•
• WPRO 9604
FIRST REGIONAL SEMINAR ON THE TEACHING OF FAMILY PLANNING, HUMAN REPRODUCTION AND POPULATION DYNAMICS IN MEDICAL SCHOOLS
Sponsored by the
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Kuala Lumpur, Malaysia 26 October to 1 November 1971
FINAL REPORT
NOT FOR SALE PRINTED AND DISTRIBUTED by the
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REGIONAL OFFICE FOR THE WESTERN PACIFIC of the World Health Organization Manila, Philippines March 1972
NOTE
The views expressed in this report are those of the consultants and participants at the seminar and do not necessarily reflect the policy of the World Health Organization.
This report has been prepared by the Western Pacific Regional Office of the World Health Organization for Governments of Member States in the Region and for those who participated in the First Regional Seminar on the Teaching of Family Planning, Human Reproduction and Population Dynamics in Medical Schools, which was held in Kuala Lumpur. Malaysia. from 26 October to 1 November 1971.
TABLE OF CONTENTS
1.
INTRODUCTION OBJECTIVES SEMINAR PROCEDURE
2. 3.
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1 1 1
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4.
SUMMARY OF DISCUSSIONS 4.1 Pre-seminar vis its
.................................... . . .. .. .. .. .. .. .. .. .. .. .. .. . . . . . . . .. . .. ..
2
2
4.2 4.3
4.4 4.5
4.6
4.7 4.8
The Teaching of Human Reproduction •••.•••••• Post-Graduate Education •••••••••...•••••••.• Teaching of Population Dynamics .•••••••••••. On Methods of Contraception •••••.•••••.••••. Abortion as a Method of Family Planning Organization of a Family Planning Programme Administrative Considerations in Strengthening Family Planning, Human Reproduction and Population Dynamics in Medical Education ..
4 6
7 11
13
15 17 19
5.
SUMMARY OF THE SEMINAR
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ANNEXES
ANNEX 1 ANNEX 2
LIST OF PARTICIPANTS, CONSULTANTS, SECRETARIAT AND OBSERVERS . •. • . . •• ••• •••• •••• •••• ••. . . OPENING SPEECH BY THE HONOURABLE MINISTER OF HEALTH •• . •• . . •••••• •. . ••• . •• ••. ••• LIST OF COUNTRY REPORTS AGENDA
21 27 31/32 33 37
ANNEX 3 ANNEX 4 ANNEX 5
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LIST OF WORKING PAPERS
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1.
INTRODUCTION
A regional seminar on the Teaching of Family Planning, Human Reproduction and Population Dynamics was convened by WHO at the Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, from 26 October to 1 November 1971. All of the sixteen participants from twelve countries were active teachers of either obstetrics and gynaecology, maternal and child health or preventive medicine in the Region (see Annex 1). 2. OBJECTIVES
The main objectives of the seminar were: 2.1 To provide an opportunity for an exchange of information on the organization and programmes of medical schools in the Region concerning the teaching of family planning, human reproduction and population dynamics; To discuss the methods of establishment and/or development of such teaching programmes; To consider the place of family planning, human reproduction and population dynamics within the medical curriculum. 3. SEMINAR PROCEDURE
2.2 2.3
Dr Donald R. Huggins, WHO Representative for Malaysia and Singapore welcomed the participants on behalf of Dr Francisco J. Dy, Director, WHO Regional Office for the Western Pacific. In the welcoming speech, the importance that WHO attaches to the teaching of family planning, population dynamics and human reproduction ,in medical schools was stressed. It was explained that although WHO had been involved in group educational activities in other subjects taught in medical schools and had organized meetings of deans of medical schools in the Region, this was the first seminar devoted to this particular subject. It was explained that in the future WHO intended to hold other seminars on family planning and its teaching, not only in medical schools but in other educational centres for health personnel. The importance of health workers working as a team was highlighted and of the teaching of family planning, human reproduction and population dynamics to medical students as future leaders of this team was stressed.
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The seminar was officially opened by the Honourable Minister of Health, Tan Sri Haji Sardon bin Haji Jubir. In his speech, he stressed the relevance of family planning, human reproduction and population dynamics in the development of Malaysia (see Annex 2). The participants and consultants were welcomed on behalf of the University of Malaya by the Dean of the Faculty of Medicine, Dr T.J. Danaraj. Following an introductory statement by the Director of the seminar, Dr Samuel M. Wishik, there was a session of selfintroduction by participants, consultants and WHO secretariat. Dr Winifred Danaraj was elected Chairman of the seminar and Dr Nguyen van Hong, Vice-Chairman. The following were designated rapporteurs: Dr Dr Dr Dr Dr Dr Dr Dr Dr A. de la Paz C. A. Michael D.G. Johnson Vannareth R.C. Begg T.A. Sinnathuray J.J. Tsuei V. Tuivaga S.W. Km
The proposed agenda of the seminar was adopted by the participants and this was followed by a general discussion of the country situation. There was no individual presentation of country reports (see Annex 3) but during this session and throughout the seminar participants were encouraged to give details relevant to the situation in the country. The following sections give a summary of the discussions during the remainder of the seminar. These followed the general plan of the Agenda (Annex 4). A list of the working papers which served as a background to the discussions is given in Annex 5. 4. 4.1 SUMMARY OF DISCUSSIONS
Pre-seminar Visits
The Seminar Director, Dr S.M. Wishik, and the consultants Dr G. Aragon and Dr K. Smith gave the highlights of their preseminar observations in visits to twelve medical schools and schools of public health in seven Western Pacific Region countries. As yet, only a small proportion of these medical schools have developed an organized family planning teaching programme. There is a fairly wide range in the extent of coverage of the subjects
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of population dynamics and demography. In all the schools, family planning services usually started by private agencies and, in some instances, subsequently taken up by the national governments, ante-dated the initiation of formalized family planning teaching. The departments of social and preventive medicine and/ or obstetrics and gynaecology started the programme. Instruction begins at the third year level or later. Infertility and cytology instruction are not emphasized. Student participation in services is very limited and is largely by passive observation. Pre-natal and postnatal clinics are not always utilized for family planning motivation of patients or for training of students in family planning. One progressive medical school has greatly reduced the hours devoted to didactive lectures. There seems to be a trend toward the tutorial system and seminars on assigned topics. Some schools have demonstration comprehensive health programmes, including family planning services, or demonstration clinics or areas. In the discussion that followed the consultants' presentations, the advantages of block teaching of medical subjects were advanced. There was also much said on the question of the teaching of family planning as a separate subject versus its integration into the medical curriculum. One participant felt that, because of an overloaded curriculum, family planning should be offered only at the post-graduate level. However, others mentioned that the majority of doctors do not return for post-graduate courses. To offset the problem of an overcrowded curriculum, it was . suggested that facets of human reproduction be distributed among the subjects of anatomy, physiology, pharmacology and biochemistry in addition to obstetrics and gynaecology, while demography be added to vital statistics in social and preventive medicine together with other social considerations. A participant suggested that a full-time faculty member be in charge of integrating and co-ordinating the family planning programme in the medical school and that theory be integrated with practice. Curric~lum changes constantly pose problems in an already crowded curriculum. Although authority to modify the curriculum may be restricted at the national and university levels and by the curriculum committee of the medical school, considerable autonomy seems to exist in departments to make changes within allotted hours. It was observed that there is a positive supporting policy for family planning in some national governments and no serious negative attitude toward the teaching of family planning in any country. The teaching staff for family planning in medical schools were observed to have a heavy responsibility. Some carry dual teaching assignments, such as in the medical school and school of public health or in medical schools and schools of nursing. Others also do teaching outside of the medical group of professional schools.
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It was urged that greater use be made of clinical services for the teaching of family planning, such as' in hospitals, health centres, rural health units and domiciliary services. It is felt that building a proper outlook of "social concern" early in the medical course of students could enhance the effectiveness of family planning teaching. Mention was made of offering an optional course in sex education in the first year, to respond to the personal interests of the students. Clearly, there is a general need for teaching materials - films, slides, models. To improve the teaching of family planning in medical schools, it was brought out that a start must be made by teaching the faculty members the rudiments of family planning, population dynamics and human reproduction so they may have greater awareness and be effective teachers of these subjects to medical students. 4.2 4.2.1 The Teaching of Human Reproduction Content
The seminar considered that the endocrinological aspect of reproduction in the female was an important subject to be taught because of two reasons. Firstly, it provided the physiological basis of reproduction. Secondly, it was important because the contraceptive pill is a widely used method for contraception. It was also felt that other methods of contraception, e.g., mechanical methods and others should also be taught to students. It was also agreed that sex education forms an integral part of the teaching of family planning. This could be taught early to students who seem to be themselves very interested in this subject. 4.2.2 Timing and method of instruction
It was felt that the teaching of human reproduction should be started in the first year and then repeatedly reinforced in subsequent years. Lectures, audio-visual aids and practical demonstrations of surgical techniques are to be used together with opportunities for student participation in seminars, exhibitions and personal discussion with ante-natal and post-partum mothers. Patient and community contact by the students were emphasized. 4.2.3 Instructors
It was agreed that the approach should be a multidisciplinary one. In the pre-clinical years, human reproduction can be taught by staff from the departments of anatomy, physiology, biochemistry, pharmacology and psychological medicine with clinical teachers at times giving the applied aspects. In the clinical years, the staff of the departments of obstetrics and gynaecology, paediatrics, urology and social and preventive medicine would give the instruction, while calling on pre-clinical teachers to help when
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necessary. An integrated approach would be employed wherever possible. Also, the community mindedness of students should be stimulated and sustained in the teaching of family planning. It was in the area of who should be the co-ordinator of the teaching programme in human reproduction in the faculty of medicine that there were differences of opinion. The suggestions made were as follows: (i) The head of the department of obstetrics and gynaecology - some felt that this was logical, since that department teaches and is involved in the practical issues of human reproduction. A caution was raised that the department head faced with such a heavy service load may be unable to give as much attention to the direction of a teaching programme as is required. A professor of maternal and child health and family planning might be appointed. He could devote his full time to co-ordinating the teaching of family planning in the medical school. The department of obstetrics and gynaecology (a rather restricted term) should be enlarged and changed to a department of reproductive medicine. The departmental head should then have responsibility for co-ordinating the programme of the teaching of family planning in the faculty. A university based institute to co-ordinate the teaching and practice of family planning and population dynamics might be formed. The dean of curricular affairs, together with a small committee, should adopt certain themes for consideration by the faculty. These were topics of importance which for their solution required the co-ordinated efforts of several discplines. These themes could be changed from time to time. Some themes for current consideration were: (a) (b) (c) (d) accidents, growth, development and ageing, epidemiology of family health, family planning, human reproduction and population dynamics.
(ii)
!
(iii)
(iv)
(v)
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At this stage it was felt desirable to define the following terms: (1) Population control A policy, usually at government level, to modify the population according to the country's need by various means, including social legislation. More recently, the trend has been to try to decrease the rate of population growth. This would also include aspects of population modification, i.e., total numbers, rate of change of population density, social and environmental factors, geographic distribution. (2) Fertility control This refers to any effort within the family or nation to modify the fertility performance. (3) Contraception A subcomponent of the above terms. This refers to the methods taken to prevent conception. (4) (5) Birth control, on the contrary, includes therapeutic abortion. Family planning This restricts the matter to the family level. This includes timing of the pregnancy in relation particularly to the woman's age and to the family's plans and needs. It would include the problems associated with the subfertile couple aiming to have children and highly fertile individuals actively avoiding further pregnancy. In the future, even the sex of the child may be knowingly determined at conception. 4.3 Post-Graduate Education
A broad outline of various training programmes for medical graduates in the fields of family planning and human reproduction was given. These included training for the intern (resident medical or house officer), general medical officer and trainee specialist. It was realized that all trained staff required intermittent refresher courses. It was generally agreed that medical officers working in rural or urban areas required short instructive courses in the theoretical and practical aspects of family planning but there were differing opinions as to whether these best took the form of weekend -meetings or courses lasting one or two weeks. Small numbers of
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participants were essential, one suggestion being that a doctor attend a short course at the end of annual vacation. Life-sized models are available on which the insertion of I.U.D.s can be practised but their limitations were also stressed. Respect for a patient's privacy is always an important consideration when teaching. Some discussion was centred on the importance of creating and maintaining a basic interest in family planning. The distribution of suitable booklets to practitioners was suggested and in many centres monthly clinical meetings for practitioners could be used for demonstrations and dissemination of information. The training of specialists in the fields of family planning, public health and obstetrics and gynaecology was briefly mentioned but considerable variation was noted in the programmes being undertaken in different countries. Some dissatisfaction with the training of specialists from developing countries was noted when the whole programme was conducted in a developed country. Research into aspects of reproduction should be carried out in all countries as part of a family planning programme. Much could be done that is relevant, inexpensive and suitable for medical undergraduates or other health workers. Instances were given of good field surveys by students concerning the attitudes of patients to family planning and acceptance of various techniques. The development and long-term investigation into the acceptability of a new plastic cap was outlined and the importance of a good clinic recording system was emphasized. University departments should stimulate research but governmental services should also participate. It was realized that endocrine research was generally restricted to the more developed countries where the necessary facilities and financial backing have been available. There is need for continuing research into improving the quality of children yet to be born. 4.4 Teaching of Population Dynamics and came to the
The participants considered this subject following conclusions: The problem of the living
Any administrator involved in the provision of services would do well to have full knowledge about the population he is to provide for, both at that time and in the future. A country's economy at any moment in time is tuned to the current number of people and sudden upsurges are likely to upset the economy and services. It has been well demonstrated and is apparent that many countries today are expanding their populations to such an extent that services and facilities are already over-committed. The world's population in 1970 was almost four billion people.
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By the year 2000, it will be seven billion at the present rate of increase. Eighty-five percent of the increase occurs in underdeveloped countries. If we are to teach our medical students the art of family planning and contraception, it is clearly important to give them information on why it is necessary. Where rapid population expansion is a factor, this must be highlighted as well as giving the reasons relating to family and individual health. In any public health problem, which of course population growth is, it is necessary to survey the problem, to find the causes and eliminate these as far as possible with appropriate action. Since the cause of rapid population growth is found in the marked reduction in mortality among the infant and young, of course, a reversal of this is not desirable. The only acceptable way of showing the growth rate lies in the limitation of new births. Incentives might be given for people to do this and government policy might even demand it, but in the end it is the doctor and his medical associates who have to advise individuals and couples on how this can be achieved and who have to help them to obtain the service. In order that a doctor may play his part effectively, he must be experienced in the art of counselling, family planning and contraception. He can only do this adequately if he is properly trained and if he is prepared to interpret matters to his patients so they will be encouraged thereby to accept and continue with contraception. Such training is important not only for the doctor who is going to practise family planning but also for a person in other specialties so their advice can be reinforcing rather than negating. The same applies also to staff at medical schools. What do we mean by the term, population dynamics, who should teach it, when and how? What is population dynamics? The study of population structure (numbers, age, sex, geographical situation, work, marital state, etc.) past, present and estimated in the future. We must teach the medical students the sources and reliability of such information. We must teach them to be critical in their acceptance and analysis of such information. Information should be presented in an interesting and practical way relevant to the situation in the students' own country and in comparison with the situation in others.
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(a) Mortality rates - crude, age and sex adjusted, causespecific, infant mortality rate, etc. Are these rates likely to become better or worse? (b) Fertility - crude birth rates, age-specific fertility rates, etc. Levels and trends are affected by other variables, e.g., economic state, culture, contraception and abortions (legalized or not). The consequences of high or low fertility in women, their families and the total population should be discussed. (c) Migration - this may be from the rural areas to town or it may be between countries. Having analyzed these results and made the population projection (in the case of India it is an increase of thirteen million people per annum), it is necessary to explain the consequences of such expansion in the face of already over-extended resources. It may be that the country concerned has no population expansion problem, but thought must be given as to whether this could occur in the future, in which case planning may be required at some stage. The consequences of uncontrolled population expansion should be discussed. There is the matter of food shortages, over-crowding, increased pollution, unemployment, bringing frustration and tension and the breaking down of medical and other services under increased demand. How and when? The teaching should be given by the department of preventive and social medicine using, where necessary, economists and statisticians. It is important to give the elements of this subject early in the course, possibly even in the pre~edical or first year in association with the teaching of sociology. During the fourth or fifth year, the subject would also be included in statistics and vital statistics, and also in the specialist departments of obstetrics and gynaeco10gy and psychiatry where these are relevant. Teaching should be integrated with the other components of the subject of family planning and in such a way as to give a complete picture of the necessity or otherwise for family planning in the context of the population problem. There was considerable discussion on trying to relate population dynamics to clinical problems to promote student interest and to make the subject more meaningful. The increased mortality in the elderly grand multipara and also in very young multipara
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was cited. A girl of fifteen to seventeen who has repeated and closely spaced pregnancies is very much at risk. Information on family planning should be given to women attending ante-natal clinics and in hospital as they may not attend for post-natal examinations. Patients' beliefs were important in this matter as many think that the first delivery is the dangerous one and that thereafter there is no problem. The husband's place in family planning was also discussed. When he is against family planning, all the information and effort directed at the wife could be wasted. Possible reasons for this attitude were advanced and the suggestion that the husband should also be advised and asked for consent was made. Sterilization is offered in one country in the Region to people who have had more than four children and the husband's consent is not required. Doctors' attitudes were also discussed and the example of one country was quoted where the doctors held that there was no problem. In this connexion, it was emphasized that it is not the total area of a country which should be used in calculating the population density but only the area which can be utilized for living. Discussions on the results of population explosion resulted in the conclusion that famine was a real risk, but threatens not from insufficient food as much as from poor distribution. Until people develop a conscience for international well-being as opposed to national interest, this would continue to be a potential problem. Very few human studies have been done on effects of increased density of population. Modern technology could result in replacement of depleted resources. Pollution could be a real problem, especially as nations become highly industralized. A great deal of discussion centred around the content and time at which students should be exposed to the subject. The necessity for students to receive "sex education" at an early stage was constantly stressed. Some Western students may already be "sophisticated" in this direction but many are not, nor are they in most Asian countries. It was agreed that the teaching of population dynamics should be given very early in the course, preferably as an introduction to family planning and incorporated in a series of lectures on sociology. This would have to be fairly basic at this stage, but later on in the course when the student was more mature and had had experience in the clinical subjects, it can be more detailed and better taught in small groups. At this stage, it would form part of the teaching given by the social and preventive medicine department and also the obstetrics and gynaecology and other departments in which a study of appropriate vital statistics was part of the course. The department concerned should retain autonomy in the teaching of this subject as part of its programme. In the teaching of population
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dynamics at any stage, help of economists, statisticians and demographers can also be useful. Psychological and social anthropological aspects should not be neglected. A definition of "population dynamics" along the following lines was suggested: (1) statistics about populations - totals and distribution (age, sex, ethnic, etc.) especially relating to changes that occur over time; measurement of such aspects - WHO tending toward including details on nuptiality among other vital statistics; factors contributing to change (education, economics, mortality, etc.); consequences of such changes (health, economics, etc.).
(2)
(3) (4)
Finally, the student should, as a result of such teaching, be able to look at the patient in a more profound and complete way and see how, at the family and individual level she falls into the demographer's groupings. 4.5
On Methods of Contraception
The need for teaching the undergraduate medical student currently used methods of contraception was unquestioned. It was generally agreed that this subject was to be introduced early during the clinical years (third or fourth year, depending on the curriculum of each particular school), and that.it be taught by the staff of the Department of Obstetrics and Gynaecology. The course contents would include basic knowledge on all aspects of contraceptive methodology, such as: methods of contraception (classification was briefly discussed), types available, the advantages and disadvantages as well as the indications and contraindications; mode of action and correct usage; the various factors (effectiveness or limitations), acceptability, hazards and side effects (psychological, emotional, cultural and religious), which to a large measure, determine the ultimate choice of contraceptive. The manner of instruction could initially be by the lecture seminar method, for small groups of students; using teaching aids such as slides, films, samples of contraceptive devices, demonstrations and initial student practice on pelvic models or mannequins before the actual introduction to the patient. Such theoretical instruction is to be supplemented during clinical clerkship and
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internship by actual attendance and student participation in all activities of family planning clinics. At this point, it was stressed that respect for the patient's privacy and feelings were to be observed, by allowing the presence of only a very limited number of medical students (one or two at a time), for each patient. For a more comprehensive learning experience, it was felt desirable to have, whenever possible, both a hospital based and a community type of family planning clinic. The student would then participate as a member of the working team of each of these clinics and even make field visits with them. The students should not only be well informed on the types and modes of action of each contraceptive modality, but should also be able to guide the patient on the proper choice of contraceptive method - the one best suited for her needs (from the medical, social or cultural, moral or religious considerations); as well as be competent to give her proper instructions on the method chosen. A prerequisite to all of these would be competence in pelvic examination, history-taking and an evaluation of her psycholo-sexual make-up and home environment. In this connexion, mention was made of the varying significance attached to possible side effects (like spotting), from the pill or IUD, by women of different cultures and ethnic backgrounds. This was considered important in giving these women the proper advice and guidance during their follow-up visits. Other items discussed were: (a) the observed low incidence of thrombo-embolic diseases among Asians and its implication on the use of the pills; the possible inaccuracies of statistics on incidence of cancer of the cervix in some areas; the varying composition of the different types of pills in use and their possible side effects, inclusive of their possible effect on lactation, when employed in the immediate post partum period; the use of long-acting injectable progestogens; the benefits which may be derived from the use of pills - other than contraception (euphoria, correction of menstrual cycle). the use of the IUD in the immediate post-partum; advantages and disadvantages; precautions to minimize its hazards; how long it may be left within the uterus and the relation of its effectiveness to the ratio of IUD size/uterine cavity;
(b) (c)
(d) (e)
(f)
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(g) (h)
the newer methods still under experimentation; the usual methods of male and female sterilization.
The group felt that the prevailing cultural and ethical practices in each country, tempered by the individual's personal conscience, would guide each physician in the offer of contraceptive and sterilization services to the patient. 4.6 Abortion as a Method of Family Planning
Induced abortions as a method of family planning and population control has long been practised by mankind. The attitudes of governments and community leaders toward induced abortions and the methods employed for the termination of pregnancy have varied, depending upon such factors as culture, religion, degree of socioeconomic development, advances in contraceptive technology and the legality of the issue. 4.6.1 Indications for induced abortion
The motives for induced abortions are many; i.e., medical, social and economic; but probably, at present, the most frequent reason for induced abortions is family limitation. In the context of modern obstetrical and gynaecological practice, the broad indications for induced abortion are: (a) (b) (c) (d) (e) maternal organic diseases; maternal psychiatric diseases; eugenic reasons; social indications including rape and illegitimacy; family planning.
It is "in this last field that there has been a widened sphere of activity throughout many countries of the world in this decade. It is also because of the significant role that therapeutic abortion has assumed in relation to family planning in the second half of this century, that there has been considerable advance in the medical technology of abortion induction. 4.6.2 Methods of induced abortions
These can be divided into conventional or scientifically acceptable methods and the crude unscientific methods. The former group of scientifically acceptable or conventional methods are wel1known to all of us. Of these, the most widely practised is D & C (dilatation and curettage). More recently employed methods for the
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induction of abortions, are the use of the suction-curette in the first trimester of pregnancy and the intra-amniotic injection of hypertonic saline in the second trimester. Still under experimental use, for the same purpose, are the PROSTAGLANDINS. It was pointed out that there are still many crude and unscientific methods of induction of abortion being practised, which are peculiar to each ethnic and regional group of population. 4.6.3 Hazards of induced abortions
The hazards of induced abortion when improperly performed are too well-known to all practising obstetricians and gynaecologists. However, haemorrhage, infection, shock, peritonitis and embolism resulting from illegally-induced abortions are still major causes of maternal mortality in the under-developed and developing Asian countries. It was also pointed out that the less apparent causes of maternal morbidity resulting from improperly induced abortions, such as chronic pelvic pain, chronic anaemia, chronic pelvic sepsis and secondary infertility, contribute to a far more common problem. Such complications often cause the patient to become a "gynaecological cripple". The "ICEBERG" analogy was cited to point out that whereas the maternal mortality was represented by that small portion of the iceberg apparent above water level, the occult maternal morbidity was represented by the large hidden portion of the iceberg. 4.6.4 Country situation
The position of induced abortions, both legal and illegal, in different countries of the world and the problems experienced were presented and discussed by several of the participants. The seminar also discussed the question of teaching medical undergraduates the practical and technical aspects of abortioninduction. Although opinion was divided, it was pointed out by several participants that whether or not legalized abortion is to be made available to the patient on psychiatric or socio-economic grounds or after failed contraception, it is still imperative that the medical undergraduates be given instruction on all aspects of abortion, including the technical aspects of induction. It was also pointed out that the recent advances in medical technology in the field of abortion-induction, such as the suction-curette, intra-amniotic hypertonic saline, vibration-dilatation of the cervix (and more recently prostaglandins), have all aimed at rendering the procedure of abortion-induction technically easier for the doctor and certainly much safer for the patient. The psychological problems that might be associated with a liberalized practice of legalized abortion were also discussed and the existence of such problems was accepted. However, it was
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pointed out that such psychological problems may even be more marked and more extensive with widespread practice of illegally induced abortions. In conclusion, it was pointed out that abortion is not the solution or alternative to effective contraception in any family planning programme. It is certainly an inefficeent and not universally accepted method of effecting family planning. With greater social awareness and elevation of the educational and economic levels of the community, there may be a greater demand and usage of all methods of contraception, especially the sophisticated modern methods for family planning, rather than relying heavily or primarily upon induced abortions to attain the same goal. 4.7 4.7.1 Organization of a Family Planning Programme Objectives
The group felt that the aims of a family planning programme are two-fold: (1) (2) to reduce the birth rate to a favourable level for social and economic reasons; to teach the general public that family planning is a respectable way of life, and to make service available in the country to promote good health for the family and community.
4.7.2
Type of programme
It was agreed that the "shape and size" of a programme should be designed to suit the situation in the country and its needs. 4.7.3 Budget
It was felt that for a good national programme nowadays, the budget should be generous, having regard to the assistance now available to governments from international organizations which are involved and interested in population control through family planning. 4.7.4 Methods to be used in the family planning programme
Opinions expressed were in favour of the teaching of all methods of contraception to medical students. The rhythm method was specifically mentioned because of the large number of women who are denied the benefit of a family planning service through the reluctance of the serving phYSician to teach the methods, especially because it is time-consuming and thought to be ineffective.
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Participants were reminded that many couples prefer this method because of religious beliefs and convictions. Moreover, there are some couples who would not like to use any contraceptives, but the rhythm method. It was thought that the 'extent to which a woman continues to use a method depends mainly on how it was chosen. If the woman had her say in the choosing of the method, she is likely to continue using that method for a long time if all goes well. On the other hand, if the doctor forces his choice on the woman, it is doubtful that she will use it for an appreciable length of time. The consensus was that medical students should be taught the art of counselling women on family planning. This is deemed to help women to decide on what method they would like to try. 4.7.5 Information and education
The importance of the inclusion of sex education, human sexuality and population problems in the pre-university curriculum was expressed again. A suggestion was made that approaches should be initiated to educate the Ministry of Education to accommodate the above topics in their related fields at various levels. The group agreed that students who would eventually enter the medi school would be better prepared for family planning lectures, clinical application and practical application in the field if they received some introduction to the subject in school. Religious leaders should be involved in the education of the public. How to reach the male population was again discussed. The training of medical students to educate the men through small group discussions was wholeheartedly supported. The dissemination of family planning information was dwelt on for some considerable time. It was resolved at last that male clubs, military camps, trade unions and other areas where males gather together should be well covered with posters, pamphlets, leaflets and films. 4.7.6 Training
It was felt that training should involve a large number of people, namely, medical, paramedical and non-medica1 staff. Emphasis was placed on the training and preparation of medical students to work with social workers who would be non-medica1 staff. Inter-personal relationships and the ability to work as team members was thought to be very important. 4.7.7 Targets
A national target was thought useful. However, setting targets for field workers was seen as having many pitfalls and to have proved very disapPointing in the long run.
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4.8
Administrative Considerations in Strengthening Family Planning, Human Reproduction and Population Dynamics in Medical Education
How to assess the status of the teaching of these subjects was discussed. It was suggested that it could be useful to make an "audit" of the content and location of the status of teaching of the subjects in the several most relevant departments. These are: anatomy, physiology, biochemistry, obstetrics-gynaecology, virology, social and preventive medicine. Content may be specifically identified as one of the stated subjects or more fully integrated into other subjects or case presentation. Both approaches are needed and desirable. In addition, a search could be made for opportunities or occasions when the subjects might reasonably be introduced into the teaching of paediatrics, medicine, surgery and psychiatry. Guidelines for inclusion of items would be helpful, as would illustrative case material. Field training should also be assessed, including number and types of clinical sessions, content, number and types of cases seen, participant roles of the students, time freed for instruction and supervision. There are advantages in making both block and longitudinal assignments of students to clinical work. Integration of pre-clinical and clinical subjects could be . enhanced by a system of "fortification" in response to the need that is expressed or that arises in connexion with case presentation or class discussion. Professors could be invited to follow-up or students might be asked to explore questions, seek out other profesors, search the literature and report to the others. For field services to be useful in teaching, there must be considerable flexibility in acceptance of students, permitting them to work and assigning cases to them. Qualified staff (physicians, nurses, educators, administrators) should be involved in the teaching. Services should be at acceptable standards. Various administrative patterns of relationships between the field services and the medical school are possible. The school may carry direct responsibility, as in the teaching hospital. An attempt should be made to separate clinical technical responsibility from administrative and fiscal authority. When demonstration clinics or health areas are conducted, they should be large enough to have enough teaching use but not so large as to be a great administrative burden. Agreement and affiliations with official and private programmes are necessary. The question is raised as to the extent to which students should be taught specific techniques, such as IUD insertion. The answer would seem to rest with the extent to which other procedures
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of comparable levels of complexity are taught. For example, cervical cauterization would seem to be comparable with minor surgery. At least, students should be informed and should observe. With respect to the matter of personal conscience, no person should be compelled to violate his personal code. Ethics that prevail in the profession and the current laws are determining. Too often, however, the profession sets itself up as a higher authority. For example, review committees and hospital boards often establish barriers between the patient and procedures permitted within the intent of legislation. If other services are available, referral should be made. Various procedures enhance co-ordination of the teaching. A single department (e.g., obstetrics-gynaecology or preventive medicine) can be given co-ordinating authority or a team committee can be set up. The use of comprehensive examinations rather than separate subject student assessment also helps to bring the faculty and their teaching closer together. The curriculum should medicine. At the same time, Material should be added and tion of structure and course be responsive to new knowledge in it must have reasonable stability. changed freely, but gross reorganizaofferings should be limited.
In general, none of the participants feels that his institution is doing enough on the subjects of the seminar. All the schools teach female anatomy and physiology, but all feel the need to tie the basic sciences and clinical applications together by bringing clinicians into the first years and by permitting the basic scientists to return at the time of the later clinical emphasis. Advantage might be taken of the new young students' personal interest in questions of sexuality and contraception. Demographic content given by departments of preventive and social medicine needs to be strengthened. Clinicians need to improve their skill in the art of meeting the psychological and culturallydetermined doubts and resistances of their clients. Medical students should be brought into closer contact with the contributions of their health co-workers: nurses, midwives, health educators, home visitors, etc. The student should observe, work side by side and make field and home visits with them. Students should have mandatory assignments in clinical services - in hospitals, ante-par tum and post partum clinics and health centres, preferably including rural ones. The practice of having a student relate to and follow a family for one or more years may confer understanding of the family and community to a degree not as well obtained within the protected impersonal hospital setting.
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Desire was expressed for a co-ordinated international effort to produce audiovisual materials for regional training fellowships and for other continuing support to schools that seek to improve the effectiveness of their family planning and related teaching. Although statutory authority over curriculum may be in a national government body (even international at times) or at top university level, the real decisions on curriculum modification are usually made by the departments. Leadership of a single person working through appropriate channels is the key to change and improvement. Co-ordination among schools through national associations of medical schools can be very helpful in strengthening the curriculum content in the different schools. 5. SUMMARY OF THE SEMINAR
The seminar included seven working papers and fourteen country reports, preseminar visits by three consultants to twelve medical schools in seven countries, twenty-five discussing participants from countries in the Western Pacific Region. It consisted of nine sessions of half a day each and a half-day field visit. The discussions were initiated by fourteen different people, who also acted as rapporteurs for their particular sessions. The seminar proceedings are a reflection of all these contributions. There was no attempt at strict avoidance of overlap on subject material from one session to another and this in itself highlighted the inter-relationship of the different components. The discussion was free and there was no attempt to draw up certain recommendations or produce a consensus of opinion. Emphasis was on the exchange and sharing of ideas with respect for each others point of view and amicable acceptance of differences of opinion. From this exchange of views, the following are the main pOints that emerged: 1. A confirmation of the belief and importance of the subject and the need for its emphasis in the education of physicians. 2. Recognition of the broad range of content encompassing anatomical, biochemical, physiological, clinical (diagnostic and treatment), statistical and demographic, psychological, social and cultural considerations.
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3. Examples were presented of how the task is handled in different schools in terms of departmental responsibility, number of teaching hours, years when taught, teaching methods, use of hospital and clinical facilities and services. The problems inherent in introducing new content into the medical teaching programme and ways of trying to find solutions were discussed. It was realized that the problem was not unique but reflected a larger picture. The teaching of family planning, human reproduction and population dynamics are part of the total medical education which is related to general professional attitudes which are in turn are parts of national trends within the larger world scene. It was felt that inculcating a proper outlook of social concern early in the medical course and the teaching of all faculty members the rudiments of family planning, human reproduction and population dynamics were two important ways to increase the content of these subjects in the curriculum. It was felt by the participants that as a result of the seminar each of them had learned from the others and had acquired a broader vista of the subject and a partial picture of the other institutions and activities. Through continuing personal direct contact or through contact with the WHO at the Regional Office or field level, it is expected that the flow of information which occurred during the seminar would continue.
- 21 ANNEX 1
LIST OF PARTICIPANTS, CONSULTANTS, SECRETARIAT AND OBSERVERS PARTICIPANTS AUSTRALIA Dr Constantine A. Michael Senior Lecturer in Obstetrics and Gynaecology University of Western Australia Department of Obstetrics and Gynaecology King Edward Memorial Hospital Subiaco 6008 Western Australia Dr Yuan Ping Chen Associate Professor of Obstetrics and Gynaecology National Taiwan University Taipei, Taiwan Republic of China Dr Julia J. Tsuei Associate Professor and Department Head National Defense Medical Centre Veterans General Hospital Taipei, Taiwan Republic of China FIJI Dr Vilimaina Tuivaga Family Planning Medical Officer Health Office, Medical Department Suva, Fiji Dr Cheao Seang Lan Professor at the Faculty of Medicine and Chief of the Maternity Service Khmer-Soviet Friendship Hospital Phnom Penh, Khmer Republic Dr Nhenara Chounramany Director Royal School of Medicine Mahosot Hospital Vientiane, Laos Dr Vannareth Chief of Department of Obstetrics Mahosot Hospital Lecturer at the Royal School of Medicine Vientiane, Laos
CHINA (TAIWAN)
KHMER REPUBLIC
LAOS
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MALAYSIA
Dr Winifred Danaraj Professor of Social and Preventive Medicine Department of Social and Preventive Medicine Faculty of Medicine, University of Malaya Kuala Lumpur, Malaysia Dr T.A. Sinnathuray Professor and Department Head Department of Obstetrics and Gynaeco1ogy Faculty of Medicine, University of Malaya Kuala Lumpur, Malaysia
NEW ZEALAND
Dr Richard Campbell Begg Senior Lecturer and Medical Officer of Health Department of Preventive and Social Medicine University of Otago Dunedin, New Zealand Dr Douglas G. Johnson Lecturer of Obstetrics and Gynaeco1ogy P.O. Box 1144, Boroko Papua Dr Alicia de 1a Paz Associate Professor in Obstetrics and Gynaeco1ogy Institute of Medicine Far Eastern University Manila, Philippines Dr Syng-Wook Kim Assistant Professor Department of Obstetrics and Gynaeco1ogy Seoul National University Hospital Seoul, Korea Dr D. Vengadasa1am Senior Registrar Kandang Kerbau Hospital Singapore 8 Republic of Singapore Dr Lawrence Chan Department of Obstetrics and Gynaeco1ogy Kandang Kerbau Maternity Hospital Singapore 8 Republic of Singapore
PAPUA NEW GUINEA
PHILIPPINES
REPUBLIC OF KOREA
SINGAPORE
VIET-NAM
Dr Nguyen van Hong Professor of Obstetrics at the Faculty of Medicine Director of the School of Midwifery Saigon, Republic of Viet-Nam
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CONSULTANTS Dr Samuel M. Wishik (Seminar Director) Director, Division for Programme Development and Evaluation International Institute for the Study of Human Reproduction Columbia University U. S .A.
Dr Gloria T. Aragon Professor and Chairman Department of Obstetrics and Gynaecology College of Medicine University of the Philippines Manila, Philippines Dr Karl A. Smith Lecturer Department of Social and Preventive Medicine University of the West Indies Mona, Kingston 7 Jamaica Dr A. Nadarajah Senior Lecturer Department of Hedicine University of Malaya Kuala Lumpur Malaysia SECRETARIAT Dr A.M. Rankin (Seminar Secretary) Regional Adviser on Education and Training WHO Regional Office for the Western Pacific Manila, Philippines Dr H.M.C. Poortman WHO Consultant on Family Planning WHO Regional Office for the Western Pacific Manila, Philippines Dr M. Iliyas WHO Public Health Administrator Project Korea 6401 Seoul, Korea
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Mr P. Lambert Interpreter World Health Organization Geneva, Switzerland
Miss G. Clement Interpreter WHO Regional Office for the Western Pacific Manila, Philippines Miss Aurora P. Batara Secretary WHO Regional Office for the Western Pacific Manila, Philippines Mr Jesus Gatmaitan Technician WHO Regional Office for the Western Pacific Manila, Philippines
OBSERVERS Dr I.S. Puvan Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur Malaysia Dr J.S. Sambhi Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur Malaysia Dr D.K. Sen Senior Lecturer Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur Malaysia Dr C.L. Ponnuthurai Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur Malaysia Dr Joginder Singh Public Health Institute Kuala Lumpur Malaysia
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Dr Nor Laily Dato Abu Bakar National Family Planning Board Kuala Lumpur. Malaysia Dr M. Subbiah National Family Planning Board Kuala Lumpur. Malaysia Ungku Abu Bakar Public Health Institute Kuala Lumpur, Ma1asia Dr Gerald F. Winfield United States Agency for International Development Washington U.S.A. Dr S. Sivanesan Department of Pathology University of Malaya Kuala Lumpur, Malaysia Dr K.H. Ng Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur, Malaysia Dr Paul C.Y. Chen Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur, Malaysia Dr K.L. Lam Department of Obstetrics and Gynaecology University of Malaya Kuala Lumpur, Malaysia Dr La1 Kamaliah bt. Lakasia Public Health Institute Kuala Lumpur, Malaysia
- 27 ANNEX 2
OPENING SPEECH BY THE HONOURABLE MINISTER OF HEALTH
Ladies and Gentlemen: It is indeed a great honour for me to be kindly invited by Dr Huggins to open officially the WHO-sponsored "Seminar on the Teaching of Family Planning, Human Reproduction and Population Dynamics in Medical Schools" this morning. It is also a great honour to Malaysia that this seminar is being held here, where family planning is being given one of the highest priorities by the Government, and incorporated as an integral part of Malaysia's national and economic development programme. One may ask, why adopt family planning when the size of this country is able to support perhaps three times the present population? The answer, from the economic angle, is not hard to find. Since attaining independence in 1957, especially after successfully defeating militant communism in 1960 after a twelve-year struggle. the Malaysian Government has been giving top priority to the socioeconomic development of those living in the rural areas, where the bulk of the population live, in an effort to close the economic gap between the haves and the have-nots, through a series of Five-Year Plans. However, the Government soon realized that the high rate of population increase at about 3% per year almost nullified the Government's efforts to improve the standard of living of the people. As a result, family planning was incorporated as an integral part of Malaysia's national economic development programme in the First Malaysia Plan of 1966-1970; with the long-term aim of reducing the rate of population increase to 2% by 1985. Now, as a Minister of Health, I am even more concerned with the vital need for family planning from the health point of views. The tremendous development of our health services since independence, particularly in the rural areas, has brought down the various mortality rates to almost half of the 1957 figures, and this improvement in health status is even more striking in the rural areas. However, while the infant mortality rate of 45 per thousand in 1967 was about double that in the developed countries, the toddler mortality rate was almost ten times higher than in the developed countries, indicating a state of protein-calorie malnutrition still existing in this country. more especially in the rural areas. The important role of the mother in looking after the welfare of the family including the toddlers is
... /
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well-known. If she bears children at too frequent intervals, she has less time to look after her young ones, at an age when they need good parental care as well as a balanced diet, necessary for their growth and development. Also, her own health may be affected, sometimes with disastrous effects on her married life. I think many mothers in the rural areas who have big families realize this. Their remedy is to resort to illegal abortions which have often resulted in permanent damage to health and even in death. Therefore, for the health and welfare of the family, particularly those living in the rural areas, family planning education and service should be provided as an integral part of the basic health services. It is the policy of my Ministry to integrate family planning service with the rural health services, particularly the maternal and child health services, so that family planning education ?nd service can be provided as part of a package deal for total health care of the people living in the rural areas. As you may be aware, responsibility for the National Family Planning Programme lies with the National Family Planning Board, which was set up in 1967 directly under the Prime Minister's Department. Although the Board's initial programme in the urban areas went according to schedule, the Board began to experience difficulties when expanding to the rural areas in 1969. Integration of family planning service with the existing rural health services, therefore, seemed to be the only answer.
However, being aware of some of the difficulties involved in integration such as increasing workload as well as problems concerning supervision, training and logistics, it was decided, as a start, to carry out family planning integration on a small scale, in seven areas, covering approximately one million people so that the experiences gained will be utilized in expanding the integration programme to other parts of Malaysia later on. The target of new acceptors set for the Second Malaysia Plan of 1971-1975 is 600 000 women in the fertile age group. Of these, 450 000 will come from the rural areas. It is estimated that, even after integrating family planning services with 95% of the eXisting set-up of rural health services, only 207 000 new acceptors, or less than 50% if the rural target group will be covered. The implication here is that the rural health services, particularly the maternal and child health service, will have to be strengthened quantitatively as well as qualitatively, if family planning integration were to be successfully implemented. This is now being done by my Ministry, and the strengthening of the maternal and child health services is being incorporated in the Second Malaysia Plan.
... /
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Ladies and gentlemen, you can see that we are setting our target very high, and the five years for 1971-1975 will see intensified activities in the rural areas in the family planning field. The centre of these activities will be the medical officer as well as the health officer, on whose leadership and drive will depend the success or failure of our programme. To prepare future young doctors for this important role, training is necessary in the medical schools in family planning, human reproduction and population dynamics, geared to local conditions. I am, therefore, looking forward with anticipation to the discussions and exchanges of experiences among the distinguished delegates at this seminar, and hope that a training programme will eventually be evolved in the local Faculty of Medicine, so that the University of Malaya will play an increasingly important role in family planning in this country. I might also add that, while in our country, I hope you all will take time off to see a little of Malaysia, as well as to sample our varieties of food and hospitality so that when you leave us you will take with you pleasant memories of Malaysia. With this, I have great pleasure in declaring open the "Seminar on the Teaching of Family Planning, Human Reproduction and Population Dynamics in Medical Schools."
- 31/32 ANNEX 3
LIST OF COUNTRY REPORTS
AUSTRALIA CHINA FIJI KHMER
Dr C. A. Michael Dr J.J. Tsuei and Dr Y.P. Chen Dr V. Tuivaga Dr C.S. Lan Dr N. Chounramany Dr R.C. Begg Dr W. Danaraj and Dr T.A. Sinnathuray Dr D.G. Johnson Dr A. de la Paz Dr S.W. Kim Dr L. Chan Dr N. van Hong
LAOS NEW ZEALAND
MALAYSIA PAPUA NEW GUINEA PHILIPPINES REPUBLIC OF KOREA SINGAPORE VIET-NAM
- 33 ANNEX 4
AGENDA !uesdaYa 26 October 0830 hours
Opening Ceremony Welcome from Dr Francisco J. Dy, read by Dr D. Huggins Opening Speech by the Honourable Minister of Health Welcome Speech - Dean of the Faculty of Medicine, University of Malaya Introductory Statement by Dr S.M. Wishik Coffee break and registration Round the table self-introduction by the participants, consultants and secretariat Election of Chairman and Vice-Chairman Adoption of the Agenda and general discussion of the scope of the seminar Designation of the rapporteurs, who will also open the discussion of their respective topics during the seminar
1200 hours P.M.
Lunch Country Situation Panel discussion by the three consultants with participation of representatives There will be an opportunity not only during this session but throughout the seminar for all participants to supply general comments on their respective countries. There will be no formal presentation of country reports. Note: 1. 2. During the working sessions, discussion of the subject for the day will include:
The existing situation Areas of the subject relevant to family planning teaching
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~;I
3.
Departmental responsibilities The timing of the subject in the curriculum Teaching and evaluation methods
4. 5.
Wednesday, 27 October A.M. and P.M. The Teaching of Human Reproduction 1.
Presentation by Dr A. Nadarajah Collaborative and ComElementar~ Teaching on the Endocrine Considerations in the Practice of Family Planning
2. Thursday, 28 October A.M.
General discussions, chaired and led by two clinicians of obstetrics and gynaecology
Field visit to the Family Planning Board, Kuala Lumpur, and the Family Planning Demonstration and Training Centre, Setapak The Teaching of POEulation Dynamics Presentation by one participant selected because of strong personal interest and emphasis on this aspect in his institution; especially, if there is involvement of the University outside the Medical School. General discussion chaired and led by two Professors of Social Medicine
P.M.
Friday, 29 October A.M. and P.M. Methods of Contraception and Abortion Presentation by a participant with extensive experience in family planning service General discussion chaired and led by two participants with similar experience
•
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Saturday, 30 October A.M. Organization of Family Planning Clinics and Programme Presentation by one participant with experience in administration of family planning service General discussion chaired and led by two participants with similar experience Sunday, 31 October Monday, 1 November A.M. Administrative Consideration in Strengthening Family Planning, Human Reproduction and Population Dynamics in the Medical Curriculum Seminar report and discussion Commentary (by Dr Wishik) General review and the horizon ahead Consideration of draft conclusions and recommendations of the seminar Closing of the seminar • F r e e
•
• - 37 -
~x
5
LIST OF WORKING PAPERS
WPR/HR/ET/l
Teaching of Reproductive Physiology and Techniques of Contraception in Medical Schools by Dr Gloria T. Aragon Programme of Instruction Integrating Family Planning in the Undergraduate Medical Curriculum, College of Medicine, University of the Philippines by Dr Gloria T. Aragon The Population Problem and Family Planning by Dr S.M. Wishik Organization, Administration and Evaluation of Family Planning Programmes The Physician's Role in Education and Communication for Family Planning by Dr S.M. Wishik The Physician's Role in Helping a Woman Choose a Contraceptive Method by Dr S.M. Wishik Collaborative and Complementary Teaching on Endocrine Considerations in the Practice of Family Planning by Dr A. Nadarajah Organization of Clinical Family Planning Services in Hospitals, Health Centres and Private Offices in Jamaica by Dr K.A. Smith
WPR/HR/ET/2
WPR/HR/ET/3
•
WPR/HR/ET/4 WPR/HR/ET/5
WPR/HR/ET/6 WPR/HR/ET/7
WPR/HR/ET/8
NOTE:
Copies of the above working papers can be obtained upon request from WHO.