Tools are not enough
With Egypt's total population pushing 70 million, the solution to the country's population crisis may lie in Upper Egypt.
Hannah Rashdan heads south to take stock of family planning efforts
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OUR BODIES, OUR SELVES: Promoting better health practices in Upper Egypt could also boost the adoption of family planning methods
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In 1995, the National Demographic Study estimated the nation's total fertility rate at 3.6 children born to every woman, while Upper Egypt's fertility rate was higher at 5.5 children for every woman. Due at least in part to early marriages, high illiteracy rates and a lack of education about family planning, Upper Egypt continues to hinder the nation's efforts to decrease population growth.
Amidst much fanfare, the Ministry of Health recently assumed responsibility for carrying out a family planning programme implemented in the area over the past five years by the European Union (EU).
A comprehensive assessment of the programme's achievements under EU support took place on 4 and 5 May during a conference in Luxor, where the project's past and future participants discussed obstacles and lessons learned.
The programme was designed "to improve the quality of reproductive health services -- including family planning services -- and to increase their utilisation in Upper Egypt's Qena and Sohag governorates".
"If health services are poor, then women won't come back for family planning," asserted Dr Iman Bibars, project consultant. This underlies the programme's goal of developing reproductive health services and facilities in order to expand awareness about family planning in the region.
The EU financing agreement with the government of Egypt was signed in 1995, and the programme was implemented in March 1997. It aimed at increasing contraceptive use by one per cent per year in Egypt and two per cent per year in Qena and Sohag until 2002.
Targeting 11 districts and covering a population of over 3.5 million, the programme increased the supply and demand of family planning and reproductive health services through various activities, such as providing qualified female doctors and empowering women through the distribution of micro-credit loans.
Approximately 135 reproductive health units were improved and equipped. Four hundred and fourteen doctors were employed and 606 nurses and 336 midwives were trained. Over 200 religious and community leaders were informed about reproductive health and family planning. Nine hundred women were taught basic literacy skills and 95 NGOs were trained about topics related to family planning and reproductive health.
The women, young married men, doctors, nurses and local leaders who were interviewed in impact studies of the project said they perceived the programme as having a positive impact.
"We take the women step by step," said Dr Fatma El-Zanaty, project consultant. "It is not difficult to obtain information since they are very communicative." Women's input about the project revealed both successes and weak points.
For example, midwife Safeya Bisrawi recounted, "In the beginning, some believed family planning was haram (sinful). But we told them it's a must in order to properly raise children."
While impact studies suggest a general satisfaction with the programme's supply of female doctors, most of the women's complaints "were based on the doctor/patient relationship and the lack of available medicine", said Dr Bibars. She explained that doctors are sometimes too focussed on family planning and do not give enough attention to women's health concerns. "Women don't want to be seen only as tools of family planning. They want their health questions answered as well," she said.
Another complaint about physicians concerned an overlap in public and private practices. Dr Irene Leverenz, one of the project's managers, explained that while patients are entitled to public health care at a discounted fee during designated hours, many complain that doctors are not available until after those hours, when the fee is calculated as a private visit. Many women are forced to travel long distances to the reproductive health unit, wait hours for a physical examination and then pay high fees.
In addition to this, "lab technicians are underpaid and overloaded, and this may affect the quality of their work," said Dr Bibars. This problem could hinder the sustainability of the programme under the Ministry of Health.
Another administrative problem concerns the difficulty some women face in registering as midwives. "The Ministry of Health doesn't allow the registration of new midwives and prohibits the employment of non-registered midwives," explained Dr Bibars. "They [midwives] are the ones who are there and have relationships with the women, so if bad habits persist amongst them, positive results won't be seen." Zaynab Badreddin, midwife programme director for 2002-2003, underlined the vital role played by midwives. "The doctor is closest to the midwife and maintains the health care."
A lack of adequate resources and medicine is another hurdle that must be overcome. According to the undersecretary of the Ministry of Health in Sohag, Dr Mohamed Nabil, "Proper treatment, not the provision of more medicine, is the solution for the apparent lack of medication."
Now that funding from the EU has ceased, the Ministry of Health must struggle to cover the costs of expensive reproductive health and family planning equipment and to compensate workers. Dr Nabil said that LE80,000 per year is included in the ministry's budget for the cost of the equipment, but no guarantee has been made to pay the salaries of midwives. A question remains as to whether or not midwives will continue to work without compensation.
In addition to fiscal shortcomings, several other challenges face the ministry in increasing the practice of family planning in Upper Egypt. As Dr Zanaty pointed out, while the use of contraceptives increased dramatically initially, many women have stopped using birth control because of side effects of the drugs.
Another challenge is the high percentage of women who do not want to have more children but lack access to contraceptives. "We have to find and target them in order to achieve further results," she said.
One opportunity to increase the use of family planning lies in pre-natal care. Studies show that as many as 60 per cent of births still take place at home. "If pre-natal care is targeted, family planning will increase," Dr Zanaty said. She explained that pre-natal care directs women who would otherwise be at home and unreachable towards family planning services.
While feedback about the programme has revealed many obstacles, the progress made in addressing religious perceptions of family planning may be a source of hope. Midwife Fatma Mohamed said, "While religion was a problem at the beginning, we have managed to overcome this. Now, no one thinks it's haram."
