Many societies in the Western Hemisphere (including the United States) historically have excluded or otherwise discriminated against minority populations, particularly indigenous peoples. In this issue of International Family Planning Perspectives, Jane Bertrand and colleagues present 20 years of data on contraceptive practices in Guatemala, highlighting differentials between the dominant ladinos and the Mayans [see article]. A combination of distrust, oppression and geography have left Guatemala's Mayan people cut off from other citizens of the country, and this separation is reflected in their levels of contraceptive practice: While use has climbed in both groups between 1978 and 1998, Mayans remain far less likely to rely on modern methods. Yet the method mix and the distribution of sources of supply do not differ greatly among users in both groups. The researchers conclude that while contraceptive use among Mayans in Guatemala is related to social conditions and can probably be improved with greater education and development, improving access to services will also be a key factor.
It is more than 30 years since analysts first tried to gauge the strengths and weaknesses of family planning program effort around the world using a systematic approach. John Ross and John Stover [see article] report results from the 1999 version of the Family Planning Program Effort Index. Experts from around the world were asked for their views on how well (or badly) national family planning programs were doing on 30 discrete measures. Fortunately, progress is being made: The mean index score is at its highest level ever, and differences between countries with strong programs and those with weak programs have narrowed dramatically. Even now, though, one of the most important differences between high-performing and low-performing programs is in method availability, illustrating that ensuring clients have access to a full range of methods remains a challenge in many places.
Pakistan remains a puzzle: Despite a long-standing family planning program and large numbers of women who say they want no more children, contraceptive use remains low and fertility high. Fariyal Fikree and coauthors analyze data collected through interviews with women, their husbands and the women's mothers-in-law, all living in urban squatter settlements in Karachi [see article]. A search for the factors that most strongly influence contraceptive use reveals that discussion of family planning with one's mother-in-law is a highly significant predictor. The authors suggest that in societies like Pakistan's, designers of campaigns intended to motivate couples to practice contraception should also aim at reaching other family members, especially mothers-in-law.
Also in this issue, Radheshyam Bairagi [see article] assesses the extent to which son preference affects fertility decision-making in Bangladesh. Detailed information from the Matlab program's record-keeping system is tapped to reveal that sex preference seems to have had little effect over time on contraceptive use. However, there is good evidence that son preference has influenced reliance on induced abortion: The investigator observes that in Matlab, "abortion was used more liberally than contraceptives to maintain the desired number of sons and daughters." Reductions in the recourse to abortion could be brought about both Researchers from Nepal describe in a Research Note [see article] the characteristics of women in Kathmandu who rely on induced abortion. Among the clients of a private clinic providing "safe" but illicit abortions during a one-year period, a majority were aged 25-39, many had a high school education, most had two or more children and half had been practicing contraception prior to becoming pregnant. This picture is rather different from the profile of abortion patients that is deduced from studying women who have been hospitalized for the treatment of abortion complications, the authors note.
This issue of the journal also features two Viewpoints, one focused on research and the other on service provision. First, Peter Donaldson [see article] argues that when it comes to family planning research, a picture may be worth a thousand data points. Observing that photography played a greater role in the early years of social science research than it does now, he proposes that investigators reexamine the utility of photos in studying reproductive health issues, especially given the availability of moderately priced digital cameras. Such an approach could be especially useful in documenting the context of service provision, as part of a facility survey.
Finally, James Shelton [see article] reminds us that providers are people, too. Commenting that the reproductive health field's focus on the client's perspective is useful but incomplete, Shelton argues that we need to learn much more about providers: who they are, how they see their jobs, what motivates them and how they can be enlisted to improve service quality. "We must give them a voice," he concludes, "just as we seek to engage clients and communities" in the effort to improve quality and increase men and women's access to services.