A special obligation -- access to contraception.

In rural Bangladesh, health workers go door to door to offer women injectable contraceptives. At small shops, villagers can obtain oral contraceptives without a prescription. In poor urban areas and in remote villages, trained workers insert IUDs at satellite clinics and in homes. These resourceful ways of making contraceptives available are not the norm, however. Many obstacles to accessible contraceptives exist, including physicians with little exposure to public health issues and perspectives. The executive director of the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health believes that properly trained paramedics can sufficiently provide family planning services given adequate conditions and supplies, e.g., nurse practitioners and midwives often insert IUDs more conscientiously than do physicians. In Egypt, physicians are disinclined to delegate some services to paramedics, even in remote areas where few physicians practice. On the other hand, physicians in Bangladesh realize that if they do not relinquish these services to paramedical, they must go to remote areas to provide these services themselves. Another considerable obstacle to improved access to contraceptives is the lack of a clear, specific guideline. The executive director suggests that 2 groups of step-by-step guidelines translatable at the clinic level are needed, one for senior program managers and one for providers in the field. It is important for the guidelines to minimize the musts and shoulds because they too become barriers. For example, requiring IUD users to return to the clinic after 1, 2, 3 and 6 months discourages potential users who cannot leave their homes regularly for the inconvenience of so many physical exams. Too many tests as a means to screen potential contraceptive users also deters potential users. In Bangladesh as well as some other countries, a husband's signature is required for the wife to use a new method or to undergo sterilization. This is a major obstacle.