(1) 1990 Census for Kiribati; 1993 Vital and Statistical Abstracts for Marshall Islands; As reported WHO Regional Office for the Western Pacific (1995) for the rest of the countries;(2) Ministry of Health Annual Report for Fiji (1993); Ministry of Health and Family Planning for Kiribati; SPC (1995) for Nauru and Solomon Islands; As reported WHO Regional Office for the Western Pacific (1995) for the rest of the countries;(3) UNICEF (1995) Draft Strategy Paper;(4) As reported to WHO Regional Office for Western Pacific (1995)

Worldwide, it is estimated that about 30 to 50% of maternal deaths are due to unsafe abortions, and 99 % of these deaths occur in developing countries (WHO, 1993b). What is of particular concern is the youth risking unsafe abortions. This often results in serious health problems including infection, haemorrhage, infertility and even death. WHO estimates that at least one-third of all women seeking hospital care for abortion complications are under age 20.

Every year many women have unwanted pregnancies, some of which are carried to term and others end in induced abortions. According to a recent survey conducted in Marshall Islands, 45% of women reported that they had at least one unwanted pregnancy. Abortion is illegal in most Pacific countries. Whether legal or not, many women in the Pacific resort to abortion, often traditional methods such as using herbs, abdominal massage, or the insertion of foreign objects into the uterus. These traditional methods are often performed by unskilled providers or by themselves, sometimes leading to fatalities. Abortion data are scarce and inevitably unreliable because of legal, ethical and moral constraints which hinder data collection. Estimated numbers of abortion in some Pacific countries provide some insights into the unmet need for family planning services, but unfortunately little information is available on how these estimates are obtained (e.g. whether they are based on the numbers of women treated for consequences of unsafe abortions or they are best guestimates). If these estimated numbers could be translated into abortion rates per 1000 live births, the rates would be alarmingly high, compared to 15 per 1000 for the Asia Region. Recognizing difficulties of obtaining information on abortion in the Pacific, at least the number of women receiving treatment as a consequence of unsafe abortion should be collected.

The presence of Reproductive Tract Infections (RTIs) limits a woman's choice of contraception, her fertility and pregnancy outcome. Some aspects of RTIs are preventable and treatable causes of infertility, ectopic pregnancy, cervical cancer, and negative pregnancy outcomes such as fetal wastage, low birth weight, infant blindness (Wasserheit and Holmes, 1992). Although RTIs are broadly defined to include both sexually transmitted and nonsexually transmitted infections, the former form the majority of RTIs (see Brunham et al. 1992).

STD rates in the Pacific are routinely reported. But direct comparison of STD rates between countries should be done with caution, as there are variations in availability of STD testing, case detection, coverage, and completeness and timeliness of STD reporting. While data from 1983 to 1992 for gonorrhea and syphilis fluctuated in some countries, they provide evidence for a downward trend in countries for which data are available (see Sarda and Gallwey, 1995). However, the current rates, as shown in Table 5, are still alarmingly high when compared to a developed country in the Region, such as Australia (16 per 100,000). Gonorrhea incidence rates are exceptionally high in PNG and the rates for Vanuatu, Kiribati, FSM and Fiji are worrying. Syphilis rates are available for a few countries in the Pacific and the rates for Marshall Islands, Papua New Guinea and Fiji are high, compared to Australia (15 per 100,000).

In addition to the above reported data, community based survey results are available for some countries. In Marshall Islands, the STD programme undertook community based surveys in 1989 and 1990, through which 86% of the adult population were screened for syphilis. 8% were found positive, and the prevalence was high among young and urban-based adults (ADB,1993). This rate of infection is about the average of the syphilis prevalence in developing countries (Wasserheit and Holmes, 1992). A follow-up survey conducted in 1991 for over 11,500 men and women further revealed 1.2% new cases. However, once well controlled STD rates seem to be on the rise again, according to the preliminary figures for 1994 and 1995.

Available information on STD prevalence among antenatal women, albeit sketchy, depicts a worrying picture. In Papua New Guinea, 4.5% of pregnant women were found to be reactive for syphilis in 1989. By early 1990, syphilis rates had dropped among pregnant women, but they were expected to rise in 1993. In Cook Islands, the syphilis prevalence rate among antenatal women was 0.6% in 1993. The syphilis prevalence rates in other developing countries range from 0.01% to 33%, but the median value was around 8%. The prevalence of gonorrhea among antenatal women in Papua New Guinea in the 1980s was very high, ranging from a low of 10% and to a high of 20%. The gonorrhea rate among antenatal women in Cook Islands was about 1.3%. The median prevalence rate in other developing countries was 6%. Information is also available on chlamydia. In Fiji, chlamydia rates among pregnant women were 20%, while they were 12% in Cook Islands and 33% in Marshall Islands. These rates were much higher than the developing country median prevalence rate of 8%.⁶ As they are based on small samples among clinic attendees, these rates cannot be translated into actual population prevalence and extreme caution should be exercised in interpreting these. However, what these available data suggest is the urgent need to pay attention to STD among women.

The most common and potentially devastating complication of RTIs/STDs in women is infertility⁷. It is estimated that the proportion of infertility due to RTIs in Asia ranges from 15 - 40% while the proportion in the African Region ranges from 50 to 80%. By contrast, the proportion is only between 10 and 35% in developed countries (Wasserheit and Holmes, 1992). Little is known about the magnitude and distribution of infertility in the Pacific. But there are indications of infertility problems in the Pacific. One example is the cultural tradition that men prefer to marry women who have proven their fertility. Some Pacific countries such as Marshall Islands include infertility counselling as part of the MCH/FP services, which may imply the government's recognition of the magnitude of the problem. Taking account of relatively high and rising STDs in the region, couples suffering from infertility may be high.

III. MAIN BARRIERS TO EFFECTIVE REPRODUCTIVE HEALTH AND FAMILY PLANNING SERVICES AND MONITORING

The effectiveness of RH/FP services should be measured against the programme goals. Specific goals related to reproductive health and family planning services vary from country to country in the Pacific, but one of the common goals is to improve access to health services. While the overhaul of the adequacy of health infrastructure, services provided, personnel and budget allocations in relation to the programme goals is outside the purview of this paper, this section discusses a few direct barriers to effective programme monitoring and to women's access to services and information that may in turn interfere with their ability to make informed choices on contraceptive use.

Several issues arise regarding data deficiencies, leading to poor quality of data.

Under-reporting: While communities in Pacific are well aware of births and deaths occurring in their localities, registration of deaths is regarded as the exception rather than the rule in countries such as Solomon Islands, Papua New Guinea and Vanuatu. As noted, it is estimated that deaths are under-reported by as much as 80 to 85% in Solomon Islands (O'Brien et al. 1993). Of reported deaths, causes of death are not often recorded and recorded information lacks accuracy, completeness and timeliness. In this context, it is not surprising to find that information on maternal deaths, which are relatively rare events, is very scanty. With regard to births, one estimation of the extent of under-estimation was over 30% in Marshall Islands, according to the 1994 Fertility and Family Planning Survey. Contraceptive prevalence data from routine recording and reporting systems also often lack the desired quality due to a variety of reasons. As contraceptive prevalence is one of the key indicators of RH/FP, improving quality of data should be addressed on an urgent basis.

Information gaps: Key information is often lacking, especially the extent of RTIs, female STD prevalence, the extent of infertility, the incidence of abortion and the rate of hospitalisation for abortion complications. One of the most serious problems is the lack of gender-dissaggregated information on what is routinely recorded and reported (e.g. STDs).

Low data utilisation and poor data management: Although data quality is a commonly stated problem, there are numerous surveys and other sources of data which could throw light on key aspects of RH/FP. In Marshall Islands, at least seven surveys, conducted between 1985 and 1994, can provide useful information on some aspects of reproductive health. In Solomon Islands, there are five surveys on similar subjects. Hospital records are another source of information which is not well tapped into for RH/FP information. While extensive hospital recording systems exist in many Pacific countries, only a fraction of the collected information is analysed and utilised for programme planning and monitoring. Two significant issues arise here. First, the level of data utilisation of the existing survey results is very low. Second, the data management system often does not exist, if it does, it is very poor. This leads to under utilisation of existing data and duplication of data collection activities for a need of the same information.

Data Inconsistencies: Country data on key indicators sometimes show incongruent figures that cannot be easily explained by methodological or time differences. Poor documentation of methodologies and sources of data aggravates the situation. This is one of the major impeding factors in assessing the current reproductive health situation properly for better planning.

Education generally have a negative impact on fertility, although the strength of the association varies depending on the level of economic development. A recent analysis of the Demographic and Health Surveys in 26 countries reaffirmed the association and documented that the impact of individual schooling upon fertility is stronger in communities where the education level is relatively higher (Martin, 1995). Although there are a few KAP type surveys which collected information on education and contraceptive use, unfortunately little attempts have been made to examine the linkages between the two. Setting aside the methodological problems of measuring literacy, available data on female literacy show generally high rates for the Pacific, with most of the countries exceeding 80%. Exceptions are Solomon Islands (17%) and Papua New Guinea (38%), Vanuatu (60%) and Federated States of Micronesia (79%). Girls school primary school enrollment rates per 100 boys are over 90 in most countries, except in PNG (77) and Palau (89).

Girls' education and women's literacy have direct relevance to their health status and RH/FP service utilisation. Illiteracy or low level of education may interfere with a woman's ability to understand fully the side-effects, indications and contraindications of contraceptives. This, in turn, may limit her ability to make an informed choice. Also it is not unreasonable to assume that low education and illiteracy may make women more vulnerable to rumours and false beliefs than their educated counterparts, as the former group may have a limited means to verify rumours and false beliefs. In Vanuatu, many women stopped using injectable hormonal contraception due to unfounded rumours of side-effects in the mid 1980s (Vanuatu country report for ICPD). There is an urgent need to raise women's knowledge on personal hygiene, symptoms and signs of STDs, RTIs, sex-negotiating skills especially for young women. While there are effective means of reaching illiterate and less educated women for RH/FP messages (e.g. dramas and songs), information, education and counselling efforts will have only a limited impact, if the literacy and education level is low.

The majority of the Pacific population reside in rural areas, where health services related to reproductive health and family planning are provided as part of primary health care. As Pacific island countries are made of dispersed and scattered islands occupying tracts of ocean, many small and remote outer islands have often one health clinic staffed with a health worker, who is the first contact point for women for their reproductive health and family planning care. A high proportion of health workers in general and health workers at the primary care level in particular are males in many countries in the Pacific. This is one of the factors hindering women from seeking timely health care. To reflect these cultural sensitivities, a few countries have taken positive steps. Marshall Islands, for example, began to recruit more female health assistants. In Solomon Islands, NGO family planning clinics (Solomon Islands Planned Parenthood Association) have a plan to staff with two nurses, one male and one female to be more effective in responding to community family planning needs. However, still there is a large gender imbalance in the health workforce particularly at the primary care level.

Although family planning programmes are mainly targeted toward women, women often lack the autonomy to make decisions about contraceptive use. Data on couples' decision making processes are rare. But if there are systems or customs which could potentially deter women from exercising their desires and preferences in family planning, they should be addressed as part of the reproductive health programmes. One such example is the use of a consent form. In Marshall Islands, the Majuro hospital requires a consent form to be signed by husbands of female clients for female sterilization. This procedure was promulgated by the hospital after an incidence in which the husband of a woman who underwent female sterilization accused the hospital for carrying out the procedure without a proof of couple consultation. The consent form requirement was practised also in Papua New Guinea up until recently. In 1993, however, the Government of PNG did away with the consent form! .

While requiring a consent form may have ensured consultations between couples on female sterilization, consultations between couples should be ensured for all contraceptive methods, not only on a particular method. The practice of the consent form has a potential to limit woman's reproductive rights. Moreover, the reciprocal procedure, a consent form for vasectomy is not enforced. The informed choice of contraceptives based on couples' joint decisions would be better achieved through the provision of adequate information, education, and counselling on contraceptives than introducing procedures such as a consent form.

IV. DISCUSSION AND CONCLUSION

Although data are of poor quality, analysis of the existing information on the main areas of reproductive health and family planning shows some salient features in the Pacific. Table 6 summarises the status of each country in the main areas of reproductive health and family planning.

• The level of fertility in the Pacific is high compared to that of small island nations in other regions. This is especially so in Solomon Islands, Papua New Guinea, Vanuatu, Marshall Islands, and Nauru. The Total Fertility Rate (TFR) in these countries exceeds five per woman.

• Two specific groups, teenagers and women aged between 40 and 49, are particularly vulnerable to reproductive health problems. Fertility levels of these two groups show sharp contrasts among Pacific island countries. Four countries show relatively high fertility levels on both of these groups, FSM, Marshall Islands, Solomon Islands and Vanuatu. Fertility of high reproductive health risk groups should be monitored separately.

• Little information is available on infertility.

• The level of contraceptive use is low throughout the Pacific, although prevalence may be higher than reported in some countries. Countries where trend data are available such as Fiji and Kiribati show little changes over time. There is a dearth of information on contraceptive use patterns of two vulnerable groups, teenagers and women aged between 40 and 49.

• Apart from a few methods, a wide range of choice is available throughout the Pacific. Injectable hormonal contraception is by far the most popular method in the Pacific, followed by oral pills and female sterilization.

• Despite the wide range of methods available, the level of reliance on a single method is an issue that deserves urgent attention. This over-reliance on one method is very pronounced in many countries including Solomon Islands, Vanuatu, Palau, Cook Islands, Palau and Tokelau.

• Male participation in family planning is very low throughout the Pacific. It is interesting to note that the acceptance of male sterilization is relatively high in Kiribati.

Maternal Care, Pregnancy Outcomes, and Abortion

• Two countries, Papua New Guinea and Solomon Islands, Report staggeringly high levels of maternal mortality. While maternal care situation seems favourable in the Pacific compared to other regions in terms of antenatal care coverage and attended delivery, these coverage data may be over-estimated. One of the pregnancy outcome measures, infant mortality rates are still relatively high in the Pacific, at least in six countries. If estimated numbers of abortion are representative of the Pacific situation, this issue should be given a top priority.

• While women appear to experience the impact of STDs more harshly than men, are more susceptible to acquiring infection, and more likely to experience complications arising from the primary infection, STDs data in the Pacific, which are routinely reported, are not gender-disaggregated. Available evidence suggests that chlamydia, syphilis and gonorrhea infection rates among antenatal women are high, compared to other developing countries.

The linkages between the current MCH/FP and STD programmes in the Pacific are very tenuous. Family planning programmes mainly focus on women and pay little attention to STDs. On the other hand, STD programmes deal primarily with men and ignore other services such as family planning. In discussing incorporating STDs into MCH/FP, a number of reservations have been expressed in other regions. These include: comprehensive RH services including STDs would have a large financial implications and would be too costly to consider in a resource-poor environment; family planning services are already overburdened and cannot accommodate expanded service obligations; Family planning clients will not appreciate being asked or screened for diseases such as STDs. Also there is the widely held misperception that STDs occur primarily among limited numbers of sexually promiscuous adults.

It is important to review the above concerns in the Pacific context in order to make informed decisions and improve programme effectiveness. There are compelling reasons for the existing MCH/FP programmes to take into account STDs in the Pacific. First, the presence of STDs limits women's contraceptive choice. Most cases of pelvic inflammatory disease in the developing world are caused by gonorrhea or chlamydia, conditions that could limit women's choices of contraceptive methods such as IUD (Wasserheit and Holms, 1992). Without addressing STD issues in RH/FP, efforts to improve quality of care, especially widening a choice aspect, would have only limited effectiveness.

Secondly, there are approaches available which can detect STDs with relatively low cost and minimal training of family planning staff. A syndromic approach, for example, relies on signs and symptoms of diagnosing and treating such conditions as urethral and vaginal discharge, without using laboratories to determine the organism causing the condition (De Lay, 1994). The drawbacks of this approach, however, are that this has a low level of predictability and does not detect asymptomatic patients especially among women with gonorrhea and chlamydia infection. For men, this approach has proven to be accurate and cost-effective. For women, this method is less effective. The level of STDs in women with no symptoms or poorly recognised symptoms in the Pacific is not known. However, for Pacific countries where a large proportion of women live in remote and isolated islands and general health services are inadequate, this approach may present an affordable alternative that will service more women for STD education, counselling, referrals and treatment. This approach is already being practised in some countries in the Pacific.

In order to identify the priority areas of reproductive health that need strengthening, it is essential to decide on the basic key indicators which need to be collected routinely for programme monitoring and planning. While many Pacific island countries collect information on some aspects of RH/FP, there are no clearly defined RH/FP indicators. In selecting indicators, there are a few factors to consider. First, one has to be parsimonious. While RH/FP issues should be the forefront of the health and development agenda, there are other important areas which require a long list of indicators for routine monitoring. Making the utilisation aspect of selected indicators clear at the outset would help to limit the number of indicators.

Second, indicators that could be collected through a routine recording and reporting system should be given a high priority. There are three main sources of data for key RH/FP indicators, routine health recording and reporting systems, civil registration systems for vital statistics, and surveys. For births and deaths, including maternal deaths, civil registration systems should be the best source but they are currently poorly established in many Pacific countries. While population based surveys are the best source for contraceptive prevalence and many KAP type of information, repeat surveys for trend analysis often depend on funding availability. As a very large proportion of surveys in the Pacific are funded externally, future availability of survey data is often uncertain. The recording and reporting system provides the best prospect for producing data for key indicators on a regular basis. Many countries already have established recording and reporting systems. However, efforts should be made to improve the quality of data from the ! curr ent recording and reporting systems in terms of reliability, validity, specificity and sensitivity (see Section III A for detailed discussions).

Third, indicators reflecting ICPD issues should be included in the key RH/FP indicator list. There are three dimensions that are particularly relevant to the Pacific context. They are quality of care (widening the choice of contraceptives aspect), gender perspectives (women's reproductive rights, men's reproductive health needs and men's participation in family planning) and special geographic and age groups (teenagers, women aged between 40 and 49, and rural women).

Quality of Care: Quality of care is the key to more effective family planning programmes, increasing contraceptive prevalence, and continuity of use. It has been suggested that having a small number of acceptors per year and ensuring their continuation rates by meeting the client's needs would increase contraceptive prevalence (Jain 1989). But if the programme focuses mainly on recruiting a large number of acceptors and fails to meet the client needs, then this strategy will have only a short-term impact on contraceptive prevalence that cannot be sustained. While quality of care methodology is still evolving, widening the choice indicators can effectively be monitored within the existing data collection systems. From the analysis of the Pacific situation, it is clear that broadening the variety of methods available by itself does not guarantee the widening choice. It should be accompanied by other activities such as counselling, education, and information to assist women to maximise the benefits of availability of different contraceptives. Long-acting contraceptive methods such as IUDs, subdermal implants (Norplant) and female sterilization are among the most effective methods available for preventing unwanted pregnancy. From the user's point of view, they require little effort on the part of the user after initial service delivery. However, women may have less control over use than with other contraceptives, as these methods must be delivered, removed or reversed by providers.

Widening the choice of contraceptives applies also to men. Men's choice of contraceptives is very limited. While the exact level of effectiveness of coitus interruptus (withdrawal) as contraception needs to be established through more research (see Rogow and Horowitz, 1995), Pacific countries may wish to review this method for promotion as part of the family planning programme in the Pacific. This method lacks side effects, user controlled, and requires no supply. Especially couples living in isolated islands where supplies of contraceptives may be irregular, this method might pose as an alternative, or a backup method to their choice of other contraceptives. The contraceptive use pattern suggests that the proportion of couples using male methods, such as condoms and withdrawal are higher in developed countries than that in developing countries. An indicator of male participation in family planning needs to be included in the RH/FP indicator list and monitored.

RH/FP Needs of Teenagers: Those who are younger than 15 make up about one third of the Pacific population, and they will soon need contraception. Teenage pregnancy and unsafe teenage abortions are the major consequences of not meeting the needs of adolescents. Infants born to teenage women are twice as likely to die than those born to older women, as shown in data in Marshall Islands (Lee and Katoanga, 1995). Teenage pregnancy often poses a higher risk than that for women in older age groups, because of their late service seeking, limited knowledge and information on antenatal care, limited resources, and social and cultural barriers. Yet their contraceptive use is low mainly due to social constraints and lack of knowledge.

RH/FP Needs of women over 40: While family planning needs diminish with age, reproductive health problems increase with age. One of the common reproductive morbidities is cervical cancer. While pap smear tests are routinely carried out in some of the Pacific countries, the results are not routinely reported.

Rural-Urban Disparities: Analysis of the current situation in the Pacific shows that the patterns of contraceptive use, maternal health care, pregnancy outcomes differ considerably between rural and urban areas.

Men's Reproductive Health Needs and Involving Men in Family Planning: Little is known about men's reproductive health and family planning needs in the Pacific. To involve men more in RH/FP, it is essential to understand men's concerns regarding contraception, reproductive health needs and reproductive responsibility. Until recently, research in the family planning field seldom included men. Informing and educating men about contraception may be particularly crucial in cultures where women have little control over contraceptive decision-making, as observed in some countries of the Pacific.

Policy indicators are important in determining whether national authorities give formal endorsement to certain policies and strategies. RH/FP issues should be monitored closely, not only by health officials but by planners as well. Reproductive health and family planning (RH/FP) is a priority issue in the Pacific as it is inextricably linked with women's status enhancement and family well-being in a society. Many countries in the Pacific espouse RH/FP as one of the population and development priorities, and include the subject matter in their population and development policies, as seen in Marshall Islands. This priority, however, is not well braced judging from the financial resource allocations. The health expenditure spent on the MCH/FP programme is relatively small, for example, 7% in Marshall Islands and 10% in Kiribati. The proportion of donors' funding on MCH/FP programmes is also small compared to that for hospital and hospital base services.

The new reproductive health approach calls for a need to include services related to prevention aspects of STDs, abortion, and infertility to which the conventional MCH/FP programme has not paid much attention. This may require some adjustments in the current health service delivery, and may have budget implications for further training and retraining, operational research and supplies and equipment. Without appropriate budget and personnel support, the RH/FP programme would have only limited effectiveness. In view of likely reduction in donor funding in the Pacific including programmes concerning MCH/FP, STD/HIV/AIDS, it would be unrealistic to expect a substantial increase in RH/FP related programmes. However, the level of RH/FP resources needs to be closely monitored.

Another area requiring policy indicators is the progress toward removing barriers to effective RH/FP, as noted in Section III. Women and men living in rural areas deserve special attention as they are one of the most disadvantaged groups receiving least adequate health services. Health workers at the community level are the first contact point for these groups. A high proportion of health workers at the primary care level is males in many countries in the Pacific. This is one of the factors hindering women from seeking reproductive health services. To reflect cultural sensitivities there is a need for a larger representation of female health workers to be trained as primary level health. It has been proven that the most effective way of meeting community's health care needs is to have a team of a male and a female health workers. Some countries, such as Marshall Islands, have already taken a step to address this gender imbalance in the health workforce. But as the workforce is dynamic by nature, this needs to be monitored on a continuing basis.

It is envisaged that the demand for reproductive health and family planning services will increase in the near future in the Pacific. The large and growing young population (aged 0-14) will reach their reproductive age soon. While the level of political commitment to health and population has been lukewarm in some countries in the Pacific, improvements in education especially girls' education and increased awareness of reproductive choices and population issues will further generate the demand for family planning services. Through global and regional developments such as the ICPD, however, there seems to be a renewed interest in health and population issues. It is an opportune time for Pacific island countries to develop country-specific RH/FP strategies specifying realistic and clear objectives and input requirements, to maintain the momentum gained through the global RH/FP developments. Identifying key indicators to monitor the progress toward objectives is a concrete step towards this. The list of the key RH/FP indicators presented in Table 8 is the reflection of the analysis of the Pacific situation and the principles of the recent developments in RH/FP. Indicators listed in Table 8 are the ones which could be collected through routine recording and reporting systems, with a few minor changes. However, it is important to have periodic population-based surveys to supplement and verify the information collected through the routine recording and reporting system.

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