National Health
Services and Family Planning
Thailand,
a
Case Study
CHITT HEMACHUDHA, MD ALLAN G. ROSENFIELD, MD
Implementation of a national family planning program in Thailand is described.
Introduction An increasing number of countries, particularly in Asia, have declared national population policies during the past 10 years.' In most cases, implementation of these policies has been carried out through the establishment of national family planning programs. While there have been debates concerning the effectiveness of family planning programs in bringing about reductions in fertility as rapidly as some think necessary,2 others have suggested that attention to family planning programs or even to population is a mistake; overall socioeconomic development is the important issue.3 The debates will continue4 but at the present time, countries continue to develop such programs for the purpose of carrying out population policies aimed at a reduction in fertility and/or improvement in health. Within the field of family planning, there are also debates, these involving questions about the most effective ways to implement such programs. A major question concerns the role of the national health service system. It seems clear that present technology requires the participation, in a major way, of the health infrastructure. Sterilization, induced abortion, IUDs, and, to a lesser Dr. Hemachudha is presently Undersecretary of State for Health and Director of the National Family Planning Program (NFPP), Ministry of Public Health, Thailand. Dr. Rosenfield was Medical Advisor to the NFPP and Representative in Thailand of The Population Council from 1967 to 1973. He is now Director of the Center for Population Sciences and Professor of Public Health and of Obstetrics and Gynecology at Columbia University, New York, New York 10032. Please address reprint requests to Dr. Rosenfield at the Center for Population Sciences, 78 Haven Avenue, New York, New York 10032. This article was revised and updated in February, 1975. 864 AJPH AUGUST, 1975, Vol. 65, No. 8
extent, hormonal contraception generally require some sort of medical supervision. In the past, physicians have been required for all of these procedures, but it is increasingly understood that there is no hope of being able to deliver the necessary services if the small numbers of doctors presently available, particularly in rural areas, have to see every patient.5 Thus, nurses and auxiliary personnel are increasingly being utilized to insert IUDs and to prescribe oral contraceptives. A serious question, and one that is difficult to answer, or not the health profession presently, or in the whether is future, will give sufficiently high priority to family planning programs to allow for rapid implementation of service activities. One of the obstacles to the more rapid development of successful programs may be the medical profession itself and the need to work through the health services. There are those who feel that there must be a way to carry out the activities in a uni-purpose, massive campaign and they suggest that this will not be possible through existing health services.6 It has been suggested that the utilization of the community and of the commercial sector to spread both information and services is of utmost importance.7 In opposition to these arguments are those in the health field who feel that family planning activities are an integral part of maternal and child health programs and should not be divorced from these programs, with the World Health Organization presenting this argument most
cogently.8
As a result of arguments such as these, family planning programs have developed in different ways in a variety of countries. In some countries, programs have utilized full-time family planning workers, referring potential acceptors to governmental or private medical facilities for services,9 some have developed an autonomous family
planning infrastructure,'I 012 some have established fulltime national coordinating boards which work in cooperation with existing agencies,' 3 while a few have integrated the activities totally into an existing infrastructure, usually the health system.4,15 All of the approaches have led to both successes and problems, and it is clear that there is no one organizational system that will be best for all countries. But, in most instances in which a totally separate infrastructure has been created in countries where there was already also a governmental health infrastructure, there have been many problems due to lack of cooperation and coordination between the new family planning system and the old health network. In this paper, the experiences in Thailand will be related, in which the basic family planning program was organized, planned, and implemented primarily through the rural health and hospital services of the Ministry of Public Health. While not necessarily a model for other countries, the approach seems to have been an appropriate one for Thailand.
The National Family Planning Program Thailand is a predominantly Buddhist country in Southeast Asia with a population in 1974 of over 40 million people. Over 80 per cent of the people live in rural areas, and most have had 4 years or less of education. As in most developing countries, the age structure is such that over 40 per cent of the total population is under the age of 15, thus producing a serious burden on the developmental efforts of the country. In late 1967, the Undersecretary of State for Public Health, who was concerned about the population problem, directed that a national "research" family planning project be prepared. Because of the lack of an official governmental population policy, no consideration was given to the establishment of a separate family planning infrastructure. It was clear that integration of activities within existing health services was the only approach that would be acceptable to the government. But, more than that, there was a conviction that, at least for Thailand, the integrated approach made good sense. While, admittedly, there were many problems within the Thai health system, there was, at least, a reasonably good infrastructure already in existence, and the use of these personnel and facilities reduced both the cost of the activities and unnecessary duplication. In addition, improvement of the matemal and child health care system was one of the objectives of the development of a family planning program. Between 1968 and mid-1970, family planning activities were developed under the euphemism "Family Health (Research) Project," and the project was carried out very quietly, with no public information activities, without special full-time family planning workers, without targets, and without incentives.'5 The 3-year plan (1968-1970) called for short training courses in the field of population/ family planning for at least one doctor and one nurse from each of the 84 provincial hospitals and all doctors, nurses,
and auxiliary midwives working in rural health services throughout the country. After completion of the training courses, family planning clinics were to be opened in all hospitals and health centers staffed with a physician. Staff of clinics without physicians were assigned the duty, in the early years of the program, of providing information and motivation to potential acceptors and also to distribute resupply of oral contraceptives. An official national population policy was declared by the Thai Cabinet in mid-1970. The policy called for the lowering of the rate of population growth through the practice, voluntarily, of family planning. A 5-year plan (1972-1976) was developed with the basic objective to reduce the population growth rate from over 3.0 per cent to 2.5 per cent by the end of 1976, through the provision of family planning information and services as widely as possible throughout the country. The training and the opening of clinics during the period 1968-1970 allowed the Ministry of Public Health (MOPH) to move ahead after the policy declaration, with an impetus already created. In Thailand, most modern medical care is provided through governmental health services, with the MOPH providing the bulk of care outside the capital city of Bangkok-Thonburi. For the 71 provinces, there are a total of 84 provincial hospitals, ranging from 50 to 450 beds, plus three large hospitals in Bangkok. The MOPH also has primary responsibility for curative and preventive rural health services through a large network of three classes of health centers. There are close to 4,000 health centers, with only about 175 centers having a physician in residence. The remainder of the centers are staffed either by an auxiliary midwife and a male health worker (sanitarian) or by an auxiliary midwife alone. The smallest unit, the midwifery center, is supposed to cover a population of from 2,000 to
3,000 people. As is true in many countries, more than one-half of all doctors in Thailand live and work in the capital city, most working in government hospitals or urban health centers, with the remainder working full-time in private practice. The doctor to patient ratio in Bangkok is a respectable 1:1,000, but for the rest of the country it is about 1:35,000 people. Even this figure is misleading since the majority of the doctors outside Bangkok live in the provincial capital towns, most working in the provincial hospital, so that the ratio in the more rural areas is only one doctor for approximately 110,000 people. Most government doctors conduct private practices after official working hours; obviously most of these practices are in Bangkok and a few other large cities. There is a similar maldistribution of nurses, but the majority of auxiliary personnel (both male and female) work in the rural areas rather than in the cities. Thus, given the existing situation, much emphasis had to be placed on this latter group of
personnel. Training Because of the large number of personnel to be trained and because of the very limited training staff, courses of FAMILY PLANNING IN THAILAND
865
only 1 week's duration were developed, although it was realized that longer periods of training were desirable. In all courses essentials of population dynamics were taught, with particular emphasis on the effects of rapid population growth on various aspects of socioeconomic development in Thailand. In addition, methods of contraception to be used in the program (primarily the IUD and oral contraceptives) were described in detail. All physicians and nurse/midwives were trained in Bangkok, while the training for the larger numbers of auxiliary midwives was conducted in the provinces. During 1970, brief, 2-day indoctrination courses were also developed for male health workers so that they too would be familiar with the aims of the program and would then be in a position to assist in the motivational aspects of the program. Over 7,600 personnel of the MOPH received training in the field of population and family planning between 1968 and 1972 (Table 1). By 1972, the basic training had been completed and thereafter only refresher courses were provided.
clinic; the acceptors simply learned from friends or satisfied acceptors. ' 6 When the government announced a national population policy in 1970, the restriction on public informational activities was removed, but for a variety of reasons, nationwide public information activities in campaigns were implemented for the first time only in late 1972. It should be emphasized, however, that from the beginning both Ministry health personnel and, more important, satisfied acceptors, served as communicators about family planning, this being a most effective means of communication.' 7,18
Services Following training of their personnel, family planning clinics were opened in the provincial hospitals and in those rural health centers staffed with a physician. The auxiliary midwives were expected to provide motivation and information to couples in their areas of coverage, referring those interested in services to the health centers and hospitals. By mid-1970 there were close to 350 clinics in hospitals and health centers throughout the country where oral contraceptives and intrauterine devices could be obtained. Female tubal ligation was available, primarily as a postpartum procedure, in about 90 hospitals, with the majority of them being performed in a small number of hospitals. After the successful conclusion of a pilot study, in which auxiliary midwives in four provinces were allowed to prescribe the pill primarily, utilizing a simple checklist, the Ministry ruled, in mid-1970, that auxiliary midwives throughout the country could prescribe the pill.' 9 Because it was felt that the basic family planning training course was
Public Information During the early years of the program, the government did not allow any public information activities about family planning. The MOPH, therefore, did not undertake any public health education programs, but stressed instead simple person-to-person communication. There already was evidence in Thailand that this was a most effective means of the spread of information. In 1965, a large Bangkok hospital opened a family planning clinic and during the first 3 years patients came from 65 of Thailand's 71 provinces, without any attempt to spread information about this TABLE 1-Training, 1968-1972
Year
Classification
1972
Total
158 190 49 -
588 1,060 3,868 1,985
83
183
1969
1970
87 174 948
102 203
141 323
1,003
-
-
1,139 1,985
-
-
-
20
80
1,209
1,308
3,608
1,079
480
7,684
Physicians
Nurse/midwives Auxiliary midwives Sanitarians F.P. clinic workers Total
1971
1968
100 170 729
TABLE 2-Family Planning Acceptors* in The National Family Planning Program, 1968-1974
IUD Pill
Tubal ligationt Vasectomyt Total
1968
1969
1970
1971
1972
1973
1974
35,300 10,000 12,000
54,500 60,500 15,300
74,400 132,400 18,700
86,000 294,600 23,600
89,100 327,400 32,000
93,600 268,300 46,400 2,900 411,200
89,400 302,600 73,100 7,000 472,100
-
-
-
-
-
57,300
130,300
225,500
404,200
448,500
* Figures rounded to nearest hundred. t Until 1973, male and female sterilization procedures were reported together, the vast majority being female postpartum tubal ligation.
866 AJPH AUGUST, 1975, Vol. 65, No. 8
sufficient to prepare the midwives to carry out this new duty, more than 3,000 midwives already trained were then able to prescribe the pill. In 1968, there were approximately 57,000 acceptors of the IUD, pill, and female sterilization. By 1972 the annual total had increased dramatically to almost 450,000 new acceptors which, after a slight fall in 1973, rose to over 460,000 in 1974 (Table 2 and Figure 1). There similarly had been a dramatic change between 1968, when IUD acceptors outnumbered pill acceptors 3:1, and 1972 wherein IUD acceptors had increased from 35,300 to 89,100, but pill acceptors had increased from almost 10,000 to 327,400, producing almost an exact reversal in the IUD:pill ratio. Thus, the number of pill acceptors increased from approximately 10 per cent of the total in the early years to 72 per cent in 1972. Similarly by 1972, most acceptors (78 per cent) received services in rural health centers throughout the country, whereas in the earlier years there was a predominance of acceptors in urban hospitals, particularly in Bangkok. In 1972-1973, there was a drop in pill acceptors, due, in part, to a change in pill brand, with some increase in side effects (primarily intermenstrual spotting).20 Because the rural health personnel were not sufficienty prepared for this problem, they were unable to offset the rumors that spread relating to the new pill. The numbers of both acceptors and continuing users fell, but by 1974 the downward trend had been reversed and new acceptors of the pill rose again to approximately 300,000. Postpartum tubal ligation is offered in most hospitals which provide maternity care. There has been a gradual increase in the number of procedures done each year since 1968. In 1972, the cost of the procedure to a patient was reduced from a range of $10-40 to $7.50 and in 1973, a UNFPA project provided an additional $7.50 per case to the hospital to help cover costs. As a result there was a
significant increase in the number of acceptors in 1973 and 1974,2 1,22 reaching approximately 70,000 in 1974. Interval tubal ligation has not been a popular procedure, but with the development of a simplified procedure, called the "mini-lap," at one Thai teaching hospital,2 3 it is hoped that this procedure will also increase in popularity throughout the country. Training of physicians in this technique is simple and initial training courses are already underway. At some of the larger hospitals interval procedures such as laparoscopy, culdoscopy, and/or posterior colpotomy are available. Vasectomy has not yet been widely accepted, but information efforts are underway, and in 1974, there was a significant increase, with vasectomy acceptors totaling approximately 7,000, as compared to 2,900 in 1973 and much smaller numbers in preceding years.22 Role of Nursing and Auxiliary Personnel The medical complications and contraindications of the pill and the IUD were reviewed and after weighing the risks and benefits to be gained, it was recommended that nursing and auxiliary personnel be allowed to prescribe the pill without the requirement of a pelvic examination, and further that, with appropriate training, these personnel could also insert the IUD.' The increase in numbers of pill acceptors, since implementing this concept in the Thai program, is a dramatic example of the effectiveness of an expanded role for nursing and auxiliary personnel in the field of family planning. During the four-province pilot study mentioned above there was a 4-fold increase in the number of pill acceptors in the 6-month period after initiating the study and the 12-month continuation rates were higher among women who received the pill from auxiliary midwives than were the rates in women who received them from physicians.' 9 One hypothesis proposed
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* XIUS xjg
1UI g -
t*¢j-_ s17
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to explain these differences is that the auxiliary midwives are more accessible to the acceptors, both physically and socially, than are physicians. When the MOPH reviewed this project and decided that all auxiliary midwives who had already been trained could prescribe the pill, the national program then moved forward at an even faster rate than expected. Figure 2 presents the acceptors by method for each 6-month period between 1969 and 1971. As can be seen, the ruling concerning the auxiliary midwives resulted in an almost immediate increase in the pill acceptors, and thus in the overall totals. More recently, with assistance from the UNFPA and UNICEF, motorcycles have been provided to all midwives in an attempt to increase their mobility and thereby- hopefully their effectiveness. The MOPH has carried out a special study in which nurse/midwives are taught the technique of IUD insertion. Evaluation is underway at present, but the preliminary results suggest that this is both a safe and appropriate next step, with very high 12-month continuation rates (87 per cent) in women receiving the insertion from a nurse/midwife. We strongly feel that family planning programs (and the health system in general) must make better use of nursing and auxiliary personnel, particularly in developing 160,000 =
countries. We must be practical and accept that doctors are not required for all such services. The Postpartum Program
In 1966 four Bangkok hospitals joined an international cooperative study called the International Postpartum Program.24 In 1969-1970 the program was expanded to 11 MOPH hospitals located outside Bangkok.25 Eight of the hospitals belonged to the provincial network of the Department of Medical Services. The other three were a part of a new category of facility in Thailand, called Maternal and Child Health Centers, which include an auxiliary midwifery school and a 60- to 80-bed maternity hospital.26 All of the hospitals in this expanded program provide care for 1,500 to 7,000 obstetrical and abortion cases per year, with a mean of 3,700 cases per year. The program in each participating hospital stresses the provision of information and motivation to maternity patients in the antenatal clinics, in the labor rooms, and, most particularly, on the postpartum wards.25 Immediate postpartum IUD insertion is offered every day, with the insertion usually done on day 2 to 4 postpartum. Thailand has been a leader internationally in the insertion of the IUD
SteriizatiWn
-IUD
i....
140,00Q
-.:e-_.. = Pill'
120,000
100,0001_ 0 40 S
80,000
F
60,000
F
.0
E
z
40,000_ 122
20,000
fl 8,153
7,11
Jul-Dec
Jan-Jun
_199
-- -q
9* j
m
I
Jan-Jun
4'
1970L
Jul-Dec
I
1-9
i
Jan-Jun
Ministy ruling on auxiliary rrmdwife pit prescription FIGURE 2 Family planning acceptors by 6-month periods, 1969-1971. 868
AJPH AUGUST, 1975, Vol. 65, No. 8
never practiced contraception before, although obviously the percentage has decreased somewhat in more recent years. Thus, the Thai program has been reaching rural women of lower socioeconomic status, the primary target for assistance in general by the government. There have been a series of home interview follow-up surveys of acceptors in the national program. In 1971, the first nationwide sample survey of acceptors was conducted; the earlier studies were of selected groups, with the first one in 1969 (Table 3). The continuation rates, particularly for the pill, have been among the highest reported from national programs in Asia, with 12-month rates of 76 per cent for the IUD and 68 per cent for the pill; at 24 months, these rates have fallen to 63 and 53 per cent, respectively.28 Even at 48 months, the IUD continuation rate was a surprising 48 per cent. It is suggested that these rates may be higher than those reported from other programs because the Thai program has not used incentive payments either for the health staff or for acceptors, no formal targets per worker or per clinic were established, and most acceptors pay a small fee for service. Thus, perhaps the Thai acceptors are more highly motivated, therefore continuing use longer. A second national survey of pill acceptors was conducted in 1974. Preliminary analysis shows a drop in pill continuation rates to 59 at 12 months, falling to 41 at 24 months.22 This drop apparently is related to the fall in pill acceptance rates mentioned earlier. Further analysis is underway which, it is hoped, will help to explain the fall of the decreased rates. In 1969, the Institute of Population Studies at Chulalongkorn University conducted the first rural round of its National Longitudinal Survey of Social, Economic, and Demographic Change.29 In that round, they found that 11 per cent of married, fertile women, age 15 to 45, were currently practicing contraception or were sterilized.30'3 1 In the second rural round conducted in mid-1972, this percentage had already risen to 23 per cent, a 100 per cent increase.32 In urban areas the percentage currently practicing contraception increased in the 2-year period by about 12 percentage points, to 41 per cent in provincial urban areas and 48 per cent in Bangkok-Thonburi.32 This has contributed to about a 12 per cent decline in general marital fertility between the two survey periods. While a significant percentage of these changes may be
in the immediate postpartum period and has been responsible for over 70 per cent of all immediate postpartum insertions reported in the international program. To date there has not been any increase in infection or perforation, although the expulsion rate is slightly higher than in the regular IUD insertion cases. The most dramatic successes have been noted at the Chulalongkorn Hospital in Bangkok where there had been over 85,000 IUD acceptors by early 197527 and at the MCH centers, where close to 65 per cent of all obstetrical and abortion patients accept family planning services, the majority accepting an immediate postpartum insertion of an IUD or a female sterilization. The 15 hospitals in this study accounted for approximately 20 per cent of all acceptors in the overall national program in 1970-1971.
Evaluation A special evaluation section was created within the Ministry to follow the progress of this program. A carbon copy of the basic demographic data on all new acceptors of family planning services is sent directly to the central research and evaluation unit, as is one copy of the monthly report from all clinics. Through this rapid reporting system, the central unit receives data within 2 weeks of the end of the month from well over 90 per cent of participating clinics, and the unit, in turn, prepares for wide distribution a report with data by district, province, and organizational department or agency. Recently the system has been computerized, which has increased the efficiency significantly. Analyses of patient characteristics are carried out periodically. The results have not changed significantly over time and have revealed, in general, that approximately 80 per cent of all new acceptors live in rural areas, mostly working as farmers, and over 90 per cent having attended school beyond the 10th grade. The acceptors have been younger than in some other Asian programs, with over 50 per cent being under 30 years of age. In addition, two-thirds of the acceptors have had four or fewer living children. The majority accepted services for purposes of limitation and almost one-half accepted within 6 months of the last pregnancy, indirect evidence of the importance of the postpartum concept. Finally, the great majority had TABLE 3-Continuation Rate Studies, 1969-1974 12 Months
Study Potharam District-1 969 Postpartum program-1970
Selected districts-1970 National-1971 National-1 974t
Pill
IUD
-
70 79 76 76
72 67* 68 59
-
48 Months
24 Months Pill
IUD
Pill
IUD
-
56 65 56 63
-
41 47
-
48
53 -
53 41
-
-
-
* The 12-month pill continuation rate in a special study in which auxiliary midwives were allowed to prescribe and resupply the pill was 76 per cent. t Preliminary results.
FAMILY PLANNING IN THAILAND 869
due to the NFPP, it also should be noted that an undetermined percentage of pill users obtain their supplies from an active commercial sector, particularly in urban areas. It is estimated that approximately 300,000 cycles are distributed monthly.20
Conclusion The family planning program in Thailand has demonstrated the successful integration of family planning services within a national health infrastructure even in the absence of full-time workers, public information activities, and incentives. It seems clear that the program would not have developed anywhere as rapidly had a separate infrastructure and system been established first. The acceptance of family planning in government health facilities exceeded expectation, thus suggesting the high motivation that exists for family planning among Thai couples. The importance of the utilization of nursing and auxiliary personnel to prescribe the pill has been clearly demonstrated, particularly in view of the critical shortages of physicians in rural areas. The effect of the Ministry's ruling that the 4,000 auxiliary midwives throughout the country could prescribe the pill was a dramatic demonstration of this c6ncept. It allowed the program to exceed the 1971 national target number of acceptors by over 100,000 and preliminary evidence suggests that pill continuation rates are higher when prescribed by auxiliary midwives than by doctors. Thailand's program has also demonstrated the importance of the postpartum family planning concept. When women do deliver in a hospital setting, special motivational efforts should be made during the antenatal clinic visits and, more important, on the postpartum wards. With proper motivational efforts, a majority of women who receive maternity coverage will accept family planning services postpartum, whether for purposes of spacing or of limitation. The Thai experience has shown the safety of the insertion of an IUD within the first few days postpartum, a most popular procedure. Similarly, the decision conceming a sterilization procedure should no longer be based on a set number of children, but rather on the wishes of the couple concerned, after consultation with their physician. The challenge now is to adapt what has been learned in the provision of maternity and family planning services for women delivering in a hospital setting to the great majority of women in rural areas throughout the developing world who deliver their babies in the home without trained medical attendants present. Studies are now underway to attempt to find ways to improve such services in rural areas. In spite of these successes a variety of problems remain. Increased high level governmental support is needed with increases in budgets, civil service positions, supporting public statements, etc. Supervision within the health system, so important in the development of a truly effective long term program, is relatively ineffective at the present time and a major effort is required to improve it. Several questions presently either being evaluated or under 870 AJPH AUGUST, 1975, Vol. 65, No. 8
consideration as the government attempts to develop ways to maintain the present momentum include: are full-time field workers necessary in later, more difficult, stages of a family planning program; how best can community-based distribution programs be developed and can oral contraceptives be distributed safely outside the usual medical or paramedical system; can Depo-Provera be introduced safely into the national program and will it prove an important and effective addition to the methods presently offered; what is the role of incentives; how can the performance of less effective clinics be improved; how can population education be introduced most effectively; and how best can public information activities be developed? In addition, the National Economic and Social Development Board is coordinating efforts aimed at involving other ministries and agencies in appropriate ways. Thailand seems well on the way to bringing about a reduction in its high population growth rate, which should, in turn, assist the nation's important efforts at socioeconomic development.
References 1. Nortman, D. Population and Family Planning: A Factbook, Ed. 6. Reports on Pop/Fam Plan. Population Council Monograph, New York, 1974. 2. Davis, K. Zero Population Growth: The Goal and the Means. In The No-Growth Society, edited by Olson, M., and Landsberg, H. H., pp. 15-30. W. W. Norton & Company, New York, 1973. 3. Tabbarah, R. B. Population Policy Issues in International Instruments: With Special Reference to the World Population Plan of Action. J. Int. Law Econ., in press. 4. Berelson, B. The Great Debate on Population Policy. In preparation. 5. Rosenfield, A. G. Family Planning: An Expanded Role for Paramedical Personnel. Am. J. Obstet. Gynecol. 110:1030-1039, 1971. 6. Spengler, J. J. Population Problem: In Search of a Solution. Science 166:1234-1238, 1969. 7. Speidel, J. J., Ravenholt, R. T., and Perry, M. I. Non-clinical Distribution of Oral Contraceptives. In Advances in Planned Parenthood, edited by Lewit, S., pp. 28-40. Excerpta Medica, Amsterdam, 1973. 8. World Health Organization. Family Planning in Health Services. W. H. 0. Tech. Rep. Ser. 476, 1971. 9. Worth, G., Watson, W. B., Han, D. W., et al. Korea/Taiwan 1970: Report on the National Family Planning Programs. Stud. Fam. Plann. 2:57-69, 1971. 10. Hardee, J. G., and Satterthwaite, A. P. Pakistan. Country Profiles. Population Council Monograph, New York, 1970. 11. Marzuki, A. B., and Peng, J. Y. Malaysia. Country Profiles. Population Council Monograph, New York, 1970. 12. Gaisie, S. K., Jones, S. B., Caldwell, J. C., and Perkin, G. W. Ghana. Country Profiles. Population Council Monograph, New York, 1970. 13. Soewondo, N., Djoewari, O., and Ryder, B. Indonesia. Country Profiles. Population Council Monograph, New York, 1971. 14. Soni, V. India's Family Planning Programme: A Brief Analysis. (Mimeographed) 1971. 15. Rosenfield, A. G., Hemachudha, C., Asavasena, W., and Varakamin, S. Thailand: Family Planning Activities 1968-1970. Stud. Fam. Plann. 2:181-191, 1971.
16. Fawcett, J. T., Somboonsuk, A., and Khaisang, S. Thailand: An Analysis of Time and Distance Factors at an IUD Clinic in Bangkok. Stud. Fam. Plann. 1:8-12, 1967. 17. Schramm, W. Communication in Family Planning. Reports on Pop/Fam Plan. Population Council Monograph, No. 7, New York, 1971. 18. Rosenfield, A. G., Asavasena, W., and Mikhanorn, J. Thailand: Family Planning Communication through Person-to-Person Contact. Stud. Fam. Plann. 4:145149, 1973. 19. Rosenfield, A. G., and Limcharoen, C. Auxiliary Midwife Prescription of Oral Contraceptives: An Experimental Project in Thailand. Am. J. Obstet. Gynecol. 114:942-949, 1972. 20. Alers, J. O., Asavasena, W., Suvanavejh, C., and Rosenfield, A. G. Thailand (1972). Stud. Fam. Plann. 4:124-127, 1973. 21. Suvanavejh, C., and Donaldson, P. J. Thailand (1973). Stud. Fam. Plann. 5:169-172, 1974. 22. Varakamin, S. Thailand (1974). Stud. Fam. Plann., in press. 23. Osathanondh, V. Suprapubic Mini-laparotomy, Uterine Elevation Technique: Simple, Inexpensive and Outpatient Procedure for Interval Female Sterilization. Contraception 10:251-262, 1974. 24. Zatuchni, G. I. (ed.). Postpartum Family Planning. McGraw-Hill Book Company, New York, 1970. 25. Rosenfield, A. G., and Varakamin, S. The Postpartum
26.
27. 28.
29.
30.
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32.
Approach to Family Planning: Experiences in Thailand, 1966-1971. Am. J. Obstet. Gynecol. 113:1-13, 1972. Rosenfield, A. G., and Asavasena, W. Maternity Care in Rural Thailand. Am. J. Obstet. Gynecol. 115:10131020, 1973. Somboonsuk, A., and Rosenfield, A. G. Experiences with the Lippes Loop, 1965-1970. Int. J. Gynaecol. Obstet. 11:16-24, 1973. Hemachudha, C., Asavasena, W., Varakamin, S., Rosenfield, A. G., Jones, G., and Alers, J. 0. Thailand (1971). Stud. Fam. Plann. 3:151-156, 1972. Prachuabmoh, V., and Thomlinson, R. (eds.). The Methodology of the Longitudinal Study of Social, Economic, and Demographic Change. Institute of Population Studies, Chulalongkorn University, Bangkok, 1971. Prachuabmoh, V., Knodel, J., Prasithrathsin, S., and Debavalya, N. The Rural and Urban Population of Thailand: Comparative Profiles. Research Report No. 8. Institute of Population Studies, Chulalongkorn University, Bangkok, 1972. Knodel, J., and Pitaktepsombati, P. Thailand: Fertility and Family Planning among Rural and Urban Women. Stud. Fam. Plann. 4:229-225, 1973. Knodel, J., and Pitaktepsombati, P. Fertility and Family Planning in Thailand: Results of the Second Round of the Longitudinal Study. In press.
SYMPOSIUM ON "ADOLESCENCE AND PSYCHOSIS: A HOLISTIC APPROACH TO DIAGNOSIS AND TREATMENT" SCHEDULED FOR NOVEMBER "Adolescence and Psychosis: A Holistic Approach to Diagnosis and Treatment," for physicians and mental health professionals, will be held at the Roosevelt Hotel, New York City, November 15, 1975. Sponsored by the Joint Committee on Schizophrenia, New York State District Branches, American Psychiatric Association, the symposium will examine the multiplicity of factors that operate to produce maladjusted adolescents and which exist both as independent entities and in a complex interrelationship with one another. For additional information on the symposium, contact Lester E. Shapiro, MD, General Chairman, 43 Andover Road, Rockville Centre, NY 11570.
FAMILY PLANNING IN THAILAND
871
Services and Family Planning
Thailand,
a
Case Study
CHITT HEMACHUDHA, MD ALLAN G. ROSENFIELD, MD
Implementation of a national family planning program in Thailand is described.
Introduction An increasing number of countries, particularly in Asia, have declared national population policies during the past 10 years.' In most cases, implementation of these policies has been carried out through the establishment of national family planning programs. While there have been debates concerning the effectiveness of family planning programs in bringing about reductions in fertility as rapidly as some think necessary,2 others have suggested that attention to family planning programs or even to population is a mistake; overall socioeconomic development is the important issue.3 The debates will continue4 but at the present time, countries continue to develop such programs for the purpose of carrying out population policies aimed at a reduction in fertility and/or improvement in health. Within the field of family planning, there are also debates, these involving questions about the most effective ways to implement such programs. A major question concerns the role of the national health service system. It seems clear that present technology requires the participation, in a major way, of the health infrastructure. Sterilization, induced abortion, IUDs, and, to a lesser Dr. Hemachudha is presently Undersecretary of State for Health and Director of the National Family Planning Program (NFPP), Ministry of Public Health, Thailand. Dr. Rosenfield was Medical Advisor to the NFPP and Representative in Thailand of The Population Council from 1967 to 1973. He is now Director of the Center for Population Sciences and Professor of Public Health and of Obstetrics and Gynecology at Columbia University, New York, New York 10032. Please address reprint requests to Dr. Rosenfield at the Center for Population Sciences, 78 Haven Avenue, New York, New York 10032. This article was revised and updated in February, 1975. 864 AJPH AUGUST, 1975, Vol. 65, No. 8
extent, hormonal contraception generally require some sort of medical supervision. In the past, physicians have been required for all of these procedures, but it is increasingly understood that there is no hope of being able to deliver the necessary services if the small numbers of doctors presently available, particularly in rural areas, have to see every patient.5 Thus, nurses and auxiliary personnel are increasingly being utilized to insert IUDs and to prescribe oral contraceptives. A serious question, and one that is difficult to answer, or not the health profession presently, or in the whether is future, will give sufficiently high priority to family planning programs to allow for rapid implementation of service activities. One of the obstacles to the more rapid development of successful programs may be the medical profession itself and the need to work through the health services. There are those who feel that there must be a way to carry out the activities in a uni-purpose, massive campaign and they suggest that this will not be possible through existing health services.6 It has been suggested that the utilization of the community and of the commercial sector to spread both information and services is of utmost importance.7 In opposition to these arguments are those in the health field who feel that family planning activities are an integral part of maternal and child health programs and should not be divorced from these programs, with the World Health Organization presenting this argument most
cogently.8
As a result of arguments such as these, family planning programs have developed in different ways in a variety of countries. In some countries, programs have utilized full-time family planning workers, referring potential acceptors to governmental or private medical facilities for services,9 some have developed an autonomous family
planning infrastructure,'I 012 some have established fulltime national coordinating boards which work in cooperation with existing agencies,' 3 while a few have integrated the activities totally into an existing infrastructure, usually the health system.4,15 All of the approaches have led to both successes and problems, and it is clear that there is no one organizational system that will be best for all countries. But, in most instances in which a totally separate infrastructure has been created in countries where there was already also a governmental health infrastructure, there have been many problems due to lack of cooperation and coordination between the new family planning system and the old health network. In this paper, the experiences in Thailand will be related, in which the basic family planning program was organized, planned, and implemented primarily through the rural health and hospital services of the Ministry of Public Health. While not necessarily a model for other countries, the approach seems to have been an appropriate one for Thailand.
The National Family Planning Program Thailand is a predominantly Buddhist country in Southeast Asia with a population in 1974 of over 40 million people. Over 80 per cent of the people live in rural areas, and most have had 4 years or less of education. As in most developing countries, the age structure is such that over 40 per cent of the total population is under the age of 15, thus producing a serious burden on the developmental efforts of the country. In late 1967, the Undersecretary of State for Public Health, who was concerned about the population problem, directed that a national "research" family planning project be prepared. Because of the lack of an official governmental population policy, no consideration was given to the establishment of a separate family planning infrastructure. It was clear that integration of activities within existing health services was the only approach that would be acceptable to the government. But, more than that, there was a conviction that, at least for Thailand, the integrated approach made good sense. While, admittedly, there were many problems within the Thai health system, there was, at least, a reasonably good infrastructure already in existence, and the use of these personnel and facilities reduced both the cost of the activities and unnecessary duplication. In addition, improvement of the matemal and child health care system was one of the objectives of the development of a family planning program. Between 1968 and mid-1970, family planning activities were developed under the euphemism "Family Health (Research) Project," and the project was carried out very quietly, with no public information activities, without special full-time family planning workers, without targets, and without incentives.'5 The 3-year plan (1968-1970) called for short training courses in the field of population/ family planning for at least one doctor and one nurse from each of the 84 provincial hospitals and all doctors, nurses,
and auxiliary midwives working in rural health services throughout the country. After completion of the training courses, family planning clinics were to be opened in all hospitals and health centers staffed with a physician. Staff of clinics without physicians were assigned the duty, in the early years of the program, of providing information and motivation to potential acceptors and also to distribute resupply of oral contraceptives. An official national population policy was declared by the Thai Cabinet in mid-1970. The policy called for the lowering of the rate of population growth through the practice, voluntarily, of family planning. A 5-year plan (1972-1976) was developed with the basic objective to reduce the population growth rate from over 3.0 per cent to 2.5 per cent by the end of 1976, through the provision of family planning information and services as widely as possible throughout the country. The training and the opening of clinics during the period 1968-1970 allowed the Ministry of Public Health (MOPH) to move ahead after the policy declaration, with an impetus already created. In Thailand, most modern medical care is provided through governmental health services, with the MOPH providing the bulk of care outside the capital city of Bangkok-Thonburi. For the 71 provinces, there are a total of 84 provincial hospitals, ranging from 50 to 450 beds, plus three large hospitals in Bangkok. The MOPH also has primary responsibility for curative and preventive rural health services through a large network of three classes of health centers. There are close to 4,000 health centers, with only about 175 centers having a physician in residence. The remainder of the centers are staffed either by an auxiliary midwife and a male health worker (sanitarian) or by an auxiliary midwife alone. The smallest unit, the midwifery center, is supposed to cover a population of from 2,000 to
3,000 people. As is true in many countries, more than one-half of all doctors in Thailand live and work in the capital city, most working in government hospitals or urban health centers, with the remainder working full-time in private practice. The doctor to patient ratio in Bangkok is a respectable 1:1,000, but for the rest of the country it is about 1:35,000 people. Even this figure is misleading since the majority of the doctors outside Bangkok live in the provincial capital towns, most working in the provincial hospital, so that the ratio in the more rural areas is only one doctor for approximately 110,000 people. Most government doctors conduct private practices after official working hours; obviously most of these practices are in Bangkok and a few other large cities. There is a similar maldistribution of nurses, but the majority of auxiliary personnel (both male and female) work in the rural areas rather than in the cities. Thus, given the existing situation, much emphasis had to be placed on this latter group of
personnel. Training Because of the large number of personnel to be trained and because of the very limited training staff, courses of FAMILY PLANNING IN THAILAND
865
only 1 week's duration were developed, although it was realized that longer periods of training were desirable. In all courses essentials of population dynamics were taught, with particular emphasis on the effects of rapid population growth on various aspects of socioeconomic development in Thailand. In addition, methods of contraception to be used in the program (primarily the IUD and oral contraceptives) were described in detail. All physicians and nurse/midwives were trained in Bangkok, while the training for the larger numbers of auxiliary midwives was conducted in the provinces. During 1970, brief, 2-day indoctrination courses were also developed for male health workers so that they too would be familiar with the aims of the program and would then be in a position to assist in the motivational aspects of the program. Over 7,600 personnel of the MOPH received training in the field of population and family planning between 1968 and 1972 (Table 1). By 1972, the basic training had been completed and thereafter only refresher courses were provided.
clinic; the acceptors simply learned from friends or satisfied acceptors. ' 6 When the government announced a national population policy in 1970, the restriction on public informational activities was removed, but for a variety of reasons, nationwide public information activities in campaigns were implemented for the first time only in late 1972. It should be emphasized, however, that from the beginning both Ministry health personnel and, more important, satisfied acceptors, served as communicators about family planning, this being a most effective means of communication.' 7,18
Services Following training of their personnel, family planning clinics were opened in the provincial hospitals and in those rural health centers staffed with a physician. The auxiliary midwives were expected to provide motivation and information to couples in their areas of coverage, referring those interested in services to the health centers and hospitals. By mid-1970 there were close to 350 clinics in hospitals and health centers throughout the country where oral contraceptives and intrauterine devices could be obtained. Female tubal ligation was available, primarily as a postpartum procedure, in about 90 hospitals, with the majority of them being performed in a small number of hospitals. After the successful conclusion of a pilot study, in which auxiliary midwives in four provinces were allowed to prescribe the pill primarily, utilizing a simple checklist, the Ministry ruled, in mid-1970, that auxiliary midwives throughout the country could prescribe the pill.' 9 Because it was felt that the basic family planning training course was
Public Information During the early years of the program, the government did not allow any public information activities about family planning. The MOPH, therefore, did not undertake any public health education programs, but stressed instead simple person-to-person communication. There already was evidence in Thailand that this was a most effective means of the spread of information. In 1965, a large Bangkok hospital opened a family planning clinic and during the first 3 years patients came from 65 of Thailand's 71 provinces, without any attempt to spread information about this TABLE 1-Training, 1968-1972
Year
Classification
1972
Total
158 190 49 -
588 1,060 3,868 1,985
83
183
1969
1970
87 174 948
102 203
141 323
1,003
-
-
1,139 1,985
-
-
-
20
80
1,209
1,308
3,608
1,079
480
7,684
Physicians
Nurse/midwives Auxiliary midwives Sanitarians F.P. clinic workers Total
1971
1968
100 170 729
TABLE 2-Family Planning Acceptors* in The National Family Planning Program, 1968-1974
IUD Pill
Tubal ligationt Vasectomyt Total
1968
1969
1970
1971
1972
1973
1974
35,300 10,000 12,000
54,500 60,500 15,300
74,400 132,400 18,700
86,000 294,600 23,600
89,100 327,400 32,000
93,600 268,300 46,400 2,900 411,200
89,400 302,600 73,100 7,000 472,100
-
-
-
-
-
57,300
130,300
225,500
404,200
448,500
* Figures rounded to nearest hundred. t Until 1973, male and female sterilization procedures were reported together, the vast majority being female postpartum tubal ligation.
866 AJPH AUGUST, 1975, Vol. 65, No. 8
sufficient to prepare the midwives to carry out this new duty, more than 3,000 midwives already trained were then able to prescribe the pill. In 1968, there were approximately 57,000 acceptors of the IUD, pill, and female sterilization. By 1972 the annual total had increased dramatically to almost 450,000 new acceptors which, after a slight fall in 1973, rose to over 460,000 in 1974 (Table 2 and Figure 1). There similarly had been a dramatic change between 1968, when IUD acceptors outnumbered pill acceptors 3:1, and 1972 wherein IUD acceptors had increased from 35,300 to 89,100, but pill acceptors had increased from almost 10,000 to 327,400, producing almost an exact reversal in the IUD:pill ratio. Thus, the number of pill acceptors increased from approximately 10 per cent of the total in the early years to 72 per cent in 1972. Similarly by 1972, most acceptors (78 per cent) received services in rural health centers throughout the country, whereas in the earlier years there was a predominance of acceptors in urban hospitals, particularly in Bangkok. In 1972-1973, there was a drop in pill acceptors, due, in part, to a change in pill brand, with some increase in side effects (primarily intermenstrual spotting).20 Because the rural health personnel were not sufficienty prepared for this problem, they were unable to offset the rumors that spread relating to the new pill. The numbers of both acceptors and continuing users fell, but by 1974 the downward trend had been reversed and new acceptors of the pill rose again to approximately 300,000. Postpartum tubal ligation is offered in most hospitals which provide maternity care. There has been a gradual increase in the number of procedures done each year since 1968. In 1972, the cost of the procedure to a patient was reduced from a range of $10-40 to $7.50 and in 1973, a UNFPA project provided an additional $7.50 per case to the hospital to help cover costs. As a result there was a
significant increase in the number of acceptors in 1973 and 1974,2 1,22 reaching approximately 70,000 in 1974. Interval tubal ligation has not been a popular procedure, but with the development of a simplified procedure, called the "mini-lap," at one Thai teaching hospital,2 3 it is hoped that this procedure will also increase in popularity throughout the country. Training of physicians in this technique is simple and initial training courses are already underway. At some of the larger hospitals interval procedures such as laparoscopy, culdoscopy, and/or posterior colpotomy are available. Vasectomy has not yet been widely accepted, but information efforts are underway, and in 1974, there was a significant increase, with vasectomy acceptors totaling approximately 7,000, as compared to 2,900 in 1973 and much smaller numbers in preceding years.22 Role of Nursing and Auxiliary Personnel The medical complications and contraindications of the pill and the IUD were reviewed and after weighing the risks and benefits to be gained, it was recommended that nursing and auxiliary personnel be allowed to prescribe the pill without the requirement of a pelvic examination, and further that, with appropriate training, these personnel could also insert the IUD.' The increase in numbers of pill acceptors, since implementing this concept in the Thai program, is a dramatic example of the effectiveness of an expanded role for nursing and auxiliary personnel in the field of family planning. During the four-province pilot study mentioned above there was a 4-fold increase in the number of pill acceptors in the 6-month period after initiating the study and the 12-month continuation rates were higher among women who received the pill from auxiliary midwives than were the rates in women who received them from physicians.' 9 One hypothesis proposed
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1UI g -
t*¢j-_ s17
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to explain these differences is that the auxiliary midwives are more accessible to the acceptors, both physically and socially, than are physicians. When the MOPH reviewed this project and decided that all auxiliary midwives who had already been trained could prescribe the pill, the national program then moved forward at an even faster rate than expected. Figure 2 presents the acceptors by method for each 6-month period between 1969 and 1971. As can be seen, the ruling concerning the auxiliary midwives resulted in an almost immediate increase in the pill acceptors, and thus in the overall totals. More recently, with assistance from the UNFPA and UNICEF, motorcycles have been provided to all midwives in an attempt to increase their mobility and thereby- hopefully their effectiveness. The MOPH has carried out a special study in which nurse/midwives are taught the technique of IUD insertion. Evaluation is underway at present, but the preliminary results suggest that this is both a safe and appropriate next step, with very high 12-month continuation rates (87 per cent) in women receiving the insertion from a nurse/midwife. We strongly feel that family planning programs (and the health system in general) must make better use of nursing and auxiliary personnel, particularly in developing 160,000 =
countries. We must be practical and accept that doctors are not required for all such services. The Postpartum Program
In 1966 four Bangkok hospitals joined an international cooperative study called the International Postpartum Program.24 In 1969-1970 the program was expanded to 11 MOPH hospitals located outside Bangkok.25 Eight of the hospitals belonged to the provincial network of the Department of Medical Services. The other three were a part of a new category of facility in Thailand, called Maternal and Child Health Centers, which include an auxiliary midwifery school and a 60- to 80-bed maternity hospital.26 All of the hospitals in this expanded program provide care for 1,500 to 7,000 obstetrical and abortion cases per year, with a mean of 3,700 cases per year. The program in each participating hospital stresses the provision of information and motivation to maternity patients in the antenatal clinics, in the labor rooms, and, most particularly, on the postpartum wards.25 Immediate postpartum IUD insertion is offered every day, with the insertion usually done on day 2 to 4 postpartum. Thailand has been a leader internationally in the insertion of the IUD
SteriizatiWn
-IUD
i....
140,00Q
-.:e-_.. = Pill'
120,000
100,0001_ 0 40 S
80,000
F
60,000
F
.0
E
z
40,000_ 122
20,000
fl 8,153
7,11
Jul-Dec
Jan-Jun
_199
-- -q
9* j
m
I
Jan-Jun
4'
1970L
Jul-Dec
I
1-9
i
Jan-Jun
Ministy ruling on auxiliary rrmdwife pit prescription FIGURE 2 Family planning acceptors by 6-month periods, 1969-1971. 868
AJPH AUGUST, 1975, Vol. 65, No. 8
never practiced contraception before, although obviously the percentage has decreased somewhat in more recent years. Thus, the Thai program has been reaching rural women of lower socioeconomic status, the primary target for assistance in general by the government. There have been a series of home interview follow-up surveys of acceptors in the national program. In 1971, the first nationwide sample survey of acceptors was conducted; the earlier studies were of selected groups, with the first one in 1969 (Table 3). The continuation rates, particularly for the pill, have been among the highest reported from national programs in Asia, with 12-month rates of 76 per cent for the IUD and 68 per cent for the pill; at 24 months, these rates have fallen to 63 and 53 per cent, respectively.28 Even at 48 months, the IUD continuation rate was a surprising 48 per cent. It is suggested that these rates may be higher than those reported from other programs because the Thai program has not used incentive payments either for the health staff or for acceptors, no formal targets per worker or per clinic were established, and most acceptors pay a small fee for service. Thus, perhaps the Thai acceptors are more highly motivated, therefore continuing use longer. A second national survey of pill acceptors was conducted in 1974. Preliminary analysis shows a drop in pill continuation rates to 59 at 12 months, falling to 41 at 24 months.22 This drop apparently is related to the fall in pill acceptance rates mentioned earlier. Further analysis is underway which, it is hoped, will help to explain the fall of the decreased rates. In 1969, the Institute of Population Studies at Chulalongkorn University conducted the first rural round of its National Longitudinal Survey of Social, Economic, and Demographic Change.29 In that round, they found that 11 per cent of married, fertile women, age 15 to 45, were currently practicing contraception or were sterilized.30'3 1 In the second rural round conducted in mid-1972, this percentage had already risen to 23 per cent, a 100 per cent increase.32 In urban areas the percentage currently practicing contraception increased in the 2-year period by about 12 percentage points, to 41 per cent in provincial urban areas and 48 per cent in Bangkok-Thonburi.32 This has contributed to about a 12 per cent decline in general marital fertility between the two survey periods. While a significant percentage of these changes may be
in the immediate postpartum period and has been responsible for over 70 per cent of all immediate postpartum insertions reported in the international program. To date there has not been any increase in infection or perforation, although the expulsion rate is slightly higher than in the regular IUD insertion cases. The most dramatic successes have been noted at the Chulalongkorn Hospital in Bangkok where there had been over 85,000 IUD acceptors by early 197527 and at the MCH centers, where close to 65 per cent of all obstetrical and abortion patients accept family planning services, the majority accepting an immediate postpartum insertion of an IUD or a female sterilization. The 15 hospitals in this study accounted for approximately 20 per cent of all acceptors in the overall national program in 1970-1971.
Evaluation A special evaluation section was created within the Ministry to follow the progress of this program. A carbon copy of the basic demographic data on all new acceptors of family planning services is sent directly to the central research and evaluation unit, as is one copy of the monthly report from all clinics. Through this rapid reporting system, the central unit receives data within 2 weeks of the end of the month from well over 90 per cent of participating clinics, and the unit, in turn, prepares for wide distribution a report with data by district, province, and organizational department or agency. Recently the system has been computerized, which has increased the efficiency significantly. Analyses of patient characteristics are carried out periodically. The results have not changed significantly over time and have revealed, in general, that approximately 80 per cent of all new acceptors live in rural areas, mostly working as farmers, and over 90 per cent having attended school beyond the 10th grade. The acceptors have been younger than in some other Asian programs, with over 50 per cent being under 30 years of age. In addition, two-thirds of the acceptors have had four or fewer living children. The majority accepted services for purposes of limitation and almost one-half accepted within 6 months of the last pregnancy, indirect evidence of the importance of the postpartum concept. Finally, the great majority had TABLE 3-Continuation Rate Studies, 1969-1974 12 Months
Study Potharam District-1 969 Postpartum program-1970
Selected districts-1970 National-1971 National-1 974t
Pill
IUD
-
70 79 76 76
72 67* 68 59
-
48 Months
24 Months Pill
IUD
Pill
IUD
-
56 65 56 63
-
41 47
-
48
53 -
53 41
-
-
-
* The 12-month pill continuation rate in a special study in which auxiliary midwives were allowed to prescribe and resupply the pill was 76 per cent. t Preliminary results.
FAMILY PLANNING IN THAILAND 869
due to the NFPP, it also should be noted that an undetermined percentage of pill users obtain their supplies from an active commercial sector, particularly in urban areas. It is estimated that approximately 300,000 cycles are distributed monthly.20
Conclusion The family planning program in Thailand has demonstrated the successful integration of family planning services within a national health infrastructure even in the absence of full-time workers, public information activities, and incentives. It seems clear that the program would not have developed anywhere as rapidly had a separate infrastructure and system been established first. The acceptance of family planning in government health facilities exceeded expectation, thus suggesting the high motivation that exists for family planning among Thai couples. The importance of the utilization of nursing and auxiliary personnel to prescribe the pill has been clearly demonstrated, particularly in view of the critical shortages of physicians in rural areas. The effect of the Ministry's ruling that the 4,000 auxiliary midwives throughout the country could prescribe the pill was a dramatic demonstration of this c6ncept. It allowed the program to exceed the 1971 national target number of acceptors by over 100,000 and preliminary evidence suggests that pill continuation rates are higher when prescribed by auxiliary midwives than by doctors. Thailand's program has also demonstrated the importance of the postpartum family planning concept. When women do deliver in a hospital setting, special motivational efforts should be made during the antenatal clinic visits and, more important, on the postpartum wards. With proper motivational efforts, a majority of women who receive maternity coverage will accept family planning services postpartum, whether for purposes of spacing or of limitation. The Thai experience has shown the safety of the insertion of an IUD within the first few days postpartum, a most popular procedure. Similarly, the decision conceming a sterilization procedure should no longer be based on a set number of children, but rather on the wishes of the couple concerned, after consultation with their physician. The challenge now is to adapt what has been learned in the provision of maternity and family planning services for women delivering in a hospital setting to the great majority of women in rural areas throughout the developing world who deliver their babies in the home without trained medical attendants present. Studies are now underway to attempt to find ways to improve such services in rural areas. In spite of these successes a variety of problems remain. Increased high level governmental support is needed with increases in budgets, civil service positions, supporting public statements, etc. Supervision within the health system, so important in the development of a truly effective long term program, is relatively ineffective at the present time and a major effort is required to improve it. Several questions presently either being evaluated or under 870 AJPH AUGUST, 1975, Vol. 65, No. 8
consideration as the government attempts to develop ways to maintain the present momentum include: are full-time field workers necessary in later, more difficult, stages of a family planning program; how best can community-based distribution programs be developed and can oral contraceptives be distributed safely outside the usual medical or paramedical system; can Depo-Provera be introduced safely into the national program and will it prove an important and effective addition to the methods presently offered; what is the role of incentives; how can the performance of less effective clinics be improved; how can population education be introduced most effectively; and how best can public information activities be developed? In addition, the National Economic and Social Development Board is coordinating efforts aimed at involving other ministries and agencies in appropriate ways. Thailand seems well on the way to bringing about a reduction in its high population growth rate, which should, in turn, assist the nation's important efforts at socioeconomic development.
References 1. Nortman, D. Population and Family Planning: A Factbook, Ed. 6. Reports on Pop/Fam Plan. Population Council Monograph, New York, 1974. 2. Davis, K. Zero Population Growth: The Goal and the Means. In The No-Growth Society, edited by Olson, M., and Landsberg, H. H., pp. 15-30. W. W. Norton & Company, New York, 1973. 3. Tabbarah, R. B. Population Policy Issues in International Instruments: With Special Reference to the World Population Plan of Action. J. Int. Law Econ., in press. 4. Berelson, B. The Great Debate on Population Policy. In preparation. 5. Rosenfield, A. G. Family Planning: An Expanded Role for Paramedical Personnel. Am. J. Obstet. Gynecol. 110:1030-1039, 1971. 6. Spengler, J. J. Population Problem: In Search of a Solution. Science 166:1234-1238, 1969. 7. Speidel, J. J., Ravenholt, R. T., and Perry, M. I. Non-clinical Distribution of Oral Contraceptives. In Advances in Planned Parenthood, edited by Lewit, S., pp. 28-40. Excerpta Medica, Amsterdam, 1973. 8. World Health Organization. Family Planning in Health Services. W. H. 0. Tech. Rep. Ser. 476, 1971. 9. Worth, G., Watson, W. B., Han, D. W., et al. Korea/Taiwan 1970: Report on the National Family Planning Programs. Stud. Fam. Plann. 2:57-69, 1971. 10. Hardee, J. G., and Satterthwaite, A. P. Pakistan. Country Profiles. Population Council Monograph, New York, 1970. 11. Marzuki, A. B., and Peng, J. Y. Malaysia. Country Profiles. Population Council Monograph, New York, 1970. 12. Gaisie, S. K., Jones, S. B., Caldwell, J. C., and Perkin, G. W. Ghana. Country Profiles. Population Council Monograph, New York, 1970. 13. Soewondo, N., Djoewari, O., and Ryder, B. Indonesia. Country Profiles. Population Council Monograph, New York, 1971. 14. Soni, V. India's Family Planning Programme: A Brief Analysis. (Mimeographed) 1971. 15. Rosenfield, A. G., Hemachudha, C., Asavasena, W., and Varakamin, S. Thailand: Family Planning Activities 1968-1970. Stud. Fam. Plann. 2:181-191, 1971.
16. Fawcett, J. T., Somboonsuk, A., and Khaisang, S. Thailand: An Analysis of Time and Distance Factors at an IUD Clinic in Bangkok. Stud. Fam. Plann. 1:8-12, 1967. 17. Schramm, W. Communication in Family Planning. Reports on Pop/Fam Plan. Population Council Monograph, No. 7, New York, 1971. 18. Rosenfield, A. G., Asavasena, W., and Mikhanorn, J. Thailand: Family Planning Communication through Person-to-Person Contact. Stud. Fam. Plann. 4:145149, 1973. 19. Rosenfield, A. G., and Limcharoen, C. Auxiliary Midwife Prescription of Oral Contraceptives: An Experimental Project in Thailand. Am. J. Obstet. Gynecol. 114:942-949, 1972. 20. Alers, J. O., Asavasena, W., Suvanavejh, C., and Rosenfield, A. G. Thailand (1972). Stud. Fam. Plann. 4:124-127, 1973. 21. Suvanavejh, C., and Donaldson, P. J. Thailand (1973). Stud. Fam. Plann. 5:169-172, 1974. 22. Varakamin, S. Thailand (1974). Stud. Fam. Plann., in press. 23. Osathanondh, V. Suprapubic Mini-laparotomy, Uterine Elevation Technique: Simple, Inexpensive and Outpatient Procedure for Interval Female Sterilization. Contraception 10:251-262, 1974. 24. Zatuchni, G. I. (ed.). Postpartum Family Planning. McGraw-Hill Book Company, New York, 1970. 25. Rosenfield, A. G., and Varakamin, S. The Postpartum
26.
27. 28.
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30.
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32.
Approach to Family Planning: Experiences in Thailand, 1966-1971. Am. J. Obstet. Gynecol. 113:1-13, 1972. Rosenfield, A. G., and Asavasena, W. Maternity Care in Rural Thailand. Am. J. Obstet. Gynecol. 115:10131020, 1973. Somboonsuk, A., and Rosenfield, A. G. Experiences with the Lippes Loop, 1965-1970. Int. J. Gynaecol. Obstet. 11:16-24, 1973. Hemachudha, C., Asavasena, W., Varakamin, S., Rosenfield, A. G., Jones, G., and Alers, J. 0. Thailand (1971). Stud. Fam. Plann. 3:151-156, 1972. Prachuabmoh, V., and Thomlinson, R. (eds.). The Methodology of the Longitudinal Study of Social, Economic, and Demographic Change. Institute of Population Studies, Chulalongkorn University, Bangkok, 1971. Prachuabmoh, V., Knodel, J., Prasithrathsin, S., and Debavalya, N. The Rural and Urban Population of Thailand: Comparative Profiles. Research Report No. 8. Institute of Population Studies, Chulalongkorn University, Bangkok, 1972. Knodel, J., and Pitaktepsombati, P. Thailand: Fertility and Family Planning among Rural and Urban Women. Stud. Fam. Plann. 4:229-225, 1973. Knodel, J., and Pitaktepsombati, P. Fertility and Family Planning in Thailand: Results of the Second Round of the Longitudinal Study. In press.
SYMPOSIUM ON "ADOLESCENCE AND PSYCHOSIS: A HOLISTIC APPROACH TO DIAGNOSIS AND TREATMENT" SCHEDULED FOR NOVEMBER "Adolescence and Psychosis: A Holistic Approach to Diagnosis and Treatment," for physicians and mental health professionals, will be held at the Roosevelt Hotel, New York City, November 15, 1975. Sponsored by the Joint Committee on Schizophrenia, New York State District Branches, American Psychiatric Association, the symposium will examine the multiplicity of factors that operate to produce maladjusted adolescents and which exist both as independent entities and in a complex interrelationship with one another. For additional information on the symposium, contact Lester E. Shapiro, MD, General Chairman, 43 Andover Road, Rockville Centre, NY 11570.
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