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18 juin 2009 4 18 /06 /juin /2009 18:05

FAMILY PLANNING AND CONTRACEPTIVES IN MOROCCO (II)

 

Prof. Dr. Abdessamad DIALMY

University Mohamed V Rabat

 

4- Contraceptive prevalence 

 

Since the beginning of family planning in 1966, woman has constituted the main target of programs. Men are aimed through some messages in order to push them to accept and to facilitate the women's use of contraceptives. Generally, men reject contraceptives for themselves. The male acceptance rate of continence, withdrawal, condom, and vasectomy is weak because the male “defines contraceptive practice as a female thing, as "the business of women”[1]. The masculine involvement in contraception is weak; it is neither a lifestyle nor a conjugal policy[2]. When it is not a medical indication, the contraceptive alternation[3], that is to say the contraception use in turns by the conjugal couple, is  perceived such as a gift that the husband makes to his wife. The contraceptive alternation is never defined as woman's right.

 Woman remains, therefore, the main agent of the contraceptive practice. Her knowledge and her contraceptive method practice have positively evolved with time. Thus, in relation to the investigation of 1995 Panel, PAPChild (1997) records a clear improvement of the contraceptive method knowledge among women in age of procreation (15-49 years). The best known methods are by order of importance: the pill (100%), the DIU (95%), the horn ligature (92%), the injectables (83%), the condom (81%). The least known methods are the Norplant (57%), the vaginal methods (as the diaphragm, the moss and frost (21%)), and the masculine sterilization (6%). More than nine women out of ten (94%) mentioned a traditional method such as : the maternal nursing (88%), the periodic continence (78%) and the shrinking (70%). 

Concerning the modern contraception, 78% of women brides already used it, against 71% in 1995 and 63% in 1992. The pill comes on top with 75% against 68% in 1995. At the time of the investigation, 58,4% of women aged between 15 and 49 years declared that they use a contraceptive method, including 3,2% of women that use the prolonged maternal nursing. This means that the rate of modern methods use is 48,8%. 

Otherwise, the new generations tend to delay the first pregnancy. Indeed, among women without children, the first utilization shifted from 4,2% for women born in the 1950 years to 45,8% for women born in the 1980 's. In 1996-97, 13% of women without children resort to the contraception. The use of the contraception after the first child shifted from 33% for women born around 1950 to 60% for women born around 1976.  

Globally, the rate of the contraceptive use didn't stop increasing. 

 

Figure 7: Evolution of the contraceptive prevalence rate  

 

Year

1980

1992

1995

1997

Contraceptive prevalence rate

19,4

41,5

50,3

55,3

 

In 1996-97, the rate of contraceptive prevalence reaches the most elevated level in: 

- the age group 35-39 years with 66% 

- the urban area with 65,8% against 51,7% in rural area. 

- the category of women having the secondary or superior level in education: 72,1%. 

The proportion of women in situation of unsatisfied need in family planning, that is to say women who want to stop pregnancies or to space them but failed to do so, knew a meaningful decrease[4]. The rate of this category of women shifted  from 22% in 1987 to 20% in 1992 to 16% in 1995. The satisfied demand concerning family planning is in progression[5], it increased from 59% in 1987 to 77% in 1995. However, these measures remain imprecise because they are exclusively based on women's declaration. Men's needs and women's needs are not always the same within the marital couple, that is to say the husband's opinion is an important factor in the evaluation of unsatisfied needs of contraception[6].

 

5- Decrease of the total fertility rate

The positive interrelationship between the elevation of education level and the elevation of the contraceptive prevalence implies that, for the educated woman, having a child doesn't have the social and the economic value that it has for the illiterate woman. For the illiterate and dependent mothers, a child is a factor of valorization and stabilization. For these mothers, it is important to have enough children, - boys especially- for old age[7]. The status of family assistant usually reserved for rural woman does not enable her neither income nor autonomy. Besides, in the countryside, the child is a source of wealth rather than of expense: since 6-7 years, the child is able to work in the fields, chores of water and wood,  trade, and the handicraft. In this rural context, contraception is for woman a means to fall in value socially[8].

This rural specificity explains a weaker decrease of the total fertility rate (TFR) in comparison with the urban area. If at the national level the TFR in 1997 is 3,1 child by woman, the gap between urban and rural areas is still meaningful: 4,1 in rural area and 2,3 in urban area. In the countryside, motherhood and work in the fields are not incompatible. On the contrary, having a lot of children is for the rural mother a means to unload her an important part of the daily labor. It is therefore with urbanization that one moves towards a weaker TFR. A further weaker TFR is also achieved through education. Indeed, for the category of women who have a superior educational level, the TFR is 1,6 children per woman, that is to say a weaker TFR than the replacement rates[9]!  

In spite of the relative rural resistance, the decrease of the TFR is perceptible on the longitudinal plan, which testifies the success of family planning programs. Between 1962 and 1997, the TFR recorded a remarkable decrease of 20%, between 1962 and 1980 and 56% between 1962 and 1997 (PAPChild). 

Figure 8: Evolution of the TFR

 

Year

1962

1980

1997

TFR

7,0

5,6

3,1

 

Moroccan TFR decreased to lower than a half in 35 years. The decrease of fertility rates has reached all ages, without exception. Besides, the precocious fertility is relatively weak: the teenager mother's percentage lowered. It shifted form 8,5% in 1982 to 4,5% in 1995. In accordance with this, the rate of fertility to 15-19 years is only 35°/°° (PAPChild).  

To conclude, the evolution towards a nuclear type of family (owed to the urbanization, to schooling, to the elevation of the average age of the first marriage and to the contraceptive prevalence) leads to the decrease of fertility. The role of the contraceptive prevalence is even more important. Indeed, more than half of the reduction of the fertility is owed to the contraceptive method utilization. This utilization, while meeting understandable some resistance, could seriously reach the rural, the illiterate and the poor woman. Even if the rates of schooling (of girls) and of education (of adult women) have not increased, and although the response to family planning services is not always guarantied[10], the demographic transition is taking over thanks to programs of family planning that Morocco has put in practice since 1966. 

 

6- Toward integration of FP in reproductive health programs

 

The emergence of the reproductive health notion is currently leading to a shift form the FP traditional worries such as acceptance rate, the use prevalence and the unsatisfied contraceptives needs.  "Reproductive tract infections are associated with infertility, cervical cancer, adverse outcomes of pregnancy, and HIV transmission. These infections also have socioeconomic costs related to their treatment and to their impact on functioning and status… It is clear that disease conditions that are contraindicated by methods of contraception should be of concern to a family planning policy"[11]. The reproductive health implies that FP would not succeed without taking into consideration the women's health as a whole, particularly reproductive morbidity and the STD-HIV. Moreover, the reproductive health paradigm needs to work on the quality of cares, respect of human rights [12] as well as the involvement of men[13].

Part of the PAPChild investigation (ENSEME 1997) is the examination of reproductive morbidity. This includes the diagnosis of the treated illnesses[14] among bachelor women during their reproduction age (15-49 years). It also raises the question of the perception of [the suggestive] symptoms of reproductive morbidity  such as prolapse, urinary incontinence, vaginal losses, urinary tract infection and troubles of menstrual cycle. Infertility is perceived as the most morbid symptom. Such an attitude is very common in a patriarchal society that constructs fertility as a major determinant of woman's social integration. The investigation was also interested in the gynecological morbidity that comes with pregnancy and post partum. The socio-cultural perception of a symptom as morbid is important in the sense that it determines the condition of searching for care.

This investigation revealed that for women reproductive morbidity means[15], infertility (18,6%), troubles of the cycle (13,5%), genital prolapse (12,9%), urinary infection (12,9%), vaginal losses (10,3%), and urinary incontinence (5,4%). Accordingly, 13,5% of women declared more a symptom of reproductive morbidity. Sterility is the symptom induces most of to the consultation, 75,6% of infertile women consulted a physician. Troubles of the cycle symptoms were a reason of less consultation. Concerning other symptoms considered by women as morbid 50% among women don't consult mainly because of the expensive consultations. The majority of women who consult are educated and urban, that is to say financially solvent or have a medical insurance. For other women, apart sterility, these morbid symptoms do not constitute a problem, they need no consultation. It is important to point out that the consultation is not always medical. " 26,7% of people have recourse to the traditional healer and the herbalist because of the problem of barrenness" [16].

PAPChild/ENSEME 1997 has also taken the pathologies bound to pregnancy, childbirth and post partum into consideration. These pathologies are bound to the weak rate of the antenatal consultation[17], to the predominance of the childbirth at home (in rural areas especially) and to the weakness of the postnatal follow-up with regard to both the mother that the newborn [18]. But "the insufficiency of the surveillance of the childbirth by medical structures as well as the existence of some unjustified practices such as the forceps can be to the origin of rips some of are serious, especially the vaginal rip or fistulas vesico-vaginal, which is a real major "handicap [19]. Consequently the quality of cares becomes a major worry. The Dialmy's study entitled "The socio-cultural management of the obstetric complication in Morocco" showed that the inaccessibility to health services is mainly due first to : the bad quality of health care services and second to some cultural factors such as male resistance to the hetero-consultation[20]. Indeed, the husband refuses in some cases that his wife be examined and treated by a male nursing.

From these observations, an integration of the STD/AIDS services to the services of primary health cares and programs of maternal and child health proves to be necessary. But the different programs of maternal and child health[21], namely the "Program of Surveillance of Pregnancy and the Childbirth" and the "Integrated Hold in charge of the child's illnesses" (PCIME) don't mention the STD-AIDS explicitly. Maybe it is due to the fact that programs of the health ministry need a better integration and coordination. Indeed, sometimes, the action of the ministry of health is compromised by the fact that different ministry administrations are working on the same issues with the same objectives. Thus, diseases are objects of specific programs within the Direction of Epidemiology and Struggle against diseases and are also the object of other programs within the Direction of Population[22]. For instance, the program of pregnancy surveillance childbirth is one of the programs that are shared between these two main administrations.

However, according to "Strategic National Plan for the struggle against AIDS"[23], this integration is in progress. Concerning STD taking in charge, there was a training of 3800 general physicians and 4500 nurses working in cells of maternal and child health and family planning, in primary health care institutions, in emergency services as well as among the dermatologists and gynecologists. Within the domain of follow-up and epidemiological surveillance, a system of epidemiological surveillance of the STD-HIV has been effectively institutionalized. This system allows the examination of HIV infection tendencies among pregnant women in order to warn the vertical transmission mother-fetus. Let's recall that the sero-prevalence rate among the pregnant women is 0,15% in 2000 (Source: Ministry of Health).

However, it is necessary to point out that the expenses of the ministry of health in maternal and child health (MCH) concerning the primary health cares (27,2 millions of $US)[24] are distinguished from the relative expenses of the STD-AIDS. In other words, the expenses concerning the STD-AIDS don't go to the financing of the MCH. For the STD-AIDS, the ministry of health spent 54 millions DHS in 1998-1999 while the Moroccan Association of Struggle against the AIDS (ALCS) spent 4,6 millions of DHS[25]. To what extent could we consider this separation of budgets an obstacle against the complete integration of STD programs in primary health cares?

 

 



[1] A. Dialmy: Identité masculine et santé reproductive au Maroc, op. cit. p. 142.

[2] Ibid. p. 143.

[3] Ibid. 144.

[4] Santé de reproduction au Maroc…, op. cit., p. 66.

[5] Ibid. p. 66.

[6] A. Zguiouar : Planification familiale au Maroc: besoins non satisfaits et intention d'utiliser, Université de Montréal, 1995.

[7] Analyse de la situation des enfants au Maroc, op. cit. p. 41.

[8] Ibid. p. 41.

[9] Ibid. p. 41.

[10] F. Navez Bouchanine et Al : Etude des pratiques sociales et de l'acceptabilité des services de santé materno-infantile et de planification familiale, Ministère de la santé publique/FNUAP, 1994.

[11] H. Zurayk, N. Younis, H. Khattab : "Rethinking Family Planning Policy in Light of Reproductive Health Research", in C. M. Obermeyer (ed): Family, Gender, and Population in the Middle East, Cairo, The American University in Cairo Press, 1995, p. 249.

[12] J. Jacobson: Family, Gender and Population Policy: Views from the Middle East, The Population Council, New York, 1994, p. 18.

[13] A. Dialmy: "The husband use of male contraceptives in the couple is not adopted as contraceptive alternation, as private conjugal policy. Its only a help that husband brings to his wife in order to permit her to take rest", in Identité masculine et santé reproductive au Maroc, op. cit. p. 143-144.

[14] ENSEME/PAPchild, op.cit. pp. 116-119.

[15] Ibid. p. 120.

[16] Ibid. p. 124.

[17] Only 3,8% of the rural women benefited the antenatal consultation at the time of pregnancies recorded during the last 3 years preceding the PAPchild survey, against 22,4% in urban area.

[18] The postnatal cares only touch 12,3% of parturients at the national level. They only touch 50% of the rural women that give birth in supervised middle (against 86% in the urban). The absence of complication, the nonexistence of the service and the cost generated are the main factors that drive to the weakness of the postnatal consultation rate (PAPchild).

[19] PAPchild, op. cit., p. 96.

[20] A. Dialmy: La gestion socioculturelle de la complication obstétricale dans les régions Fès-Boulemane et Taza-Al Hocéima-Taounate, Ministère de la Santé/Direction de la Population/USAID, Fès, Imprinego, 2001.

[21] National Program of immunization, Program of Struggle against the Illness Diarrheic, National Program of Prevention and Control of the Diabetes…

[22] Analyse de la situation des enfants au Maroc, op. cit. p. 81.

[23] Plan National Stratégique de Lutte contre le SIDA, op. cit. p. 4.

[24] Z. E. El Idrissi M. Driss et al: "Analyse des dépenses de santé maternelle et infantile à travers les comptes nationaux de la santé: Cas du Maroc", Symposium International sur les Comptes nationaux de la Santé, York, Angleterre, 20-21 june 2001.

[25] Z. E. El Idrissi M. Driss : "Analyse de la Réponse face au VIH-SIDA, adéquation du financement", Atelier de Consensus National sur les Stratégies de Lutte contre les MST-SIDA pour 2002-2004, Rabat, 7-9 June 2001.

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