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18 juin 2009 4 18 /06 /juin /2009 18:08

FAMILY PLANNING AND CONTRACEPTIVES IN MOROCCO (I) [1]

 

Prof. Dr. Abdessamad DIALMY

University Mohamed V Rabat

 

Since the 1960, sexuality has been transformed in public health issue through programs of family planning that aim to reduce fertility rate. 35 years after, the impact of contraception birth control proved to be more important than the other factors (mainly the elevation of the woman's average age at the first marriage). The contraception indicator appraised to 0,56 in 1979-80 and to 0,82 in 1995 indicates that contraception use contributed to the decrease of the fertility rate to of 18% in 1979-80 and 44% in 1995 "[2].

In fact, Family Planning has been adopted by the economic and the social planning since 1968 and was granted the status of a national priority[3] in the 1973-1977 five years plan (plan quinquennial). 

 

1- Attitudes toward Family Planning

 

Since King Hassan II's official declaration that stated the "choice" to adopt Family Planning (FP) as a national policy, there has been no research that has dealt with the senior national executives, physicians or community leaders (both civic and religious). All the social studies have dealt with the attitude of women, and only in some rare cases with the husband attitude[4]. The following questions were not asked to the relevant actors: is population an issue in Morocco? Does FP have an adequate answer to population issue? Consequently we don't really know what the practitioners really think about the relevancy of FP and to what extent they are for or against it? These two questions are still without any answer. In sum, we can conclude that the FP policy was in its beginnings a mechanical execution of a preeminent politically made decision. Political power had to produce a religious legitimacy to this policy. In this sense, Mekki Naciri, since the middle of the 1960s, argued for the FP Islamic legitimacy while appraising that Islam licit the interrupted coitus. He also thought that the prophetic saying "gets married yourselves and multiply yourselves I'll be proud of you…" is not an incitement to maximal procreation[5]. Maybe the unique negative attitude towards FP in the 1960s was expressed and defended by Allal al Fassi and his political party, Istiqlal.  They both defined FP like "an imperialistic action against religious principles"[6].

Surveys on Knowledge, Attitudes and Practices, in 1966 in cities[7] and in 1967 in the countryside[8], indicate that 61% among women accept the idea of the contraception. Yet, 87% among them don't use any modern contraceptive. 52% of men accept the idea of contraception. Yet, 92% don't practically worry and believe that it is women's thing.

 

2- Insitutionalization and orientations

 

What are the major national program stages of family planning in Morocco? Through some documents from the Direction of the Population of the Ministry of the Public Health, we can expose these stages in the following way. The beginning is the 1965 royal memorandum that displays the impact of the fast demographic growth on economic and social development in the Kingdom of Morocco and the HassanII's signature of the Declaration of chiefs of state on the population. Since then, the programs of FP have functioned through the structures of the Ministry of the Public Health along with the Supreme Commission on the Population in Morocco.  In the 1970s, the Division of the Population in the ministry of health together and the Family Planning Moroccan Association (AMPF) were instituted. AMPF's task consists of sensitizing the population and of offering birth control services. Households visits experience to sensitize people to PF took place during 1977. The 1980's were also rich years for the FP: the involvement of female and male nurses in the FP services, the creation of the National Center training on the Techniques of the Human Reproduction in Rabat and the regional centers for FP services and IUD installation (Intro-uterine Device). But the most important action happened in 1988 with the beginning of social marketing programs, partnership between ministry of health and USAID to involve the medical and the pharmaceutical private sectors in the sensitization operation and in the contraceptive technique sale with adequate prices. During the 1990s, the generalization of the training on IUD techniques for no medical employees was finalized. Some new techniques were introduced like Norplant technique (1993) and injections (1994). In 1993, the ministry of health implemented a public strategy of Information/Education/Communication.

Underlying the 1988 cut would complete this historical account[9]. Indeed, from 1967 to 1988, resistance to the FP emerged, especially in the rural area. According to advanced explanations, rural resistance would be a reaction due to the under-information of the target population. But it seems that information, in spite of its importance, is not able alone to create planned demographic behaviors in radical contradiction with procreative patterns anchored in the dominant collective psyche[10]. Anyway, the social resistance to FP drove to the adoption of a new plan of orientation[11] in 1988. The five big objectives of this plan were privatization, modernization, de-feminization, ruralization and advertisement of mass. 

 

3- Contraceptives: between public grant and purchase

 

The family planning policy proposes programs of action that consist of offering services and contraceptives: consultation, grant and pose of products. Yet, the 1988 plan's orientation indicates that the sanitary authorities were tempting contraception users to acquire contraceptives so that the public sector doesn't finance all the FP. The purpose of this orientation was also the development of FP towards responding the user's need. The exemption from payment of the contraception, owed to the international assistance (Ford Foundation, World Bank, USAID...) do not leave to the user neither the choice of the contraceptive technique nor the possibility to express the need of the contraception. The public authorities insistence on this kind of FP leads society to realize that the FP is above all a public need. Marketing consists, therefore, in treating society like a market and to deal with the user of the contraception like a consumer, which implies bringing the user to buy, to express the need of the FP, and to select a specific technique.  Even with regard to the weakness of the spending power of the population, the social programs had to continue. The 1988 plan orientation foresaw that the private sector could only cover 30% of expenses of the FP program. The Moroccan Program of Social Marketing of the FP Al Hilal passed this prevision: "in 1992, 37% of provision was assured by the private sector and this part increased slightly in 1995 reaching 38%[12]. This program is a successful example of the partnership between the ministry of health and the private pharmaceutical sector that targets couples with weak income.

Thus the FP program became widespread thanks to the continuous execution at the national level of the strategy of the Visit at Home of Systematic Incentive and thanks to the implication of the private sector. "Today, services of FP are available by various channels for the whole of the population"[13]. Of course, the public sector remains the privileged sector of provision in contraceptive methods. 60% of women addressed themselves to public centers of health and clinics, the others addressed themselves to the private sector, nearly exclusively to pharmacies. "The public sector covers 55% of methods requiring a regular provision (pill, condoms and injectables) and 84% of clinic methods (IUD, horn ligature)[14]. In urban area, female acceptors get a stock to equal part close to the two sectors, while three quarters of rural women make it close to the public sector. To say the public sector for the urban woman half and for the three rural woman quarter, it say the exemption from payment. In other terms, the success of programs of the FP is financed mainly by the state thanks to the international help. These data are summarized in the next figure.

 

Figure 5: Source of provision in modern contraceptive methods[15]

           

Year

Source

ENPS-II 1992

%

Panel 1995

%

Evolution

%

Dipensary/Health center

42

46

+4

Pharmacy

31

33

+2

Mobile team

11

5

-6

Hospital/Maternity

10

11

+1

AMPF

3

1

-2

Other private

3

4

+1

 

The contraceptive practice is characterized in general by the under utilization of IUD. Indeed, among contraception users, only 8% chose the IUD in 1992 whereas 68% chose the pill. The IUD is rejected in general for four main reasons: incompatibility with the arduous physical work, rumors, opposition of the husband, problems of access and of follow-up process[16].


 

The contraception use by method is as following:

 

Figure 6: Use contraception by method[17]

 

Year/Source

 

Methods

ENPS-II 1992

%

Panel 1995

%

Evolution

Pills

68

64

-4

IUD

8

9

+1

Feminine sterilization

7

8

+1

Condom

2

3

+1

Other modern methods

1

1

0

Traditional methods

14

16

+2

Prevalence rate

42

50

+8

 

In general, an increasing positive attitude towards contraception is observed, but it seems that traditional populations "resort to modern contraception in order to stop childbearing when they have reached a desired number of children, rather than to space births or reduce their fertility"[18].


 



[1] Extracted from my paper entitled « Sexuality and Sexual Health in Morocco », in "Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, OMS, Genève 2002.

 

[2] M. Amghari: "Fécondité: niveaux, tendances et déterminants", in Population et développement au Maroc, op. cit., p. 32.

[3] Fécondité, Infécondité et nouvelles tendances démographiques au Maroc, Rabat, Direction of Statistics, CERD, 1993, p. 33.

[4] A. Akhchichene: Les hommes et la planification familiale au Maroc, Rabat, Ministry of Health, 1998, unpublished; A. Dialmy: Identité masculine et santé reproductive au Maroc, MERC/Ford Foundation, 2000.

[5] Mekki Naciri: "Aperçus sur la planification familiale dans la législation islamique", communication to Séminaire National sur la planification familiale, Ministry of Public Health, Rabat, October 1966.

[6] See that in Hassan al Alaoui: La planification familiale au Maroc, Rabat, Ere Nouvelle, 1979, p. 46.

[7] “Enquête d'opinion sur la planification familiale au Maroc, 1966”, BESM, 104-105, 1967.

[8] M. Martenson: “La planification familiale au Maroc”, BESM, n° 112-113, 1969.

[9]"Politiques de l'éducation sexuelle au Maroc", in Santé de reproduction: facteurs démographiques et socioculturels, Ministère de la Prévision Economique et du Plan, Centre d’Etudes et de Recherches Démographiques, Rabat, 1998, p. 205

[10] A. Dialmy: Femme et sexualité au Maroc, Casablanca, Editions Maghrébines, 1985,  p. 110 ‘en arabe).

[11] Plan d’orientation pour le développement économique et social 1988-1992. Rapport de la commission santé, nutrition et planification familiale, MSP, 1987.

[12] "Programme Al Hilal", Caducée (Casablanca), n° 38, undated, p. 24.

[13] Enquête Nationale sur la santé de la mère et de l'enfant (ENSEME) 1997, Ministry of Health/ PAPchild, 1999, p.165.

[14] Ibid. p. 180.

[15] Enquête Panel, SEIS/Ministère de la Santé, 1995.

[16] La dynamique du programme de planification familiale du Maroc 1992-1997, Ministry of Public Health/The Evaluation Project, 1998, pp. 32-33.

[17] Enquête Panel, SEIS/Ministère de la Santé, 1995.

[18] C. Varea et al: "Determinants of contraceptive use in Morocco : stopping behavior in traditional populations", Journal of Biosociological Sciences, 1996, 28, pp. 1-13.

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