Elements of Family Planning Success

Frontiers in Reproductive Health (FRONTIERS) is a global operations research project that tests innovative interventions to ensure high-quality, client-centered family planning and reproductive health services. FRONTIERS produces evidence needed by policy makers and program managers to make sound decisions regarding new reproductive health policies and program improvements. Started in 1998, FRONTIERS builds on three previous Population Council operations research and technical assistance (OR/TA) projects funded by USAID: 1) Africa OR/TA Project (1988-1998); 2) Asia and Near East OR/TA Project (1990-1998); 3) INOPAL Project in Latin America and the Caribbean (1984-1998). INOPAL's partners were the International Center for Research on Women (ICRW), which addresses gender issues in family planning programs, and Ipas, which supports improved postabortion care. These three regional projects conducted more than 370 studies that used operations research to improve the quality, availability and sustainability of family planning and reproductive health services. This CD-ROM represents an electronic archive of materials produced by these projects since 1990, including final reports, workshop reports, OR summaries, policy briefs, surveys, other special reports, and photographs. Portions of some documents, such as appendices, are not available in electronic form.

The pilot phase 1999-2003 Women and Infants' Health (WIN) project and the scale-up phase 2003-2006 Maternal and Child Health Initiative (MCHI) integrated family planning into the spectrum of maternal and infant health care in 16 regions of the Russian Federation. WIN/MCHI's innovative design helped regional and municipal government-supported health facilities adopt internationally recognized, client-centered, evidence-based maternal and child health standards and practices in multiple areas: antenatal care; family-centered maternity care; essential newborn care; exclusive breastfeeding; and family planning counseling and services, especially for postpartum and post-abortion clients. Attention was also given to family planning for HIV-positive women and the prevention of mother-to-child transmission of HIV. The objectives were to provide a new evidence-based model for reproductive health care services and to increase access to, demand for, and quality of these services, as well as to increase the practice of preventive health behaviors among women in the community. WIN/MCHI chose strategies that not only stressed evidence-based medicine but that also offered a total paradigm shift from focus on the provider to focus on the client, a shift that transformed the way maternal and infant services were delivered. Implementation involved health care providers, administrators, and authorities in the planning, policymaking, hands-on training, and public education needed to achieve change. This case study looks specifically at the integration (horizontalization) of the family planning component into the other WIN/MCHI components. As a result, access to client-centered counseling has increased, unplanned pregnancies have decreased, and the abortion rate has declined. (author's)

The Romanian Family Health Initiative (RFHI) rapidly expanded access to family planning services and supplies by integrating family planning into primary health care delivery. The program initially focused on reaching rural clients. The clients represented the majority of Romania's poor and had limited access to family planning services, which were located primarily in urban areas. The RFHI used an innovative Three Pillars Approach that focuses on creating the following three conditions at the same place and at the same time: (1) training rural family health doctors and nurses at primary health care centers in contraceptive technology and client-centered counseling, (2) contraceptive supplies, and (3) demand creation activities. Between 2001 and 2005, family planning services expanded beyond the 210 urban-based clinics to more than 2,200 primary health care centers in rural communities, representing 80 percent of the country's rural areas. As a result, contraceptive prevalence increased significantly, and there was a concurrent and dramatic decrease in abortion rates. A number of innovative approaches were essential for the initiative to be successful; the nationwide scale up also resulted in important lessons learned. Because of the clear success of the initiative, USAID asked DELIVER to identify, through this case study, the successful strategies and key steps that can be taken to replicate the success and address some of the challenges that arose during program implementation. These strategies and key steps have been incorporated into guidelines that program managers and policymakers in Eastern Europe and Eurasia can use when facing similar challenges as they expand access to family planning. (author's)

The Family Planning Training for Primary Health Care Providers was developed in 2005 by the Maternal and Child Health Initiative. It is intended to train Russian health providers in international evidence-based practices and standards for family planning services, with an emphasis on counseling. This manual is designed for training health care providers to strengthen their knowledge and counseling skills in order to provide quality family planning services, integrating family planning into the broader spectrum of reproductive health care services. Participants can include obstetrician/gynecologists, nurses, midwives, family medicine doctors, general practitioners, field-searchers and pediatricians who provide prenatal, delivery, postpartum, breastfeeding, postabortion, well-baby, adolescent and HIV/AIDS care. The training design will work best for a group of 15 to 25 people. At the end of the training, health care providers will be able to: counsel clients effectively on contraceptive choices; provide information on modern contraceptive methods to clients; use the skills of family planning counseling for different population groups; describe the measures necessary for prevention of sexually transmitted infections and HIV; share information on contraceptive methods and family planning counseling skills with other providers at the health facility, and support colleagues in implementation of modern methods and counseling approaches. The curriculum focuses on client-centered counseling skills. Detailed information on medical technology is provided to participants as reference material, but is not the main focus of the sessions. Participants will have many opportunities to practice family planning counseling in different scenarios. (excerpt)

Pakistan is a high-fertility country with elevated levels of maternal mortality and unmet need for family planning. Limited access to and poor quality of reproductive health services and gender-related problems comprise the major explanations for these poor indicators. The authors designed an intervention to address some of these issues and implemented it on a quasi-experimental basis in Bhalwal Tehsil of the Sargodha district of Punjab. The intervention introduced a client-centered approach to providing reproductive health services, including family planning and infant, child, and maternal health care. The intervention consisted of training health-care providers based in fixed-location clinics and in communities. It introduced the concept of SAHR (an acronym for salutation, assessment, help, and reassurance), to inculcate a client-centered approach to care that acknowledges explicitly and addresses a client's gender and power relations within her family and household. Results of the intervention indicate significant effects on providers' behavior related to SAHR elements. The changes provide demonstrable evidence that the public sector can shift toward client-centered services in reproductive health care in a challenging setting. (author's)

Limited access to and poor quality of reproductive health services and gender-related problems comprise the major explanations for these poor reproductive health indicators in Pakistan. Researchers designed an intervention to address some of these issues which introduced a client-centered approach to providing reproductive health services, including family planning and infant, child, and maternal health care. The intervention consisted of training health-care providers based in fixed-location clinics and in communities. Results of the intervention indicate significant effects on providers’ behavior.

The Women and Infant Health (WIN) Project evaluation demonstrates that a new evidence-based, client-friendly model for women's health services was successfully implemented in Russian pilot sites. The changes promoted so effectively by the WIN Project are now being adopted in oblasts across the country. Policy makers and health care managers in Russia emerged from the Soviet period facing a population with deteriorating health status, low levels of health knowledge and very low fertility rates-achieved primarily through high rates of abortion. At the International Conference on Population and Development (ICPD) held in Cairo in 1994, the Russian government was challenged to respond more effectively to women's reproductive health needs and to institute "client-centered approaches" to providing health care. (excerpt)

The Reproductive and Child Health (RCH) interventions that are being implemented by Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from Method-Mix-Target based activity to client-centered demand driven quality services. Attempts are being made by GoI to not only re-orient the programme and service provider's attitude at grass-root level, but also to strengthen the services at outreach levels. The new approach requires decentralisation of planning, monitoring and evaluation of the services. With these objectives, district being the basic nucleus of administration, GoI is interested to generate district level data, other than service statistics, on utilisation of the services provided by government health facilities. It is also of interest to assess people's perceptions on quality of services. Therefore, it was decided to undertake District Level Household Surveys (DLHS) under RCH Project in the country. In the phase I of II round of DLHS-RCH about 50 percent of the districts were covered and the remaining districts are to be taken-up in the Phase II of the DLHSRCH. Betul district is one of the 14 districts covered in the first year of the project in Region 6 comprising Madhya Pradesh other than South West and Chhatisgarh. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC & immunisation services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI, STI and HIV/AIDS; 6. Utilisation of health services and the users? satisfaction; 7. Nutrition status of women and children. (excerpt)

The Frontiers in Reproductive Health Program (FRONTIERS) is a 10-year cooperative agreement between the United States Agency for International Development (USAID) and the Population Council in partnership with Family Health International (FHI) and Tulane University School of Public Health and Tropical Medicine. Begun in 1998, FRONTIERS followed previous operations research and technical assistance contracts awarded to the Population Council by USAID in three regions of the developing world. Similar to these programs, FRONTIERS tests innovative interventions to ensure high-quality, client-centered family planning and reproductive health services, but it is global in scope and has a broader reproductive health mandate than the regional contracts. Tulane had two primary roles in FRONTIERS: impact evaluation and the implementation of a small grants program. Specifically, Tulane was charged with developing and implementing an evaluation plan for FRONTIERS based on the program’s results framework. This approach would track the impact of the operations research studies conducted under FRONTIERS, defined as the extent to which individual OR studies result in changes in service delivery or policy action in the country in which they are conducted, and are replicated elsewhere. (excerpt)

Established in 1973, JHPIEGO, an affiliate of Johns Hopkins University, builds global and local partnerships to enhance the quality of healthcare services for women and families around the world. To achieve this goal, JHPIEGO supports programs throughout Africa, Asia, the Near East and Europe, and Latin America and the Caribbean to increase access to services and to improve the quality of those services at the lowest resource setting?the home and the community?where women most at risk live and die. The organization?s work spans a continuum of client-centered care?from prevention to treatment?in FP/RH, HIV/AIDS, maternal and neonatal health, and cervical cancer. Today, JHPIEGO works collaboratively with partners at the international, national, and community levels in more than 30 countries to improve the accessibility and quality of healthcare and is renowned for its expertise in five areas: building capacity; promoting sound health policies; creating innovative learning resources; developing networks of trainers; and promoting best practices. The TRH Project has been one of the key global USAID awards implemented by JHPIEGO. At its inception, TRH had a broad global mandate to develop sustainable FP/RH training systems in low-resource settings and strengthen provider performance to meet the FP/RH needs of women and their families in developing countries. In response to this mandate, the TRH Project established sustainable FP/RH programs in 42 countries over the last 10 years. These programs developed a global network of FP/RH expert trainers, advocates, and leaders; institutionalized competency-based training in both preservice education and inservice training systems; improved provider performance using innovative approaches such as PQI and accreditation; and strengthened service delivery in FP/RH, IP, PAC, maternal health, and HIV/AIDS. (excerpt)

Integrating family planning programs with those centered on sexually transmitted infections (STIs) like HIV involves providing prevention and care services as part of a unified, coordinated strategy. Integrated services must address clients' risks for unintended pregnancy and HIV/STI transmission, as well as their need for pregnancy and HIV related care and support. An integrated approach to counseling is often a key component of such synergized programs and services, and this more comprehensive, client-centered approach to counseling has become critically important in light of the growing HIV/AIDS pandemic. Not only do family planning clients need to understand their risks for HIV, and take these risks into account when making decisions about their sexual and reproductive health, but HIV-positive women have pregnancy prevention needs as well. Clients' needs relating to HIV and family planning (FP) are often inextricably linked; addressing sexuality is fundamental to both. (excerpt)

Integrating family planning programs with those centered on sexually transmitted infections (STIs) like HIV involves providing prevention and care services as part of a unified, coordinated strategy. Integrated services must address clients' risks for unintended pregnancy and HIV/STI transmission, as well as their need for pregnancy and HIV related care and support. An integrated approach to counseling is often a key component of such synergized programs and services, and this more comprehensive, client-centered approach to counseling has become critically important in light of the growing HIV/AIDS pandemic. Not only do family planning clients need to understand their risks for HIV, and take these risks into account when making decisions about their sexual and reproductive health, but HIV-positive women have pregnancy prevention needs as well. Clients' needs relating to HIV and family planning (FP) are often inextricably linked; addressing sexuality is fundamental to both. (excerpt)

The Reproductive and Child Health (RCH) interventions being implemented by the Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from method-mix, target-based activity to client-centered, demand driven quality services. Attempts are being made by the GoI to not only re-orient the program and service providers? attitudes at the grassroots level, but also to strengthen outreach services. The new approach requires decentralization of planning, monitoring and evaluation of the services. Given the objectives and with the district being the basic nucleus of administration, the GoI is interested in generating district-level data, other than service statistics, on utilization of the services provided by Government health facilities. It also wanted to assess people's perceptions on the quality of services. Therefore, it decided to undertake District Level Household Surveys (DLHS) under the RCH project in the country. In the first year of the Phase I of the second round of DLHS-RCH Project, about 50 percent of the districts were covered and the remaining districts are to be taken up in the second year. West Siang district is one of the seven districts covered in the first year of the project in Arunachal Pradesh. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunization services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilization of health services and users? satisfaction. (author's)

The Reproductive and Child Health (RCH) interventions being implemented by the Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from method-mix, target-based activity to client-centered, demand driven quality services. Attempts are being made by the GoI to not only re-orient the program and service providers’ attitudes at the grassroots level, but also to strengthen outreach services. The new approach requires decentralization of planning, monitoring and evaluation of the services. Given the objectives and with the district being the basic nucleus of administration, the GoI is interested in generating district-level data, other than service statistics, on utilization of the services provided by Government health facilities. It also wanted to assess people's perceptions on the quality of services. Therefore, it decided to undertake District Level Household Surveys (DLHS) under the RCH project in the country. In the first year of the Phase I of the second round of DLHS-RCH Project, about 50 percent of the districts were covered and the remaining districts are to be taken up in the second year. Thoubal district is one of the five districts covered in the first year of the project in Manipur. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunization services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilization of health services and users’ satisfaction. (excerpt)

The Reproductive and Child Health (RCH) interventions that are being implemented by Government of India (GoI) are expected to provide quality services and achieve multiple objectives. Over the last few years, there has been a positive paradigm shift from Method-Mix-Target based activity to client-centered-demand driven quality in RCH services. Attempts are being made by GoI not only to re-orient the programme and service providers? attitude at the grass-root level, but also to strengthen the services at the delivery points. The new approach requires decentralisation of planning, monitoring and evaluation of the services. With such objectives the district being the basic nucleus of administration, GoI has been interested to generate district level data (other than routine service statistics) on utilisation of the services provided by the Government health facilities. It was also of interest to assess people's perceptions about the quality of services. Therefore, it was decided by the GoI to undertake District Level Household Surveys (DLHS) under RCH Project in the country. In the phase I of second round DLHS-RCH project, about 50 per cent of the districts were covered by the survey. The remaining districts will be taken-up in the second year of the survey. Mahe is one of the four districts covered in the first year of the project in Pondicherry. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunisation services; 2. Proportion of safe deliveries; 3. Contraceptive Prevalence Rates; 4. Unmet need for Family Planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilisation of health services and the users? satisfaction. (excerpt)

The Reproductive and Child Health (RCH) interventions being implemented by the Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from method-mix, target-based activity to client-centered, demand driven quality services. Attempts are being made by the GoI to not only re-orient the program and service providers? attitudes at the grassroots level, but also to strengthen outreach services. The new approach requires decentralization of planning, monitoring and evaluation of the services. Given the objectives and with the district being the basic nucleus of administration, the GoI is interested in generating district-level data, other than service statistics, on utilization of the services provided by Government health facilities. It also wanted to assess people's perceptions on the quality of services. Therefore, it decided to undertake District Level Household Surveys (DLHS) under the RCH project in the country. In the first year of the Phase I of the second round of DLHS-RCH Project, about 50 percent of the districts were covered and the remaining districts are to be taken up in the second year. Chandel district is one of the five districts covered in the first year of the project in Manipur. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunization services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilization of health services and users? satisfaction. (excerpt)

The Reproductive and Child Health (RCH) interventions being implemented by the Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from method-mix, target-based activity to client-centered, demand driven quality services. Attempts are being made by the GoI to not only re-orient the program and service providers’ attitudes at the grassroots level, but also to strengthen outreach services. The new approach requires decentralization of planning, monitoring and evaluation of the services. Given the objectives and with the district being the basic nucleus of administration, the GoI is interested in generating district-level data, other than service statistics, on utilization of the services provided by Government health facilities. It also wanted to assess people's perceptions on the quality of services. Therefore, it decided to undertake District Level Household Surveys (DLHS) under the RCH project in the country. In the first year of the Phase I of the second round of DLHS-RCH Project, about 50 percent of the districts were covered and the remaining districts are to be taken up in the second year. Lungeli district is one of the three districts covered in the first year of the project in Mizoram. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunization services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilization of health services and users’ satisfaction. (excerpt)

The Reproductive and Child Health (RCH) interventions being implemented by the Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from method-mix, target-based activity to client-centered, demand driven quality services. Attempts are being made by the GoI to not only re-orient the program and service providers’ attitudes at the grassroots level, but also to strengthen outreach services. The new approach requires decentralization of planning, monitoring and evaluation of the services. Given the objectives and with the district being the basic nucleus of administration, the GoI is interested in generating district-level data, other than service statistics, on utilization of the services provided by Government health facilities. It also wanted to assess people's perceptions on the quality of services. Therefore, it decided to undertake District Level Household Surveys (DLHS) under the RCH project in the country. In the first year of the Phase I of the second round of DLHS-RCH Project, about 50 percent of the districts were covered and the remaining districts are to be taken up in the second year. Kolasib district is one of the three districts covered in the first year of the project in Mizoram. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunization services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilization of health services and users’ satisfaction. (excerpt)

The Reproductive and Child Health (RCH) interventions being implemented by the Government of India (GoI) are expected to provide quality services and achieve multiple objectives. There has been a positive paradigm shift from method-mix, target-based activity to client-centered, demand driven quality services. Attempts are being made by the GoI to not only re-orient the program and service providers’ attitudes at the grassroots level, but also to strengthen outreach services. The new approach requires decentralization of planning, monitoring and evaluation of the services. Given the objectives and with the district being the basic nucleus of administration, the GoI is interested in generating district-level data, other than service statistics, on utilization of the services provided by Government health facilities. It also wanted to assess people's perceptions on the quality of services. Therefore, it decided to undertake District Level Household Surveys (DLHS) under the RCH project in the country. In the first year of the Phase I of the second round of DLHS-RCH Project, about 50 percent of the districts were covered and the remaining districts are to be taken up in the second year. Ukhrul district is one of the five districts covered in the first year of the project in Manipur. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunization services; 2. Proportion of safe deliveries; 3. Contraceptive prevalence rates; 4. Unmet need for family planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilization of health services and users’ satisfaction. (excerpt)

The Reproductive and Child Health (RCH) interventions that are being implemented by Government of India (GoI) are expected to provide quality services and achieve multiple objectives. Over the last few years, there has been a positive paradigm shift from Method-Mix- Target based activity to client-centered-demand driven quality in RCH services. Attempts are being made by GoI not only to re-orient the programme and service providers? attitude at the grass-root level, but also to strengthen the services at the delivery points. The new approach requires decentralisation of planning, monitoring and evaluation of the services. With such objectives the district being the basic nucleus of administration, GoI has been interested to generate district level data, (other than routine service statistics,) on utilisation of the services provided by the Government health facilities. It was also of interest to assess people's perceptions about the quality of services. Therefore, it was decided by the GoI to undertake District Level Household Surveys (DLHS) under RCH Project in the country. In the phase I of second round DLHS-RCH project, about 50 per cent of the districts were covered by the survey. The remaining districts will be taken-up in the second year of the survey. Yanam is one of the 4 districts covered in the first year of the project in Pondicherry. The main focus of the District Level Household Survey is on the following aspects: 1. Coverage of ANC and immunisation services; 2. Proportion of safe deliveries; 3. Contraceptive Prevalence Rates; 4. Unmet need for Family Planning; 5. Awareness about RTI/STI and HIV/AIDS; 6. Utilisation of health services and the users? satisfaction. (excerpt)