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ORIGINAL:
ENGLISH
~INAR
ON THE ROLE OF NURSES AND MIr:MIVES IN FAMILY PLANNING
I
Sponsored by the WORLD HEALTH ORlANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Manila, Philippines 16-23 September 1974
FINAL REPCIIT
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 January 1975
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The the and the
views expressed in this report are those of consultants and participants at the seminar do not necessarily reflect the policies of 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 Seminar on the Role of Nurses and Midwives in Family Planning which was held in Manila, Philippines, from 16 to 23 September 1974.
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COtn'EJIITS
1.
INTRODUCTION •••••••••••••••••••••••••••••••••••••••••.• PREPARATION ...................................................................................... ..
1 1
2.
ORGANIZATION" ...................................... ,. .............................. ..
2
3.1 3.2
Agesa ............................................. Prooed~
It............... .....
2
...........................
It . . . . . . . . . . . . . . . I t . . . . . . . . . . . . . . . . . . . . . .
.3 3 3 3 4 7 10 14
4.
CON'I'.E)I'l' ............................................................................ ..
4.1 Weloome by the Rea10nal Ddrector •••••••••••••••••• 4.2 TOpi.s, disoussions and oonolusions ••••••••••••••• TOpic 1 TOpio TOpi. TOpio Topio NUrses and midwiyes in the oontext of soe:1et,. ................................... Nurses and midwhes in family health care 2 Family plannins in primary health oare •• 3 Manpower problems in family planning •••• 45 - Dapaot of nurses and midwiyee on policy. praotie. and preparation •••••••••••••.•• It .. • .. .. • • .. .. • ..
18 20
5.
EVALUATION
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . It . . . . . . . . . . . . . . . . . . . . . . . . .
It . . . . . . . . . . . . .
AMNKX 1
LIST OF PARTICIPANTS, CONSULTANTS AN[)
SERErARIAT •••••••••••••••••••••••••••••• ANNEX 2 - COUNTRY QUESTIONNAIRE •••••••••••••••••••••••• ANNEX 3 FAMILY PLAHNING ACTIVITIES IN 'mE CONTEXT OF HEAL'm SERVICES - Dr P. RAJASINGHAM ••••••• M:mn:~
21 27 29 37
ANNEX 4 - THE ROLE AND FUHCTION OF NURSES AND
IN FAMILY PLANNING - MS H. COON
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ANNEX
5
LIST OF DOCU4ENTS SEtn' TO COUlfl'RIES ••••••••••
47/48 49
ANNEX 6 - BIBLIOORAPIfIY ............................ .o . . . . . . . . .
ANNEX 7 ANNEX 8 ANNEX 9 ANMEXl~
EVALUATION QUESTIONNAIRE ••••••••••••••••••••• PROVISIONAL AGENDA AND PROGRAMME OF WORK •••••
51 57 61/62
GROUP
ASSIG~S
••.••••••.•...••..••..•..•••
SOMNAfty OF EVALUATION ••••••••••••••••••••••.•
63
CHARTS CHART 1 SUGGESTED SOCI~POLITICAL
ORGANIZATION •••••••
77/r8 79/80 81
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CHART 2 CHART 3
CClilMUNlTY CASE LOAD ••• .o . . . . . . . . . . . .o ... .o.o ..... .o .... .o • • CASE WAD ANALYSIS ...... .o.o • .o . . . . . . . . . . . . . . .o •
.o • .o ....
1.
INTROWCTION
The seminar was beld at tbe Hegional Office of tbe World Health Organization, Manila, Philippines, from 16 to 23 September 1974. The development of family planning ac.tivities, whether integrated with maternal and child health or forming an independent programme, depends to a great extent on Dlu·ses and midwives: tor implementation. The degree to which these activities enhance and expand the role of nurses and midwives by adding a new dimension to their function, or restrict their role by taking precedence over generalized bealth care of mothers and children, poses problems which require serious consideration and study. The purpose of the seminar was to provide an opportunity for nurses and midwives to reach some conclusions on the implications of these problems and their possible solutions. The objectives of the seminar were: 1. 2. To consider family planning activities within the context of
health services; To exchange information on the extent to which nurses and midwives are currently involved in family planning activities in countries in the HegionJ To identify the role and functions of nurses and midwives in
3.
family planning;
4.
To discuss ways and means of integrating family planning activities into existing nursing and midwifery practice.
2.
PREPARATIOO
Countries and territories in the Western Pacific were invited to nominate nurses and midwives in responsible positions, preferably, in service and administration as opposed to teaching, to attend the seminar. Twenty-one partiCipants from eighteen countries attended {see Annex 1). The participants were asked to complete questionnaires on various aspects of family planning in their own countries, particularly as they related to nurses and midwives. Th~ completed questionnaires assisted the Secretariat in preparations for the seminar and, in addition, led the participants to review their own situations betore leaving their coWltries (see Annex 2) •
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Tb assist the WHO Secretariat, a public health administrator, Dr P. Rajasingham,and a public health nurse-midwife specialized in maternal and child health, Me H. Cohn,were appointed as consultants. They made observation visits to two participating countries and prepared two working papers: - Family planning activities in the context of health services (Annex 3) - The role and function of nurses and midwives in family planning (Annex 4) One temporary adviser was appointed from the Phil1ppines and two WHO staff members attended the seminar as resource persons. Three official observers attended (see Annex 1). A package of documents and reprints pertaining to MCH and family planning was sent to each participant before the seminar and a bibliography was compiled of suggested readings in the WHO library in Manila (see Annexes 5 and 6). An evaluation questionnaire was prepared for distribution before the close of the seminar (see Annex 7). 3. OOOANIZATION
3.1
Agenda
The agenda was designed to focus on family planning as a health measure wi thin the scope of the functions of nurses and midwives; to suggest, at the outset, society's concern for the health effects of uncontrolled reproduction; to consider some approaches to the problems through health services for the individual, the family and the community; and to determine the potential impact of nurses and midwives on the expansion of their role to include family planning activities. The agenda included various topics for discussion at the seminar (see Annex 8 - provisional agenda and programme of work). Each topic was introduced at the afternoon plenary session by two speakers. The follOwing morning the Rapporteur gave a br1ef summary of the two presentations and read out the "major issue" raised by the speakers for group discussion. At the second plenary session on the topic the group reports were read, followed by discussion from the floor and culminating in "conclusions" on the implications of the major issue for nurses and midwives. Typed copies of the conclusions were distributed to the participants. These constituted the basis for the final discussion on the draft report.
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3.2
Procedure
One Chairman and one Rapporteur were nominated to conduct and record each of the agenda topics. Tbey were responsible for formulating the ·conclusions" reached by the total group at the final plenary session on their particular topic. Group work was conducted in three working groups to which participants were assigned on the basis of:
(a) (b)
the similarities of their situations as reflected in their answers to the country questionnaires; and common language, to facilitate free discussion without interpretation lsee Annex 9 - Group Assignments).
The three groups elected their leaders (Chairman and Rapporteur) who retained the position for the duration of the seminar. Each group also nominated a representative to attend the steering collllll1ttee. The steering collllll1ttee met each oorning to review the progress of the proceedings and make changes where indicated.
A working collllll1ttee met each afternoon. In addition to the Secretariat, the Chairman and Rapporteur 1'or the topic completed that day attended the meeting to review the conclusions before circulating them; also the Rapporteur for the topic still in progress attended to prepare the swnmary and maJor issue for discussion the following oorning. 4. CONTENT
4.1
Welcome by the Regional Director
The Regional Director, Dr F.J. Dy set the tone of the proceedings in his welCOming address to the participants. Be referred to the World Population Conference held recently in Bucharest and to the concerns of many countries, with regard to population and economic development. Dr Dy emphasized however, that WHO's major collllll1tment is to the health aspects of family planning. He went on to say that nurses and midwives have always been quick to recognize and adopt new methods for proooting the health of families, particularly families with young children. 4.2 Tbpics, discussion and conclusions This section of the report includes summaries of the presentations given. After each set of summaries, the issue raised for discussion at the working groups is mentioned; those in turn are followed by "conclUSions", which are the COmbined reports of the three discussion groups, presented and discussed at the plenary session.
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Tbpic 1. Summary:
Nurses and midwives in the context of society
demographic characteristics of countries in the Western Pacific
Countries in the Region are in various stages of delOOgraphic transition. Auetralia, New Zealand and Japan have reached a stage of low fertility and low mortality. Other countries are at an intermediate stage, where mortality has dropped sharply, but fertility is still high. No country in the Region is at a primitive stage, namely with a high mortality rate and a high fertility rate. Excluding Australia, New Zealand and Japan, countries in the Region exhibit a similar population profile. The populations are young; in Malaysia and the Philippines, 45-41% of the population are under fifteen years of age. These young populations place a heavy burden on the family breadwinner. Japan has a dependency ratio of 3:2 where there are three workers for every two dependents. In the Philippines there is one working member for every dependent. Countries are agricultural, with a greater portion of their populations in a rural setting, although in some countries, like Korea, there is increased industrialization. Also large families, a characteristic of rural life, cannot support the younger members and there is a migration to cities in search of jobs and education opportunities. The health sector has a new challenge now. It must meet the health needs of out of school youth, the nuclear families displaced from familiar extended family environments and the health problems caused by congested urban life. It must also continue to find better ways of reaching families in rural areas, many of whom have no access to the present systems for the delivery of health care. Three important factors were mentioned in consideration of how to lower the birth rate - namely, the child survival hypothesis, the status of women and the provision f0r old age pensions and retirement plans. Summary: influence of population trends on the development of health services
Countries have been taking a keen interest in family planning during the last fifteen years and are in various stages of development. WHO has been actively involved in the health aspects of family planning since 1965. The World Population Conference in Bucharest adopted ten basic principles giving timely directives. The present socio-political organization is not helpful in delivering health services effectively and faster. The rural areas have continued to be neglected as this organization is far removed from the grass root level of countries. The influx of rural population into cities in the situation of a central and city based organization has resulted in slums ann human misery. Piecemeal decentralization of services to ameliorate the situation has had very little impact. The organization is not capable of bridging the gap between tbe haves and bave-nots. It does not facilitate effective participation by all concerned in planning and implementation of approved plans. Furtber, this does not help in meaningful coordination of work with other ministries and the private sector which includes the voluntary agencies. In short, it is far removed from the concept that health is everybody's business. A suggested organization (see Chart 1), for countries of more than six million population, with modifications for countries of less than six million nopulation, were presented as a possible remedy. The main pOints are: (1) Tbe lack of a central organization for delivery of services.
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(2)
The creation
or
development regions/sectoral divisions. the local level in the delivery of health
(:5)
The importance services.
or
Irrespective or the type or organization, it was proposed that nu.rsing and midwifery personnel should take over responsibility ror the delivery or health services at the local level, with the few doctors available at this level providing consultant services. The fUnctions of the local level as related to the seminar were outlined with special mention of: (i) The question of whether family planning should be integrated with MCH or be independent;
(ii). Paediatric centred ramily planning; (iii) (iv) Importance of breast feeding; Staffing at village health organization level, unipu.rpose vs multipurpose and the role of male nurses; Need ror establishing training centres at local level; Evaluation and research and the role that nurses and midwives could play in this; Supervision and guidance.
(v) (vi)
(vii) Discussion
Changes in population have an errect on its health and, consequently, on the administration or heal. th services. This has implications ror nu.rses and midwives particularly in the organization and administration or nursing and midwirery practice. Conclusions There are wide variations in the countries of the Region related to cultu.ral as well as economic factors: (a) (b) (c) (d) (e) (f) The extent of the national population problem; The effect on ramily planning policies of legal constraints; The rate of urbanization and migration of young people into the towns; Values relating to status or women, preference for sons or daughters and family size; Acceptance or male nu.rses for maternity care and delivery, but not for the insertion of IUDs; Economic dependence on children in the absence of pensions and old age aSSistance, consequently, the efrect of the child SUrvival rate.
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These variations account for differences in national policies and programmes and, therefore, differences in the role and function of nurses and midwives as indicated below: (a) Family planning services are offered by government, voluntary, part government and part voluntary, and international agencies. In some countries there are all four types of agencies, in others a combination of two or three types. Family planning acti vi ties may be integrated with maternal and child health or family health services, or they may be independent and separate. This depends on the agency offering the service, the administration of the budget by particular ministries or the financial support available for family planning, in the absenoe of adequate maternal and child health services. In this regard the scarcity of nutrition and vaccination services was mentioned specifically. Family planning activities carried out by nurses and/or midwives in some countries include IUD insertions and prescription of the pill, and in other countries are restricted to the traditional methoclswhich do not require technical skills.
(b)
(c)
However, some aspects of family planning are the accepted fUnctions of all nurses and midwives, varying only in the degree to which they are hospital, clinic or community based workers, namely: (a) Infornation, motivation and follow-up. This includes individual and group activities; the use of pamphlets and other visual aids; counselling in pregnancy and post-partum services; involvement with schoolchildren and young people for health education, and the identification of a growing need of young 'oouples for "preparation for marriage"; maintenance of records and referrals. (b) Training and supervision of auxiliary workers in family planning activities. (c) Distribution of contraceptive supplies to people for whom they have been prescribed. While nurses and midwives are fully involved in family planning, the extent varying only in relation to the policies and programmes of their own countries, it was felt that major changes should be made with regard to: (a) The inclusion of family planning in the basic preparation of all nurses and midwives in preference to the short-term post-basic and inservice training only of those engaged in family planning; (b) More participation at the policy making level where the "nursing load", as well as the needs of the people, would be more adequately represented by nurses and midwives.
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Topic 2. SWDIII&r;y:
Nurses and midwives in family health care
concepts of family health care
Family planning has three goals: (1) (2) Population control: the concern of countries with economic development problems. Human rights: the concern that parents should be free to decide whether and when to have children and the ultimate size of their families. Family health: the concern of human reproduction and its effect on the health of the mother, the family members including the newborn and the family as a whole.
(3)
Nurses and midwives may be in agreement with all three goals, which in fact do not negate each other but are directed to the health and welfare of the state and all its people. li:>wever, nurses and midwives are qualified for, and committed by their choice of profession to, the third goal which is family health. Family planning is a family-related health need and as such it affects, perhaps to different degrees, all family members. Terminology relating to family health is somewhat Jargonistic but always denotes something good. In offering family planning as a component of family health care, it is important to develop a clearer concept of what is meant by family health care and more precise procedures for its implementation. The family unit is characterized by a specific structure of Idn relationships between parents and children, by mutual responsibilities for and relationships between members and by interactions in a common environment. These factors determine the growth and development of individuals particularly young children. When she encounters the family, the nurse or midwife should be aware of health-related factors involved in the size and rate of growth of the family unit: (a) number of pregnancies and intervals between pregnancies, (b) sex and age relationships of members, (c) whether the family is complete or still growing in size and (d) ability of parents to meet the different needs of its members who are at various stages of development. In practice, there are several approaches to family health care:
(1) A health programme for the family as a unit. A family appraisal 1E made and care for individuals is coordinated in service. (2) Individual care. All members of the family are eligible for service and may receive it at the same centre, but no systematic attempt 1s made to coordinate the service.
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(3) The individual seen in the context of the family environment. This approach is most appropriate in maternal and child health and family planning. The treatment of the individual is extended to the care of other members who are affected by or may affect the condition of the individual. The extended service promotes a healthy environment for the individual member at the same time safeguarding and improving the health of all other members. The question: RWhose health would be affected if another pregnancy occurred?" may be answered, in a family health programme, by advice against pregnancy and by providing additional or special care for family members as well as for the mother. In the context of family health problems, it is evident that family planning alone is not a solution. Malnourished children and overburdened mothers do not automatically recover because a subsequent pregnancy is prevented. Family planning, however, is an important component of family health care and an appropriate activity for nurses and midwives when their patients are seen in the context of the family unit.
Summary: maternity-centred family planning in the Philippines The maternity-centred family planning programme is one of the strategies for the delivery of family planning service. This approach is primarily concerned with post-partum and post-abortion cases in hospitals, but also .~th women availing themselves of the maternal and child services and with all eligible women and men consumers of other hospital services. The development and implementation of this new programme within a hospital involved the administration from national or central level, down the line to the operating level. In addition, administrative arrangements had to be made for training of selected hospital personnel, the provision of additional staff and the supervision vital to the development of the programme. The general acceptance of the programme by the hospital personnel made possible the establishment of family planning as part of the hospital services. The nurse and midwife of the family planning clinic are responsible for the motivational and educational components of the programme, and for providing continuing care to patients during their regular check-up visits. Trained nurses in the comprehensive family planning service do IUD insertions and reinsertions, pelvic examinations, physical assessments and other related procedures in normal cases. The coordination of family planning with maternal facilitated where these services are combined. In the referral system between the family planning clinic and OB/GYN service although not fully utilized, has helped achieve better coordination. and child health is hospital the intrathe paediatrics and considerably to
Plans to improve the existing maternity-centred family planning programme include: (a) Further development of the training function of the hospital in the area of r«:H-family planning, and management of contraceptive complications;
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(b) strengthening of the two-way referral system between the hospital and rural health family planning centres, with better provision of care; (0) An increase in the number ofmidw1ves tra1ned 1n comprehensive MCH.care incl~d1rtg fam1~Y' planning;
{d) 'Dle deWl'IIIinat1on of an est~mated populat1on target which will be applicable· to hospitals in the prograDBDe. The 1ntegration of fam1ly plann1ng into the matern8J. and child health services of the hosp1tals requires strengthen1ng of the promotive and prevent1ve aspects of these serv1ces. However, the first phase of the matern1ty-centred family planning programme in twenty-five government hospitals in the Philippines seems to have been _rked with success.
D:l.scuss10n The ind1v1dual 1s a member of his family and shares the same env1ronment. It is therefore necessary to offer a serv1ce that will not only treat the
pat1ent bat will raise the level of health of the family as a whole. Service to individuals will be extended to other family members whose health needs affect or are affected by the condition of the patient first encoantered. This has implications for nurses and midwives in hospitals, clinics and homes. Conclasions Nurses and midwives are strongly in favour of family health care. as a meaDs of safegaarding the health of individaals within their environment and more effectively achieving the health goals of family planning. This was expressed in the groap reports: "Tbe health staff mast reqaire a new concept which cons1sts of regard1ng the c11ent as a member of her f8m1ly and considering that trea~nt given to patients will not be really effect1ve if attention is not paid to the physical, mental and social conditions of the family." "All family planning activities shoald be seen as an effort to raise the level of health of the whole family." "The pablic health worker with her knowledge of the family as a anit is in an ideal position to impart knowledge on family planning as a health measl1re." "Public health narses need an increased awareness of all aspects of family health." When family planning is the presenting need of the individual, it may provide an opportunity to establish contact with the family for the identification of health problems of other f8m1ly members, and should therefore lead to more comprehensive service to the family as a whole. Similarly, the presenting need of other family members should lead to the identification of family planning needs. One group felt that this principle was adequate reason for administrative policies enabling the development of narse-family relationships necessary for comprehensive family health care including family plann1ng counselling.
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One family planning programme was described as having been initially developed as an independent service aimed at population control. This has now been incorporated into a family health service and remains a more effective family planning service than other programmes. In contrast, when the population control goals take precedence over the health goals, nurses and midwives may be involved in a programme which restricts free health services to small families. Other problems in providing family planning as a component of family health care are: (1) Shortage of staff trained in general publio health;
(2) Inaccessibility of general health services to the rural areas, inoluding problems of transportation and communication. One group reoommended mobile health units, whioh would provide nutrition and immunization services as well as family planning. (3) Fragmentation of services and the delegation of motivational aspects of family planning to workers, including \XlYsicians. who are not involved .with the family as a whole and do not relate the need to the total situation. Problems were also cited with regard to cultural and religious resistance to family planning by health workers as well as clients. It was suggested that ways should be found to coordinate the services of different hospital departments, as well as hospital and community services, so that the health needs of individual family members are seen in relation to each other and in the context of the family environment. Meetings of the staff of different departments and services was suggested as one "coordinating" mechanism. Topic 3. Summary:
Family planning in primary health care
primary health care and community participation
In spite of the efforts made by national health administrations, a very large proportion of the population in rural areas is not reached by basic health services. On the other hand, even when services are available, the utilization is often poor. It is felt that one of the reasons is the gap in communication between health service personnel and the community served and the gap between community expectations and the services provided. An approach to organization of community-based health services, is being studied in several countries/territories of the Region.
looking at the services needed by the total population at community level, it is thought that basic health needs and care should comprise health education, home sanitation, personnel hygiene, nutrition education, maternal health including safe delivery and family planning, child health supervision, communicable disease control and prompt care in cases of accident and illness.
,.
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The objective of community-based health services is to provide more adequate coverage for the total population. In order to reach this objective, it is suggested that:
(a)
community groups/members be given responsibilities in health matters, utilizing their own administrative structure and various influential groups and individuals; traditional medicine be reconciled with modern medicine and that traditional healers and birth attendants be integrated within the health care delivery system.
(b)
The concept of ·primary health worker" who, at village level, is a member of the community, selected by the community, trained in the community, and accountable directly to the community, is gaining support. The roles and function of nursing/midwifery personnel posted at the second level of the health system ne.d to be understood as the proviSion of basic health services including primary medical care, as training of primary health workers at village level and as supervision and technical guidance of those workers. The nurse/midWife also needs to be particularly perceptive of community needs and expectations and be able to act as community leader in her field. Preparation ot: nurses/m1dwives for a deeper involvement in community affairs needs to be studied. Sulllnary:
case load management and standard procedure
The case load is the population of patients or families to whom the nurse or midwife is assigned. To ensure coverage and quality of care to all who need the service, three management principles are applied to the case load.
(1) Knowing tile Size and struoture of the case load.. This means knowing theIWlllber of families, tile number of children and their age groups,. the e:s-t1mated DUlllber of' birthll and. thus the est1mated number of pregnancies. '!hese are essellt1al guides in planning the service and determining the staff required. (2) Knowing the progralDlllB goals. This means knowing the procedures in wu.ld health supervision and JlBternity oare, the prograJDDe for iJlllll.Ul1zation of all children, and the number of times all pregnant women are visited at home and seen at the health centre. When the size and struoture of the oase load and the manpower available are known, the programme goals may have to be met by less frequent visiting; but an essential minimum must be standardized for all.
(3) Knowing the people. It 1s important but not suffioient to know the oonmun1ty in terms of numbers. A continuing relationships with the families develops mutual trust and sensitivity to their ability or inabil1ty to cope with their health needs. In addition, a more preoise method ahould exist for categorizing people as "high risk", for wh()m additional care must be provided, or Urout.1ne" for whom standard 'procedures exist. Some families may not need or want the serv1oe. We w111 not know this unless we vis1t thelll at least onoe. They ahould not be excluded from the oase load.
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. A 5% case load sample was Characteristics of family but health needs are very young baby was in serious from the record it seemed presented and analyzed (see Charts 2 and 3). structure were seen to be similar in some families different. One family in which there was only one trouble and the parents refused family planning; that this was a "routine" family.
A system for registering families (or patients) according to the category of care to which they belong was discussed and a card register was sugsested.which allows for alerting of the nurse to families in the high risk category. It also allows for transfer of the family card from one category into another as their needs increase or diminish, and serves to keep the nurse informed at all time of the demands of the case load. Discussion The issue raised is the necessity to develop a network of primary health care which will involve the community in meeting the people's needs and the necessity for ensuring coverase and quality of care through the development of standard procedures. This has implications for nurses and midwives, particularly in regard to the planning and management of services, quality of care provided and adequate supervision. Conclusions Discussions focused on primary health care in rural areas where special problems exist in coverage of community needs by routine as well as priority procedures. While the discussion involved a broad ranse of subjects and illustrations, four main concerns were common to all groups. (1) Community organization.
,
(2) Systems of delivery of services appropriate to the situations of different countries. (3)
Training in respect of professional workers and community members.
(4) Utilization of manpower, including professional workers and community members. Community organization. Local authorities. official and voluntary organizations and conmunity-based activities exist in most areas. They constitute a framework within which nurses and midwives should operate. It is necessary to identify community leaders. to understand their range of activities and responsibilities and to make use of them on behalf of individual patients and families. Community leaders are known by such titles as Panghulu. Barangay Leader. Soncho and many more. These leaders are senerally elected by the people and paid by the governments. Their fuaotioas include (i) census taking. (ii) organization of groups for disseminating information. discussing problems. conducting health education classes. etc. (iii) storase and distribution of supplies which may include medical supplies. food supplements and agricultural supplies. In addition. chanses in community statistics. villase or family problems, reactions to new laws are reported to the community leader. There are also individuals in
the co-.m1ty - the tra~tional lI1dw1te, the teaeber, the _dicinli an, the rellgious leader _ who bani di8tinct re8J)OIl81bUitie8 and 8tatu8 and with whom nUl'ses and midwinls should collaborate in respect ot high risk tlllll1lles, i~l'IIIILtion on tllllli17 plannill8 and surveillance ot problem cases. OOmmanit7 groaps and working committees were similar17 described and aiscassed b7 the participants. Some have general interests while others blLve specitic flmctions otten in relation to a catesol'7 of patient (tlllll117 plannill8, D, hospitallzed veterans, etc); and still others, althoggh not involved in health matters, are concemed with the general wltare of the eo_It:y and are a~ of c("*"."1 t:y needs. While there are 10M variations in the situation in the different coantries there 11 adeqaate evidence of a rich SOUl'Ce of information from which nUl'ses and midwives can bam a great deal about their case loads. various serviaes alllo constitllte vel'7 impressive resource for the support and strell8thenill8 ot health work in the COIIIIIIIlDit7, and nurses and midwives would do well to collaborate with them. The7 include services in sanitation and aa:ricult\lre and in other health related activities such as malar1a control. What is needed i8 the inclusion, in the basic training ot nUl'ses and midwives, of principles of COIIIIIIUD1t7 organization, to ell8ender an understanding of the social strllct\lre of vill8f!:e or rural commanities in which professional wrkers tram the olltside will develop wrking relationships. Dallvel'l of serrlee. ate group felt that as a basic principle tllllli17 planning should be introdllced as a health service on17 in conJanction with maternal and child health .. rrlaes. lblltine OOftl'll@;e of all tllJd.11e8 with children was a prerequisite for the additional procedares required for high risk tlllllilles. In SOlll8 of the collDtrie8 it 11 necessar:y to select and train awd.llal'7 wrkers (1n nUrsill8); while in o~rs volllDteers provide taad.17 planning information and coansellill8. In at leUt ODe collDtr:y tbe flmot1oDs ot tbe m1dwite include general child health ..rrlaes. In one coantr:y mentioned a neighbourhood volanteer is assigned to ten hoUHholds to ginl guldllDC8 IIDd advice. In another coantl'7 the professional nurse visits a COIIIIIIn1 t:y infrequent17 and depends on -interim- saperrlsion b:y whoever seems to be appropriate for the particular case. Methods wre sagaested for keepill8 registers and developing records which indicate the progrelS of the service and the continuing needs. The need for colllJllllDication and transportation where nurses' visits are infrequent and the need for regular meetill8s between Bllpervisors and awd.llar1es at tbe peripher:y wre d1lcllssed. 'l'he organization of the service depends on collaboration with other agencies for the sllpp17 and distribution of IIIIIdication8, contraceptives, and other equi~nt IUld supplles required in the dellver:y of the serrlce. Mathods tor reachill8 people who are bolated mIlst be follDd and ma:y depend on COIIIIIIIlDit:y-based volllDtar:y groups. Training. Oommanit7 organization and pr1mar:y health care have evolved as
the basic cllrr1cullllll ot health workers. Also required in the role of the nUl'se IIDd midwife 11 proticienc:y in trainill8 and sllperrlsing primar:y health workers recruited tram the COIIIIIIIlDit7' At present these aspects of primar:y health care which are lIaportant elements in the role of nurses and midwives, are developed largel:y throllgh on-the-Job experience. Trainill8 and supervision of primar:y health workers, and estimates of their capabilities in terms of qllanti t7 as wll of quall t7 of wrk, are neaessar:y.
matters wiich require stlld7 and supervised experience and as such belong in
- 14 -
• Utilization of personnel. Factors to be considered include the capabilities of workers of different levels as well as the "weight" of the case load. Whether a home visit, for example, is too costly or is an economically feasible procedure depends on (a) how long· it takes, (b) who will do it, (c) the purpose and (d) what was accomplished. Thus a visit by a public health nurse to inform a patient that she should come to the clinic may be judged too costly. A visit by the same public health nurse to make an appraisal of the home situation and to use this appraisal as the basis for dietary advice, advice and assistance regarding domestic hygiene and the prevention of infection, as well as planning with the mother to come to the clinic for contraceptives prescription, may have a life saving effect on members of her family which cannot be measured in terms of cost. This example was discussed to illustrate a principle which must be applied in the utilization of staff. Standardized procedures are required for staff assignments in routine and priority situations. Finally, it was agreed that the delivery of primary health care could be organized in such a way as to achieve coverage and quality of care if: (a) nurses and midwives become involved in the life of the community and accept. and are accepted. by the people; (b) primary health workers. recmi ted from the cOmmunity. are trained and/or supervised in a collaborative role with nurses and midwives; (c) the community needs are met by routine procedures available to all. and supplemented by additional services required by priority or high risk families; (d) records and registers are maintained to evaluate the service and Topic 4. Summary; Manpower problems in family planning keep the staff aware of the state of the case load.
medical manpower problems in rural areas
There is a shortage of doctors and nurses in a number of countries in the Region. Though between 1950 and 1970 the number of physicians in the world doubled the ratio increased only from 5.7 to 7.9 for 10 000 people Owing to population growth. The comparable figure for Asia was only 1.)6 per 10 000 population. These are overall figures and do not give information about the distribution of doctors. We are aware that nearly 6CJ1> to 7CJ1> of the doctors are concentrated in large towns and cities. These urban trained doctors invariably have no idea of the health problems of the rural folk. They get isolated in institutions and treat every patient as a case and are likely to forget that they have a home and a different environment to go to when discharged. Some of these doctors are forced to work in rural areas to satisfy a political need. They are unable to function due to lack of facilities in the medical and health institutions _ apart from the mental reservation they have about working in rural areas. FUrther, due to lack of attention to rural areas there are not even minimum facilities in many cases to make them liveable. This is partly due to political leaders being urban oriented. It is for this reason that a change in the socio-political system was suggested in the first session. The scarce medical manpower should therefore not be wasted. The nursing personnel who are also in short supply should be better utilized. Though i t is true that there are Borne countries with
,
- 15 -
nwnerically lIXlre doctors than mlrses, owing to inequi table distribution, part1cularly of female doctors, and to unsat1sfactory working conditions, doctors are unable to provide all serv1ces required at the local level; and th1s results in wastage of scarce medical manpower. The medical profession does not generally approve of aux11iary med1cal staff but would welcome the nurs1ng personnel taking over Bome of the traditional medical funct10ns as they have been associated with them as students and later on as members of the health team. Therefore, the nurses should be the alternate choice for plann1ng and delivery of health services at the local level. The main points to be considered in this scheme are: (1) Designation of a hospital or health oentre at the district level to be responsible for health activities, both preventive and curative, in the district and to serve as a l'~al th centre for .a_dI!f:l.1led area. ,
-
(2) level. (3) (4)
Determination of the staffing pattern at district and village
Consideration of the family as the basic social unit. Establishment of a workable referral services system.
(5) Preparation of staff concerned to play their defined roles, and the legal aspects involved.
(6) (7) SUlIIDSry:
Continuous lIXlnitoring and evaluation of services. Record keeping and reporting. the traditional birth attapdant eTRA)
The emphasis in the seminar was on the provision of family planning services in the context of family health care. As pointed out, the members of a community respond and utilize health care services when they feel that it meets their felt needs. These felt needs are expressed best by community leaders who are aware of these needs and are able to express them to personnel concerned with developing health programmes in the community. The TBA is a respected member of the community. People listen to her as they feel that she is "one of them" and will protect them from outside intruders. She is a valuable friend who can, if given guidance, support and recognition, improve maternal and child care and promote the acceptance of family planning. Her livelihood depends on deliveries, thus health personnel must find ways and means of expanding her role to ensure that if she is successful in curtailing fertility 1n her commun1ty, she 1s compensated for this poss1bly by expansion of her role to include some aspects of child health superv1sion and maintenance of family health. Studies on the extent to which TBAs can contribute to improved MeR, care with wider coverage, and on ways of providing compensation must be initiated. Reference was made to WHO Expert Committee recommendations on the utilization and training of TBAs.
- 16 -
Summary: family planning in the education of nurses and midwives Nursing and midwifery education has followed the pattern set by medical education. The basic educational programmes, particularly in nursing, has prepared staff to care for individuals and families who are experiencing a life or family crisis: for example, pregnancy, illness or the rehabilitation of individuals recovering from a crisis situation. Planning for children is not viewed by most couples or individuals as a crisis Situation, unless the pregnancy is complicated by a physical illness or presents a social or economic problem. Pregnancy is not viewed in the same light as poliomyelitis, tetanus or possible death. Family planning in basic educational programmes of nurses and midwives must go beyond methods. If nurses and midwives are to be effective in this area, they must understand the social and cultural factors which promote high fertility and the development of adult human sexuality, and they must have the opportunity to gain insight into their own feelings about sex and maleness and femaleness. Nurse and midwife practitioners need training to prepare them to function in this new role - as educators and supporters of couples and individuals who must make the final decision for themselves as to how many children they want and when they want them. Skill training in diaphragm fitting and IUD insertion depends on a country's needs and resources for personnel trained to provide this service. Skill training in pelvic and breast examinations should be included in the basic preparation of all nurses and midwives as this will improve and promote maternal health through case-finding, providing that the country's health care services are in a position to act when cases of deviation from the normal are referred. Discussion Nurses and midwives have added responsibility where there is a shortage of doctors. This will mean that they have to take over some of the traditional functions and in turn transfer some of their functions to other health workers. This has implications for nurses and midwives in terms of their preparation as well as their responsibility for auxiliaries. Perhaps further stUdies are necessary to delineate nursing midwifery practice at different levels. It will be necessary to determine how such stUdies could be undertaken, and whether a final document "Suggested solutions to manpower problems in nursing and midwifery" would be useful in the context of a continuing shortage of doctors. Conclusions All the groups expressed the need for stUdies to redefine the roles and functions of nurses and midwives and the need for supplementation by health workers at different levels of preparation and the delineation of their functions. The discussions oentred on the reasons why stUdies were necessary, the scope of such stUdies and the method for their implementation. .,
- 11 -
Need for studies.
Reference
was made to a number of points:
(a) Nurses and midwives have added responsibil1 ties because of the addition of family planning activities, greater demand for health services and the shortage of doctors, particularly female doctors. (b) There is an overlap of functions of workers at different levels of preparation and, as a result, duplication and poor utilization of staff. (c) The study would contribute to the development of Job descriptions for staff members and this in turn would influence curriculum content in the basic training and preparation of health workers. (d) The delineation of functions would assist in the coordination of services and assure comprehensive coverage of health needs. (e) Legal protection for nurses and midwives should be related to their expanded roles and should also safeguard them from being required to perform practices outside their roles. Scope of studies. The groups made various suggestions as to the scope of the stuc:Q', calling for: (1) evaluation of the functions presently carried out by nurses and midwives and auxiliary personnel; (2) evaluation of health needs of the co-.mities served; appraisal of the present admin1strative structure; survey of the number of personnel in each grade and their responsibilities;
(3) (4)
(5) consideration of the question: "which co-.m1ty needs were being met by which oadre of personnel?" A second aspect considered, regarding the scope of the study was that of national, intercountry or regional studies. It was generally felt that national characteristics of manpower utilization were too different from each other for Joint studies to be useful. One group identified some of these differences. In one country nursing education is specialized so that each student Jlll.y enter training in the area where she intends to make her future career; in some countries general nursing includes midwifery while in others midwifery requires an additional period of training. In one country, the traditional birth attendant is registered and supervised and is given refresher courses; and in another the multiplicity of languages as well as lack of transportation makes training and supervision very dUficul t. Trained MeR aides in one country are replacing the 'mA although the people's confidence in the familiar 'mA slows down this process.
one group felt that the findings of national studies would be more relevant to the countries' needs; another emphasized the need for national studies as a preliminary to a regional study whiCh should be undertaken with the assistance of the WHO Regional Office.
- 18 -
Method. The following BI1ggestions were made as to how the studies should be conducted: (a) Within the Ministry of Health, with participants from nursing and midwifery and other categories of nursing and midwifery personnel. (b) Through questionnaireS completed by consumer groups representing urban and rural areas. (c) By a survey of existing studies and doouments pertaining to functions and practices. Among the documents mentioned were: nurse and midwifery legislation; practice manuals; written Job descriptions, basic and post-basic curricula. (d) With partiCipation by the medical profession and other categories of health workers in all studies undertaken. (e) Through which questionnaires sent to doctors and nurses to ascertain the willingness of doctors for certain practices to be undertaken by nurses and willingness of nurses to undertake them. A study of this kind now in progress was cited. Finally, the groups exproesHd two main guiding principles for undertaking such studies: (1) that they should reBl11t in changes which would ensure the maxillDlDl utilization of lUlrses and midwives; (2) that they should ensure an administrative infrastructure where the role of nurses and midwives is recognized as the ·practice of comprehensive family health care, where the co-.m1ty participates in the development of primary care services and where family planning is offered as a health service. Topic 5. Impact of nurses and midwives on policy, practice and preparation Procedure '!bis was discussed in a plenary session. '!bere were no pr"esentations and the topic was introduced by citing illustrations of policies, pr"actices and pr"eparation on which nurses and midwives may have varying degrees of impact. Discussion '!be control of population growth at the Economic Planning Unit level, supported by budget and given priority status over national progranmes, was compared with the policy of the Ministry of Health, making family planning services available to all who wish to avail themselves of the service. Practice. Illustrations of pr"actices for discussions .ere (a) the "target" concept of family planning and its effect on service and (b) the insertion of IUDs as routine pr"actice in maternal and child health, or specialized practice by some nurses and midw1 ves in family planning.
- 19 -
Preparation. The impact of nurses and midwives on the basic curricula was discussed, using IUD insertion as an illustration of a new procedure. Conclusions Policy. I t is recognized that the impact nurses and midwives may have on national policies is limited by various factors. In the case of family planning, fbr instance, the decision may be taken by authorities concerned with population control, not involved in health matters and to which nurses and midwives have no access. JJowever, when this is the case and when nurses and midwives know that some of the rules may be detrimental to the health of some families, ways and means to be heard were mentioned such as: - information of the problem through ~tessional
associations
- mobilization of pressare groupe, including women's clubs - gathering of data, presentation of facts to demonstrate on objective ground that other rules may better serve the tinal objective of child survival. In this connexion, an example was cited where a group of midwifery personnel was able to obtain permission from the health autborities to . disseminate information re8&Z'ding child spac1ng in spite of national restrict1ve legislat10n on 1'IIII1ly planning. It was concluded that even when direct action is not possible nurses and midwives need to wrk individually and in groups to shape educated opinion on any health and related matters affecting their 1iOrk in order to exert influence IIIld bave an impact on any rule or policy of the autllorities. Attention was drawn .on the necsuit:r to avo1d reaction to new policies Just because they are new and lIIply a Chllllge in practice, behaviour or wrking relat10nsh1ps. In this conoexion, the introduct10n of new categories of health personnel, such as .ale nurses and med1cal assistants was mentioned and discussed. No general. conclll8ioDs were reacIIed. It was, however, agreed that questions related to beal.th II&I1power need to be considered at national level anqlor in consultation with the exist1ng professional groups involved. Pract1ce. In relat10n to nurses' and midwives' practice 1t was observed by the partic1pants that the concept of targets as applied in some countries 1n family planning wrk is contradictory to the family health care approach for which they are prepared and respons1ble. Ment10n was made of the difference between targets wb1ch concern only one part of a service and measurable obJect1ves wh1ch cover a whole programme. The group tinally questioned the value of the "target approach" even for a specific activity and re-affirlDed its belie! that t'alld.ly planning ia part of tam1ly health care and 1 ts eff'1ciency cannot be measured in a :fragmented way. Preparation. Fam1ly planning wrkers require preparat10n in various metbods and procedures. '!'be participants agreed that general approaches and methods 1n family planning need to be included in the preparat10n of all nurses and midwives. JJowever, technical skills such as the insertion of IUDs required constant repetition to maintain safe practice, and·.no conclusion was reached as to whether such specific procedures should be included in the basic preparation of' all nurses and midwives. or whether they should be restricted to in-service post-basic training of wren eDgll8ed in these activit1es.
- 20-
by
ntring the seminar, reference was made to the need for greater impact and midwives on the special needs of adolescents. Some basic curr1c~la do DOW inclnde such courses. However, nurses and midwives presently in practice have not all been formally prepared to engage in this area of work. It was felt that the role of adolescents as f~t~re parents should be given serions considerations, as constit~ting an area of work for all nurses and midwives. n~rses
5.
EVALUATION
A questionnaire for eval~ation was completed. An interesting finding was the fact that 16 of the 21 participants had never before left their countries and 15 had never attended a WHO seminar, workshop or intercountry meetings. This may have been reflected in the ans1lers of ~ participants who had not been "very eager· to attend. Nevertheless all 21 participants checked ·very pleased" that they had. For analysis of the eval~ation see Annex 10.
- 21 ANJIE[ I
LIIfl' OF PARTICIPAITS. COlISULTAJlTS AND SBCJIETARIAT
1. BIlTISH SOLCIICIf ISLAIIDS Pl'lOTECTtWlATB
PARTICIPAJITS
Ma. Pau11u Mary Downilll C; Heal~ S1ner Metieal 0.,..-' 1m iIoa1aN Me. Upokolna Tulproa Publ1e Health Marae Heal1:ll Depal'tMn, M1D1ltr7 of Soeial SerYieel J!IInWIW!
d.,.
COCI!: ISLANDS
PIn •
L~"~-,'''''''''':'''(Ji:z 87'1l_:. . . . :,~ ~lo
Ma. 'nka W&qatabu ' . . . . .rtUas Heel.... S11Mr
-tat...' ~~••
Lautoka
.... Ti. Te_ Aa. PubliCI Health Sr. c.n'Nl ColOII)' Hoap1 tal Btkea1beu. Tarawa
HOllO lCONG
MI. ApM '1'0118 CheIl8 Mo-foll8 BeD10r !Ital1:ll Viiitor ...~ aM Child. Health Beninl
,...10al UIIIl H.al.... Deparilllent x.e Gardena. lIburth Floor
Hre!
AY_ •.
ca_q _
MI. Yaeko Ma1olUlllOW
D1reowr of MidwifeIT EdUCIation Blhool of Midwi.,.1
Ma1oional Okara HOlpital 2-l~1.
anara,
Bltqqa-ku
'!'Oklo
. Mme N)' Saftlln Blrvlee de eonaulta101on SYft'cologlque et prinatale HSpl10al de l'A81t14 kbm'ro-Iov14tlque PIm_ PaM
- 22 -
Annex 1
KHMER REPUBLIC
(cont 'd )
Mme Kim Hat Khou Chef de salle adJointe Centre de Pediatrie de l'HSpital Preah Ket Mealea Phnom Penh M. Ianh Prachomphonh Infirm1er moni teur c/o Ministere de la Sante publique Vientiane Mme
LAOS
Houang Solyphanh Sage-femme rurale surveillante Direction generale de la Sante publique Vientiane Ungku Maimunah Bt. Ali
. MALAYSIA
State Health Matron PeJabat Pengarah Perkhidmatan Perubatan dan Kesihatan Pulau Penans Ms. Margaret Naupa Public Health NUrse Rural Health Service Port-Vila PHILIPPINES Ms. Virginia S. Orais NUrsing Consultant Office of Health Education and Personnel Training Department of Health Manila Ms. Sarah R. Austria NUrsing Programme Supervisor National Family Planning Office Department of Health Manila REPUBLIC OF KOREA
Ms. Kum-Bok Hwang Publio Health Supervisory Nurse Nursing Section Ministry of Health and Sooial Affairs Seoul
- 23 Annex 1
SINGAPORE
Ms. Tan Pbaik In NUralns Offioer Maternal and Chl1d Health Servioes Headquarters Natlonal Faml1y Planning centre 26. Dunearn Road Slne;apore 11
TONGA
Ms. Lavinla M. Heimuli Publi. Health Sister val01a Hospital Min1stry of Health Nuku'alofa MIlle Bu1 Quang Hui Mattresse sage-femme nationale Min1sWre de la San~ 59. Bd. Holl8"''DIap-Tu Saigon
REPUBLIC OF VIET- NAM
Mlle Do ",00 TuJ't Mattre..e sage-femme Min1ster. dela Sante 59. Bd. Hong-'l11ap-Tu Sa1l0n Mlle Do Kim Cuons Inapeotrioe san1taire troiaieme reglon Mln1st~re de la Sante 59. Bd. Holl8"''lhap-Tu Saigon WESTERN SAMOA ~glonale.
Ms. Iwlipou S. Betbam Matron Distriot Nursing Servioe Health Department Apla
- 24 -
2.
CONSULTANTS
Ms. Helen D. Cohn (Seminar Director) Lecturer on Public Health Nursing Department of Maternal and Child Health Harvard University, School of PUblic Health 677 Huntington Avenue Boston, Massachusetts 02115 Dr P. RaJasingham Consultant on Strengthening of Health Servioes WHO Regional Office for the Western Pacific ~~ 3. lEIIPORARY ADVISER
Ms. Carmen Panganiban Senior Executive Assistant II Materni,ty-Centred Family Planning Bureau of Medical Services Department of Health Manila
4.
SECRETARIAT
Ms. Helen E. Fillmore (Operational Officer) Regional NUrsing Adviser on Family Health WHO Regional Office for the Western Pacific Manila Ms. Madeleine Lenoir (Co-operating Officer) Regional AdViser in Nursing Administration and Services WHO Regional Office for the Western Pacific Manila Ms. Mary O. Abbott Regional Adviser in Nursing Education WHO Regional Office for the Western Pacific Manila
Annel< 1 4. Dr T. C. Hau
SECRETARIAT (collt'1\
Regional Adviser on MCR/FamilY P1Rnning WHO Regional O:ft:l.ce for the Western Pacit:l.c MllDila Dr G.M. l!Dery
Regional Adviser on Strengthening of Health Services WHO Regional O:ft:l.ce for the Western Pacific Manila Ma A. Guyet (liesource Person) lfUrBe
Organization mandiale de la Sante llotte postale ~3 V1entiane, Laos
Ms M.E. Leavy (Resource Person) Public Health Nurse c/o the, Director of Medical Services KlIching, Sarawak *laysia 5. OBSERVERS
Me EVelyn Johnson Office of International Health Dep&rtment of Health, Education, and Welfare Washington, D. C. 2a!40 United States of Amei:l.ca Me Pilar B. Pacifico Assistant Chief Burse Manila Health Department 1663 Kansas St. Manila Ma. Alice Cerdinio Family Planning Organization of the Philippines Population Center Foundation Building South Super IJ1ghvay Maltati, HI. zal
-'i!7• ANNEX 2
COUIfl'RY QUFBl'IONNAIRE
lfame of oountry _ _ _ _ _ _ _ _ _ _ _ _ _....:Report prepared by_ _ _ __
tate: _ _ _ _ _~l974 1• li'amUl pllUUling pro~
in the oouny
(a) (b)
Does the countrz have an official famUy progralllll8? Yes (If les, oont1nue with question (0» -
No
If no, does the Qovernment support private family planning activities? Yes_ No What are the oountrz's pol1cies/obJeotives for its family pllUUl1ng prograa.? What are the overall plans for the implementation of these objectives? What other ministries or government agencies are involved besides the Ministrz of Heal th? Is there a voluntary organization for family planning activities 1n the oountry? Organization of the family planning prograame: Please attach an organizational chart of the health services in the countrz and speoify where tam11y planning activities fit 1nto the existing struoture for delivery of health asre. Central level: Intermediate level: Delivery of services to the people:
(0)
(d) (e)
(f)
(g)
(h)
Operation of the progr_. 1. A. Suuaary of government progra_, 1nclud1ng methods and achieveJDents and relationship of family plann1ng programme to the oountrz' s system for deli very of health care. SUlllMry ofprivate'progra_. to Qover11ll8nt prograaE)
B.
(if applicable) (relationShip
- 28-
Annex 2
2.
What categories of health personnel are presently available for family planning activities and what are the major responsibilities of each category listed? What training programmes are in the planning or are ongoing for the preparation of nursing/midwifery personnel for family planning activities? Are new categories of staff planned? If so, what will be their title(s) and responsib111t1es in the family planning programme? Is there a plan to involve traditional practitioners in the family planning programme particularly traditional birth"attendants. Is there a plan to expand the role of any of the categories of the nursing/midwifery personnel in family planning. If so, please specify the responsibilities of the expanded role and preparation planned or completed to permit functiOning in the expanded role. We would like your comments on the con'r1bution presently being made by the nursing/midwifery personnel in your family planning programme (comment in terms of training and preparation of staff for family planning, workload, Job satisfaction, degree of utilization of this category of personnel for maximum programme aohievements and any evaluation of the nursing/midwifery component of the progr&llllMl).
3.
4.
5.
6.
(1)
-29• FAMIU PLANNING ACVIi'lyrrmS IN THE CONTlOO.' OF HBAIll'H S&RYlCBS
by Ill:' P. Ra ,1asingham
WHO Consultant
1. INTRODUCTION At the very outaet, the writer wishes to state that this paper, by no means an ellbaustiw dissertat1.on on the subJect, is presented in the hope that it will be of so. use in the .discussions. Health sernces de'9810~nt in oountries and the prablellll and constrainte involved in the process have exercised, and are still exercising, the 111nd8 of both the political and technioal people responsible for providing an aooeptable and accessible service.. For man;y years attempts have been made to establiBh a consensus as to what health means. Fortunately, the creation of the World Heal th Organization in 1948, alllOst the time when a number of developing countries were emerging as independent states, has given a new direction and an opportunity for exchange of views in this field of endeavour, which is the basis of hwnan happiness, welfare and, in faot, the '98ry surnval of the hlman race. WHO has enunciated that health is a state of complete Ii17sical, IISntal and sooial wellbeing and. not merely the absence of disease or inf1rad.ty and has deolared that these Bhould be long tera objectives to be attained througl1 an effioient and appropriate DIltional health system in countries with the available resouroes and technology and. those where they are likely to becOllS available. In this effort, governments should endeavour to utilize as applicable the colleotive experience gained in the different countries of the world. In fOl'lllulating a health system, the fall1ly should fol'll the basic social unit. It therefore, becomes illllll!diately obvious that faDlily size needs to be kept at a level which will allow for Pl'ovision of adequate health and. welfare services b7 govei'nDlents. 'Dlis would also ensure that all economio development which has its main objective to secure IIIIIIl'S wellbeing does in reality attain this objective and. is not submerged by an ever-increasing popllation. Palll1l.y size and economic dewlopment Bhould thus be comple.ntary. The operatiODlll units of health services DIlturally vary aocording to the needs of each country. aenerally speak1ng, they include: general practitiOller services; con8Ultant sernces; hospital services, including maternity, outpatient screening, and general inpatient care; health centres for general care; maternal and. child health clinics, with or without domiciliary maternity services, home visiting, and general health eduoation; cOl8Ulity Plblic heal th care, including environmental and persODlll services; mobile units for general or speoifio osre Pl'ograDlll8s, with or without health eduoation facilities; and dispensaries for simple outpatient care or as special clinios. 2. HBAIll'H SBHVICES IEVELOIMENT
In the early stages of heUth services developnent, the i_diate objective was to reduce morbidi t)' to anageable size. The services were therefore minly curative and oonfined largely to urban areas and to those working in industry and on plantations. The rural population - nearly 70'1> of the total poPllation in SOlIS countries - was relatively neglected.
- 30 Annex' •
Unfortunately. some of the dev.lopins countri.s .lso .mbarked on prestiaious project. with .id trom donor oountri•••nd thi. meant • further d.l.y in takins he.l th ..rvices to the rur.l .re... Blare was .1.0 the probl.m of .cce.s to rur.l .re••• nd government. had to buUd road•• bridge. and other co-..nication f.oiliti ••• eta. 'D1e short.ge of h•• lth manpow.r bas continu.d to be anoth.r deterrant to the .xp.ndon of he.lth •• rvioes to .nsure bettar he.lth oov.r.... 'l'he World He.l th A ...mbly. takins cocniZan.. of .11 the •• f.otora, baa ••sumed le.derahip to ellllUN orderly develo..-nt of he.l th "rvioea. 'lbi. leaderahip baa the nec....r;y force behind it, •• the World Health A...mbly 1a the voice of the Mellber countriee. With the ~ ooutr.int. that partioipanta DOW, only • !*a..d develop.-nt at health eerv1o•• over. period of ti_ 1a ~.dble, lnvolvine firat the hoapital •• nd 011010. in lar.. urban .re•• , then .maller urban .re•• , then ..1Iirur.l .re•• , and flnally rur.l cI1.trlct.. Fort\.llUltelJ', 111 lIO.t countrle. we have now re.obed ..m-rur.l cI1.trlot., .lbalt on • modest .oale, with lncre••m. re.Uzation that he.lth ..rvloe. to rural are.. ahould now rec.i ve prlorl tJ' • '!'biB bad been poe.l.l. clue to the coorc\1nated develo..-nt ot he.lth, educ.tlon .nd oo-..n1cation f.oUltl... In.ll the . . developmants. lt bas also now be.n f'1r1ll;r e.tabliabed that partlolpation bJ' .n lnformed popul.tion ls neoe."rT not onlJ' ln PLannm. for ..rYloe. but al.o 1n their utlll.atlon. All the .. devel0Jlllllnt. bave taken pl.ce usiq .tandard pattern. ot .tattins .nd orpo1.. tlon. with oo..,n sen.. and. publio he.lth pr.otloe a. the main tools for the pl.nnlns .nd implementatlon of health progr...... In the development of health ..rvic... ana cannot help obeerv1n& that MCH bas .lways been the oore proara- .round whioh other .0tiv1t1as were bull t • 'l'h1. 1. true even to the pr...nt day wh.re, .1 thouah MCH 1. part of the gener.l he.lth ..rvloe •• lt baa not lo.t It. ldentltJ' .1ther 1n the curative or the preventive ..rvioe.. Pami1y plannina whloh was malnly promoted by volunt.ry agencie. with .xt.rnal .1d 1a now becamine lncre.singly an lntearal part of MCH ..rYlce •••• lt ahould be. 'lbl. brlngs out the f.ct that tram the tll11B h •• 1 th s.rvlc.s .s suoh w.re thoual1t of. nur... and m1dwiws bave continu.d to be the backDone of the.. "rvl0.s. In f.at tbeJ' w.re the p10naers in takine the beal th ..rvlce. trom 11\11ti tutlon. to the ho.... Nur... and midwive • •nd nursinr!midwlfer;y auxiliarie. even today consti tIlta the l.rge.t group of health work.r. in mo.t ..dioal .nd ba.l th o.re Prom the time pha.ed developnant of be.l til ••rvioe. wlth the ultimata obJectlv. of total health oov.rap bec... the .a.eptad peliay of government•• he.l th lElJICI'Nr d.velop!l8nt he. rec.lved prlority .ttention tram natlonal governments .nd international .nd bil.taral .8!IJlCie.. One other cOllcurrent concept is that he.lth in.titutlon. cannot an;y longer f'lmction in isol.tion. 'DIey bave to be .ffectlvely 11nked wlth the ho.... where the f.mily. the baslc .ocl.l unit of • coaamity. 11v... 'l'h1s bas f.cil1tated proDIOtion of f.mUy pl.nniDa, whloh more than an;y other .oclo-eaonomic develop!l8nt proara_. bec.u.. of lts inti_ta nature. baa •• lts focal point the home.
.,..te....
- 31 -
•
Annex 3
One ditt1aulty 1n the development ot health serv1ces, particularly the1r expans10n to rural areas, has been the reluotance on the part of' dootors and nurses to appreoiate the importanoe ot auxiliary health personnel tor health servioes delivery. The writer, theref'ore, stresses that health serv10as ara reaponsibla tor the development of' health DIlnpower aooording to the needs, teohnologioal stage ot development, and nnancial resouroas ot the oountry concerned. QoverlllMnts have also the responsibility f'or employing the health manpower produced and its equiteble distribution 1n the oountry. The _Jority ot rural areas, at present, are not attraot1ve enoulh tor health manpower, partioularly doctors and nurses. Adequate t1nanoial incentives w1th reasonable living quarters should be provided tor rursl health workers, at the same time ensuring Job satisf'aotion.
}.
FAMIIX PLANlmfQ ACTIVlTIBS (Historioal Sketch)
Interest in tamU,. planning has developad rapidly in DIlny countries during the past ten tot1fteen years. Family planning has usually been disoussed under the subJeot of huan reproduction in a number of World Health Assembly . .etings. As is well known, to begin With, WHO . . s not fUlly o~1tted to developing tamily planning activitiea. From 1965, however, when WHO parti01pated in the Seoond World Population Conterence oonduoted under United Nations auspices, there has been 8 change in this vi... At the Bll!hteenth World Health Assembly in 1965, the D1reotor-Qllneral was asked to prepare a progra_ of aotivities in the health aspeots ot tamUy planning _cause it was oonsidered that the ohanges in the size and struoture ot the population had repercussions on health oonditions. In 1966, it was agreed to inolude inforuation on the health aspeote ot population problelll8 in the eduoation of medioal students, nurses, midwlves and other _mbers ot the heal th team. Member countries were also to be given technioal advioe on family planning without impa1ring the nor_l preventive and ourative servioes. Again in 1967, it was p01nted out that abortion and h1gh IIIlternal and child mortality rates oonstituted a serious problem in DIlny countries and that there was there tore the need for oontinuing aotivities in the field ot the health aspeots ot human reproduotion. Further, in 1968, it was the Assembly's opinion that every family should have the opportunity ot obta1ning infornat1on and advioe on problema oonneoted with family planning, inoluding in fertility and sterility. In 1969, it was accepted that medicine and public health have a substantial contribution to make in the development ot aotivit1es 1n the haalth aspects of human reproduction, family planning and population dynamios. Apart from WHO, IIBny international, bilateral, and private agenoiea are aotively engeged in family planning activities. The United Nations agency most oonoerned with this aotivity is the United Nations Fund for Population Aotivitias. In the Philippines, this prograUIM is
- 32 Annex 3 r
conducted by some 25 different orsanizations with vsrying degrees of participation. In countries where such situations exist there is need for coordination and direction of activities.
4.
HRALTH SKRVICES AND FAMn.y PLANNING
'lbe main objective of governments in oountries where family planning haa become offioial polioy is to reduce the total fertility rate to almost 6~ of the current rate so that the sverage annual population growth rate is olose to 21' rather than the present high rate of ~. Family planning refers to praotioes that help individuals or oouples to attain certain obJeotives to avoid unwanted births; to bring about wanted oirths; to regulate the intervals between pregnancies, to control the time at whioh births occur in relation to the ages of the parents; and to deteI'llline the number of children in the family. Services that make these practices possiole include education and counselling on family planning; the provision of contraceptives; the management of infertility; eduoation about sex and parenthood; and organizationally related activities such as genetic and marriage counselling. screening for malignancy end adoption services. Health workers are in an advantageous position to promote fam1ly planning aooeptanoe becauae of their opportunities to introduoe the subject and service a in the oontext of relevant activities such as prenatal. post-natal, post-aoortal oare. infant and child oare and immunization. family oounselling on nutrition needs and management of sps cia 1 disease problems. FUrthermore. many types of health workers are trained and experienoed in person-to-person and group eduoation approaches, whioh are essential for family planning efforts. In this context. it is _11 to remember that parents tend to be innuenoed oy the high ohild mortality witnessed by them in their ohildhood. If a heal th servioes progra_ demonstrates that children are being cared for. thus inoreasing their chanoes of survival. then the parents may respond oy acoepting family planning. Famlly planning meaBures CBn best be provided from a health oase. as the more modern contraceptive methods - the intra-uterine devioe (IUD). hormonal contraoeption. and tha surgloal oontrol of fertility - require medioal skills. In Beveral countries. m1dwives and nurses are being trained to insert IUDs. 'Illi" is being done in the Republic of Korea. 'Illis is a good trend as otherwiae. i f only medical skill is depended on. it will not be possible to expand the services to rural areas for many. many years. Family planning in hospitals. oommonly known as the maternity-centred family planning approaoh, ia one of the recent innovations in promoting family planning
,
- 33 Annex 3 measures. Here again, the programme depends very largely on the nursing/ midwifery personnel in hospitals. A further step has been taken to include indigenous practitioners and traditional birth attendants in fsmily planning eoti vi ties. Because there are many of these workers in some countries and they are well accepted in the community, it has become the responsibility of nursing personnel to give the necessary training and supervision to enable them to function satisfactorily. There is one other point that merits discussion, namely whether it is better to train more of the existing personnel or to give additional training to existing personnel or both or to have recourse to the trainin~ of single-purpose family planning tIOrkers. The latter approach should not be advocated, as such workers are sanarall), not acceptable to the cOmnl.lni ;.:,-, p~rt1cularly if the)' are left to work without adequate supervision. It must be emphasized that for family planning which is a very long-term programme, merely providing aervioes on a crash programme basis without Anequ~te follow-up will be a failure in the long run. Only an acceptable hp.~lth service on a national soale can ensure the necessary follow-up. The health services, therefore, playa key role in all aspects of +11e family planning progranme: the assessment and definition of alternative strategies; and the administration. organization, implementation, and evaluation of the various component. of the programme. 5• FAMILY PIANNING AND SERVICES 0'mER 'mAN 'DIE HEALTH SERVICES
Health ministries have realized tha need for oolleborating with other ministries such as the MinistrIes of Education, Local Government, v,lbl1c Works, COlllll.lI1ioations and Industry. The collaboration of these ministries 1s required in greater measure for the promotion of family planning. Sex and population education have to find a place in the senool curriculum; the support of local government units is essential : ) ensure participation by the population; the support of the Public ·... "rks and CODl1lUllications Dlpartments ere essential to make family planninp: ser'/ices acceSSIble and to promote 8 rural electrification programme (we all remember how the bIrth rate went up in New York during the period of electric power failure); and the support of the Ministry of Industry is necessary to establish small-scale and cottage industries in rural areas so that the rural population are not only gainfully employed but Co," also usefully occupy their spsre time. In fact, the provision of g~od health services, including family planning, to the working population should also be their responsibill ty. 6. SOME NEW TRmOO IN THE PLANNING, ArMINISTRATION AND DELIVERY OF HEALm SERVICES
6.1
Nat10nal health planning
With the current trend to adopt a health team approach, national health planning has become vItal. This is a mult1-discip11nary approach
- 34 r
Annex ;;
even going beyond the traditional disoiplines of the health services. It involves a ohen~ in the role of the nurse/midwife from the traditional one of ass1atant to the physioian to that of partner in the planning. implementation and evaluation of health programmes. National health planning is carried out as part of the sooio-eoonomic development plans. Therefore. any health plan for the health and welfare of a oountry must be based on government interest as manifested by clear direotives given by the politieal autheri ty. WhAtever tha organizational structure for health planning. it is essential: (i) for planners to have been trained in planning. (ii) for them to enaura that the heads of all the technical units in the Ministry are aotively involved. and (iii) for them to have access to the assistanoe of speeialists in the other disciplines involved. 6.2 country health prograna1ng
Broadly speaking, this is an attempt to solve health problems in their national context, identifying areas susceptible to chen~ and using available national and external resouroes. 6.3 Regionalization of health servioes Some of the oomponents of this sre (i) defining the area to form the region; (11) integrating health and curative services and activities
wherever feasible to avoid duplioation and wastega of steff; (iii) establishing a referral system; (iv) assisting in the development of nat10nal health plana, including manpower development and overseeing the implemntatian of approved plans at the regional level. This will involve ooordination of health servioes provided by the private sector and the voluntary aa-noies. The aim is to provide comprehensive health care wi thin the resources available and to ensure maxiDllm utilization of the servioes provided. 6.4 Health practioe researoh (operational researoh)
This is at times mistakenly considered a luxury for developing countries. Health problems and methods of sol ving them need oonstant study and review as an aid to effeotive planning for health servioes. 6.5 Use of managamnt tools in the development of health servioes
The use of project systems analYSis in the formulation and of health projects is being promoted in the Western Pacific Region. The other mana~ment tools are oostjbenefit and cost/effectiveness techniques which are considered in the planning of programmes in the Region. mana~ment
6.6
Indigenoua categories of health workers
Increasing importance is being given to the education and training of these categories to supplement the steff of the Department of Health Services.
..
- 35/36 AmlOjiC
3..
6.7
New disciplines
It 18 now belng NBlued that i t 18 no ~ollPr po.alble to de~nd only on the her. to e.tabl1l1hed cadre ot health aervlce. to develop tile health servlcea. '1he as.lstance ot economi8t8. management experts. demographers and sociolop8ts is there tore being increasingly 80ulht tor plann1nS. evaluation and tile introduction ot innovatlve sppro8che8.
/
- 37 ANNEX 4
TIlE ROLE AND FUNCTION OF NURSES AND MIJ)lIVES IN FAMII:i PLANNING by Helen D. Cohn, R.N., S.C.H., M.P.H. WHO Consultant 1• INTRODUCTION
,
The development of family planning aotivities in reoent years has depended to a great degree on the availability of nurses and midwives in ho£pitals. clinios. and homes. and on their partioular role in regard to promotive and preventive health oare as well as the oare of patients· under treatment. Principles and practices which are characteristic of the nursing and midwifery professions, and whioh sooiety has for many years oome to expect of them, are preoisely those which are required in family planning services. I t 1s the intent of this paper to outline the role and funotion of nurses and midwives in respeot to the general health care of individuals and groups for whom also family planning is a required health measure, to disouss some of the faotors to be oonsidered in offering family planning services. and to suggest situations in which their applioation by nurses and midwives is likely to be the most effeotive.
l The WHO Expert Committee on Family Planning in Health Servioes refers to the opportunity for nurses and midwives to assist in family planning a~tlvit1es within the framework of their funct10ns in homes. ohild health cl1nics and maternity servioes. FUrther referenoe is made to the role of these categories of health practitioners in the WHO Report of a Scientific Group on Health Aspeots of Family Planning.2" - - - In several countries - - - midwives have been trained to provide full IBI\Ilgellllmt, inoluding the insertion of the IUD's".- - - "the main role of nurses in family planning has been to engage in eduoational and oounselling aotivities and to assist physioians." - - - Publio Health Nurses and health visitors - - - "partioipate in family planning aotivities by counselling in the home, supervising the work of auxiliary staff. and distributing certain oontraceptive supplies."
1 2
Wld. Hlth. Org. techn. Rep. Ser •• 1971. 476. p.37. WId. IUth. Org. teohn. Rep. Ser •• 1970, ~2.
p. 26.
- 38 Annex
4 2. CHARACTERISTICS OF NURSINafl4IJ1trII~ PRACTICE
The role and function of nurses and midwives in hospitsl and public health nursing and maternity oare have been well documented in reports of various national and international groups. It is nevertheless useful here to consider some broad functions and qualities which charaoterize these two oategories of health practitioners which are particularly pertinent to the delivery of family planning care within the framework of general nursing and midwifery services. 2.1 Case planning in the ability hood of the finding: the ability to recognize the need for family patients whose presenting need is something else, and to identify other individuals within the family or neighbour_ patient for whom family planning is advisable.
2.2 Collaboration with the medical and other professions, and skills in carrying out olinical as well as supportive procedures independently or in conjunction with other workers involved in a programme of care for the patient. 2.3 The opportunity to develop a long-term or continuous relationship with a patient or family which allows for a growing sensitivity or appraising (a) their abil1 ty to oope with their problems, (b) their responsiveness to intervention and counselling, and (c) their likelihood to modify their habits and accept new patterns of behaviour. 2.4 A further oonsequenoe of this long-term relationship is a peroeptiveness on the part of nurses and midwives of the effect of social, emotional and eoonomic factors on the health of the patients, and particularly of the children. 2.5 Advocacy: a role, perhaps more highly developed in nursing and midwifery than other health profeSSions, whereby the needs of the patient are presented and interpreted to the appropriate quarter for obtsining whatever assistence the patient requires and is entitled to. In addition to these qualities in working with or on behalf of patients, nurses and midwives have responsibility for administrative funotions which include: (a) the orgenization of their oase load so as to provide systematically the coverage of all patients and the particular attention required by high risk categories; the assignment and supervision of auxiliary personnel in such a way as to extend the services of nursing and midwifery while at the aarne time maintsining the level of practice to whioh the professions are committed;
(b)
,/
- 39 Annex 4
(0)
maintaining reoords and oontributing to data on which evaluations oan be made both of the individual patient's progress, and of the extent and effectiveness of the overall program. FACTORS TO BE CONSIDERED IN FAMIIX PlANNING SERVICES
}.
These features which are oharaoteristic of the role and fUnction of nurses and midwives are appropr1ate to the delivery of family planning care, whether it is offered as a service, integrated into basio health services, or delivered through free-standing family planning olinics. Their application to family planning, however, requires knowledge and skills specifically pertaining to human reproduction and family formation. (It is well to note here that nurses and midwives who engage in family planning servioes, without fully employing those fUnctions characteristic of their professions, give leas than their best in service to patients and families.) Knowledge of human reproduction and family formation is as essential to health care as is knowledge of nutrition, hygiene, and infeotious diseases. Course content has by now been introduced into the curricula of JIIIny sohools of nursing and midwifery. WHO is providing assistance/in this area. These basic and post-basic educational activities will produoe faculty prepared to include family planning in the curricula and practitioners for providing the service. The content of the curricula vary aooording to the obJeotives of the progrsaune and the level and experienoe of the atudent. For the purpose of this paper it will suffioe to oonsider aoma aspeots of the theory and practioe of family planning whioh are intrinsio to the role and fUnotion of nurses and midwives.
4.
FAMILY SIZE
Studies have shown that large families have more problems than smaller ones, and that the ability of parents to cope with their ohildren deoreases as the number of ohildren increases. Nevertheless, the differences between individual families are so numerous and varied that it would be presumptuous to advooate only, from the point of view of health, an ideal family size for any community.
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Annex 4
Certain factors determine the size of the completed family: - the mother's age at the time of her first pregnancy - the continuation of the marriage partnership - pregnancy spacing and the number of surviving children - attitudes and values related to family size - the age at which the parents decide that their family is complete - availability of family planning services Each of these factors may be influenced by cultural mores, national policies, socio-economia conditions, snd health services. In many societies the large family denotes virility of the male, his wife's fertility and devotion, and evidence that the couple has reached a certain economic level. In some cultures a sex preference motivates parents to continue having children until they have at least one of the desired sex. Sex preference has religious as well as economic values. Sons will grow up and bring daughters-in-law into the home; they will contribute to the support of their parents, say the prayer at their death, and continue the family name. Daughters, on the other hand, will stay close to the home, assisting the parents until they too will provide grandchildren for the old mother to care for when her own children are grown. Cultural mores change, however, as national population policies call for a reduction in family size and enlighten people on the advantages of birth control and the opportunities for advancement available to smaller families. In communities where the death rate of children is high, people are likely to have more children than they want in order to ensure that at least some will grow to adulthood. The improvement of environmental conditions and nutrition, and the availability of health and medical and maternity care are essential for reducing the death rate of children, and consequently to promote a sense that it is not necessary to have large families. These factors should be borne in mind when families seem to resist family planning advice or reject intervention Offered without regard to their customs and values. But in addition to these considerations, nurses and midwives should direct their attention to the particular hazards to the mother of high parity and the potential disadvantages to the children of large families.
/
- 41 Annex
4
While the second and third pregnancies are safer than the first, there is increased risk to the mother and the fetus with each subsequent pregnancy. Complioations which are more likely to ooour in late pregnancies include anemia, oalcium defioienoy, and toxallia. In labOUr and delivery there is a higher incidenoe of malpresentation of the fetus, rupture of the uterus, haemorrhage and . . ternal mortality. In addition, there is higher risk of fetal death, higher neonatal mortal1 ty, and higher infant mortality with each subaequent pregnancy. For the children of large families there is often the risk of hipr exposure to infeotious diaeaaes, inadequate nutrition, and emotional problems arising trom negleot or apparent reJeotion by overburdened and harassed parent.. 'lbe greater risk of maternal mortality among mothers of high parity inoreases the poasibili ty of displaoement, neglect and reJection of orphaned ohildren. These risks are reduoed with improvements in socio-economic oonditions, in the general health of paople, and with improved health care in the child-bearing period. For . .ny fand.lies, however, these risk faotors prevail and should be understood as a basiS for counselling on the advantages of limiting tamily size.
5.
PREGNANCY SPACING
Muoh that has been said about limitation of family size applies also to spaoing of pregnanoies. Inoreasing the intervals between pregnanciea aervea to reduoe the number of ohildren born and achieve the deaired size of the oompleted family. There are h0108ver additional oonaiderations for timing snd spacing pregnanoies unrelsted to the number ot children desired. 5.1 Maternal Health
'lhere is no more important faotor in determining the timing of a pregnanoy than the haalth atatus ot the mother. Chronic illness and other health probleDlll of the non-pregnant woman persist and may be aggravated by presnanoY, thus having a detrimental effeot upon herself and the infant. 'lbis faot should be viewed not only as a reason for delaying or preventing a pregnanoy, but also for PE'oviding the health oare neoessary to prepare her for a plarmed presnanoy at acme later date. Nurses and midwives in adviaing parenta to prevent or delay a pregnancy ahould take into aooount the following maternal health factors and their possible imPlioations: Age of mother: . .ternal health appears to be best for pregnancy between the ages of 20 and 30 years. 'lbis does not mean that all child,. bearing DUst take place within this ten year span, but a mother very much
- 42 Annex 4
younger or very much older should be viewed in the context of other factors which frequently relate to age: her socio-economic situation, emot10nal stability, preparedness for mothering, and, in the older age group, the effects on her health of childbearing, lactation, and the stresses of child care. Nutritional state: even healthy women require adequate calories and supplementary protein, iron and calcium during pregnancy. Women suffering from malnutrition in the non-pregnant state are at risk of complications affeoting themselves and the1r infants unless these deficits can be corrected before I!I pregnancy occurs. Higher maternal mortality, higher risk of prematurity, fetal or perinatal death are associated with poor living standards and maternal malnutrition. Recovery from a previous pregnancy: pregnancy and responsiblli ty for a new baby is a taxing experience even for women whose health status rel!Bins good thrcughout the maternity cycle. A period of rest and recuperation is essential for all women and should be of longer duration for those with health problems. If the previous pregnancy was interrupted for any reason relating to health, special care should be exerted to prevent a similar outcome in a subsequent pregnancy. Pregnancy history: mothers with repeated complicat10ns of pregnancy and poor outcomes should be cautioned against further pregnancies and may be advised to accept sterilization as a safeguard to health. The mother's mental health is an important factor in determining her readiness for a pregnancy. She may be too young to be emotionally' prepared for mothering, or suffering from other forms of emotional instability. ').2 The Health of Children
Recovery time between pregnancies has implications not only for the mother's health, but for the last child born. His age and dependence on his mother, in addition to health problems he may have, are reasons for delaying a fUrther pregnancy. A child still at the breast may be abruptly weaned when the mother becomes pregnant again. Weaning and the gradual addition of new foods is an important process in the motherchild relationship, and unless managed carefully, fUrther complicates the adjustment a child has to make to a younger sibling and diminished maternal attention. 5.} Age Relationship Between Children
There is no ideal pattern for spacing pregnancies, and families differ in their ideas on the best age relationship between their chIldren.
, ~.
Some parents prefer to have sll their ohildren olosely spa oed while they the_lves are still yoWl8; they feel better able to meet the needs of early childhood and that children form closer bonds when there is not too DUoo differenoe in their age.. 'DIe parent. look forward to a period of b'eedoll b'om the dsmands of YOWI8 OOUdren or ot return1ns to work .ooner. Other. prefer 1I1der difterenae. in their oh11dren's .... and -1' 1111111 to apaoa tbeir prepanaie. by four or t1ve y_rs. Usually. period ot two or "tbPee year. i. advi_d to allow tor .ternal recuperation and .dequate o.re ot the laat child. However. a healthy .other in • health7 t.1I11y _1' vary thia pattern . without Ul ettecta. i
'DIese t.otora rel.tins to tamily size and child ,pacing have been outUned in ao_ dstail beoause on the one hand they oonati tute • baaia tor oonsideration by nurses and midwives in .ssi.tins f.miUes to plan the ir pregnanoie.. On the other hand. they point up some of the re.aona wb7 fu1Uea _y be al~ to aooept advice lIh10h oalla for ohanp in their reproduotive bebav1O\!l'. It is bIportant that f.miUes t ..l oonfident that nursea and lI1dw1fta do not di_aard the illlPOrtance ot their belie_ta and cultural value •• and that the health benefit. of tllll11y pl.11ft1ng are re.l. and are n&bt tar the. and their particular needs. 'Jhis takes the role ot ourses and lI1dw1ves out of the realll of gener.l1aetions about popul.tion proble. and into the are. of tunctioning tor which they are beat known - the he.lth oare ot people. 6•
SI'l'UA'lICIIS!IOR BPPl!CtI VB PAMIIH PLANKDIO CAR!
)fUrses and midwivea in their oare of patients gain experienae and abUi ty in reoopiz1.n& proble... and health needs related to. or in .ddition to. the patient's presenting needB. Conditions.t home or at work. anxieties and aspir.tions regarding their children or their family as a wole are disou..ed by patients as they develop confidence or perceive interest on the part of the nurse. In ma~ .ituations wh_ nuree and patient meet. thi. oase finding aotivi ty. char.oteri.tic ot nurse. and 111dw1 ves. should unoover the need tor tall117 plum1Dg oare.
6.1 t • .s.ly OUr8BS
C11l11oa1
In addition to eettings speoi.lly deaigned for the delivery of pl.nn1ng servioes. there are a IlLUllber ot situations in which and lII1dw1ves should offer the servioe.
Male or femele patients who visit olinics or are admitted to hospitals with a chronio illness "'1' be reoeptive to assistanoe in
- 44 _ Annex 4
preventing or postponing pregnancy. Post-partClm pa tients in materni ty hospi tals should be carefully advised on the advantages of family plannin" and in many cases an IUD may be inserted before the patient is discharged. Problems arise, however, in the follow-up care of patients after they leave the hospital, so that both in the case of ,dvlce given or the actual administration of a contraceptive, it is essential for hospital staff to develop a liaison with community health services. 6.2 Home
Because of the health effects of family planning on the mother, the infant and the family as a whole, the home visit offers a very important opportunity for effective advice by nurses and midwives and their auxiliaries. Whether a visit is made in relation to a health problem or to a mother and newborn, problems of other family members and of the family as a whole can be identified in the home situation. In the home environment the theory of family planning and its general advantage to health can be directly applied to the family's own life situation. Thus, while one family may demonstrate its ability to have pregnancies at short intervals without detriment to their health, in another family the conditions at home may indicate the importance of longer spacing or prevention of any more births. Furthermore, the home environment often provides clues as to which method of contraception will be most acceptable. In return visits for follow-up care a longterm relationship develops with the family which leads to insight and sensitivity in respect of their ability to change their patterns of behavior, or to modification in the service necessary for its greater effecti veness. 6.3 School
Reference has been made in this paper to the hazards of childbirth to very young mothers. Usually after a girl leaves school she is not known to health services unless she becomes pregnant, 50 that between school leaving and motherhood there is a gap in her health care. In many countries girls are remaining in school longer than in the past and their social lives are less restricted. School health programmes have traditionally focused on the younger child, but in the interest of family health and family planning, more attention should be given to the adolescent. The nurse has an important function in supervising the general health of the young girl as well as preparing her both physically and emotionally for her role as a mother. Included in this function is the education and counselling on the physiology of sex and acceptable sex behaviour; nutrition and other health deficit must be met and treated; above all every effort must be made to prevent a first pregnancy until the conditions, including maternal health and age and her family situation, are conducive to the birth of a wanted and healthy baby.
- 45/46 -
6.4
Speolal Cllnios
When servioes are speolfioally set up to provlde tamly plann11l8 oare, lnoludlll8 the adm1nlstration ot oontraoeptlves and, in so_ oa .. s, abortlon servloes, nurses, midwives and auxiliarles are involved in the ollnic prooedures tor Wbioh their basio protessiona have quallfied them. It ls important in these sltuatlon., as ln all others, to e.ploy tho.. qual1ties and teatures Wbioh are oharaotarlstl0 ot the two protesslona. The patlent _y need asslstance in relation to other health needs and problelllll ot hi.elt and _mbers ot the tamly. The III1rse and mc1w1te have the opportunity to identity these proble., and Should make every ettort to collaborate with other protesslone in a prosra_ ot care tor the tamly. 7. CONCWSI(J(
'lhls papal' has not addres..d it.. lt to the proble. ot overpopulation ln t1w world today. Rather, the a.ewaption is _de that the role and function ot nur..s and m1dw1ves are squarely ba.ed in proaot1ll8 the health ot 1ndiY1duals and taml1es.
- 47/118 ANNEX 5
LIST OF DOCtlmNTS SElIl' TO CotnmUES
(a) (b)
Dr P. RaJasingham: FaII11y p1annilll activities in the context of health services (Document WPR;aR/NURS/Ol).
Helen D. Cohn: 'lbe role and f'IInot1on of nurses and m1dwives in family plannilll (Document WPR/HR/NIllIB/(2). WHO: QrJ.
(0)
'lbe orlanizaUon and. administration of MCH serY1... (Wid Hlth.
wbB. Rep. Ser •• 1966. No. 428).
(d)
Id8lll, Health aspe.ta of fullY p1ann1nc (Wid HUh Ora. teobB. Rep. _ §!!:., 1970, No •••2). Id_, Ser. , (Wid Hlth Ora. techn. Rep.
(e)
- 49 -
ANNEX 6 BIBLIOORAPHY ARNOLD, Elizabeth (1967) Individualizing nursing care in family planning. NIlrs. Outlook, 15: 26-27. BOGUE, IbDald J., ed. (1967) Mass colllJllllnication and motivation tor birth control, Chicago, University ot Chicago, Cbmmunity and Jam11y Study Center. CHESTERMAN, Helen (1964) The public health nurse and family planning. Nura. Outlook, 12: 32-34. ,"
lIO'l'CBESON, Hazel Ann. et al. (1970) Extending family planning services. Amer. J. !fUr!!;, 70: 1516-18
IlI'.I.'ERlfATIOIAL PLADED PARI5W1'HOOlI FEDERA'l'ION, SWTJIEAST ASIA AND OCEABIA RmION (1971) Acceleratiy ft.Iaill planning. Problems and approaches, Qmezon City, University ot the Philippines. KLEINMAN, R.L. (1971) Family planning tor midWives and nurses. London, International Planned Parenthood. KOHL, S.G. et a1. (1972) The Nurse-midWite as a tamily planner. ~. J. Pub1. mth, 62: 1448-1450. MCCALIS~, Ibnald V. et 81. (197') ReadingS in family plannin".
A.ch!ll.eng New
to the health proteaaions, St. Louis, C.V. Mosby MABISOFF, Miriam (1969) FamilYJ;lanning • A teaching guide tor nursea. York, Planned ParenttiOod rld popUlation.
MANISOFF, Miriam (1969) !!!gulation des naissanea •• I.e 1"8le de 1 'infinnH!l'e. New York, Population Council. MEIER, Gitta (1965) The role ot hospital nurses in tam11y planning. J. Nurs., 65: 86-91. ~.
CMRAM, Abdel R. (1971) '!'he health theme in tam11y planning, Chapel Hill, University ot North Carolina, Carolina Population Center. POHLMAN, Edward H. (1971) Incentives and compensations in birth planning, Chapel Hl.ll, University ot North Carolina, Carolina Population Center. POHLMAN, Edward H. (1969) PSycholOgy ot birth planning, cambridge, Schenkman Publishing. POLGAR, Steven, ed. (1971) Culture and population: a collection ot current studies. Chapel Hill, university ot North Carolina, Carolina Population Center.
- 50
Annex PTOLEMY, Cnnnie Gray (1969) Family planning interpretation - the nurse'c role. Canad. J. Publ. H1th., 60: 4~-408, October 1969. SLOANE, R. Bruce (1969) The unwanted pregnancy. 12~-1213.
New Engl. J. Med. 280: ~.
SMITH, Edna (1970) Family planning coordinator in a city hospital. J. Nurs., 70: 2363-2365.
- 51 -
ANNEX 7
EVALUATION QUESTIONIfAlRE
This questionnaire has been prepared to assess the administrative aspects ot the conference as an aid in the planning and operation of future meetings ot this nature. Please check the appropriate statements and write your comments legibly. Your trank criticism, suggestions and comments are cordially invited. 1.
Travel arrangemente wre: Physical arrangements of the site of the conference were: Accommodation and services were:
Excellent
1::7
satisReasonably Unsatisfactory L:7 satistactoryL:7 tactory L:7
2.
Excellent D Excellent
Adequate
1::7
Fairly good
D
Unsatisfactory D Unsatisfactory D Too long
D
Adequate
D D
Fairly good D Too Short Too
4.
The total length of the conference was: The working hours \/ere: The intormation bulletins were: ~cumentation
Very satistactoryD Very satistactoryD Very Helpful
Adequate
D
D
5.
Satiefactory
D D
Short
D D
Too long
D
6.
D
Helptul
Of some
help
or little help
D
7.
to cover the subject matters \/ere:
ExcellentD
Satisfactory
D
Fairly good
D
Poor
D
8.
Opportunities to become acquainted with other participants and statt Ample were:
D
Satisfactory
D
Fairly good D
Poor
D
9.
What improvements on administrative aspects would you suggest for future meetings of this nature?
- 52 -
Annex 7 This questionnaire is intended to evaluate the technical aspects of the Seminar by utilizing your opinions and comments. We would appreciate your answering the questions very frankly. If you do not feel able to answer a question i t is better to leave a blank than to make a statement that does not satisfy you. Because the questionnaire does not carry your name, the first 4 questions will give additional meaning to the remainder of the questionnaire. Kindly answer these questions by putting a check in the appropriate box. I 1.
Is this the first time you have been outside your own country?
U 2.
Yes
D U
No
Have you ever attended a WHO seminar, a workshop or intercountry
meeting before?
U
Yes
No
If yes, where: when: 3. Were you eager to attend this one?
U U U 4.
Very eager Fairly eager Rather reluctant
Are you pleased you attended this Seminar?
U U U II Seminar Objectives
Very pleased Fairly pleased Not pleased
The agenda was desig!1ed to meet the 4 objectives listed below. We would be interested to know your opinion on whether these objectives were adequately met in the time allowed. Objective 1 To consider family planning within the context of health services.
- 53 -
Annex 7 Objective 2 To exchange information on nurses and midwives involvement in family planning. Objective 3 To identify role and functions of nurses and midwives in family planning. Objective 4 To discuss integrating family planning in nursing and midwifery practice. Please answer these questions by putting a check in the appropriate column. Q.uestions 1. Which objective did you consider the most important before the seminar started? 2. Which objective was most satisfactorily achieved in the seminar? adequately achieved in the seminar? 4. If you could have a further 2 days to work on one objective, which one would you select? you yourself participate most in the discussions? Obj. 1 ObJ. 2 ObJ. 3 Obj.4
3. Which objective was least
5. On which of the 4 objectives did
Annex 7 III Agenda Items
For each of the a@enda items there were 2 presentations focused on a theme presented by two speakers followed by a discussion of major issues brought to a plenary session for conclusions. Would you please let us have your opinions on these by placing a check in the columns provided. A. Usefulness of presentation to you.
Titles of presentation 1. population characteristics in the countries of the Western Pacific Region Influence of population trends on the development of health services Conoepts of family health care Maternity. centred family planning Family health care and oonmmi ty participation
Very Useful
Fairly Useful
Of little Use
2.
:;. 4. 5.
6. Case load mana@ernent and standard procedures
7. Medical manpower p"oblems in rural areas
8. Traditional birth attendants. 9. Family planning in the education of nurses and midwives
- 55 -
Annex 7
B.
TiIll8 given to d1scuss1ona 01' _Jor is_s.
Ti tle of major issues
Adequate
Too Much
Too Little
1.
Implications for nurses and midwives of demogE'aph1c trends and adm1n1strat1on of services Implications for nurses and midwives of the conoept of tamily health care Implications for J1IJ1'1IeS and midwives of the principles of priDary health care and standard prooedures in ca. load mn&pll8nt and
2.
).
4. Implications for nurses
midwives of the -..ower problema and the Decessity for further stud7 01' the problem.
5. Poss1bU1ty and 1'eas1bU1t)'
01'
nurses and midwives effecting chanp 1n the expansion of the1r roles to include the health aspects of famil)' planning
- 56 -
Annex
7
C.
Conclusions
Each agenda item was terminated after certain conclusions had been agreed upon - of these conclusions -
All
More than half
Less than half
1.
How many reflect a need for change in your programme? How many will be acceptable to your colleagues at home?
2.
3. How many were already fully implemented in your country's programme?
IV.
Please tell us in one sentence which specific feature of this Seminar pleased you most.
V.
Any additional comments .•
- 57 -
ANNEX 8 PROVISIONAL AGmDA AND PROORAMtti OF WORK
Monday, 16 September
ITEM I 8.~
opening session Weloome by Dr F.J. Dy, Regional Direotor, Introduotions
-
9.~ am.
10.00 - 12.00 pm
Seminar procedures - Ms Fillmore
Review and adoption of the agenda - Ms Cohn ."
12.00 -
12.~
pm
Preliminary meeting of groups to eleot Chairman and Rapporteurs '!be nurse and m1dw1fe in the changing sooiety
ITEM II
Chairman - MS Sarah Austria Repporteur - Ungku MailDl!nah Bt. Ali 1.~
_
2.~
pm
DeIllOgl'8ph1o oharaoteristios of oountries in the We stem Paoifio Region - Ms Fillmore
2.45 - 4.00 pm
ot Tuesday,
Influence of population trends on the development health servioes - Dr Rajasingham
17 September ~y
8.~ - 9.00 am
and identifioat1on of major issues
9.00 -
10.~
am
Group work National programmes, problems and polioies 'lhe Effect on the role of nurses and midwives
11.00 -
l2.~
pm
Reports of Group Leaders Discussion led by Panel Conclusions
- 58 -
Annex
8 ITEM III Nurses and midwives in family health care Chairman - Ms Tie Teewa Rapporteur - Ms Luaipou S. Betham Concepts of family health care - Ms Cohn
2.45 - 4.00 pm 4.00 - 4.15 pm Wednesday, 18 September 8.~ - 9.00 am
Matern1ty-centred family planning Film: My Brother's Children
- Ms Panganil>an
summary and identification of major issues Rapporteur - Ms Luaipou S. Betham
9.00 -
10.~
am
Group work Family planning as a family health service by nurses and midw1ves Reports by Group Leaders Discussion led by Panel Conclusions Family plann1ng in primary health care Chairman - Mme Houang Solyphanh Rapporteur - Mlle Do Ngoc Tuyet
11.00 -
12.~
pm
ITEM IV
l.~
- 2.~ pm
Primary health care and comrmmity participation - Ms Lenoir Case load management and standard procedures - Ms Cohn
2.45 - 4.00 pm
- 59 -
Annex 8
ThUrsday, 19 September 8.30 - 9.00 am
Summary and identification of major issues
ITEM IV (cont'd) 9.00 - 10.30 am
Gr'oup work Prior1tie s for family planning in primary health care by nurses and midwives Reports by Group Leaders Discussion led by Panel Conclusions Manpower problems in family planning Chairman - Ms Pauline Mary Downing Rapporteur - Ms Tan Phaik In
11.00 - 12.30 pm
ITEM V
1.30 - 2.00 pm 2.00 - 2.45 pm 3.00 - 4.00 pm
Medical manpower problems in rural areas Dr Rajasingham The traditional birth attendant - Ms Fillmore Family planning in the education of nurses and midw1ves - Ms Fillmore
Friday, 20 September 8.30 - 9.00 am 9.00 - 10.30 am /3"_'"7 and identification of major issues
Group work Admin1stration, supervision and training for family planning service
ITEM V (cont'd)
11.00 - 12.30 pm
Reports by Group Leaders Discussion led by Panel Conclusions Impact of nurses and midwives on policy, practice and preparat10n Chairman - Ms Lavinia M. Heimuli Rapporteur - Vika Waqatabu
ITEM VI
- 60 Annex 8 1.", - 2.00 pm
Introduction of topic - Ms Cohn Group work Problems and progress in the impact of nurses and midwives in their own countries Reports by Group Leaders Conclusions
2.00 - 3.00 pm
3.15 - 4.00 pm Monday, 23 Se ptember ITEM VII 8.30 - 10.00 am
Presentation of draft final report Chairman - Ms Agnes Cheng Mo-fong RaPporteur - Ms Virginia Orais
10.30 - 11.00 am 11.00 am
Review of participants' evaluation Closing session
ANNEX 9
GROUP ASSIGNMENTS Group I Oroup II Group III
1. Ms Vika Waqatabu FiJi 2. Ms Ya.ko Matsumoto Japan
1. Ms Pauline Downing
1. MIlle N7 Sarad.n KbIIIIr Republio 2. MIlle Kim Bat Khou
BSIP 2. Ms Upokoina 'l'an8aroa Cook Islands Ti. Te.wa Gilbert & Ellice Islands
,. 4.
Ms AgDlts Tong Cheng Mo-fong, Hong Kong Ungku MailllUllAh Bt. Ali MalQ'sia
3. Ms
,. 4.
IIhmer Republic M. LaDh Praohompcmh Laos MIlle Houang Sol)'pbanh
4.
Ms Marpret Naups New Hebrides Lavinia Heimuli Tonga
Laos
5. Ms Virginia Orais Philippines
5. MB
5. Mll. 6. Mll.
Do Nsoo 'l'U1et Vi.t . . . Do Kim CUong Vi.t-Nam
6. Ms KUm-Bok
HIIang
6. MB Luaipou Bstham We stern Samoa
Republic of Korea
7. 8.
Ms Tan Phaik In Sinsiapor. Ms Sarah R. Austria Philippines
7.
MIlle Bu1 ClUanc Hue
Vi.t.......
- 63 -
ANNEX 10 SUMMARY OF I.VAWA1'IOJr 011 THE RmIOlfAL SDIIlIAR OK THE ROLE OF NURSES AID MIDWIVES D FAMILY PLAJIJrDG
Manila, Philippines, 16-2' September 1974 WPRO
9602
Two questionnaires were distributed in order to assess the administrative as well as the technical aspects of the seminar. Although there were on~ 21 participants in the seminar, 24 completed questionnaires were received by VlIS for evaluation. It is therefore our assUlllption that the other , questionnaires were completed by observers attending the seminar. 1I0rmal~ observers' comments are not included in the evaluation of a seminar. Since all the observers' questionnaires could not be distinguished from those of the participants, it was decided to process all 24 questionnaires. The responses to the questions on the administrative aspects are tabulated in Annex lOCal. In this table, the four alternatives provided for each query were arranged so that the first colUllln indicated excellent arraDg_nts, the second satisfactory or adequate, the third reasonab~ satisfactory or fair~ good and the last unsatisfactory. A colUllln for -00 answer- vas also prorlded. 45.~ satisfactory, 12.~ reasonab~ satisfactory, O.5~ unsatisfactory and 2.1~ no answer. Tbe on~ unfavourable rep~ stated that the accOllllllOdation
Of the 192 replies,
40.l~
rated the administrative aspects excellent,
and services were unsatisfactory.
Although the administrative aspects of the seminar were considered satisfactory, there is room for impIOV rnt of future meetings of this nature as indicated in the suggestions given by the respondents (see Annex lO(b). Or the 24 respondents, 3 complimented all those responsible for a well ..,nsged sea1narj 4 sussested the follov1Dg 1mpro¥ements: . participants should be briefed before departure in the currency of the country of destination and wbat would be expected of him at the seminar, accommodations should be so arranged that the participants would be able to get to know each other more, everyone should take turns in being chairman and rapporteur in their said groups; the rest made no suggestions. Responses to . the second questionnai,re .:rUrnished information with which to assess the technical aspects of.. th.e .. lIemina r. 29.1 .~ ...0.1 . the .' participants stated that this vas the first time they haVe been outSide of their awn country. About 33.~ of the participants have attended a WHO seminar, workshop or intercountry meeting before. With regard to attitude towards attendance of the seminar, while 83.~ were very eager to attend the seminar, lOO.~ were very pleased that they attended the seminar. (Annex 10(c) ). AnnexlO(d) contains the following tables: Opinions of the participant~ on whether the 4 objectives of the seminar were adequate~ met in the time allowed, usefulness of presentation, adequacy of time given to discussion of major issues, and opinions on conclusions agreed upon for each agenda item.
- 64 Annex 10
The main objectives of the seminar are: 1. 2. to consider family planning activities within the context of health services; to exchange information on the extent to which nurses and midwives are currently involved in family planning activities in countries in the Region; to identity the role and functions of nurses and midwives in family planning; and to discuss ways and means of integrating family planning activities into existing nursing and midwifery patterns.
3. 4.
Following are the objectives arranged in order of the most frequently mentioned objective to least mentioned for each query: 1. The objective considered most important before the seminar started Obj. 2 (35.~ of the re~lies)t Obj. 1 (32.1~), Obj. 3 (17.~), Obj. 4 {lO.~J 2. Tbe objective which was most satisfactorily achieved in the seminar Obj. 1 (34.6~), Obj. 2 (23.1~), Obj. 4 (23.l~), Obj. 3 (11.5~) 3. The objective least adequately acbieved in the seminar Obj. 3 (45.8~), Obj. 4 (16.~), Obj. 2 (12.5~) 4. The objective which the participants would want to spend a further 2 ~s to work on, if possible Obj. 4 (50.~), Obj. 3 (30.8~), Obj. 1 (11.6~), Obj. 2 (3.8~) 5. The objectives which the respondent participated most in the discussions Obj. 1 (29.5~), Obj. 4 (26.5~), Obj. 2 (17.6~), Obj. 3 (17.~) FOr each of the agenda items there were 2 presentations focused on a theme presented by two speakers followed by a discussion of major issues brought to a plenary session for conclusions. The presentations which were focused on the 9 themes were considered very useful by 61.1% of the replies. fsirly useful 25.5%. of little use 6.9% and no BDSWer 15.5%. 82.5~ of the replies indicated that the time given to the discussions of the 5 major issues, namely, implications for nurses and midwives
- 65 Annex 10
of demographic trends and administration of services, of the concept of feaily Ilealtll care, of tile principles of primary Ilealtll care and standard procedures in case load l118.!1agement, of the manpower problems and the necessity fOr fUrtller study of the problem; and possibility and feasibility of nurses and midwives effecting change in tile expansion of their roles to include the health aspects of family planning were adequate, 5.Oi stated the time 118.8 too IllUCh and 12.5j, too little. More than half of the conclusions agreed upon at the termination of each agenda item retlecta need fOr change in the partiCipants' programme according to 41.. 71> of the replies; will be acceptable to the participants' colleagues at home according to 83.?11>, were already f'ully implemented in the country's p~ according to 79.2'{0. TIle responses on the specific feature of the seminar which pleased tile participants most were quite varied and could not be summarized succintly and so these answers vere listed and are contained in Annex 10(e). Add1tionai comments by the participants ~ also be seen in Annex 10(el. In s~, the adm1n1stratiTe aspects of tile s ....in.r vere rated as satisfactory by 85.4~ of the replies. With regard to the technical aspects of the seminar -!-Ccording to the rQpoDdents, the objectiTes considered the most important befOre the seminar started was Obj. 2 (35.71> of the replies); the objective which the participants believed to haTe been most satisfactorily achieved is Obj. 1 (34.6j of the replies); the objective least adeq1l&tely achieved is Obj. 3 (45.8j); the objective the participants would waRt to spend a further 2 ~s to work on is ObJ. 4 (50.~); and the objective which the respoDdent participated most in the discussions is ObJ. 1 (29. 5j) • TIle presentations on 9 themes vere considered very usef'ul by 61.l~ of the replies, the time given to the discussions of major issues vere adequate accordi!i8 to 82.5j and more than half of the conclusions vere found to be acceptable to the part1cip&nts'colleagues at hOme. In the light of the above findings based on participants' as veIl as observers' comments, the seminar ~ be considered BUccessf'ul.
- 66 -
Annex lOra) REPLIES TO QUESTIONS RELATING TO THE ADMINISTRATIVE ASPECTS OF THE SEMINAR
,----Administrative aspects EXCELIENT excellent l.
SATISFACTORY
REASONABLY SATISFACTORY
UNSATISFACTORY unsatisfactory
NO
,~NSWER
Travel arrangements v.ere;
satisfactory reasonably satisfactory
6 excellent
12 adequate
4
2
2.
Physical arrangements of the site of the conference were:
fairly good
unsatisfactory unsatisfactory
16 excellent
5 adequate
3 fairly good
3.
Accommodation and service s were: The total length of the conference was: The working hours were: The information bulletins were: cover
6 very satisfactory 9
12 adequate
5 too short
1 too long
4.
12
3 too short too long
5.
very satis- satisfactory factory
9 very helpful
15 helpful of some help of little help 1
6.
15 excellent
6 satisfactory
2 fairly good poor
7. Documentation to were:
the subject matters
9 ample
13 satisfactory
1 fairly good poor
8.
Opportunities to become acquainted with other participants and staff were:
7
12
5
TOTAL PER CENT
192 100.0
77
87 45.3
40.1
23 12.0
1 0.5
4 2.1
67 Annex lOeb) ArMINISTRATIVE ASPECTS
9. What improvements on administrative aspects would you suggest for future meetings of this nature?
(1) (2) (3)
Well taken cared of. Advise participants on Country's currency before arrival. AccoDlllOdation should be arranged so that participants will come in contact and get to know each other more. Everyone should take turns in being chairman and rapporteur in their small groups. Participants should be briefed on what he will be expected at the conference like this before he leaves the country. None. I would like to congratulate all those responsible for a well managed seminar ~ Everything seems to have progressed as scheduled and very smoothly. It is good as it is. It ia hoped that the group presentation will be reproduced and distributed to the participants. No answer - 16 respondents.
(4)
(5)
(6)
(7) (8)
- 68 Annex 10(c) REPLIES TO QUESTIONS RELATING TO THE T&:HNICAL ASPEX:TS OF THE SEMINAR
I
I
Technical aspects 1. Is this the first time you have been outside your own country? No.
YES
NO
NO ANSWER
TOTAL
I
% 2. Have you ever attended a WHO seminar, workshop or inter-country meeting before? No.
7 29.1
16
66.7
1 4.2
24 100.0
%
8 33.3
16
66.7
24 100.0
Technical aspects 1-
VERY
SATISFACTORl' very eager 20
SATISFACTORl'
UNSATISFACTORl'
NO ANSWER
Were you eager to attend this one? .No.
fairly eager rather reluctant 2 8.3 fairlY pleased 1 4.2 not pleased 1 4.2
%..
83.3 very pleased
i 2.
Are you pleased you attended this Seminar? NQ .• ~.
24 100.0 44 91.6 2 1
TarAL PER CENT
48 100.0
1
Jl.2
2.1
2.1
Anno
10(d)
TECHNICAL ~TIVES
AS~TS
4.1 OPINIONS OF THE PARTICIPANTS ON WHETHER THE FOOR OF 'mE SEMINAR WERE AlEQUATEIH MEr IN 'mE TIME ALLOWED
Que s t ion s
. :Ob,1. ,
. 1 .
Obj •
Obj.
Obj.
2 10 35.7 6 23.1 3 12.5 1 3.8
3 5 17.9 3 11.5 11 45.8 8 30.8 6 17.6
1. Which objective did you oonsider
the~
most important before the seminar started? 2.
No 9
, 10.7 6 23.1 4 16.7 13 50.0 9 26.5
4
No Answer
Total
1 3.6 2 7.7
28 100,.0 26
,
l' 32.1 No 9
Which objective wsa most satisfactorily achieved in the seminar? ;
I
l' 34.6 3. Which objeotive wsa lesat adequately No achieved in the seminar?
100.0 24 100.0 26
6
l' 4. If you could have a further 2 days to No. 3 , work on one objective, which one would you select? 11.6 1
2.5.,0. 1 3.8 3 8.8
5. On which of the 4 objectives did you yourself participate most in the discussions?
"
lotJ.6 34
I
NQ 10
6 17.6
i
l' 29.5
'ioo.o
Objective 1 Objective 2 Objective 3 Objective 4
To oonsider family planning within the context of health services. To exchange information on nurses and midwives involvement in family planning. To identify role and functions of nurses and midwives in family planning. To disouss integrating family planning in nursing and midwifery practioe.
- 70 AlmeJ[H lO(d)
4.2 USEFUINESS OF PRESENTATION
Title of presentation* 1.
Very Useful
Fairly Useful
Of little Use
No Answer
Population oharSQteristios in the oountries of the Western PSQific Region.
14
5
2
3
•
2. Influenoe of population trends on the development of health services.
14
7
1
2
3. 4.
concepts of family health care. Maternity centred family planning Family health care end conmrunity participation Case load management end standard procedures Medioal manpower problems in rural areas Traditional births attendante
20 12
3
1
9 4
2
1
5.
19
1
6.
15
7
1
1
7.
11
11
1
1
8.
7
6
8
3
9. Family planning in the eduoation of nurses end midwives T
20
3
1
0 T A
L
216 100
132 61.1
55 25.• 5
15 6.9
14 6.5
P E R C E N T
*For
eSQh ot the agenda i tams there were 2 presentatiOns focused on a theme presented by two speakers follOWed by a discussion ot major issues brought to a plenary session for oonolusions.
- n.. A..a 10(4)
4.3
ADEQUACY OF TIME GIVEN TO DISCUSSIONS OF MAJOR ISSUES
Title ot major isaues 1.
Adequate
Too Mlch
Too Little
Implications for nurses end midwives ot demographic trsnda end adm1nistration ot services. Implioations for nurses end midwives ot the conoept ot flUll11y health oare. Implioations tor nurses and midwives ot the prinoiples ot primary health care end standard procedures in cue load management. and midwives ot the manpower problema and the neee8lli ty for further study ot the problem.
17
1
6
2.
22
1
1
3.
18
3
3
4. Implications for nurses
22
2
5.
Possibility and feuibility ot nurses and midwives effeoting change in the expansion of their roles to include the health upeots of family planning. TOTAL PER CENT
20
1
3
120 100
99
6 5
15 12.5
82.5
AMex lO{d)
7~
-
4.4
OPINIONS ON THE CONCLUSIONS AGREED UPON FOR EACH AGENDA ITEM
Each agenda item waa tenninated after oertain conclusions had been agreed upon -' of these oonclusions
All
More than half
Less than half
No Answer
Total
1-
How many reflect a need for change in your progrllllllle
No.
4 16.7
6 25 16 66.6
11
3 12.5
24 lOCloO
~
45.8
2.
How many will be acceptable to your colleagues at home?
No,
4 16.7
1 4.2
3 12.5
24 10Cl00
~
3.
How many were already fully implemented No, 1 in your country's progrsmme? 4.2 ~
18 75
5 20.8
24 1001)
- 73 Annex 10(e)
IV.
Please tell us in one sentence which specific feature of this Seminar pleased you most.
1. 2.
Integration of family planning in nursing and midwifery practice. I could reassure the importance of family planning in primary family health care. But 118 a midwife (recognized as a specialist in maternity rather than child health worker with preparation in general nursing) I still would have some time before finding the place to fit in. This Seminar helps me a lot and gives me experience so I will hope to Join another seminar. The opport\Ulity to meet colleagues from adjoining cO\Ultries, and to discuss their progress and problems associated with the total heal th oare of the cOIIIIIUIli ty. Discussion on family planning within the oontext of family health servioe. All, but most of all, able to exchange ideas from other partioipants who are well ahead - those who plan or are able to plan for the future of their OO\Ultry relating to health and health aspects. Participants were given the opportunity to demonstrate the fullest capacity as members of the group in terms of participation. ilIe group work on issues with its exohange of information. The advantage of meeting with other participants and exchanging ideas and with additional knowledge from the lecturers brought solutions and ways of solving problems at home. Group discussion and the exchange of ideas on the work of nurses and midwives in different cO\Ultries was very effective. The group discussion of this Seminar pleased me most, plus the dinner and entertainment given·by the Philippine Nurses Association.
3. 4.
5. 6.
1. 8.
9.
10.
11.
, - 74 • Annex 10(e)
12. 13. 14. 15. 16.
The Seminar helped me to improve my new knowledge about family planning programme. The group discussion and the dinner provided by the Nurses Association. Planning, arrangement and operation are excellent. Group work pleased me most because everybody in the smaller group is able and is more confident to talk. I have learnt a lot more on case load management and family planning in the education of nurses as part of maternal and child health and not on population problem or as on target basis. Reports from various countries may also help my country on various health activities. Plenary sessions and discussions. Meeting representatives from all countries. This meeting is most interesting to increase our knowledge. Meeting representatives from all countries and islands is most interesting. For me this was a very interesting experience. Group discussions gave us an opportunity to exchange ideas with other countries and enable us to know the points of view of other governments which are sometimes very different from the situation in our country. Meeting the representatives from the different countries, especially the islands - Fiji and Western Samoa - for the exchange of information is most interesting because before we had very little information on these remote countries.
17. 18. 19. 20. 21.
22.
- 75 Annex 10(e)
V.
AnY addi tiona! comments
1.
Since I am one of the observers I fael that I am not in a position to _wer all the questions. Hope you'll understand. Even though the Seminar is mainly oanoerned With family planning, it would be profi table to include observatian tours on nursing and midwifery acti vities (or eduoation 1nstitutions) • I could have
2.
eo
broader outlook on health care and health workers.
Thank you for giving
me a good opportunity.
3. 4.
Can we have inservice training for family planning to give more experience on inserting IUD and more experience on family planning?
A stimulating and well-organized cOUl'lle.
Thank you.
5.
Congratulation to those responsible for the planning and operational officers as well as director and consultants to this· Seminar. Thank you for the PJd.v11ese to be one of the group.
6.
I think there is no4efinite t1llle tor the partioipants to diSCUBS their problems.
Definite time should be alloted.
Thank you.
7.
Resource speakera h1'8 so helpful in the discuaa10n of the subJeots taken up. More HIIIf.nare 11ke this in the future Will prove helpful in our work. Hearty thanks to all seminar organizers for conducting this Seminar which WIIB very useful indeed. Thank you! More seminers of this type is recommended. Plenary session was okay but most participants did not find it stimulating. as it appears very quiet at times.
8.
9.
Social activities should be arranged for participants atter office hours. 10.
No additional conment • Nil.
•
11.
- 76 -
• Annex lO(e)
12.
The general discussion was not very lively due to many particip~~ts not expressing their views. etc •• leaving only the same few people talking most of the time. A visit to a particular health set-up where family planning is integrated in MCH services may provide more ideas to the participants. PartiCipants should be provided with summaries of the papers presented in the plenary sessions. Group work was too structured so that there is not much opportunity to go into depth on a particular issue or problem. indeed. the Seminar was too Short that there was no alternative but delve on generalities.
13. 14.
15. 16. 17.
It was cold. It was too cold for me. If the papers of consultants and advisers were reproduced and distributed to the participants. comments and questions voiced by tr_e participants would be more interesting and more numerous. It was too cold in the meeting room.
18.
No answer - 6 respondents.
•
SUOGES'
ILITICA l.o_
-
(lOr CCIIIIl' or 6.11:
lOll
SOCIETY
CHART 1
CHIEF EXECUTIVE
_illeu\,4'rlae MiDlste
CABINET/SUPREME COUNCIL NATIONAL U :VEL
abo MinIster rm Defen. "Fmei. Affairs) NATIONAL
MINISTER FOR HOME AFFAIRS AND INTERREGIONAL UAlSON
1
.
MINISTER FOR PLANNING AND FINANCE
~
"'-
t::
IlEGIONAL DEVT. MINISTER! SECRETARY
(as many as oeceaary)
r--------I
j!I'{iIONAL CO-ORDINA TlNG COUNCIL
REGIONAL LEV EL
REGIONAL 1.£' EL
I REG. DEVT. DEPT. (InduslJies)
L REG. DEVT. DEPT. Il'1Iblic Works) REG. DEVT. DEPT. (Healdl)
I REG. DEVT. DEPT. (Labour)
REG. DEVT. DEPT. (Agriculture)
1 DISTRICT LEVEL HEALTHORG. DISTRICT LEVEL HEALTHORG.
I DISTRICT LEVEL I£ALTH ORG.
LOCAL LEV °Vl~lage
BS--9 Health Org~nization
I
. I
J IVH<1
I JvHO"I
~HO"J
~
I IVHO"
I
I IVHO"
I •
•
•
..
"
•
- 79/80 !
CHART 2
C(MIIUNITY CASE LOAD 5~ Sample Popula t1on: 200 families.
960
lnd1 viduals.
Ages _ _ _~)
• Fam. No. 6 0 1 2
-
50
~ ~
40
-
~
-
20
-
10 -
cf
f
tf~
~ tf~
, e , J< if i ~
"i -
4 - 3
2
1
~ ~ .~
3 4
5
tI ~ ~ ~ ~ ~
~
I
6 7 •
~ t!~ ~ ,,~ 20-44: 21
"' ~
tI~ ---
8
Jt (Sample) 45-60: 6 (Total) 120
~
s 10 Age groups:
t
~ if ~ ~ ~ ~ ----~ ~
---
0-19:
42&
21 420
• •
•
- 81 CHART )
!
CASE WAD ANALYSIS
Fam. No.
Family Planning Use Preg.
Children Healthy At Risk
Classification Urg. Rout.
Specific Problems
Refu. Ine1-
W&:W
12. ). «
x x x x x x x '
5 2 1
x
x X
x
x
'-4.
2 2~'
x x
x
5. 6.
2
2
x
x
7. 8.
.... x x 1 2
9. 10.
x
x x
I
.
3 \
2
3
11
10
4
4
2
Total Case Load (200 families) Family Planning: Use 60 Pregnant 40 40 Refused Ineligible 60
Children: Healty 220 At risk 200 Family classification: Routine only 80 Routine & urgent 80 W&Wonly 40
• •