and promoted a widespread use of contraception. The number of contraceptive users increased from an average of about 47 000 new clients per year during 1965 to 1968 to almost one million by 1979. Population growth rate had a fall from 3.2 - 3.4 per cent ann uall y in the early 1960s to below 2.0 per cent in 1980.11
The Kerala experience12 illustrates the impact which socio-economic change has on fertility. This South Indian State is poor (per capita income US$135 compared with the Indian average of US$190) and heavily populated, yet has a high literacy rate, a falling infant mortality (55 per 1000 livebirths compared to 125 for all India) and a lower birth rate than the rest of the country (26.4 per 1000 compared with 33.3 for all India in 1978). In this socialist-leaning State there has been a major emphasis on land and income re-distribution, on female education and literacy, and on political partici-pation. These policies seem more important to implement than a specific family planning programme, if birth rates are to be affected.
Recipes for success
The acceptance of family planning by a couple depends not only on the technology available but also on other interacting factors, such as the literacy status of women, economic participation of women and the survival rate of children.
The women whose infants survive choose to stop bearing children, while those who experience infant or child deaths continue to reproduce. There is a long period between the drop in infant mortality rate and a fall in birth rates, as it takes time for awareness of better child survival to become widespread. Therefore child health care is a good basis for setting up family planning activities, as the connection between child survival and birth spacing is more easily made clear.
Use of family planning services increased further with the introduction of the home-based mother's record (see Fig. 1.4.13). By this means the health worker and traditional midwives monitor the health of the mother and her menstrual history every month during the inter-pregnancy period and educate and motivate the mother to use appropriate family planning methods for spacing of children. 13
In order to provide the desired continuity in health care, a community-based surveillance process should include all women at grass-roots level during their reproductive age. For surveillance purposes, a compre-hensive home-based mother's record represents an appropriate technology, in its written or pictorial form, for semi-literates or non-literate mothers, traditional
92 Delivering the services
3lR"-
-m&r---
---midwives and primary health care workers. The card could be used for the entire reproductive period of a woman (Fig. 1. 4 .14). Local women's associations, mother's groups or older schoolchildren, particularly girls, can playa useful role in maintaining a surveil-lance system using this home-based record and to identify women who are exposed to health risks asso-ciated with unfavourable reproductive patterns. Simi-larly they can be motivated to space their children and be provided with modern contraceptive methods.
Governments cannot hope to bring about fertility control without introducing policies which promote the
m.
---Fig. 1.4.13 Pictorial mother's record as used in India.
status of women, raise the age of marriage and increase their job opportunities. If it falls within religious tolerance, nation-wide legislation to allow abortion on medical grounds should be introduced.
The prevention of unwanted or closely spaced preg-nancies is possible. Child spacing is an alternative that should be available to everybody. Relevant sectors and health personnel should ensure the provision of information, technology and resources for families who want and need to space their children. The choice should be within the reach of all through primary health care and community organizations.
References 93
OBSERVATIONS IN PREGNANCY PERIOD
Expected date of deli_y Menstr~1 cycle lind attitude towards family planning KASA MODEL INTEGRATED
MOTHER-CHILD HEALTH NUTRITION (MCHN) PROJECT RNIOn for speciel cere Fourth preg.
~~-rrT'-rT'-~'-rT'-rT'-rT~ ~
~ I
~ I
: I
~ !
~ ~
~ €
~ m
~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~
:~~~r+~r+1-~1-~1-~-~~~ ~
.:
~~~~r+1-r+1-~1-~~~~~~
47~~r+1-r+1-~1-~~~~~~
~~~~~~~~~~~~~~~
~.~~+4~+4~+4~+4~+4~~~
~.~~~~~~+4~+4~+4~~~
~.~~~~~~+4~+4~~~~~
42'~~+4-++4-++44~++4~+-l--j
~,~~~~~~tttt~~~
~.~~+4-++4-++4-++4~+4~+-l--j
~.~~~~~~+4~+4~+4-+~~
37~~~~~~+4~+4~+4-+~~
~~-+~-+++~+4~~-++4~+4--j
~~i~-r~~~-r~~~-r~81-~9~
1 2 1 2 3 4 5 . . of
pregMncy POlition of head
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
PrIm8rY H_lth Centre, K_, Teluka DIIMnu, Dilt. THANA
'2 Obserwtions of mother's hellth
VIII ... /~".:'~~ _______ Indo No. _____ 0 . _____ _
~mt _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Oltl of birth First menstruilion Dete of merr ....
( ... L _______ ( ... 1 ________ ... L _______ _ Addr ... ___________________________ _
Wlight ___________ Helght ___________ _
HHmogIobin _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
History of previous deliveries Pari Antenllli hulth Deihl.,., Boy OIri
,.
Blood- ~ f - f - .. - - t--i--f- .- . 1--l--j--+-+--+-+-I
35
Urine albumin VKCint
Postnetel observation
36 37 38 39 40 41 42 43 44 Child
Mot ...
V Period
'l
f.~~~Z,~i~ ~ Sterililltion regularOlto
Note Weight Note S".stfeeding
X Period WFamilY planning
0 Broutfeed ing
missed pill.
0 Abortion
VII
Condom ~ LoopFig.1.4.14 Home-based mother's record. The central panel comprises of surveillance on menstrual cycle and practices of family planning. (The weights shown apply to India.)
References
1. World Health Organization. Maternal Mortality Rates. A Tabulation
if
Available Iriformation. Second edition.FHE/86.3 Geneva WHO, 1986.
2. Shah K, Shah PM. Relationship of weight during pregnancy and low birth weight. Indian Paediatrics 1972; 9:
526-31.
3. Venkatachalam PS, Shankar K, Gopalan C. Changes in body weight and body composition during pregnancy.
IndianJournal oj Medical Research. 1960; 48: 511-17.
4. Gopalan C, Naidu AN. Nutrition and Fertility. Lancet 1972; 2: 1077-9.
5. Kramer MS. Determinants oflow birth weight. Bulletin oj the World Health Organization. 1987; 65: 663 -737.
6. De Meyer E, Adiels-Tegman M. The prevalence of anaemia in the world. In: The Health oj the Family: Some Key Issues. World Health Statistics, WHO, No. 38, 1985.
pp. 3q2-16.
7. Wyon JB, Gordon JB. The Khanna Study: Population Problems in the Rural Punjab. MA, USA, Harvard University Press, 1971.
8. Huffman SL. Maternal and child nutritional status, its association with the risk of pregnancy. Social Sciences and Medicine. 1983; 17: 1529-40.
9. Lews, JH, Burton N. BreastJeeding, contraception and spacing in Mali. Presented at the USAID Health/Population and Nutrition Conference, Getty-sburg, Pennsylvania, June 19-20 1984.
10. Rataam SS, Tambiraja RL. Health benefits of appro-priate timing, spacing and avoiding high parity and risks of unplanned fertility for the mother. In: Delmundo F, Ines-Cuyegkeng K, Aviado DEeds. Primary Maternal and Neonatal Health: A Global Concern. New York, Plenum,
1983. pp. 43-52.
,-11. Knodel J, Debavalya N. Thailand's continuing and
94 Delivering the services
reproductive revolution. Internal Family Planning Perspec-tives. 1980; 6: 84-97.
12. Morley DC, Rohde], Williams G. Practising Healthfor All.
Oxford University Press, 1983.
13. Hutchings], Lyle S. Assessing the Characteristics and Cost-if.fectiveness of Contraceptive Methods. PIACT Papers Seattle, Washington, 1985.