Elements of Family Planning Success

In late 2004, the Senegal USAID Mission requested that IRH provide limited technical assistance to MSH, its main reproductive health coordinating agency, and the Ministry of Health (DSR) to introduce the SDM into the family planning program. USAID/Senegal provided a small amount of funding to IRH to cover staff time and costs for a trip to conduct a training of trainers (TOT), one monitoring trip, and long-distance technical assistance. In August 2005, MSH -as part of the Prevention of Maternal Mortality (PREMOMA) project -launched the SDM program with a TOT at central and regional levels conducted by two IRH representatives. With the DSR, MSH then trained health providers and community agents in 8 districts in the regions of Dakar and Thies. About six months after the initial TOT, IRH conducted a monitoring trip that showed both great provider and client interest and the need to raise community awareness about new services. MSH trained 38 trainers and 256 providers from 58 government clinics in the two project regions. MSH also worked with IRH to implement a quality monitoring system of regular visits to providers, using IRH's Knowledge Improvement Tool (KIT) and an MSH coaching guide. Unfortunately, MSH had difficulty obtaining data on the number of SDM acceptors, and therefore, this information is unavailable. MSH also trained 40 community agents from the Christian Children's Fund (CCF) and 12 trainers from a local FBO, Senegalese Association for the Promotion of the Family. The PREMOMA project ended in September 2006, and the Mission included the SDM as part of the next reproductive health project, awarded to IntraHealth. IRH oriented IntraHealth staff in the U.S. and Senegal to SDM activities in Senegal, but had no funding or contact after that point for any needed follow-up. To maintain momentum between projects, IRH funded a local community based organization, Tostan, to conduct awareness-raising in the areas around the pilot sites. IRH trained 75 Tostan trainers who subsequently trained approximately 850 community mobilizers. Because of the pilot nature of SDM introduction in Senegal, progress toward full integration into norms and protocols, and management information, supervision, procurement, and distribution systems was limited. As mentioned, MSH implemented a supervision system for the pilot series. It also adapted provider job aids from IRH samples. Neither the government nor NGOs have included the SDM in their information systems, nor are CycleBeads part of the commodities management system. IRH understands that the DSR included the SDM in its revised norms and protocols. The Mission instructed their CAs, including IntraHealth and CCF, to include the SDM in their portfolios, both in clinics as well as in a proposed community-based distribution program. The Mission has also provided funding to purchase CycleBeads, further strengthening the potential for SDM scaleup. An assessment is planned for 2008 to determine the status of SDM in Senegal and identify potential needs for further assistance. (excerpt)

There is growing recognition of the public-health burden of intimate partner violence (IPV) and the potential for the health sector to identify and support abused women. Drawing upon models of health-sector integration, this paper reviews current initiatives to integrate responses to IPV into the health sector in low- and middle-income settings. We present a broad framework for the opportunities for integration and associated service and referral needs, and then summarize current promising initiatives. The findings suggest that a few models of integration are being replicated in many settings. These often focus on service provision at a secondary or tertiary level through accident and emergency or women's health services, or at a primary level through reproductive or family-planning health services. Challenges to integration still exist at all levels, from individual service providers' attitudes and lack of knowledge about violence to managerial and health systems' challenges such as insufficient staff training, no clear policies on IPV, and lack of coordination among various actors and departments involved in planning integrated services. Furthermore, given the variety of locations where women may present and the range and potential severity of presenting health problems, there is an urgent need for coherent, effective referral within the health sector, and the need for strong local partnership to facilitate effective referral to external, non-health services. (author's)

Mali, a large, landlocked country in western sub-Saharan Africa, has high fertility and low contraceptive use. Only 8% of married women use any method of contraception, with 6% using modern methods. Its approximately 13 million people are mainly Muslim (90%), and 80% live in rural areas with limited access to family planning services. The total fertility rate was seven children per woman in 2006, compared to an average of five in Africa. The government of Mali (GOM) actively promotes family planning and contraceptive security as part of improving quality of life. Unlike other countries in the AWARENESS Project, the GOM committed to national integration of the Standard Days Method® (SDM) without undertaking a pilot study. A relative newcomer to the AWARENESS Project, Mali began implementing project activities in 2006, utilizing the SDM and LAM as an approach to repositioning family planning. (excerpt)

In 2003, the USAID Mission and the National Reproductive Health Program (PNSR) invited IRH to introduce the SDM in the Democratic Republic of Congo (DRC). The strategy focused on training providers and integrating the SDM into existing clinic, community, and pharmacy services in Kinshasa, Lubumbashi, and Bukavu, and the rural area of Katako Kombe. By 2004, 14 organizations were able to offer the SDM. CycleBeads are included in the national list of essential medicines and the five-year contraceptive security plan. The SDM is part of in-service family planning training curricula. The PNSR is developing national norms and protocols and intends to include the SDM. IRH also worked with the MOH to incorporate the SDM into national policies and logistics and reporting systems. However, the lack of overall government norms and functioning distribution and reporting systems is an obstacle requiring more comprehensive attention than the AWARENESS Project could offer. The program leveraged significant resources, as most partners paid for their own training programs and CycleBeads. The Congolese program participated in a study to determine the impact of the social marketing campaign, a general evaluation of SDM integration in the DRC. Major findings from the simulated client study showed that 89% of clinic providers gave spontaneous information on the SDM as opposed to only 38% of pharmacists; confidentiality was observed in over 70% of both clinics and pharmacies; 96% of providers in clinics told clients that CycleBeads represent a woman?s cycle while only 35% of pharmacists did so; and 7% of clinic providers attempted to convince clients to use other methods of family planning as opposed to 23% of pharmacists. The success of recent initiatives in DRC to introduce the TDM through services of an faith-based organization (FBO) suggest that this method may also be an appropriate addition to family planning services. (excerpt)

MSH and the MOH officially launched the SDM in November 2005, with IRH participation. At that time, a total of 141 key Haitian trainers and service providers received general training. MSH also conducted official launches in each province and trained trainers in some provinces, using materials developed by IRH that MSH translated and adapted. MSH procured 25,000 sets of CycleBeads, some of which were distributed at regional launches and trainings, and provided technical assistance to the MOH for follow-on cascade training. The 14 institutions where MSH offers direct support initiated SDM services, as did a number of government sites and clinics of some FBOs. In February 2007, IRH conducted a service assessment that showed SDM integration in Haiti did not follow an optimal process due to the weak central government, lack of stakeholder commitment, lack of a central supervision system, insufficient funding for technical assistance, and the lack of an organized commodities procurement system. Many providers had not been formally trained but were offering the SDM with incomplete information. Although some services collect SDM data, the SDM has not been included in the national database for family planning. The SDM is sporadically available in more than 20 clinics countrywide, and more than 700 users have been registered (although the actual number is unknown). Interest is high on the part of clients and providers, but there is little coordinated effort on the part of stakeholders. Introducing the SDM in an unstable environment without consistent technical assistance is extremely difficult. Further discussions with the USAID mission on implementing organizations are needed to assess the potential for future success. (excerpt)

Benin became the first African country to introduce the SDM when the Ministry of Health (MOH) and IRH agreed in December 2000 to conduct a pilot introduction study in two urban centers, Cotonou and Parakou. The study determined that strong demand for the method existed; that the SDM could be offered effectively through existing service delivery channels; that there was a high degree of acceptability and continuation of use; and that the SDM could be used correctly and consistently. The government requested IRH?s help to expand delivery of the method nationwide, an effort that began in December 2004. As service sites multiplied, Benin participated in other international, multisite studies, including a long-term (up to two-year) follow up of users and a study to determine the impact of social marketing campaigns on SDM use, particularly comparing pharmacy and clinic-based services. There was no significant difference in correct use between clients who obtained the SDM through clinics and those who obtained it in pharmacies. The government has included the SDM in national reproductive health norms, policies, and training protocols and materials. The AWARENESS Project, in collaboration with local partners, trained more than 600 providers countrywide, recording more than 12,000 SDM acceptors between 2004 and 2007. The SDM is currently offered in more than 150 public, community, and commercial sites in all 12 departments of the country. An evaluation of the integration process after three years showed that the SDM is well integrated into the health system, and was offered in all visited clinics, where 57% of providers had been trained on the SDM. The Benin program serves as a demonstration site for neighboring francophone countries. (excerpt)

The paradigm shift in population and development that occurred at the International Conference on Population and Development (ICPD) in Cairo, in 1994, from reduction in population growth for socio-economic progress to ensuring sexual and reproductive health and rights as a fundamental human right and as a means for improving the quality of life, has also become apparent in the Pacific. The Millennium Development Goals (MDGs) provide the current global framework for development efforts and were formally endorsed in 2000 by 189 countries, including Pacific island countries. The importance of sexual and reproductive health was not fully articulated during the formulation of the MDGs as an explicit goal. However, during the World Summit convened in 2005, world leaders endorsed the fundamental human right of "universal access to sexual and reproductive health services" _ an additional target to the MDG 5, as a result of intense lobbying by sexual and reproductive health advocates, including the Prime Minister of Tuvalu. The full integration of the MDGs into national sustainable development strategies and plans outlining an allocation of a certain percentage of the national budgets to poverty reduction is requiring a lengthy internalization and implementation process for many Pacific island countries. Part of the challenge for many of those countries has been the relevance of the poverty definition and the prevailing perception by some country leaders that "poverty of opportunity" is the more fundamental issue. Repositioning family planning as an integral development strategy for poverty reduction and as a mechanism for achieving fundamental reproductive rights needs to be acknowledged at the highest political level. (excerpt)

The objectives were to document the pilot experience of provision of safe abortion / post-abortion services implemented in 2002 at the Mother Child Health clinic in Sihanoukville, Cambodia, and to profile clients and assess their uptake of post-abortion contraception. The initial package of safe abortion / post-abortion clinics (SAPAC) services included counselling on family planning and prevention of sexually transmitted infections, pain management, Manual Vacuum Aspiration procedure and standard universal precautions at an affordable price (US$12.5). SAPAC services became operational in August 2002. The data of medical records from 1 August 2002 to 31 December 2005 (2224 clients) were analysed. The mean number of clients per month attending SAPAC services ranged from 26 in 2002 to 64 in 2005. Fifty-three per cent were housewives, 24% worked in sales or services, 8% in factories, 11% in bars or karaoke lounges and 3% were brothel-based sex workers. Ninety-three per cent of clients came for induced abortion and 7% sought post-abortion care. Pain management was used in 99% of cases. The overall rate of complications during intervention was 2.1% and dropped from 9.4% in 2002 to 1.3% in 2005. After SAPAC implementation, fewer women in Sihanoukville sought abortion services without any quality control and a safer technique was used. On average, 40% of patients took up contraception after the abortion. Integrating comprehensive abortion-care services at a peripheral government health facility is feasible. There is a demand for such services provided at an affordable price in Sihanoukville, Cambodia. (author's)

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures. (author's)

This paper argues that many internationally financed literacy programs do not sufficiently take into consideration important daily life issues of the learners, including nutritional deficiencies that may hinder learning, or of children-parent-society interactions that may improve learning. As a result, many programs have become synonymous with increased supply of a low-quality education. Often, these programs address almost exclusively Education for All (EFA) international policy targets, without sufficiently addressing other poverty alleviation targets, as defined by the Millennium Development Goals (MDGs). This paper further contends that approaches that would generate the greatest effects within an EFA-perspective may not be the best way to alleviate poverty within a MDGs-perspective. Based on a case study of a women's literacy program in Senegal, this paper proposes to look at needs within an MDG perspective, and to use multi-pronged and integrated approaches to intervene in sectors where the poverty alleviation impact is the greatest. Current achievements against the MDG indicators show that significant efforts are needed to reduce maternal and child mortality, boost primary school enrollments, and remove obstacles so that a greater number of girls can attend school. One important target group for promoting greater achievements against these indicators would be young adults living in poverty, especially girls and young women. An approach that combines youth and family literacy, early child development (ECD), as well as health and nutrition interventions, could help to break a cycle of poverty that is fundamentally intergenerational in nature. Further, it is argued that integration of these different interventions, which are usually offered as separate services (but addressing essentially the same target group) could be more cost-effective than implementing each component as separate projects. Accordingly, this paper recommends the integration of such services as nutritional training for youth andadults; information and services for family planning; training on STD/HIV prevention and management; access to immunization for children and pregnant women; assistance to obtain antenatal registration and care as well as training and treatment of existing and non-complex conditions; and, if needed, micro-nutrient supplementation. (author's)

Between September 2005 and April 2007, FRONTIERS and Alva, a Nicaraguan consulting firm, conducted a situation analysis of the provision and use of contraceptive services in postpartum, postabortion and prevention of mother-to-child transmission of HIV (PMTCT) programs. This study was undertaken in collaboration with the Nicaraguan Ministry of Health (MOH) and the Nicaraguan Social Security Institute (INSS). The project's objective was to assess the degree to which contraceptive services were linked to postpartum, postabortion and PMTCT services and if this allowed the programs to meet the contraceptive needs of their clients. The project also proposes recommendations for improving the quality of these programs. The study collected quantitative and qualitative data from a nationally representative sample of 11 MOH hospitals, 20 MOH health centers and three Provisional Medical Companies (EMPs) that were affiliated to the National Social Security Institute (INSS) of Nicaragua. Data collection took place between June and September 2006 through service inventories from 33 clinics, interviews with 75 providers in primary care facilities, 156 providers in secondary care health units, 596 women in antenatal care, 487 women before discharge from the hospital after a delivery, 26 women who had received postabortion care; and 605 women in the six-months postpartum period visiting out-patient clinics and health centers. Two focus group discussions were held with women seeking postpartum care in a health facility, two with women that were in the six month postpartum period but had not sought postpartum care, and one with women who were living with HIV. In-depth interviews were held with MOH directors in charge of family planning, post-obstetric care and PMTCT, and with reproductive health experts at the national and local levels. (excerpt)

This report presents the results of a situation analysis of the provision and use of contraception in Postpartum, Postabortion and Prevention of Mother-to-Child transmission of HIV (PMTCT) Services in Haiti. The Centre d'Evaluation et de Recherche Apliquee (Center for Evaluation and Applied Research or CERA), a Haitian health research and evaluation consulting firm, was responsible for the data collection, cleaning, and entry processes. FRONTIERS provided CERA with technical assistance throughout these phases and analyzed the data. Data were collected between November and December 2006 from a sample of 41 public, private and mixed health establishments in five of Haiti's 10 departments, including the three most heavily populated departments. Data were collected through: content analysis of the National Family Planning and Maternal Health Norms; inventories of equipment, supplies, and service statistics in family planning, antenatal care, delivery care, maternal and child care in the extended postpartum, and PMTCT services; structured interviews with health providers; exit interviews with women in antenatal, delivery, and postpartum care and women in the six-month postpartum period visiting a health outlet for any reason; and with women living with HIV and receiving care in an integral care unit (ICU); observation of client-provider interactions in antenatal, delivery and postabortion care by non-participants; focus groups with women who had delivered recently, women who had delivered in the last six months and women who did not use reproductive health services. (excerpt)

A diagnostic study of the provision and use of contraception in postpartum, postabortion, and prevention of mother-to-child transmission (PMTCT) programs in the Dominican Republic was conducted with funding from USAID's Latin American and the Caribbean Bureau. The objectives of the study were to assess the contraceptive knowledge, attitudes, and behaviors of providers and clients, the degree to which information, counseling, and delivery are implemented in postpartum, postabortion, and PMTCT services, the quality of these services, and the readiness of postpartum, postabortion and PMTCT services to offer contraceptive services. Researchers visited and carried out service inventories at 59 hospitals and health centers of the Ministry of Health (MOH), the Dominican Social Security Institute, and Profamilia (the IPPF-affiliate). Interviews were held with 522 health providers (303 in Ob-Gyn wards and 219 in outpatient services), 2,965 women in antenatal care, 879 following their delivery, 162 in postabortion care, 1,421 in the six-month postpartum period, and 156 at HIV integral care units. In five facilities non-intrusive ethnographic observation were undertaken of the context where services were provided and structured observation of client-provider interactions. In-depth interviews were held with 21 providers and 20 users and three focus group discussions with women in the first six months postpartum. (excerpt)

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures.

Kingdom of Jordan Ministry of Health (MOH) have identified the importance of strengthening national capacity through the integration of reproductive health (RH) services into the primary health care system. It is reported that a high percentage of Jordanian women use traditional family planning (TFP) methods, frequently using them incorrectly. Our purpose in this qualitative descriptive study was to explore the issues and challenges related to the use of TFP among Jordanian women. Six focus groups with women of childbearing age (18-44 years of age; n = 51) were held in the northern, central, and southern regions of Jordan. Study participants used traditional methods such as withdrawal, periodic abstinence, and breastfeeding. Often TFP methods were used incorrectly, resulting in a high failure rate with unplanned pregnancies occurring within short inter pregnancy intervals. Women preferred using TFP because of side effects experienced while using modern family planning (MFP) methods, misconceptions, and lack of correct information about MFP methods. Husbands often declined to use condoms but supported the use of TFP methods. Women indicated that they have unmet needs for family planning and that they would consider using MFP methods if accurate information was available at health centers. They emphasized the importance of competent and knowledgeable health care providers (HCPs) who contribute to decision making regarding use of family planning. (author's)

This report documents the assessment of a family planning (FP) training program for providers to enable them to offer family planning counseling and methods, and make referrals where needed as part of antiretroviral therapy (ART) services in Ghana. This effort was a joint project of the Ghana Health Service, the ACQUIRE Project of EngenderHealth, and Family Health International. In December 2005, five master trainers of the Ghana Health Service participated in a week-long training session. Subsequently, 32 providers drawn from the FP and ART service areas (16 each from Korle Bu Teaching Hospital and Atua Government Hospital) were trained in groups of eight, in five day-long sessions during January and February 2006. Topics covered in the training included contraceptive technology updates, integration of FP in HIV care and treatment services, professional and personal comfort with providing condoms to ART clients, and WHO recommendations on the use of contraception by HIV-positive women. Providers were trained to offer clients oral and injectable contraceptives on site, and to make referrals to the hospitals' family planning clinics if clients desired other methods. Existing job aids and IEC materials were adapted to reflect new content from the module and produced by EngenderHealth. The goal of the evaluation is to provide information to the Ministry of Health in Ghana to help it to improve programs to deliver family planning services to women enrolled in ART programs. The objectives are: to identify the fertility desires and contraceptive needs of HIV-positive women who are enrolled in an ART program; and to determine whether trained providers are meeting the family planning needs of HIV-positive women. (excerpt)

The objectives were to estimate the effect of receiving HIV-positive test results on intentions to have future children and on contraceptive use and to assess the association between pregnancy intentions and pregnancy incidence among HIV-positive women in Malawi. Women of unknown HIV status completed a questionnaire about pregnancy intentions and contraceptive use and then received HIV voluntary counseling and testing (VCT). Women who were HIV-positive and not pregnant were enrolled and followed for 1 year while receiving HIV care and access to family planning (FP) services. Before receiving their HIV test results, 33% of women reported a desire to have future children; this declined to 15% 1 week later (P less than 0.0001) and remained constant throughout follow-up. Contraceptive use increased from 38% before HIV testing to 52% 1 week later (P less than 0.0001) and then decreased to 46% by 12 months. The pregnancy incidence among women not reporting a desire to have future children after VCT was less than half of the incidence among women reporting this desire. With knowledge of their HIV-positive status, women were less likely to desire future pregnancies. Pregnancy incidence was lower among women not desiring future children. Integration of VCT, FP, and HIV care could prevent mother-to-child HIV transmission. (author's)

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counselor-levels were 1.9-7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard maternal and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics. (author's)

Effective linkage between postabortion evacuation services and family planning is essential to reduce the incidence of repeat unwanted pregnancy and unsafe abortion. This collaborative operations research study between FRONTIERS Program, TAHSEEN/Catalyst Project, and the Egyptian Ministry of Health and Population (MOHP), with funds from USAID, was undertaken to test the feasibility, acceptability, and effectiveness of two models of integrating family planning services with postabortion services. The first model involves provision of family planning counseling to postabortion patients and referral to a clinic near their residence to receive a method. The second model involves, in addition, offering family planning methods to postabortion patients who are interested in immediate initiation of contraception. A companion study investigated pain management perceptions and practices of Egyptian patients and providers in relation to postabortion care in different types hospitals; the research methodologyand results are provided in Appendix I of this report. The study was conducted in six MOHP hospitals in Fayoum and Beni Suef governorates where staff received training on improved PAC (including FP counseling and method provision), a PAC brochure was provided to postabortion patients before discharge, and FP methods were placed on the Ob/Gyn ward. The two models were implemented in tandem over a three month period followed by an assessment using provider interviews, supervisor interviews, patient exit interviews, patient follow-up interviews at home three months after discharge and customized spreadsheets to collect information on incremental costs. (excerpt)

One of the mandates of The Extending Service Delivery (ESD) Project, a reproductive health and family planning (RH/FP) service delivery project funded by USAID's Bureau for Global Health, is to identify, document, and disseminate promising and best practices in RH/FP for application at the community level. The project focuses on RH/FP community-based interventions that reach underserved populations such as urban and rural poor. Consistent with its mandate, ESD is providing the following brief on a best practice model for improving the quality and accessibility of FP and HIV services in rural communities in Zimbabwe. (excerpt)