_6_ _Regmna McNamara_ **_ct_** _al._ for training, continuing education, and institutional developwent. The ACNM was responsible for coordinating the activities of the other organizations. The John Snow, Inc. Enterprise Program provided financial and technical assistance for workshops to improve member midwives' business and management skills. Johns Hopkins University's Population Communication Services, through the Ministry of Health, provided the midwives with posters, pamphlets and other educational materials. Columbia University's Operations Research Program supplied financial and technical assistance for data collection and analysis for purposes of program planning, management, and evaluation. The Ghana Social Marketing Program provided a free supply of contraceptives after training and makes supplies available to the GRMA at wholesale prices for the participating midwives. With this concentration of financial and technical assistance, since 1986 the GRMA has grown from a staff of volunteer members to eleven paid staff engaged in organizational management, public relations, membership services, and national and international liaison.

Information collected on the first 134 trained indicate that the midwives in this program are a diversified group; approximately one-third are under age 45, and one-quarter over age 55. More than six Ghanaian ethnic groups are represented. Thirty-seven percent practice in rural areas, and both rural and urban midwives reported that at least part of their clientele comes from villages or poor, crowded urban areas. Only seventeen of the midwives in this group had had previous training in family planning and only 11 percent of the maternities offered family planning services prior to entering the GRMA program. Following training, all maternities provided services. In addition to the small profit to the midwife on each family planning client, an incentive for the midwives was a potential increase in clientele for future antenatal visits and deliveries and for child health services where they are offered.

Training was conducted in 1987 and 1988 for groups of about 25 each. The characterization of this program as a success is based in part on the records of 130 midwives in the first six groups covering the period from the completion of their training in 1988 through December 1989. (Estimates given are believed to be on the low side since not all midwives complied 100 percent with reporting requirements.) These midwives reported 12,411 new family planning clients (new to them; not all were new acceptors). Deliveries during the same time period were 18,884 giving a ratio of about 1 family planning client to 1.5 deliveries.

The midwives gathered background information on all of their new family planning clients for two to five months after training, depending on training dates. Of the 4,462 new clients interviewed, four out of five were using contraceptives for the first time. One in four (26 percent) were contracepting in order to cease childbearing (although 33 percent indicated that they wanted no more children). Sixty percent were spacing births. The more effective methods were chosen by over three-fourths of the women (60 percent oral contraceptives, 18 pea.ent injections, and 6 percent IUCD).' Men were also using the family planning services at the maternities (9 percent of all clients). Most of the male clieLr. were obtaining condoms for protection against sexually transmitted diseases as well as for contraception. Little is known as yet about continuation of contraceptive use. There were approximately 800 revisits per month by the fourth

> 4 Among the 204 midwives trained, 45 were instructed in IUCD insertion at the University College Hospital in Ibadan, Nigeria since practical training was not available for them in Ghana.