Matern Kesehatan Anak J (2006) 10: S157-S160 DOI

10,1007 / s10995-006-0109-8

PAPER ORIGINAL

Pelayanan Keluarga Berencana: Sebuah Komponen penting dari Prasangka

Perawatan

Lorraine V. Klerman

Dipublikasikan secara online: 1 Juli 2006

C Springer Science + Business Media, Inc. 2006

Abstrak Family planning services are necessary for the widespread cies will not benet from preconception advice. Second, family planning
adoption of preconception care for two reasons. First, preconception care counseling provides an opportunity for promoting and providing
is more likely if pregnancies are planned, and family planning services preconception care. At the same time women and their partners are
encourage pregnancy planning. Second, family planning services usually receiving advice about family planning, they can also receive instruction
include counseling, and counseling provides an opportunity to discuss the about the range of activities that lead to healthy pregnancies and healthy
advantages of preconception care. However, the potential of family infants.
planning services to promote preconception care is limited by
underutilization of these services and inadequate attention to Unfortunately, several factors prevent family planning from reaching its
preconception care during family planning visits. This article suggests ways maximal potential for preconception care. These include underutilization of
to reduce these problems. family planning services and inadequate attention to preconception
counseling during family planning visits.

Keywords Family planning . Preconception care . Pregnancy .

Intendedness . Access Underutilization of family planning services

If all women of reproductive age, or at least those at elevated risk, are to Two types of data point to underutilization of family planning services with
benet from preconception services, the use of family planning services implications for decreasing opportunities for preconception care: the
must be increased and the content of such services expanded. Family percentage of women actually seeking family planning services and the
planning services are essential for preconception care for at least two percentage of unintended pregnancies.
reasons. First, in the absence of such services, pregnancies will occur that
have not beneted from preconception care. Preconception care during the
reproductive years is dependent on women and men planning their Visits for family planning
pregnancies, not only in respect to their timing but also to healthrelated
factors that wouldmaximize the chances for a healthy pregnancy and a The 2002 National Survey of Family Growth (NSFG) reported that 41.7% of
healthy infant. In the absence of such care, offered by family planning women 15 to 44 years of age received at least one family planning service
services, many pregnan- from a medical care provider in the 12 months prior to the interview [ 1 ].
This percentage is not as alarming as it might appear at rst glance,
because some of the women who did not seek family planning services
already were pregnant, seeking to become pregnant, or infertile because of

L. V. Klerman ( ) sterilization or other reasons. Nevertheless, this rather low percentage

Institute for Child, Youth and Family Policy, The Heller School for Social Policy suggests that some women are not planning their pregnancies either
and Management, Brandeis University, Mailstop 035, PO Box 549110, deliberately
Waltham, MA 02454-9110 e-mail: [email protected]

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S158 Matern Child Health J (2006) 10:S157S160

or because they are experiencing problems obtaining family planning of-pocket payments. The March 2005 Current Population Survey found
services. 24.5% of women 18 to 20 years of age, 30.6% of those 21 to 24, 21.8% of
those 25 to 34, and 17.1% of those 35 to 44 to be uninsured [ 9 ]. If these
Pregnancy planning uninsured women want to receive family planning services, they must rely
on their own funds or seek care from facilities that provide services free of
It is undoubtedly true that some women do not wish to plan the timing of charge or on a sliding fee scale. These include publicly supported facilities
their pregnancies. Inmany cases, these are married women who have such as health department family planning clinics, community health
religious objections to family planning. In Women of Crisis, one woman centers and public hospitals, and facilities that combine public and private
states you dont think of life that way of having children that way. You funding sources, such as Planned Parenthood centers, womens clinics,
dont sit down and say you can afford to have a certain number of boys and school-based health centers, and not-forprot hospitals. Public funds for
girls; you have your children and try to do the best you can to be a good family planning services in such facilities come primarily from Medicaid and
parent [ 2 ]. This attitude is probably not widely held, rather most women Title X (the family planning act). These funds are inadequate to meet the
and their partners have some preferences in terms of the timing of births. need. For women whose eligibility is due to a pregnancy, eligibility for all
This may be expressed in terms of age, marital status, or attainment of medical services, including family planning, ends 60 days postpartum,
some educational, career, or economic goal. Despite this, a large except in states with a waiver to extend the period. Title X tries to ll in the
percentage of pregnancies are unintended, including those that were gaps in coverage but it is chronically underfunded. Even for those with
experienced earlier than wanted (mistimed) or those that were not wanted employer-based health insurance, coverage for family planning services is
at the time they occurred or at any future time (unwanted). not universal. In 2003, 93% of health plans offered an annual ob/gyn visit,
88% covered oral contraceptives; 87%, sterilization; and 72%, all ve
reversible contraceptives. HMOs were more likely to offer contraceptives
and sterilization than conventional plans, PPOs or POSs [ 10 ].
According to the 2002 NSFG, 30.8% of all women 15 to 44 years of age
had experienced an unintended birth at some time in their lives and, in the
ve years before the survey,
20.8% had had a mistimed birth and 14.1% an unwanted birth [ 3 ]. Using
data from the 1982, 1988, and 1985 NSFGs, as well as abortion data,
Henshaw estimated that in 1994,
49.2% of all pregnancies were unintended [ 4 ]. Employing a different set of
questions to assesswantedness, the Pregnancy Risk Assessment Tersedianya
Monitoring System (PRAMS) noted that in 1999 the percentage of
unintended pregnancies resulting in live birth ranged from 33.7% to 52% perencanaan fasilitas keluarga harus mudah tersedia baik secara fisik dan
across the 17 reporting states [ 5 ]. psikologis. Ini berarti bahwa mereka harus locatedwhere mereka dapat dicapai
dengan mudah oleh kendaraan pribadi atau umum, menjadi hari terbuka dan jam
Although the relationship between use of a family planning method and yang nyaman bagi pengguna potensial, menawarkan berbagai metode
pregnancy planning is sometimes tenuous an analysis of the kontrasepsi, memberikan materi pendidikan dalam bahasa pasien mereka, dan
1995NSFGfound that 30.9%of thewomen who stated that their pregnancies mempekerjakan personil yang dapat berbicara bahasa pengguna dan yang sikap
had resulted from a contraceptive failure nevertheless classied the dan perilaku yang hangat, ramah, dan peka budaya. Sebuah survei empat negara
pregnancy as intended [ 6 ]. These data suggest that if preconception care baru-baru ini menemukan bahwa jarak ke fasilitas keluarga berencana publik
were to be practiced widely, a larger percentage of women will need to dibiayai tidak berhubungan dengan remaja atau yang tidak diinginkan kehamilan,
seek family planning services to avoid unplanned pregnancies. menunjukkan bahwa ketersediaan geografis tidak lagi menjadi masalah bagi
fasilitas keluarga berencana [ 11 ], Meskipun masih untuk layanan aborsi [ 12 ].
Penelitian yang sama menemukan perbedaan besar dalam hal faktor-faktor
ketersediaan lain, seperti jam tertentu, beberapa pilihan kontrasepsi, dan
Reasons for underutilization kurangnya penerjemah [ 13 ]. masalah seperti mungkin sebagian bertanggung
jawab untuk penggunaan kontrasepsi yang tidak memadai.
Many reasons have been suggested for the underutilization of family
planning services, including cost, availability, and limited contraceptive
methods [ 7 , 8 ].

Financial issues metode kontrasepsi yang terbatas

The possible patient payment sources for family planning services include Meskipun sejumlah metode keluarga berencana telah meningkat dalam beberapa

private health insurance, Medicaid, or out- dekade terakhir, banyak perempuan dan laki-laki memiliki

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Matern Kesehatan Anak J (2006) 10: S157-S160 S159

Kesulitan fi nding satu dengan yang mereka merasa nyaman. 2002 NSFG Approaches to increasing utilization
memberi responden daftar metode perencanaan 19 keluarga fromwhich untuk
memilih. Di antara perempuan 15-44 tahun, 61,9% saat ini adalah Several evaluations indicate that the utilization of family planning services
menggunakan metode kontrasepsi: pil-18,9%; perempuan sterilisasi-16,7% can be increased. Californias Family Planning, Access, Care, and
dan condom- yang Treatment Program (Family Pact) provided contraceptive services to low
11.1%. About 4%were using the least effective methods, including periodic income, medically indigent women increased use and reduced the
abstinence and withdrawal. Among women who had intercourse in the numbers of unintended pregnancies [ 17 ]. State family planning waivers that
three months before the interview and who were not sterile, pregnant, expand Medicaid coverage for women beyond the 60 day postpartum limit
postpartum, or seeking pregnancy, 7.4%were not using a contraceptive - have had a similar impact [ 18 , 19 ]. Programs such as these should be
an increase from the 5.2% in the 1995 NSFG. (Of those at risk for an expanded to more states, but they address only nancial barriers. Attention
unintended pregnancy, 89.3% were currently using a method.) [ 1 ]. It is should also be paid to other access-related problems, such as hours and
important to recognize that contraceptive use data are based on days that facilities are open and language problems. Additional outreach
self-reports and provide no indication of how consistently or correctly the also needs to be directed to low literacy and immigrant populations [ 20 ].
methods are being used. Failure rates are high possibly because of
inconsistent or improper use. In one study of the 1995 NSFG, 9% of
women experienced a contraceptive failure within one year of starting to
use a reversible method of contraception: 7% of those on the pill, 9% of
those relying on a male condom, and 19% of those practicing withdrawal [ 14
]. Approaches to improving content

Moos [ 15 ] reviewed many of the activities that will be essential if

After female or male sterilization, hormonal methods are considered the preconception care is to be integrated into health care generally. The
most reliable formof contraception, but many women remain concerned American College of Obstetrics and Gynecology recently published a
about their safety. The side effects of many hormonal methods, especially Committee Opinion, The Important of Preconception Care in the
Depo-Provera, discourage many women from their use [ 7 , 8 ]. Further, the Continuum of Womens Heath Care [ 21 ]. Here the focus is on adding
need to take a pill daily even in the absence of frequent intercourse creates preconception counseling to visits for family planning. The recent
problems for many women. Finally, the absence of a male contraceptive publication by the Centers for Disease Control and Prevention of
other than sterilization and the condom is a major barrier to effective and Recommendations to Improve Preconception Health and Health Care -
ongoing contraception. United States [ 22 ] should also lead to more and better preconception
counseling.

The availability of one effective family planning method, emergency In all likelihood, it may be most difcult to change patterns of family
contraception (meant as back-up protection, not as a primary method), is planning practice among physicians in private practice. In contrast, those in
currently limited by the refusal of the federal Food and Drug Administration HMOs have the potential for exposure to more education about the need
to allow it to be sold over the counter and by the refusal of some for such counseling. The establishment of standards for family planning
pharmacists to ll prescriptions for this medication. services by the Health Plan Employer Data and Information Set (HEDIS)
might also accelerate change. However, standard setting and nancial and
other incentives may be most effective when used with community health
centers and health department and other publicly-funded sites of family
Inadequate attention to preconception counseling planning services - as the women who use seek family planning at these
sites may be those most in need of preconception care. Because such
Research is just beginning on the availability of preconception care overall sites are funded by federal, state, and local governments, these units can
although certain conditions, such as folic acid supplementation and insist that preconception care be integrated into their family planning
counseling of diabetic women, have been studied extensively. The little services.
existing evidence suggests that preconception care is not routinely
integrated into family planning services, whether provided by obstetricians
or family medicine specialists in private practice or HMOs, or by personnel
in family planning facilities [ 15 , 16 ]. Under such circumstances, the
potential of this service delivery system for improving pregnancy and infant Conclusions
health through preconception care is not yet being realized.
Progress towards preconception care for all women will only be possible if
a larger percentage of women and men plan their pregnancies. At present,
although visits for

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S160 Matern Child Health J (2006) 10:S157S160

contraceptive advice and methods provide an excellent opportunity for 205 Survei Penduduk Lancar. Isu tidak Singkat. 287, November
counseling about ways to achieve healthy pregnancies and healthy infants 2005.
10. Kaiser Family Foundation / Penelitian Kesehatan dan Educational Trust. Majikan Kesehatan
through preconception care, this potential is not being achieved. Increased
Bene fi ts. 2003 Survei Tahunan. 2003.
use of family planning and increased attention to preconception care within 11. Goodman DC, Klerman LV, Johnson KA, Chang CH, Marth N. Geographic Akses ke
family planning services may require that additional resources be devoted Keluarga Berencana: Apakah Fasilitas Lebih Dibutuhkan? (Tersedia dari penulis).

to public and professional education and to service delivery standards and

12. Henshaw SK, halus LB. The Aksesibilitas Layanan Aborsi di Amerika Serikat, tahun
nancing.
2001. perspect Sex Reprod Kesehatan 2003; 35: 16-
24.
13. Klerman LV, Johnson KA, Chang CH, Wright-Slaughter P, Goodman DC.
Aksesibilitas Pelayanan Keluarga Berencana: Dampak Faktor Struktural
andOrganizational. (Fromauthors Tersedia).
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izin Reproducedwith dari pemilik hak cipta. izin reproductionprohibitedwithout lanjut.