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The Integration of Family Planning and Childhood Immunization Services in Togo, Huntington,D., Aplogan,A., Studies in Family Planning, Vol.25 No.3, May/June 1994

Introduction

Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration, which can be achieved through improved referral across categories of health programs. The use of an unobtrusive referral message that linked family planning and the Expanded Program of Immunization (EPI) services was tested in an operations research study in Togo in 1992. The introduction of the referral message was accompanied by an 18% increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54%. These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time. In Togo, no evidence existed of a negative impact on EPI services, and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study.

Government policy and service delivery

At the time of this study, Togo did not have an officially defined national population policy. However, the Togolese government encourages the diffusion of information regarding reproductive and family health issues. Family planning services are offered in the private sector through the Association Togolaise pour le Bien-Etre Familial (ATBEF) and in the public sector through the Programme National de Bien-Etre Familial (PNBEF). Family planning services in the public-sector clinics are thus developed by the national office for maternal and child health care of the Ministry of Health in Lome, Division de la Mere et de l’Enfant (DME). At the time of this study, the national family planning service-delivery program in Togo had been concentrating on developing integrated family planning services within the government-run MCH centers and clinics primarily in two regions of the country-Kara and Maratime. In addition, family planning services were available in each of the regional MCH centers. A full range of contraceptive methods is provided in the Togo family planning program (the pill, injectables, the IUD, condoms, and spermicides, as well as limited sterilization services) at no cost to the user.

Training and contraceptive supplies

The expansion of family planning services concentrated largely on training providers and supplying contraceptive commodities. The training programs stressed the development of technical competence, the management of commodities, IEC skills. The functional integration of family planning services within the other MCH preventive health-care services was not addressed in these training programs nor in subsequent program-monitoring efforts.

Description of the Test Intervention

During each childhood-immunization session, the EPI service provider in the test sites made the following three statements to the child’s mother before immunizing her child:

1. Madame, your child is still young, and you should be concerned about having another pregnancy too soon.

2. This clinic provides family planning services that can help you delay your next pregnancy.

3. You should visit the family planning services after the immunization today for more information.

No addtional information was provided, and all questions were referred to the family planning services that were available in the same clinic at the same time as all other MCH-FP services (including immunizations). The content of the referral message is highly salient for women with infants and young children and is also succinct and easy for clinic staff to remember.

All of the EPI providers in the study’s test clinics participated in a day-and-a-half orientation session. At this meeting, the study’s objectives were presented, and participants had the opportunity to discuss and practice the family planning referral message. In addition, monthly visits were made to each test clinic to verify that the intervention was in place and that data collection was functioning properly.

The use of referral between clinic services can be an effective strategy for improving the quality of care, but indiscriminate linking of MCH services will not be productive. Clinical services that target the same population and that have similar service-delivery strategies should be identified, one or both of the targeted programs should be functioning at the desired level of performance at the time of the linkage.

Recommendations

Among child-survival programs, the Expanded Program of Immunizations has best demonstrated the ability to increase access to health-care services, thus making it an attractive "hook" for drawing clients into a clinic. In addition to its high level of coverage, the EPI focuses on a significant portion of the family planning services’ target population: women who have recently given birth. The integration of family planning and EPI services is, therefore, logical for MCH programs that seek to improve the constellation of services they provide, while enhancing the efficiency of their operations.

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Women’s Socioeconomic Position and Contraceptive Behavior in Togo, Gage, A.J., Studies in Family Planning 1995;26,5:264-277

Introduction

This article seeks to identify aspects of women’s position that have a significant bearing on spousal communication about family planning and on contraceptive practice. The effects of marriage- and employment-related characteristics are examined. The extent to which the influence of women’s socioeconomic position on contraceptive position on contraceptive outcomes is shaped by the cultural setting in which reproductive decision making takes place is of considerable interest.

Background

The data for this study are derived from the raw data from the 1988 Togo DHS. Women in Togo are well known for their domination of commerce and their substantial contribution to agricultural production. Since spouses rarely pool their resources, Togolese women derive a considerable degree of economic independence from control over the income and property accumulated from their economic activities. However, they have had limited opportunities in the modern sector of the economy, largely because of their low levels of education. More than half of the women of reproductive age have never been to school, and few have had secondary or higher schooling. School attendance has increased over time, but gender disparities in educational attainment remain wide, particularly at advanced levels.

In the 1980's Togolese women continued to bear more than six children, on average. Although the country does not have an official population policy, the Togolese government encourages the diffusion of information on reproductive and family health. In the private sector, family planning services are offered through the Association pour le Bien-Etre Familial, which was founded in 1976. In the public sector, family planning services are integrated within the maternal and child health program of the Ministry of Health and are offered through the Programme National de Bien-Etre Familial. Although the Togo family planning program provides a wide range of modern contraceptive methods at no cost to the user, women continue to rely mainly on traditional methods of family planning. The prevalence of modern contraceptive use is less than 5 percent, and unmet need for family planning appears to be considerable, estimated at 40 percent according to the 1988 DHS. Most of this expressed need is for spacing births rather than for limiting family size.

Findings

Results of this study show that not all indicators of women’s position are significant determinants of contraceptive behavior. Most notably, polygyny is not significantly associated with any of the outcomes considered.

One of the main findings is that the greater the level of individual control over selection of partner, the higher is the likelihood of spousal communication about family planning and of modern contraceptive use. These results give some important insights into the fertility implications of the shift in the control over marriage from the family to the individual. The findings also suggest that the continuum from arranged marriage to complete independence of choice may imply a different level of autonomy for women. Greater control over choice of mate and timing of marriage may enable women to communicate better with their husbands and translate their contraceptive preferences into behavior.

The results of this analysis also confirm the importance of women’s economic power for widening their contraceptive options. Workers who participate in rotating credit or savings schemes are significantly more likely than are other women who work for cash to discuss family planning methods with their spouses and to have ever used traditional and modern methods of contraception. Work that is not reimbursed with cash is negatively related to spousal communication, but it has no significant impact on contraceptive use. This finding suggests that while opportunities for women to engage in work for cash may increase their autonomy and enable them to take a greater part in fertility decision making, programs that contribute to women’s economic security through savings and credit may be more relevant to fertility change in the long run.

The results show substantial differences among ethnic groups in spousal communication about family planning and ever use of traditional methods of contraception. The proportion of women who have ever discussed family planning with their spouses ranges from 25 percent among the Para-Gourma to 43 percent among the Adja-Ewe.

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