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In the past decade policy attention has turned toward adolescent reproductive health and social development issues. During that same decade women came to comprise half of those infected with HIV/AIDS. In some parts of the world most notably sub-Saharan Africa HIV prevalence rates among young women aged 15–24 outpace those of men in that age group by two to eight times. Of substantial consequence yet largely ignored is the fact that the majority of sexually active girls aged 15–19 in developing countries are married and these married adolescent girls tend to have higher rates of HIV infection than their sexually active unmarried peers. Thus married adolescent girls not only represent a sizeable fraction of adolescents at risk but they also experience some of the highest rates of HIV prevalence of any group. Nonetheless married adolescents have been marginal in adolescent HIV/AIDS policies and programmes and have not been the central subjects for programmes aimed at adult married women. It is time—indeed past time—to give substantially greater attention to the role that early marriage plays in potentially exposing girls and young women to severe reproductive health risks including HIV. Protecting these young women may not only serve to help prevent the disease from spreading from “high-risk” groups to the general population in their own generation but also to the next generation by reducing mother-to-child-transmission among this most intensive childbearing group. (excerpt)

In the past decade policy attention has turned toward adolescent reproductive health and social development issues have begun to take centre stage in international development policy. During that same decade the shape of the HIV epidemic shifted with women of all ages now comprising half of those infected with HIV/AIDS. Much of that acceleration in the spread of HIV among women has taken place among adolescents. In some parts of the world most notably sub-Saharan Africa HIV prevalence rates among young women aged 15-24 outpace those of men in that age group by two to eight times. Of substantial consequence yet largely ignored is the fact that the majority of sexually active girls aged 15-19 in developing countries are married and these married adolescent girls tend to have higher rates of HIV infection than their sexually active unmarried peers. Thus married adolescent girls not only represent a sizeable fraction of adolescents at risk but they also experience some of the highest rates of HIV prevalence of any group. Nonetheless married adolescents have been marginal in adolescent HIV/AIDS policies and programmes and have not been the central subjects for programmes aimed at adult married women. We suggest that it is time-indeed past time-to give substantially greater attention to the process of marriage and specifically the role that early marriage plays in potentially exposing girls and young women to severe reproductive health risks including HIV. Our arguments and analyses suggest that married adolescents represent an acutely under-served group who in the context of an HIV epidemic are especially vulnerable. Epidemiological analyses have failed to appreciate the importance of HIV prevention to young married women who are unlikely to spread the disease through peer interactions. Yet protecting these young women not only serves to help prevent the disease from spreading from "high-risk" groups like sex workers and truck drivers to the general population in their own generation but also to the next generation by reducing mother-to-child-transmission among this most intensive childbearing group. (excerpt)

This publication of the Population Council highlights examples of family planning and reproductive health programs that are providing unusually high quality care. Projects are selected for documentation by an advisory group made up of individuals who have a broad range of experiences within the field of reproductive health and are committed to improving the quality of services. This issue focuses on the history and achievements of the Manuela Ramos Movement in the field of reproductive health in Peru with highlights on the design and implementation of its ReproSalud project. The lessons learned and future challenges identified in the project implementation are discussed.

Following a pattern of sensory perception throughout Shakespeare's Much Ado about Nothing, Othello, and The Winter's Tale and including theories of perception and interpretation from the writings of Aristotle and Montaigne, this work explores the ways in which Shakespeare's heroes imaginatively create their own realities.

This report describes the experiences of the Family Planning Association of Kenya (FPAK) with use of Client-Oriented Provider Efficient (COPE) methods for assessing and improving quality of care in FP programs in Kenya. COPE actively involves providers in determining how care can be improved and developing practical solutions to a wide range of problems. This overview begins with a discussion of the history of FPAK and early attempts to improve quality of care followed by a description of COPE its initial use during 1987-90 and a new start in 1993. The COPE technique includes self-assessment client interviews client flow analysis (CFA) and a plan of action. The first use of COPE was a failure. The second time around the evaluation paid attention to staff needs for training information infrastructure supplies guidance back-up respect encouragement feedback and self-expression. The checklists were redefined to address client needs to be modular in form and to be used routinely and at low cost. The checklists were reframed as 10 guides of which 7 were devoted to clients rights and 3 to provider needs. CFAs were conducted only if serious bottlenecks occurred and were made more user friendly. COPE revealed major problems with supervision and poor skill levels and led to greater control at the clinic level. All staff are encouraged to attend and participate in problem-solving sessions. Use of COPE stimulated FPAK to seek client feedback on hours of operation method choice privacy safe services and continuity of supply. Six lessons learned are identified.

This booklet describes the income generation and social development activities for female adolescents living in a garbage community on the outskirts of Cairo Egypt. The activities were implemented by the Association for the Protection of the Environment (APE) a secular nongovernmental organization that managed a composting plant in Maqattam and initiated a variety of social development activities. The Health and Development Committee coordinates health literacy and income generation programs. APE aims are to ameliorate the unhealthy living conditions among the Maqattam residents and to achieve higher productivity from the traditional recycling process. Currently 70% of garbage collecting households in Maqattam are engaged in one or more activities sponsored by APE and its affiliates. 33% of all households directly benefit from APE activities. The original charter recognized the importance of targeting adolescents. About half of all Maqattam households include an adolescent girl. These girls are among the most vulnerable groups in Cairo. They suffer from anemia fatigue and low social status but must maintain high productivity. Adolescent girls in Maqattam have low levels of education despite the national mandate of universal schooling. The law stipulates that enrollment is required by age 8 years or formal education is forfeited. 44% of Maqattam children aged 6-11 years are "working." 22% of all children combine work and schooling. 66% of boys and 59% of girls aged 12-14 years are "working." 88% of working girls are engaged in garbage collection and sorting. APE income generation activities redirected work to rug-weaving patchwork and paper recycling. Nine lessons learned are identified. It is stated that literacy and girls social and economic progress are linked to productivity and that girls must be trained in human development skills as well as income generation skills.

Since the 1960s, survey data have indicated that substantial proportions of women who have wanted to stop or delay childbearing have not practiced contraception. This discrepancy is referred to as the "unmet need" for contraception. The traditional interpretation, that these women lack access to contraceptive supplies and services, has led in turn to an emphasis on expanding family planning programs. This study analyzes survey data and related anthropological studies on the causes of unmet need and concludes that the conventional explanation is inadequate. Although for many environments geographic access to services remains a problem, the principal reasons for nonuse are lack of knowledge, fear of side effects, and social and familial disapproval. This finding underscores the need for expanded investment in services that not only provide contraceptives, but also attend to closely related health and social needs of prospective clients. Programs are likely to be most successful when they reach beyond the conventional boundaries of service provision to influence and alter the cultural and familial factors that limit voluntary contraceptive use.Since the 1960s, survey data have indicated that substantial proportions of women who have wanted to stop or delay childbearing have not practiced contraception. This discrepancy is referred to as the unmet need for contraception. The traditional interpretation, that these women lack access to contraceptive supplies and services, has led to an emphasis on expanding family planning programs. Recent estimates put the total number of women with an unmet need in the developing world at about 120 million. This study analyzes national Demographic and Health Survey data and related anthropological studies on the causes of unmet need and concludes that the conventional explanation is inadequate. Sub-Saharan Africa stands out as the region with the lowest potential demand and contraceptive prevalence and having the highest unmet need. The unmet need in Asian countries is only 14%. The proportion of women not currently seeking to become pregnant and those who do not want children rises from 29% to 73% between the lowest and the highest levels of development. The prevalence of contraceptive use also increases sharply between the lowest and highest development group: from 4% to 16% for spacing, from 3% to 43% for limiting, and from 7% to 59% for total use. Although for many environments geographic access to services remains a problem, the principal reasons for nonuse are lack of knowledge (25%), especially in Sub-Saharan countries, fear of side effects both life-threatening and non-life-threatening (20%), and social and familial/husband disapproval (9%), even when the women have never discussed family planning with their husbands or families. This finding underscores the need for expanded investment in services that not only provide contraceptives, but also attend to closely related health and social needs of prospective clients. Programs are likely to be most successful when they reach beyond the conventional boundaries of service provision to influence and alter the cultural and familial factors that limit voluntary contraceptive use.

An appropriate programmatic response to what we have learned in this symposium about the variability of pharmacokinetics of steroidal contraceptives includes the need to revise two key concepts which frame approaches to giving services: “risk” and “effectiveness”. In family planning and related reproductive health programs, the scientific and clinical meaning of those concepts needs to be revised to align them more closely with the perceptions of clients who seek and use contraception on a voluntary basis.

Most sex education programs for youth have been developed by adults who ignore the reality of adolescence. In particular a substantial proportion of the more than one billion young people aged 10-19 years all over the world are sexually active. After considering factors which influence adolescent sexual activity and contraceptive use consequences of adolescent sexual activity and elements of effective programs the paper describes the experience of the Gente Joven adolescent sexuality program in Mexico. Program planners and managers first acknowledged the realities of teen sexuality and that the adverse consequences will not disappear simply by denying their existence. The author describes the context how adolescents are different from adults the program today communicating with young people and taking the program to schools factories the streets and through radio and videos. Incorporating young peoples perspectives gender differences potential adult opposition to sex education condom distribution financial constraints evaluation and new audiences and priorities are also discussed.

This article argues for attention to a neglected dimension of family planning services--their quality. A framework for assessing quality from the client's perspective is offered, consisting of six parts (choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services). The literature is reviewed regarding evidence that improvements in these various dimensions of care result in gains at the individual level; an even scarcer body of literature is reviewed for evidence of gains at the level of program efficiency and impact. A concluding section discusses how to make practical use of the framework and distinguishes three vantage points from which to view quality: the structure of the program, the service-giving process itself, and the outcome of care, particularly with respect to individual knowledge, behavior, and satisfaction with services.A framework for analyzing quality of family planning services is offered. Quality is a property that all programs have. The framework is made up of 6 parts: 1) choice of methods; 2) information given to clients; 3) technical competence; 4) interpersonal relations; 5) follow- up and continuity mechanisms; and 6) the appropriate "constellation" of services. Switching contraceptive methods is common. The ability of people to switch satisfies them. First use with temporary contraception methods is usually under 2 years. Having different contraceptive methods helps the program respond to the individual's need. Choice is not possible without an adequately developed delivery system. A positive relationship exists between a wide range of methods being available and contraceptive prevalence rates. Of Indonesian client who had reported not receiving the contraceptive method that they wanted, 85% discontinued within the year. Of those who got the method that they wanted, the discontinuation rate was 25%. Clients who wanted to practice contraception will be discouraged if not given information that can be used, or if the method is not available. How much contraception information should be given to the client? Enough so that they know that these are choices and that methods can be changed. There appears to be poor knowledge among clients of use, risks, and benefits of contraceptives. Many different monitoring technics are needed to analyze technical competence. The disparity between standards of competence in the West and what is found in the field should be addressed. Interpersonal relations is the affective content of the provider/client transaction. The characteristics of programs and clients have changed since the idea of follow-up was first brought about. The appropriate constellation of services should respond to clients rather than some artificial demarcation. Ways in which the framework may be used as an analytical and practical tool are discussed. Quality can be seen from the structure of the program, the service- giving process, and the outcome of care. The outcome of care consists of knowledge, behavior, and service satisfaction.

Though male reproductive health has only recently begun receiving attention the experiences of two clinics specializing in that area suggest than men have significant interest in the services offered. Brazils PRO-PATER clinic devotes itself exclusively to the reproductive health concerns of men. Located in the city of Sao Paulo the clinic was initially created to get men interest in the idea of family planning. But concerns over the predominance of female sterilization in the country prompted the clinic to begin offering vasectomies in 1981 which has now become its main service. Those who receive the operation must first undergo a careful screening process. Refusing about 21.5% of those interviewed PRO-PATER has had only 17 requests for reversal from over 28000 operations in 9 years. In addition to vasectomies the clinic also offers treatment for sexual dysfunctions and infertility services. The clinic which opened a branch in another Sao Paulo district in 1988 also conducts research into family planning issues and provides training for physicians from Brazil and other Latin American countries. PRO-PATERs success encouraged the creation of a similar service in Colombia Profamilias Clinica para el Hombre. Established in 1985 the clinic sprung up from a womens family planning program. Initially plagued by problems of cultural resistance staffing and a low client load Profamilia now enjoys great success measured by its self-sufficiency its 5 branches and its increasing number of patients. Among the lessons learned from the successes of both clinics: a large demand exists for such services; mass media is invaluable in informing men about the availability of the services; good quality of service increases the legitimacy of such a controversial project.

Introduction Public Definitions and Private Lives PART ONE: POLITICS, POLICY AND THE LAW Issues in the Study of 'The Family' - John Muncie and Roger Sapsford Family Policy and Political Discourse - John Muncie and Margaret Wetherell Families and the Law - Hilary Land Patterns of Diversity and Lived Realities - Rudi Dallos and Roger Sapsford PART TWO: INTERACTIONS AND IDENTITIES Constructing Family Life - Rudi Dallos Family Belief Systems Social Structure, Ideology and Family Dynamics - Margaret Wetherell The Case of Parenting The Psychoanalytic Approach to Family Life - Margaret Wetherell A Feminist Looks at the Family - Lynne Segal Endnote - Roger Sapsford Public and Private

This essay was written in response to a critical review made by Ross of one the authors previous publications. The authors agree with Ross about the unproductive nature of the debate over whether increased distribution is more important than service improvements in increasing contraceptive prevalence and about the fact that satisfactory access to modern contraceptives remains problematic in developing countries. In fact the authors made these points in the work which Ross critiqued. Ross was inaccurate when he said that the authors believe that access is not a problem. Instead the authors agree with Ross that access must include a range of contraceptive choices but they also note that access involves the additional factors of adequate counseling about side effects and opportunities to switch methods. Another issue remaining to be resolved is the role that access has in explaining unmet need. Women with unmet need can be broadly defined as those for whom access is the dominant issue and those for whom other obstacles are more important. As access improves women in the second group constitute a larger percentage of remaining unmet need. Thus for most women with an unmet need access is not more important than survey data indicate. Unmet need will remain a problem unless programs improve the quality of information given to clients and deal with social concerns underlying contraceptive nonuse.

The Population Council continues to resist setting quality of care standards for family planning programs. It contends that professionals responsible for each family planning program must define intended and achievable levels of care. The Population Council does claim however that a high quality program is client-oriented and assists clients in reaching their reproductive goals. Even though a high quality program would reduce fertility by increasing contraceptive use it must not execute fertility reduction policies that conflict with clients well being. 6 components of quality care include appropriate choice of methods responsible information technical competence interpersonal relations mechanisms to encourage continuity and appropriate mixture of services. A key problem with setting universal standard is that each country or program must validate the standards and make them work. For example standards may require providers to understand clients reproductive intentions and to help them choose a method which meets their needs yet the standards cannot define how they should do so. The standard setting process for individual countries and programs should include the technical and affective aspects of care and address the following: What quality of care does a program propose to offer can it offer is actually offered and is received by clients? Rapid assessment techniques can be used to compare the quality of care a program wants to offer and the care that is actually given to clients. Program managers can then discern gaps between intention and reality and reasons to improve service standards. In conclusion solutions to problems with quality of family planning care are only found locally.

Since the 1960s, the solution to contraception problems has been based increasingly on complexity, not simplicity. The oral contraceptive was developed in the late 1950s using newly discovered synthetic hormones that act in intricate ways on glands in the brain. Intrauterine devices were widely introduced in the 1960s in a host of scientifically engineered configurations that act inside a woman’s uterus. Nearly half of all married couples in the United States who use some method of contraception use either the pill or IUD. In examining emerging social trends and considering the special needs of some large groups for better contraceptives—adolescents, women over 30, individuals concerned with health and safety—in many respects barrier methods appear to offer a commonsense solution to age-old problems. They offer high effectiveness combined with freedom from short- or long-term side effects and the freedom to be fertile in the future. This Public Issues paper examines how good or bad today’s barrier contraceptives are, and how acceptable they are. New patterns of use and demand for barrier contraceptives in this country are documented, and the potential utility of these methods is considered for couples living in developing countries.

Evaluation of birth planning programs has heretofore been done from the service provider or the policy-planner's point of view. It is time to begin evaluating family planning programs from the viewpoint of the user. This type of evaluation would involve measuring continuation rates over time and the degree of benefit over a reproductive lifetime. Evaluation should include individual and subgroup acceptance of various methods of birth control. Knowledge of the clients' needs can be assessed and applied at 3 points in the provision of family planning services: 1) during the planning stage of programs; 2) in response to modern programs, e.g., in response to perceived risks and benefits of certain offered methods; and 3) on a longterm basis, focusing on consequences of birth planning systems to individual health and well-being.

Womens organizations such as political professional social welfare religious community development family planning government program and commercial associations have increasingly assumed leadership in providing fertility control in the developing world as part of their concern with socioeconomic development and political change. The Nepal Womens Organization a political association initiated a program in 1973 to bring family planning services to 1000 villages assist in the official sterilization program and promote literacy and economic skill development. Volunteers selected from their villages on the basis of leadership and interest attend a 10-day seminar on family planning nutrition child care sanitation immunization literacy and marketing handicrafts. As a close relationship between acceptor and worker is essential each attempts to reach 20-30 women. The objective is to have 800 village workers operating by July 1978. The Womens Medical Society of Ecuador has provided clinic-based services for 8000 clients in urban slums since 1973. The Thai Nurses Association plans a new family planning service unit in addition to their research and publication efforts begun in 1975. Social welfare organizations in Korea Sri Lanka Pakistan Thailand Egypt and the Philippines are conducting family planning services. The Social Welfare Society of Pakistan and the Cairo Womens Club have active programs where volunteers are trained to serve their own communities. A womens leadership program conducted by the Korean National Council of Churches is reaching 1/3 of all women aged 20-44 serving 40000 users in the 1st year. Concerned Women a family planning association in Bangladesh enrolled 5634 acceptors and 154 underwent voluntary sterilization. A promising strategy by the Coptic Evangelical Services in middle Egypt has proved successful in 8 villages where the approval of the village leadership is 1st sought. The Raaidat program of Egypt has trained rural women as leaders to organize self-help programs. Population control and food production are the aim of 87 cooperative societies staffed by women of the Integrated Rural Development Program of Bangladesh.

A survey of abortion facilities in New York City revealed the existence of adequate resources for both early and late terminations of pregnancy. Several important weaknesses have been noted which can be related to the policies and practices of the performing institutions: less than adequate provision of postabortal contraceptive care, and counseling, primarily in private hospitals; wide variation in restrictive admission policies to minors; and substantially higher costs in private facilities. On the whole, private patients are more likely to be receiving less than adequate care than non-private patients with respect to counseling and contraception. This has implications for several long-term risks, namely: repeat and recurring abortion with the possibility of increased risk of premature delivery or spontaneous abortion, and other hazardous outcomes of pregnancy.

There are today some 200 women's health centers in the United States providing information and, in many cases, direct health and family planning services to women in a manner responsive to their needs and preferences, and that involves them in the design and provision of services. This approach to delivering services was specifically recommended by the International Conference of Family Planning in the 1980's held in Indonesia in April 1981. in addressing the challenges facing family planning programs in the decade ahead, the conference noted that in many parts of the world, women often have little control over decisions related to their own fertility. Furthermore, low levels of acceptance and use of family planning, which are characteristic of many programs, often reflect a failure to design and provide services in a manner that is responsive to the needs and perceptions of the users. The conference called for measures to improve the status of women, and recommended that women be involved in all aspects of program design, management, policymaking, and provision of services. In this special report, Judith Bruce describes how women-oriented services are designed and provided at one of the women's health centers, The New hampshire Feminist Health Center.