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  • Title: Contraceptive introduction and the management of choice: the role of Cyclofem in Indonesia.
    Author: Simmons R, Fajans P, Lubis F.
    Journal: Contraception; 1994 May; 49(5):509-25. PubMed ID: 8045135.
    Abstract:
    This paper presents a programmatic perspective on the relationship between the introduction of new contraceptive technology and expanding contraceptive options, using the example of Cyclofem in Indonesia. Past approaches to contraceptive introduction have considered only the characteristics of the new method in the decision-making process. In assessing whether the introduction of a new method actually expands contraceptive choice for women and whether the program has the managerial capabilities to assure quality of care in this process, the authors argue that consideration must be given to all methods within a delivery system and how new technology relates to the management of contraceptive choice. Using this perspective, the authors suggest that choice would not necessarily be expanded with scaled-up service delivery of a new once-a month injectable in the Indonesian public sector context. After observation and in-depth interviews within the Indonesian Family Planning Service Delivery System, it was concluded that the introduction of new contraceptives such as the injectable Cyclofem administered once a month would be advantageous only if changes were made in operations and program management. Changes were needed in counseling and information provision, technical provision of care, training of staff, supervision, record keeping, logistics and supplies, and policy support. Informed choice was jeopardized in the prior introduction of the new method Norplant, and wide scale introduction of Cyclofem would stretch the ability of the system to respond with assurances of quality of care. Expanding the method mix would be appropriate in settings where the service delivery system is stronger, where injectables are not currently available, and where Cyclofem could replace high-dose injectables already dispensed. This study included observations of 241 individual provider-client interactions and 107 in-depth interviews among national leaders, provincial and district program managers, public and private sector providers, community leaders, and clients in Cyclofem trial and non-trial areas. Promotional activities were not performed for Cyclofem. The introduction of Cyclofem expanded women's options and in a way that included additional information not usually provided. Cyclofem has the advantage of easy reversibility, regular bleeding patterns, and high efficacy. This method, however, was not promoted as a spacing method, in part because spacing methods are generally promoted within the service delivery system. The system already provide two other injectables, DMPA and NET-EN, with very different side effects. The policy and management obstacles to planned expansion of choice in the public sector of the Indonesian Family Planning Program included the following: the emphasis on long-acting methods, charges for injectables and limited supplies, the lack of identification of specific injectables in the record-keeping system, inadequate information dissemination and counseling, and the added burden to staff time. The private sector is more suitable for introduction of all injectables.
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