**_18_**

_Regina McNamara_ **_et at._** contraceptive technology (and side effects) and addressing religious barriers, high child mortality risks, and high fertility preferences (Simmons et al., 1988).

The effectiveness of indigenous women in conveying information about family planning is a point that recurs throughout these case studies, and a second point is the need for consistency of political and administrative backing. The support forthcoming from the local health team, the district officials and the Ministry of Health for the Extension project and the second phase of the Original project was essential. Continuation of the projects depends upon their integration with a functioning public health system.

Operations research made its contributions to program success by identifying deficiencies in the first model, testing corrections, and documenting results. Also, trials of strategies that are new to the country or region can attract the interest of otherwise cautious officials and this was the case in the Sudan. Visibility for the project and cooperation between the DCM and the public health system were reinforced through planning meetings and a workshop on operations research. As in Ghana and Rwanda, the operations research was conducted with an explicit objective of enhancing political receptivity to findings, replication of any programmatic success that might be achieved, and commitment to family planning service development.

# **V.** Discussion

The judgment that these three projects were successful in raising levels of contraceptive use in their target areas was based primarily on community surveys in Rwanda and Sudan and on service statistics in Ghana. To recapitulate from these records, 130 private midwives in Ghana newly trained as service providers had a total of 12,411 clients in a little over a year; a ratio of I family planning client to **_1.5_** deliveries. In Rwanda, use of modern contraceptive methods in one experimental area increased from 4.5 percent to 28.5 percent. The post-intervention survey in Extension Area in the Sudan showed an increase in use of modern methods from 6.8 percent to 19.8 percent over three years.

Because the time periods covered in these case studies were short, 18 months to three years, evaluation according to qualitative measures such as those cited by McIntosh (1989) is provisional. The projects can, nevertheless, be judged as to their **potential** for survival, expansion in geographical coverage, and influence on regional or national family planning program development.

For the midwives in Ghana, their role as family planning service providers has been newly created and firmly linked to a central organization which benefited from intensive institution building assistance. Because they are individuals in private practice, some may not continue without stimulation from the GRMA in the form of supervisory visits, newsletters, education, and assistance with securing supplies. Others who are well-motivated, or who are satisfied with family planning as a component of their practice, will continue and will manage to get supplies through private channels as they do for their obstetric work.

The government of Rwanda has made a commitment to continuation of the program in **the** project sites and to national expansion. The operations research indicated some of the -problems that will be encountered, specifically with supervising the volunteers and maintaining