**_5_**

## **_Fanmly_** _Planning Programs in Sub-Saharan_ **_Africa_**

family planning messages. Surveys indicate that knowledge of contraceptive methods is widespread. The 1988 Demographic and Health Survey found that 76 percent of the married women and men interviewed knew at least one modern method. Reported current use, however, was five percent for modern methods and eight percent for traditional methods. An increase of 3.4 percentage points since the 1979 Ghana Fertility Survey was in traditional methods, not modern. Sixty-no percent of the women who were not currently using contraceptives did not intend to use in the future (Ghana Statistical Service, 1989).

Since 1985, signs abound of a renewed public sector commitment to the task of reducing the rate of increase of Ghana's population. A short-term primary health care plan for 1986-1988 that gave priority to MCH and family planning signaled a turn-around made possible by improvements in the national economic situation. Important roles in the initiatives were played by official multilateral and bilateral agencies and the non-governmental donor organizations such as the International Planned Parenthood Federation and Family Planning International Assistance. The United States Agency for International Development (A.I.D.), which provided support for the Ghana Registered Midwives Program described in this paper, was also assisting five other projects; the Ghana Social Marketing Program (GSMP) with approximately 3,000 pharmacists and chemical sellers distributing contraceptives, the Population Impact Project of the University of Ghana to provide information to policy makers, a Ministry of Health family planning education program, and a national prograrn for training traditional birth attendants (TBAs) in rural areas, and an expansion of the GSMP to include traders in the traditional markets. The latter two were also assisted by Columbia University as operations research projects.

# **_The GRMA Program_**

The Ghana Registered Midwives Association (GRMA) has its origins in the 1930s and is recognized by the government as the professional organization for midwive-s in Ghana. Almost all of Ghana's professionally trained midwives working in the private secwr are members and they constitute about half of the organization's membership of approximately 600 midwives. Private sector maternitles are an important source of prenatal and delivery care throughout the country. A study conducted in the Greater Accra Region in 1987 (Adjei, 1987) estimated that the private maternities were providing about as much prenatal care as the region's entire government health system. This proportion is probably even larger in the rural and semi-urban areas.

Very few of the midwives had offered family planning services, before the GRMA program began in 1987, largely because no training had been organized for them. Under the GRMA program, 204 had been trained and were providing services by May 1990 and the program will continue until all members who want the training receive it. This is a two-week course covering family planning and midwifery topics with additional instruction on MCH topics including control of diarrhea, growth monitoring, immunization, breastfeeding and weaning practices. (In many locations the maternities provide primary health care for children; some function as their community's MOH service site.) After training, the GRMA supports the midwives with continuing education, supervision, and assistance in obtaining contraceptives and other supplies.

For this work, the association received financial and technical assistance from five A.I.D.-funded organizations. The American College of Nurse-Midwives (ACNM), the professional organization for certified nurse-midwives in the United States, had the major role