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**_Famly Planning_** _Programs in Sub-Saharan Aftica_

access for DCM staff and visitors. The disadvantage for a pilot demonstration project was its dissimilarity to most other rural regions in the Sudan (although some of the 90 villages were relatively isolated) but the model to be tested was a first attempt at community-level education and distribution of contraceptives in the Sudan and involvement of the midwives as a previously underutilized resource. Reasonable travel conditions were considered to be necessary for communication and supply, and to keep public health officials informed as to its progress.

Following extensive meetings and discussions with community leaders, the midwives were trained to undertake a series of house-to-house visits in their villages to promote the interventions in sequence. They were supplied with oral contraceptives to distribute to women who indicated a desire to use them. Preparations for this first introduction of famii planning services within the govermnent system were thorough. A week-long seminar of religious leaders from the project area with an Islamic scholar had been held to allay concerns that family planning was not in accordance with the Koran. Midwives were instructed to discuss the subject in privacy and only where the women visited exhibited some interest. Birth spacing, not family limitation, was their theme.

Research on the Original project included a baseline sample survey, analysis of service records, and observations. A second survey was conducted in 1981, some nine to twelve months after the several interventions were introduced. The results, especially changes in family planning KAP, were encouraging. The post-intervention survey showed current use of modem contraceptives (orals) at 10.6 percent, compared with 8.5 percent at the baseline. Multivariate analysis indicated a proportionately greater increase in the poorer and more isolated villagesthose that were less susceptible to secular influences from Khartoum and more dependent upon midwife visits for motivation and supply. The concept of family planning as a component of primary health care appeared to be acceptable to the health workers and to the villagers.

This phase of the Original Project ended in 1982, and community outreach and supply activities of the midwives were expected to continue under the supervision of the government health personnel having responsibility for these villages. By 1986, it was apparent that services had faltered in the absence of the personal and monetary stimulation supplied by the Department of Community Medicine during the operations research phase. A good start had been made, but the likelihood was that this was going the way of so many pilot projects, that is, it was fading away as the "extras" were removed. A recently formed Directorate for Maternal and Child Health within the Ministry of Health then undertook a revitalization of the program in the villages, replicating not the Original Project but the Extension Project described below.

# **_The_** _Extension Project_

The Extension project, initiated in 1984, also concentrated on oral rehydration therapy, family planning, nutrition education, and mobilization for immunizations. Adaptations in its organization, based on the experiences in the Original area, were as follows:

- e The focus was on all paramedics working in the area and community volunteers, not the village midwives alone. Health teams were created, each within a newly demarcated health zone with a health center or dispensary. These were not new facilities or additional staff. Access to services had varied considerably among the villages and reorganization of service zones reduced travel time for many and, by