion Guide, International Federation Family of the Atericas Foundatitn, Fanily-Seinar for Family Life Promotion, 1511 K St., N.W., 1981. on Adoles'cent Stitality, 308 S. Tyler St., Washington, I).C. 2001S, U.S.A., Covington, L.A 33,Lancttit,U.S.A. Claude A., and Mary C. Martin, N'ural

J'rogramnme Gu:ljando, Jaintc P'rcz, M.etodo th i Ovulacio'n- I'lamily I'lainning Services S14 lf.ictit-idal(n ,llxVico. WOONIB ic 1:tahutatiopi Instrtument, International Fedcra- Mexico, Ave. I'aseo de las Palmas 745-1215, tion fttr Family Life Promotion, 1511 K St., Col. L.omas dc Chapultcpec. MexicoI 11) NW., Washington, ).C. 20005, U.S.A., 1991. D.F., Mexico. Martin, Mary C., John J. Sell, Robert T. Kambic, and Ililgcrs, Thomas W., AM. Prebil, K.!). Daly, and Mary Q. Kambic, Operational Guidelines S.K. Hlilgers, 7/,e Creighton Motdel for tIme and l'roceduresffor NaturalFatilyI'lantinnif Detelopmnent of Natural hiamily 'lating l'rogramns, The Iluman Life and Natural Fam- Edmucation tand Service I'rograms, Creighton ily Planning Foundation, 1511 K St., N.W.,

201 Washington, D.C. 200)05, U.S.A., 1980. Lit .l'mionqlia Vgi, Centro lnternazionale Studi Flamiglia (CISF), via Monte Rose 21, 2019-4 Tamil Nadu Family l)veopenrt (-Center, Proceed- Milano, Italy. (himonthly) ing-l-f'irst Itermiliontt l Cong'ress for /ie cimily (ofAsia (dud Attstr,'iti (htidi(a), 278 VVeI'.A'u'sLetter, New Zealand Association of Kaleei Shiraji Est ate, 1'.0. Pox -68, FI)untain Natural Family Planning, Inc., 51 Woodside Plaza, Pantheon Rd., Fgnmore, Madras Road, Mount Fden, Auckland, New Zealand. 600/01.8, India. (monthly)

The Iliuman Life and Natural Family Planning Ftn- ,Vett'shlcter. Australian Council of National Family dation, ()perating 'roc'edtures for NAttttredl Planning, Inc., 30 Sackville Street, Kew, Vic­ lcamil' I'Ianmin' Programis. Washington, toria . I, Aust ralia. (nonthly) D.C., U.S.A., 1979. Ncu'slhtter, Catholic Marriage Advisory' Council, 502 Uricchio, William A., .11d Marv Kay Williams, Pro- ('arits Ilouse, Ilouse 2-8, Caine Road, flong feedings of a Researe' (.on'fc'renc on Kong. (periodie) Na/orttl I-awniltI'Iatoming, The luman Life Foundation, 1T1i K St., N.\W., Washington, S'ERI:NA Veu'shetier, SERENA-Canada, 55 Parkdale, D.C. 20006, U.S.A., 1973 Oltawa, Ontarii Ki I-i IE5, Canada. (quarterly)

Wilsc,n, Mercedes, M/,e ()tlationt ,l/hiod ot Bfirth Tmil , AVdt'Ve's. lamil NaIdu Family l)evelopment Regtltit.on, Family of the Americas F intlda ­ (:enter, 3-1 Allidtrai Rioiad, Arun a Nagas, tion, Inc., 308 S. Tyler St., Covington, L.A I'.(). lix Th2, I'uthur, Tiruchrapalli 6201117, 70-33, I.S.A. India.

For additional lIblitation itls,t 'intac t liiTiSt NF 7/t' Coclhic, to couple L.c'a, Vc's, The (a tlple to (irganizaions starred (*) on the NFl' center list Cotuple Lcagtie Internaital, Iiec., 36 I1 Glen­ abovC. more Avenue. Cincinnati, oil 4521 I, U.S.A. (six issues anntually) NEWSLETTERS AND PERIODICALS ' i, 'itw~q(pcc' New Foglaid National Family Planning, ic., 90 Cushiiig Avenue, lBoston, AJ i;v c; Vmilh,. Ccntre de L.iaison des EqIil)es tiC MA 02 125, '.S.A. Icchierch (CIA.R. 05 l oulevard ie (li'hy , 75o1i Paris, France. (six issues anully) WI))IIl-,1'"Iy A'ctrs. Family of the Americas Fotinda­ tion, Inc., 308 S. Tiler Street, Covington, LA Blletin. Ilern:tticriitol Fcderatiin for Family I ife "(4t.03, I'.S.A. (qtu.lrtcrly) 'ro mitiont. 1511 K Strct N.W., Suite 333, W~tshingtic, I).C. 2)000I5, I.S.A. (bi-annual) SURVEY AND REVIEW ARTICLES

CM.I.(C'- lf/hitm. (atholic ,l arriage A0s isiry Council, IS [anasdchwit' Road, Liondhn WI IAJ, Klaus, Ilanna, M.I).: "Natural Family Planning: A Englantl. (quarterly) Review," in c)hstetriciil rinl (ync'ological Sturte.y, Vol. 3"7, No. 2, pp. 12A.ISO, 1982. f)iocestin Ac/ltitit IrthMy'or-,\'.'. Io)icicesan )e'o' - ''he Wiilliams and Wilkins Co., Baltimore, ient 'rigraim 1(ir NFI', 1511 K Street N.W.. M), I.S.A. Suite 33., aV;sltinticn, D)C. 2)005, I.S.A. ILantCt'lt, Claude A., MI..: ''Natural Family Planning," In "tntiliti, ec'retlriadi pira Il Familia. 'ase i in Clinics in Obstetrics aind Gii'eu'love., Vol. Colon 221 (PI), 1390 C-apital Federal, BIueC iS 6, No, I, April 1979 (\'.I). Saundcrs 0i. L.td.). Mires, Argentina. (five issues an,uall ) Martin, Mary C., Phi). and William R. Walker: "Sur- hIih' L/, Ae''s, Iltuman Life (:enter, St. john's Dt'Discloses NFP Practices, Preferences in 'niversity, Colgeville, MN 5321, I'.S.A. ' . Cat holic Ilospitals," in Ilospital (q uartcrlv) Progress,Februarry 1983.

1"ili r 1ifC.vetns, Ilun1ai Life Center, st. John S Population Reports: Periodic Abs/in'cie: Ilowt We/I Inivrsit', Collegeville. NMNS0321. 1'..A. Do Veu' Approiches Work? Series I No. 3, (Ilonthl.) September 1981. Available from Populatikn Information Program, The johns IHopkins I.auti/i i Sciedtd. Centrrie Pastioral Fainiliar para University, IHampton IHouse, 62-1 N. Broad­ America latina, Calle (,. No. 13-5)), Mezza- ,a', Baltimtore. M) 2 215. I.S.A. [line, Bogotai, (0 40l,11hiAi. ((Ilartt'rly)

.o 'rs. Bulletin dc Liaison des Eqiipes tic I:iycrs AUDIOVISUAL MATERIALS Chrnit'cns. Ihoitc Ilostale 2001, IBr'.zza%'ille, Republic cif (Cing,,. (tiin hititli) Lists of audiovisial Materials Used by national NFl' Iternitiona/ R''iewt of ,'tl l I'mi/ 'lul liMl,g, prograts May be obtained by writing to the NFP Ilurnan Life (:enter, St. Jithn's IUniversity. ork inizations that are starred (*) in the list of NFIi (:illcgeville, MN ,6321, U.S.A. (quarterly) centers in the Appendix.

202