Maternal And Child Health And Family Planning Research Articles

Thirty-five years later: Long-term effects of the Matlab maternal and child health/family planning program on older women’s well-being

Significance Few studies have addressed links between family planning programs and long-term benefits for women’s health and economic outcomes, especially in societies where old-age support and women’s status are tied to childbearing and where smaller families may carry negative consequences for women. We analyzed the maternal and child health/family planning (MCH/FP) program, a highly effective intervention introduced in the rural Matlab subdistrict of Bangladesh in 1977 with a subsequent 12-y differential in service access. We found significant differences in lifetime contraceptive behavior and completed fertility among women born 1938−1973. We found few effects on later health or economic outcomes except for an association of MCH/FP with poorer overall health and poorer metabolic health among women born 1950−1961.

Thirty-Five Years Later: Long-Term Effects of the Matlab Maternal and Child Health / Family Planning Program on Older Women's Well-Being

Background Family planning programs are widely believed to have substantial long-term benefits for women’s health and well-being, yet longitudinal studies are rare and mechanisms of impact are complex. We evaluated the effects of an in-home maternal and child health / family planning (MCH/FP) program in Matlab, Bangladesh on women’s lifetime fertility, adult health, and economic production 35 years after program initiation. Methods In 1977, women were assigned to treatment and comparison areas that were similar across most baseline characteristics. Comparable services were added to the comparison area from 1989. We followed 1,820 women born 1938-1973 from a census in 1974 to surveys in 1996 hand 2012-14. We estimated single-difference models of program impact using an intent-to-treat design with controls for baseline characteristics and potential confounders. Findings We found significant impacts on contraception, completed fertility and birth timing in aggregate and cohort-stratified models. We observed no significant positive impacts on health or economic production. Aggregate models found modest effects on poorer overall health (+0.07 SD) and respiratory health (+0.12 SD). Among women born 1950-1961, we observed poorer overall health (+0.11 SD) and metabolic health (+0.15 SD). For the 1950-1961 cohort, we observed significant increases in BMI in 1996 (0 · 76 kg/m2) and 2012 (0 · 57 kg/m2), along with a +2.5 kg/m2 secular change in BMI. As a result, treated women had a lower risk of underweight in 1996, but a higher risk of being overweight or obese in 2012. Interpretation: We found no long-term health or economic benefits of an in-home MCH/FP program. We observed modest negative health impacts among treated women that likely reflected an accelerated nutritional transition among treated women. Our findings suggest that we should not expect significant secondary health benefits from programs aimed at fertility reduction. Funding: This study was funded and supported by the US National Institute on Aging, the International Initiative for Impact Evaluation (3ie) and the Population Reference Bureau. Declaration of Interests: The authors have no conflicts of interest to report. Ethics Approval Statement: Protection of human participants during fieldwork and data analysis was ensured under icddr,b Ethical Review Committee Protocol #PR-10005.

Pregnancy termination in Matlab, Bangladesh: maternal mortality risks associated with menstrual regulation and abortion.

In Bangladesh, both menstrual regulation (MR), which is thought to be a relatively safe method, and abortion, which in this setting is often performed using unsafe methods, are used to terminate pregnancies (known or suspected). However, little is known about changes over time in the use of these methods or their relative mortality risks. Data from the Demographic Surveillance System in Matlab, Bangladesh, on 110,152 pregnancy outcomes between 1989 and 2008 were used to assess changes in mortality risks associated with MR (and a small number of dilation and curettage procedures), abortion and live birth. Tabulation and logistic regression analyses were used to compare outcomes in two areas of Matlab--the comparison area, which receives standard government health and family planning services, and the Maternal and Child Health-Family Planning (MCH-FP) area, which receives enhanced health and family planning services. In Matlab as a whole, the proportion of pregnancies ending in MR increased from 1.9% in 1989-1999 to 4.2% in 2000-2008, while the proportion ending in abortion decreased from 1.6% to 1.1%. The odds of mortality from MR were 4.1 times those from live birth in 1989-1999, but were no longer elevated in 2000-2008. The odds of mortality from abortion were 12.0 and 4.9 times those of live birth in 1989-1999 and 2000-2008, respectively. Reduction in mortality risk was greater in the MCH-FP area than the comparison area (90% vs. 75%). MR is no longer associated with higher mortality risk than live birth in Bangladesh, but abortion is.

Poor pregnancy outcomes in public health facilities in Kenya

Background: Addressing poor pregnancy and childbirth outcomes such as still births, pre-term births and neonatal deaths have continued to be a major global challenge. Nations and organisations have invested much effort and resources to promote safe pregnancy and childbirth. Objective: To identify factors contributing to adverse pregnancy outcomes among women seeking care in public health facilities in the Keiyo district of Kenya. Methods: A descriptive cross-sectional design was used employing both quantitative and qualitative methods. Three hundred and eighty four women of reproductive age (15–49 years) attending public health facilities for Maternal and Child Health/Family Planning (MCH/FP) were interviewed. Results: There are several factors which cause adverse pregnancy outcomes. Socioeconomic and demographic factors that were associated with poor pregnancy outcomes include low education level, lack of formal employment and multiparity. Other factors included pre-term birth, preexisting medical conditions, illnesses during pregnancy and obstetric emergencies. The lengthy referral pattern also was a contributory factor. Conclusions: There are several factors that contribute to poor pregnancy outcomes. Social mobilisation of the community on reproductive health issues should be done through health education to enhance proper basic obstetric care and emergency obstetric care. Health facilities should be well staffed and well equipped in order to avoid poor pregnancy outcomes, which may occur as a result of delays owing to lack of staff or equipment. There should be a well defined referral system to enable timely referrals.

Evaluation of Cervical Screening Coverage in Kalutara District

Objective: To determine the cervical screening coverage of women 40-60 years in Kalutara District since the inception of the programme in 1996. Methodology: Cervical screening which is conducted in Well Woman Clinics (WWC), involves both visual inspection of the cervix and Pap smear testing. A descriptive cross sectional survey was conducted to assess the cervical screening coverage achieved since the inception of the programme and to assess the quality of services. The area investigated was the Kalutara district and individual MOH (Medical Officer of Health) areas within it. Data of screened females between 33 to 63 years were obtained from the records maintained in the WWClinics Results The results were expressed as a percentage of the total 40-60 females in the District and individual MOH areas. The cervical screening coverage in Kalutara District was 2.2% since the inception of the programme. Although the cover-age was low, a rising trend of cervical screening from 1996 was observed particularly after the year 1998. Only three MOH areas out of 7 conducted more than 4 WWClinics per month, which is the recommendation of Ministry of Health. Seventy four percent (1135) of total screenings (1535) were performed in those three clinics. Only one MOH area conducted an out-reach clinic. Five MOH areas conducted the clinics in combination with Maternal and Child Health/Family Planning (MCH/FP) clinics, while the other two MOH areas conducted separate WWClinics. The highest cumulative coverage was observed in Bulathsinhala MOH area (9.3%) where there were more than 4 WWclinics per month and clinics were conducted separately. Conclusion The low cervical screening coverage of 2.2% over a 5 year period in Kalutara District resembled the cervical screen-ing coverage pattern in other developing countries. Cervical screening coverage could be increased by increasing fre-quency and number of clinics especially in the periphery and conducting WWClinics separately without combining with MCH/FP Clinics. Key words: Cervical screening; Well Woman Clinics; evaluation; coverage DOI: 10.4038/jccpsl.v14i1.2946 Journal of the College of Community Physicians of Sri Lanka Vol.14(1) 2009 33-38

Infant feeding practices among HIV infected women receiving prevention of mother-to-child transmission services at Kitale District Hospital, Kenya

To determine the types and modes of infant feeding practices among the HIV infected mothers on prevention of mother-to-child transmission (PMTCT) and attending MCH-FP clinic at Kitale District Hospital, Kenya. Descriptive cross-sectional study. Kitale District Hospital in Western Kenya within the maternal and child health and family planning (MCH-FP) and comprehensive care clinics. A total of 146 respondents who had delivered 150 babies were recruited for this study. Thirty five percent (52/150) of the babies were exclusively breastfed while 50% (75/150) were not breastfed at all and 14% (21/150) of the babies received mixed feeding. The length of exclusive breastfeeding ranged from 1-6 months with most (53%) women exclusively breastfeeding for two to three months. Only 13% of the women exclusively breastfed for five to six months. There was a strong relationship between mode of infant feeding and spouse's awareness of HIV status. Mothers who had disclosed their HIV status to their spouses were more likely not to breastfeed than mothers who had not disclosed their status (p < 0.05%). The choice of infant feeding method was also influenced by the socio-economic status of the mothers and nevirapine uptake. The level of education did not influence the mode of infant feeding. Infant feeding decisions were mainly influenced by the male partner's involvement and the socio economic status of the mother. Half of the respondents did not breastfeed at all. The duration of exclusive breastfeeding rarely reached six months. To encourage women to adhere to good infant feeding practices, involvement of their partners, family members as well as the community for support should be encouraged.

Family planning and safer sex practices among HIV infected women receiving prevention of mother-to-child tranmission services at Kitale District Hospital

To determine the usage of family planning services and safer sex practices among HIV infected mothers who had gone through the prevention of mother to child transmission (PMTCT) process. Descriptive cross-sectional study. The maternal and child health and family planning (MCH-FP) clinics in Kitale District Hospital, Western Kenya. A total of 146 respondents were recruited for this study. Only 44% of the respondents were using some form of family planning. The most popular method of contraception was the hormonal injectable contraceptives. Although 73% of respondents were no longer planning to have more babies, only 45% of them were using a family planning method. Only 38% of respondents reported condom use with their partners for safe sex. Married women and those who had revealed their HIV status to their partners were more likely to use condoms (p<0.05). Usage of family planning services in this studywas low. A large percentage of the women were still planning to have more babies and very few women were using condoms for safe sex. Women who had informed their partners about their HIV status were more likely to use condoms than those who had not. Male partner involvement is crucial in decisions-pertaining to family planning use and safe sex practices.

Self-reported adherence to single dose nevirapine in the prevention of mother to child transmission of HIV at Kitale District Hospital

To evaluate the uptake and adherence to single dose nevirapine among HIV positive mothers. Descriptive cross-sectional study. The maternal and child health and family planning (MCH-FP) clinics in Kitale district hospital, Western Kenya. HIV positive postnatal women attending MCH-FP clinic who had gone through the PMTCT programme. A total of 146 respondents were recruited for this study. Most (90%) of them reported swallowing their nevirapine tablets, however only 55 swallowed their tablets within 4-12 hours before delivery. The most important factor affecting nevirapine adherence was place or delivery (p<0.05). Most (71%) of mothers who did not swallow their nevirapine delivered at home. Women attending ANC for two times or less young women under 20 years of age and single women were also less likely to swallow their nevirapine (p < 0.05). Most (91%) of the babies received their nevirapine syrup with 98% of them getting it within 72 hours of delivery. Eighty eight percent of babies who did not take their nevirapine were delivered at home. Babies whose mothers did not take their nevirapine were also more likely to miss it. Self reported adherence to take home nevirapine is high. However mothers who deliver in a health facility were more likely to access nevirapine both for themselves and their babies than those delivering at home.

Impact of an in-built monitoring system on family planning performance in rural Bangladesh

BackgroundDuring 1982–1992, the Maternal and Child Health Family Planning (MCH-FP) Extension Project (Rural) of International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), in partnership with the Ministry of Health and Family Welfare (MoHFW) of the Government of Bangladesh (GoB), implemented a series of interventions in Sirajganj Sadar sub-district of Sirajganj district. These interventions were aimed at improving the planning mechanisms and for reviewing the problem-solving processes to build an effective monitoring system of the interventions at the local level of the overall system of the MOHFW, GoB.MethodsThe interventions included development and testing of innovative solutions in service-delivery, provision of door-step injectables, and strengthening of the management information system (MIS). The impact of an in-built monitoring system on the overall performance was assessed during the period from June 1995 to December 1996, after the withdrawal of the interventions in 1992.ResultsThe results of the assessment showed that Family Welfare Assistants (FWAs) increased household-visits within the last two months, and there was a higher use of service-delivery points even after the withdrawal of the interventions. The results of the cluster surveys, conducted in 1996, showed that the selected indicators of health and family-planning services were higher than those reported by the Bangladesh Demographic and Health Survey (BDHS) 1996–1997. During June 1995-December, 1996, the contraceptive prevalence rate (CPR) increased by 13 percentage points (i.e. from 40% to 53%). Compared to the national CPR (49%), this increase was statistically significant (p < 0.05).ConclusionThe in-built monitoring systems, including effective MIS, accompanied by rapid assessments and review of performance by the programme managers, have potentials to improve family planning performance in low-performing areas.

Why Are Infant and Child Mortality Rates Lower in the MCH‐FP Area of Matlab, Bangladesh?

Infant and child mortality rates are significantly lower in the Maternal and Child Health-Family Planning (MCH-FP) area of Matlab, Bangladesh, than in a comparison area. The two areas are similar in terms of socioeconomic characteristics, but the MCH-FP area provides better maternal and child health and family planning services, resulting in different reproductive patterns, including lower fertility rates and longer intervals between pregnancies. We use data from the Matlab Demographic Surveillance System for nearly 126,000 singleton live births that occurred between 1982 and 2002 to investigate the extent to which the different reproductive patterns in the MCH-FP area explain why infant and child mortality rates are lower there. Differences in reproductive patterns account for a small portion (up to 20 percent) of the variation in these rates between the MCH-FP and comparison areas, suggesting that the majority of the difference is due to the quality of MCH services.

Lover, mother or worker: women's multiple roles and the HIV/AIDS and reproductive health agenda in Tanzania

International and national campaigns to prevent HIV/AIDS and efforts to promote reproductive health remain separate in terms of conceptualisation and implementation. Local negotiations around reproductive health issues similarly seem to lack explicit attention to HIV/AIDS. This paper argues that even in reproductive health clinics a gap exists between the extent of knowledge of HIV/AIDS and AIDS talk. There also appears to be a mismatch between collective knowledge of the behavioural and biomedical context of HIV/AIDS and the socio-economic context of AIDS as a lived experience. Using an ethnographic account, I explore how one woman's lived experience and her knowledge of AIDS can teach us to take HIV/AIDS into account when theorising, promoting or providing services for improving African women's reproductive health. The background for this ethnography comes from data collected during 25 months of fieldwork at 10 maternal and child health/family planning (MCH/FP) clinic sites in the Morogoro, Ruvuma and Kilimanjaro regions of Tanzania. Rehema's story shows that AIDS, like other diseases, is significantly linked to host-susceptibility and economic vulnerability. Separate and competing vertical programmes on AIDS and MCH/FP, as commonly encountered throughout Africa, cannot meet the needs of women in countries like Tanzania. Yet, we still hear most often of abstinence, anti-retrovirals and condom use as the primary focus of HIV/AIDS prevention and intervention in Africa.

HIV/AIDS in the Shadows of Reproductive Health Interventions

In December 1999, the Tanzanian president declared HIV/AIDS a national disaster. By the time the National Policy on HIV/AIDS was released in 2001, an estimated 750,000 women of reproductive age were infected. Yet in spite of the impact of HIV on reproductive health, AIDS and reproductive health programmes are still thought of and implemented through separate channels, to the detriment of both. However, although AIDS remains in the shadows of reproductive health interventions, the lack of AIDS talk does not lessen the impact of the disease on people's lives. During the course of my participant observations in maternal and child health/family planning (MCH/FP) clinics collected during 25 months of fieldwork in 10 clinics in Morogoro, Ruvuma and Kilimanjaro Regions, I rarely heard about AIDS. This article attempts to analyse why. Historically competing bureaucracies in MCH/FP and gender and development are not easily unified with a vertical HIV/AIDS control programme under the umbrella of “reproductive health”. HIV/AIDS cannot merely be inserted into existing family planning programmes, re-named “reproductive health” programmes. As the AIDS epidemic is transformed through new technologies, reproductive health policy and priorities will be called into question and force us to look at the state of the African health care system, networks of care-giving, and how individuals and communities fail when there is no socio-economic safety net.

The Role of MCH and Family Planning Services in HIV/STD Control: Is Integration the Answer?

During the mid 1990s, high HIV and sexually transmitted disease (STD) prevalence led to calls for the integration of effective services with maternal and child health and family planning (MCH/FP) programs. There are advantages and disadvantages to integration, but little evidence existed to assess the practicalities of implementing this policy. Analysis of policy development for integration was conducted in Ghana, Kenya, South Africa, and Zambia. Semi-structured interviews were conducted with policy-makers at national, provincial and district levels and a survey of facilities was undertaken to identify gaps between policy intent and implementation. Significant advances had been made at the national level to formulate policies to integrate reproductive health and primary health care. However, barriers to implementation included entrenched HIV/STD and MCH/FP vertical programs; diverse demands on district managers and providers, such as on-going institutional reform; and conflicting objectives of international donors. Policy-makers need to address conflicting objectives between the needs for vertical accountability and the reality of providing integrated services. More careful consideration of implementation is required at earlier stages of policy design. Increased consultation with those who are to implement and provide integrated services is recommended.

Coping with changing conditions: alternative strategies for the delivery of maternal and child health and family planning services in Dhaka, Bangladesh.

The door-to-door distribution of contraceptives and information on maternal and child health and family planning (MCH-FP) services, through bimonthly visits to eligible couples by trained fieldworkers, has been instrumental in increasing the contraceptive prevalence rate and immunization coverage in Bangladesh. The doorstep delivery strategy, however, is labour-intensive and costly. More cost-effective service delivery strategies are needed, not only for family planning services but also for a broader package of reproductive and other essential health services. Against this backdrop, operations research was conducted by the Centre for Health and Population Research at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) from January 1996 to May 1997, in collaboration with government agencies and a leading national nongovernmental organization, with a view to developing and field-testing alternative approaches to the delivery of MCH-FP services in urban areas. Two alternative strategies featuring the withdrawal of home-based distribution and the delivery of basic health care from fixed-site facilities were tested in two areas of Dhaka. The clinic-based service delivery strategy was found to be a feasible alternative to the resource-intensive doorstep system in urban Dhaka. It did not adversely affect programme performance and it allowed the needs of clients to be addressed holistically through a package of essential health and family planning services.

Improvement in female survival: A quiet revolution in Bangladesh

This article examined the time trends of mortality and made a relative comparison of the mortality changes between males and females in different age groups in a rural area in Bangladesh between 1970 and 1995. Data from the Matlab Demographic Surveillance System were used for the study. Two areas were compared: 1) the maternal and child health/family planning (MCH/FP) area and 2) the other area known as the comparison area. Data showed that the mortality situation improved in both areas in every age group within the study period. However, the improvement was much greater for females in infancy and at ages 1-4 and 5-14. While improvement was seen in both areas, greater improvement was observed in the MCH/FP area, indicating a gain in life expectancy that is greater in females than in males. These improvements, however, were still below expectation for infants and children in the 1-4 age group. Thus, more efforts need to be exerted to maintain the improvement in female survival and eliminate excess female child mortality in Bangladesh.

An economic appraisal of alternative strategies for the delivery of MCH-FP services in urban Dhaka, Bangladesh

The strategy of distributing maternal and child health and family planning (MCH-FP) services at the doorsteps of the clients--through routine visits to the eligible couples by trained fieldworkers--has been instrumental in increasing the contraceptive prevalence rate (CPR), reducing fertility and attaining a considerably high immunization coverage of children and women in Bangladesh. The doorstep strategy, however, appeared to be labour-intensive and costly. With the maturity of the programme, priorities of the national MCH-FP programme have shifted to a stage that calls for more cost-effective service-delivery strategies, capable of offering a broader package of reproductive and other essential health services. The main objective of the present study was to examine the cost and effectiveness implications of the alternative strategies of delivering services from fixed sites--field-tested within an ICDDR,B operations research--in comparison to the conventional (existing) doorstep strategy. The key findings of the economic appraisal indicated that, at the end of the operations research intervention, both cost per birth averted and cost per QALY gained were lowest for the option of delivering services from static (fixed-site) clinics: US$13 and US$17 compared with the corresponding values of US$18 and US$42 for the doorstep strategy. Provision of health and family planning services from clinics--complemented with a reduced system of outreach workers to inform and target the hard-to-reach clients--was found to be the most cost-effective service-delivery alternative.

Repeated neonatal deaths in families with special reference to causes of death.

It is recognized that one infant death in a family indicates an increased risk of death of a subsequent sibling. This study examines which cause of death of a sibling is related to the mortality of the younger sibling and when. Longitudinal vital events data from the maternal and child health and family planning (MCH-FP) project and the comparison areas in Matlab, Bangladesh, were used. Primary causes of 868 neonatal deaths and 624 post-neonatal deaths resulting from 18,865 singleton live births in 1989-92 and those (967 as neonates and 708 as post-neonates) of their immediate elder siblings were categorised into infectious and non-infectious diseases. Multinomial logistic regression was used to estimate the risk of younger siblings dying in each age period from infectious and non-infectious diseases given the age and cause of deaths of older siblings and controlling for other biosocial correlates of infant mortality. A neonatal death of non-infectious causes in a family was twice as likely to be followed by another one occurring at the same age from similar causes compared with a surviving infant followed by a neonatal death from non-infectious causes. The MCH-FP project, though successful in reducing the risk of neonatal and post-neonatal mortality from infectious diseases, did not reduce the risk of dying from non-infectious diseases.

Why include men? Establishing sexual health clinics for men in rural Bangladesh.

Subsequent to recommendations from the 1994 United Nations International Conference on Population and Development, and given recent findings outlining the links between control of sexually transmitted infections (STIs) and a reduction in HIV incidence, many countries are now seeking to establish STI control programmes. In many cases this is through a policy of providing comprehensive reproductive health care through the maternal and child health/family planning (MCH-FP) system. This involves management of all reproductive tract infections including STIs. This paper demonstrates how such an approach may miss one of the largest target groups--men. In general, men are at higher risk of initially contracting STIs, but, once infected, their clinical management is usually simpler than treating equivalent infections in women. It is argued that these two factors alone make the inclusion of men in STI control programmes critical. The paper outlines the experiences of one programme in rural Bangladesh in establishing sexual health clinics for men within the existing service structure. In response to client demand, the clinics moved beyond simple STI care towards provision of comprehensive sexual health services. Finally, the paper argues that whilst including men in sexual health programmes should never be at the expense of providing services for women, excluding them from service provision may make the objectives of STI control programmes unattainable.

Decline in maternal mortality in Matlab, Bangladesh: a cautionary tale

A study in Matlab, Bangladesh, has provided evidence favouring a community-based maternity-care delivery system. 3 years of this programme coincided with a significant reduction in direct obstetric mortality compared with the 3 years before the programme. We have examined whether the effects of the programme are sustained over time. Using data from the continuing demographic survelliance system and from special investigations into the rates and causes of maternal mortality during 1976-93, we compared the trends in direct obstetric maternal mortality ratios in the Maternal and Child Health and Family Planning (MCH-FP) area (which has received extensive services in health and family planning since 1977) with those in the comparison area (with no such intensive health inputs). We divided the areas and time periods into discrete groups that best represented the effects of the introduction of the maternity-care programme. Direct obstetric mortality declined by 3% per year (rate ratio 0.97 per year [95% CI 0.95-0.99]); there was no difference between the MCH-FP and comparison areas (1.00 [0.96-1.05]). Direct obstetric mortality halved between 1976-86 and 1987-89 in the northern MCH-FP area, where the maternity-care programme was initiated in 1987 (0.50 [0.22-0.99]), but showed no change in the southern MCH-FP area, which had no such intervention at that time (1.07 [0.64-1.72]). After 1990, when the programme was expanded throughout the MCH-FP area, the southern part showed a downward (non-significant) trend in direct obstetric mortality (0.68 [0.35-1.32]). However, direct obstetric mortality also declined between 1987 and 1989 in the southern comparison area (0.48 [0.26-0.83]) in the absence of an intense maternity-care programme, and remained stable thereafter. In the northern comparison area, there was no such decline in direct obstetric mortality (0.78 [0.40-1.40]). Although the introduction of the maternity-care programme coincided with declining trends in direct obstetric mortality in the areas covered by the programme, a decline also occurred in one of the areas not receiving any such interventions. Caution is required in the interpretation of short-term trends in one indicator in studies designed without random allocation of interventions into treatment and control groups.

Cervical cancer in Kenya: Prospects for early detection at primary level

Objectives: To assess the feasibility of cytologic screening services for rural women and to establish the prevalence of abnormal cytology in Kenya. Method: Women at four maternal and child health/family planning (MCH/FP) clinics were screened, and some screens were repeated. After Pap staining they were graded in classes I–IV, where abnormal smears referred to classes III and IV. Results: The prevalence of abnormal cytology was 2.9% and 2.6% for the first and second screen, respectively. Enrolled community nurses took adequate smears and were able to diagnose overt lesions of the cervix. Training of technicians in cytologic techniques and setting up of a network of laboratories down to district level was considered feasible. Conclusions: Cytology services may be extended to rural populations through existing MCH/FP clinics. Enrolled nurses can take adequate cervical smears and diagnose overt cervical lesions, and could be used in a downstaging and screening program extending to rural areas.