In Bangladesh, the Ministry of Health and Population Control is responsible for developing, coordinating and implementing the national health and mother-and-child health care programs; population control is also within the purview of the ministry. The government's policy objectives in the health care sector are to provide a minimum level of health care services for all, primarily through the construction of health facilities in rural areas and the training of health care workers. At the national level, implementation of health-care services has not become a reality for numerous reasons such as severe financial constraints, insufficient program management and supervision and staffing problems; in Matlab, however, the health-care situation is different.
Matlab, being a field research area of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B ), formerly the Cholera Research Laboratory (CRL), has health-care programs that are largely absent in other parts of rural Bangladesh. The ICDDR,B started its operation in Matlab in 1963 with the purpose of field testing of vaccines against cholera: Matlab was chosen because it had a
high prevalence of cholera, it was easily accessible favouring the possibility of undertaking long-term, follow up studies, and it was densely populated, making field trials more efficient.
Since 1963, ICDDR,B has been monitoring a permanent diarrhoea treatment centre in Matlab supported by speed-boat ambulance services. It has conducted various epidemiological studies including several large-scale cholera vaccine trials. To further the evaluation of cholera vaccines, ICDDR,B started operating a Demographic Surveillance System
(DSS) in 1966; ever since then it has been collecting and updating records of vital events in the DSS area. At the time of the 1974 census, 233 villages were under surveillance with a total population of 276,984 (Ruzicka and Chowdhury, 1978b). In subsequent years, many modifications in the field structures and program activities were made and the population size was adjusted for demographic, economic and research considerations. The changes in field structures, population size and study objectives over time are nicely summarized in Aziz and Mosley (1991:3-15).
In 1975, ICDDR,B realized that over a 12-year period from its initiation in 1963, it had developed a well-trained field staff and evolved a highly efficient system for field studies in Matlab. In view of this, ICDDR,B, in collaboration with the Ministry of Health and Population
Control, launched a contraceptive distribution program (CDP) in half of the DSS area in 1975. The main purpose of the program was to test the latent-demand hypothesis that improved availability alone would increase contraceptive use and reduce fertility. With this aim, the program undertook a mass house-to-house, free distribution of oral contraceptives and condoms in 150 villages with a population of 135,000, while the remaining 83 villages were served by the government of Bangladesh program and designated the comparison area. Details of the CDP, its field structures, and service delivery are described elsewhere (Rahman et a l ., 1980:192-195).
The CDP followed the strategy of making the methods available rather than relating the methods to the needs of individual couples. As a result, this method-oriented, mass distribution program was successful in attracting eligible couples and increasing their contraceptive use rates only during the early stage of the program, but it failed to maintain effects over time, even among older and presumably more highly motivated women. It also failed to recruit new acceptors after the first intensive round in late 1975. The demographic impacts of the CDP are described elsewhere (Stinson et a l . , 1982); its failure led to a major modification in the workforce, training, supervision, and
During the modification in 1977, special attention was given to changing the method-oriented program to a client-oriented one. The modified program came not only with a new name,
"The Matlab Family Planning and Health Services Project' (FPHSP), but also with provision of a full clinical as well as non-clinical fertility control program. The clinical contraceptive services provided included IUD insertion and removal, male and female sterilization, treatment of severe side-effects or complications associated with contraception, and induced abortion. Menstrual regulation services were also established with the intention of providing back-up for contraceptive failures. Details of the program and its impact upon contraceptive use dynamics and fertility can be found in Bhatia et a l . (1980).
In the FPHSP, the field organization also was modified from that of the CDP. This project was introduced in 70 villages covering a population of about 80,000, drawn equally from the 150 contraceptive distribution villages and the control villages of the original CDP (Bhatia et al., 1980: 203). The lady village workers (LVW) of the CDP, who were mostly elderly, illiterate widows, were replaced by community health workers (CHWs), who were young, literate (having minimum seventh grade education), well-trained, motivated higher-level primary field-workers. They were married, had personal experience with contraception and were from respected families in the local community. These field-
workers were backed up by a strong supportive supervisory and technical staff. Interpretation of the Matlab family planning program has emphasized the key role of a high density of these female family planning workers (see Rahman, Osteria et a l . , 1978; Rahman et a l . , 1979, 1980; Huber and Khan, 1979; Bhatia et a l . , 1980; Phillips, Stinson et a l . , 1982; Rahman, 1986; Phillips, Simmons et a l . , 1988; Simmons et al., 1988; Phillips, Hossain and Koblinsky, 1989; Phillips, Hossain et a l ., 1989).
The original CDP, by undertaking a mass house-to-house distribution of oral contraceptives and condoms, tried to increase the contraceptive use rate in Matlab, a high- mortality, rural society with a somewhat conservative outlook. Parents in Matlab, like parents in other high- mortality rural societies, argue that a high infant mortality rate requires many births to ensure that some children will survive to adulthood. Parents expect their children to serve as a social-security system when they are old and unable to work. In such a situation, high mortality among infants and young children was thought to be a major barrier to raising the demand for contraception; improvement in maternal and child health and family well-being was thus considered a favourable and perhaps essential condition for an increase in family planning acceptance rates (Phillips et al., 1984).
In view of this, during the introduction of the FPHSP a Maternal and Child Health (MCH) care service was integrated into the comprehensive family planning services. The MCH component was initially limited to maternal, infant and child health and nutrition education, and the treatment of minor ailments in women and children. Over time, village- based health services were gradually enriched to include a variety of maternal and child health services. These included tetanus vaccination for pregnant women only (June, 1978), oral rehydration therapy (January, 1979), tetanus vaccination for all women of childbearing age (January, 1982), measles immunization for children with no history of measles (February, 1982), antenatal care (October, 1982) and training of traditional birth attendants to use a simple delivery kit (November, 1982) (Phillips et a l ., 1984:156- 157), a nutrition rehabilitation unit at the Matlab central clinic (1986), and curative outreach services for acute respiratory infections (ARI) (1988) (ICDDR,B, 1991:33-34).
The year 197 8 was important for the then Cholera Research Laboratory. In 1978, the CRL became ICDDR,B and gained international affiliation; the DSS area was reduced from 233 to 149 villages and divided into two parts: MCH-FP (70 villages) and comparison area (79 villages); and family planning and health services were introduced only into the MCH-FP area in a staggered fashion. The comparison area did not receive any intervention in terms of maternal and child
health and family planning services by the ICDDR,B except
for treatment of diarrhoeal diseases in the ICDDR,B
treatment centres and supply of Oral Rehydration Solution
(ORS) packets by the DSS workers. The comparison area,
however, is served by a routine but limited government
health and family planning program.
A series of detailed research studies found that integrated family planning and MCH services benefited from each other and resulted in an increase in contraceptive use prevalence rates and a decline in both fertility and mortality in the MCH-FP area (Bhatia et a l ., 1980; Stinson et a l ., 1982; Chen
et a l . , 1983; Phillips et a l ., 1984). The impact on maternal
mortality, however, was limited, with the maternal mortality ratios remaining around 5.5 per 1000 live births (Koenig et
a l ., 1988:69). These findings and the findings of a
retrospective study of causes and conditions of maternal
deaths (Fauveau et a l . , 1988:643) led the project
coordinators and investigators to further strengthen the maternity care interventions in a subsequent phase of the proj e c t .