A study of the effectiveness of family planning clinics in the Philippines.

D W MacCorquodale Abstract A study of 190 Philippine family planning clinics revealed that certain clinic and physician characteristics were significantly and positively associated with clinic effectiveness, defined in terms of the mean number of monthly acceptors of family planning and the efficacy of the methods selected. Clinics with a high degree of effectiveness were more likely to be staffed by physicians who wanted three or fewer children, who relied more extensively on the IUD (intrauterine device) than physicians in less effective clinics, and who derived more satisfaction from working in family planning than physicians in less effective clinics. Autonomous clinics were more effective than integrated clinics, and clinics staffed by physicians trained by institutions with more experience in family planning were more effective than those staffed by physicians trained by institutions with less experience in this field. The findings regarding the following hypotheses were in the predicted direction: Clinic effectiveness will be greater in clinics staffed by female rather than by male physicians, in urban rather than in rural clinics, in clinics staffed by physicians with a low rather than a high degree of religiosity, and in clinics staffed by physicians with a high rather than a low degree of concern about population growth. The differences in clinic effectiveness, however, in these instances, were not significant
A Framework for the Analysis of Family Planning on Women's Work and Income
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Support our work to improve the lives of the world's most vulnerable people.

This working paper, part of a series of working papers published by the Women's Studies Project at Family Health International, proposes a conceptual framework to examine the possible impacts of family planning use on women's work and income. Because use of family planning may have short-term and long-term effects on women's economic activity, the authors present separate frameworks for modeling both influences. Summary Family planning and population researchers have devoted considerable attention to studying the determinants of women's fertility and family planning use. There is a large body of information on the effects of timing, spacing, and number of pregnancies on infant health and a growing body of literature on maternal health outcomes. Yet, until recently, there has been little emphasis on the economic, social, and psychological consequences of family planning use and the pace of childbearing on women's lives. While it has been assumed that family planning programs have beneficial consequences for women's lives, there has been little research that evaluates the impact of family planning on women's personal, social, or economic conditions. This conceptual paper focuses on women's economic activities, an area in which family planning use may have significant influence. In addition, economic activity is an area of vital importance to the well-being of women, their children, families, communities, and society as a whole. In this paper, we describe a

framework for the analysis of family planning, specific to women's work and income. Because use of family planning may have short-term and long-term effects on women's economic activity, this paper presents separate frameworks for modeling both influences. These frameworks have evolved from the Hong-Seltzer framework and the Women's Studies Project framework. Background on women's work When exploring any dimensions of women's work, it is important to consider these factors.

Women constitute roughly half the world's population, but worldwide, their official work force participation rates are lower than those of men. Global labor force participation of women is estimated at 42 percent, and women comprise one-third of the total paid labor force. These statistics conceal the true extent of women's work since much of their work is invisible. In reality, women have three productive roles. They are producers of goods and services (paid or unpaid), reproducers of people and labor in the household, and organizers of community activities. Official statistics, however, typically record only paid, economically productive work.

Women's economically productive work is underrepresented by official statistics. The reasons for this phenomenon lie in attitudes towards women's work and the nature of women's work. Women's economically productive work tends to be devalued by their family members, by official recorders of information, and by women themselves. Their work is often not considered "real work." Surveys may stop probing on women's work if women respond that their main activity is housework.

In examining the mean percentages of women and men in the labor force in the six emphasis countries of the Women's Studies Project, we found the percentages of women ranged from 9.2 percent in Egypt, to 36 and 38 percent in Indonesia and the Philippines, to a high of 45 percent in Zimbabwe. Most working women in Egypt, Brazil, and Bolivia are in the service sector, whereas the vast majority of women workers in Zimbabwe are in the agricultural sector. In Indonesia and the Philippines, women's work is more equally distributed between agricultural and service sectors. In all six emphasis countries, the smallest percentage of women are employed in industry, and, except for Indonesia and the Philippines, smaller percentages of women than men are engaged in industry.

During the past 20 years, statistics on labor force participation trends in developed countries reveal a steady increase in women's employment, which has been partially offset by declines in male employment rates. A similar trend has been found in many developing regions, including Latin America.

Women are also increasingly becoming heads of households, due to increasing rates of divorce, separation, widowhood, single parenthood, migration and displacement by war. Often women have sole economic responsibility for their children and/or elderly relatives.

Evidence indicates that women's lives are a "zero-sum game," where women are likely to sacrifice leisure in order to make up for increases in reproductive or productive work burdens.

This is true particularly where women work multiple jobs and engage in market work as a matter of necessity rather than choice.

Women worldwide are paid less than men for comparable market work. Statistics from manufacturing show women's income relative to men's ranging from lows of 41 percent and 50 percent in Japan and Korea to highs of 89 percent in Sweden and 97 percent in Egypt. For countries that have data on relative wages of men and women for skilled (salaried) and unskilled workers, the wage gap is greater for skilled than for unskilled workers.

In households where both women and men earn wages, the men's incomes are usually higher than the women's, yet women usually contribute a larger proportion of their income (and sometimes a larger absolute sum) for pooled household expenditures. Recent studies have shown a striking difference in the proportion of their earnings that men and women devote to meeting basic family needs. In many settings, women's earnings are more likely than men's to go toward children's food, health care, and schooling.

Family planning and women's work: a conceptual framework It is important to distinguish between characteristics of work that meet the practical needs of women and those that meet their strategic interests. The former provide women with the means to fulfill immediate wants, such as increased income through more hours of work. The latter address the systemic causes of poverty and want, such as discriminatory wage and hiring practices, lack of job security, and lack of access to credit, labor unions and markets. The use of family planning may further women's practical needs by allowing them to join the labor force and to work more hours. It may also address women's strategic needs by qualifying them for jobs with a greater degree of security and more chance for job advancement. In addition, it may allow women to increase their work skills. The effect of family planning on women's labor force participation, and consequently, on women's lives, may depend upon the kind of work as well as the context in which it is done. Increased participation, or increased hours of work may not necessarily lead to an increase in women's welfare and could lead to a decrease in their overall quality of life. The most common representation of the relationship between work and fertility uses fertility and/or contraceptive use as the dependent variable and work as the independent variable. The reverse direction is usually ignored. Researchers focusing on the United States and other developed countries have considered the impact of family planning on work, usually as a simultaneous relationship. In general, there are few studies that try to sort out the temporal ordering and causal direction of work and fertility. The conceptual frameworks presented in this paper specify the time frame of family planning, childbirth and employment decisions with separate frameworks for the long-term and the short-term effects of family planning decisions. Both short- and long-term models use a sequential and comprehensive approach to explore the effects of family planning use upon work. Impact of Family Planning on Work: A Long-Term Model

Among the independent variables we consider are: family planning use, pregnancy and lactation, birth intervals and family size. Among the dependent variables: work status characteristics, such as type of occupation and place of work. Underlying and control variables include women's characteristics, such as marital status and education; household characteristics, such as income and assets and partner's education; and community characteristics, such as urban or rural setting. These frameworks suggest that the use of family planning can help women meet their practical needs by allowing them to join the labor force and work more hours. It can also address women's strategic needs by allowing them to choose jobs with a greater degree of security and more chances of job advancement. Labor force participation can have beneficial and detrimental effects on women's lives, depending on the nature the work, demands on women's time, and other individual and contextual factors. The Women's Studies Project is supporting research in developing countries that can empirically examine the relationships described in this paper. Impact of Family Planning on Work: A Short-Term Model

-- Eilene Z. Bisgrove -- Meera Viswanathan Editor's note: The full text of this paper is not posted on FHI's Home Page. For a copy of the No. WP97-01 paper, please write: Publications Assistant, FHI, PO Box 13950, Research Triangle Park, NC 27709 USA

Philippines Family Planning: Its Economic and Psychosocial Influences on the Lives of Women in Western Visayas The Philippine family planning program began in the 1970s and reflected a concern with rapid population growth and inadequate maternal and child health (MCH). Over the past two decades, the program has had varying degrees of political support and, consequently, somewhat erratic implementation. In the past six years, there has been an attempt to revive training of MCH and family planning workers and increase the choice of contraceptive methods. For example, injectables have been introduced. Among the benefits of family planning often cited by contraceptive users are improvements in women's health and the family's economic status. In research conducted in Western Visayas, the Philippines, women said family planning allowed them more freedom to participate in the work force and more time to participate in community activities. Women who used family planning were generally more satisfied with their lives and more likely to share in household decision-making. Domestic violence was a concern for many women in this region of the Philippines. Research Findings

Researchers interviewed 1,100 married women of reproductive age, plus 50 key informants. Investigators also conducted nine pre-survey and 27 post-survey focus group discussions with women, men, community leaders, members of women's groups, and family planning service providers. Both rural and urban residents took part in the study.

More than half of the women interviewed currently used contraception or had used family planning at some point. Thirty seven percent are current users. The most popular methods are the pill, tubal ligation, and injections while the most unpopular are maleoriented methods -- condoms and vasectomy. The most common reason for choice of family planning methods was effectiveness, while the most often cited side effect was dizziness. In focus group discussions, men and women expressed fears about contraceptive side effects and gave this concern as a reason for not using family planning.

Family planning users were more likely to engage in paid work than were non-users. Family planning use provided increased economic opportunities for women, including opportunities to earn a living and to become more efficient workers.

Women who used family planning were more likely to participate in community activities, such as Parent-Teacher Associations, religious organizations and beautification projects. Women found community activities relaxing, and said these activities allowed them to socialize and interact with their peers. Women reported that social participation gave them satisfaction and increased their sense of self-worth.

More family planning users than nonusers shared decision-making with their husbands in four areas: the woman's work outside the home; the woman's travel outside the community; use of family planning; and plans for future births. Nonusers were more likely to report that their husbands made decisions independently in these four areas.

More than one-third of the women reported they had been victims of physical abuse, psychological abuse, or both. Most domestic violence happened when the perpetrator (usually the husband) had been drinking. Among the perceived causes of violence were jealousy, quarrels due to suspected infidelity, and arguments over financial and other family matters. The most common reported acts of physical abuse were beating, boxing, slapping, and kicking. Contraceptive use did not reduce women's risks of violence, nor did work status.

Recommendations There should be continuous efforts to improve the family planning program, including an effort to provide integrated reproductive health. Special attention needs to be given to helping women deal with side effects. Because of demands on women's time at home and in the work place, health services should be offered at times (and places) convenient to women; for example, on weekends or after normal business hours. Policymakers should be concerned about the need for more employment opportunities for women, and should encourage women to take on greater leadership roles in the community. Community leaders should develop

strategies to minimize and eliminate domestic violence and should develop referral systems to respond to victim's needs in a timely manner. Study Details This research was conducted by the Social Science Research Institute, Central Philippines University, in collaboration with the Women's Resource Center and the Family Planning Organization of the Philippines. The principal investigators were Dr. Fely David and Dr. Fely Chin. Research was supported by the Women's Studies Project at Family Health International, through a cooperative agreement funded by the U.S. Agency for International Development. Technical assistance was provided by Dr. Eilene Bisgrove.