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)

DELIVER's technical support has significantly improved the Ministry of Health's (MOH) contraceptive availability in all the service delivery points. This successful experience in family planning logistics has also improved the process of integration for the other essential drugs. In June 2006, the Information System for the Integrated Logistics System for Essential Drugs and Contraceptives (SIGLIM) was implemented in five regions with the expectation of being extended to the rest of the country in 2007. DELIVER has also strengthened the postpartum family planning services in 22 Mother and Child Health Care (MCHC) hospitals. DELIVER provided support to Profamilia staff in the use of management tools to evaluate their logistics system and forecast their contraceptive needs. The staff have been trained on how to use the LAST and how to use the software PipeLine, which is now being used with an established community-based distribution services in nine clinics. Since 2005, assistance to the Social Security Institute (INSS) started with an assessment of the family planning logistics system and services in the companies that provide private medical services (EMPs in Spanish). Based on the findings, a training program and supervision system have been developed to further develop the commodity logistics system. In July 2003, the National Contraceptive Security Committee was created and constituted by officials from the MOH, INSS, Profamilia, donor agencies, and cooperating agencies. During 2005, the contraceptive security committee held 14 meetings, designed a Contraceptive Security Strategic Plan 2005-2008 and a proposed implementation plan, developed a manual describing roles and responsibilities for the committee members, and proposed meetings with and presentations to policymakers. (author's)

Although artemesinin derivatives are promising for the treatment of severe Plasmodium falciparum malaria, intravenous quinine remains the most affordable treatment. However, administration of intravenous quinine is often not feasible in rural areas in Africa because of the lack of simple equipment or trained staff. We compared the efficacy and safety of intrarectal quinine with those of intravenous quinine in the treatment of childhood cerebral malaria. In a randomized, double-blind clinical trial at Mulago Hospital (Kampala, Uganda), Uganda's national referral hospital, we studied 110 children aged 6 months to 5 years who had cerebral malaria. Patients were randomized to receive either intrarectal or intravenous quinine. Main outcome measures included parasite clearance time, fever clearance time, coma recovery time, time to sit unsupported, time to begin oral intake, time until oral quinine was tolerated, and death. Overall, there was no difference in the clinical and parasitological outcomes between the 2 groups (data are mean +or- standard deviation, intrarectal quinine group vs. intravenous quinine group): coma recovery time, 19.4 +or- 18.1 h versus 17.0 +or- 12.1 h; fever clearance time, 26.7 +or- 16.1 h versus 29.9 +or- 18.1 h; and parasite clearance time, 43.2 +or- 14.2 h versus 41.9 +or- 15.2 h. Mortality was similar in both groups; 4 of 56 patients in the intrarectal quinine group died, and 5 of 54 patients in the intravenous quinine group died (odds ratio, 1.3; 95% confidence interval, 0.3-5.2). Intrarectal quinine was well tolerated, and no major immediate adverse events occurred. Intrarectal quinine is efficacious and could be used as an alternative in the treatment of childhood cerebral malaria, especially in situations in which intravenous therapy is not feasible. (author's)

We conducted a survey of health facilities and household members to determine supply and demand aspects of contraceptive use in Azerbaijan. In June 2005, we conducted interviews with 758 women and 253 men in a community-based survey in 40 communities in five districts. We also surveyed a sample of health facilities and pharmacies and conducted interviews with key informants. Both men and women in these communities desire small families, yet significant supply and demand impediments exist. Despite community interest, lack of knowledge of contraception is prevalent. Fear of side effects plays a role in non-use and discontinuation of modern methods, although little opportunity exists for counselling on side effects, since few health workers are trained. An obstacle to use is legislation that only allows contraception to be prescribed by gynaecologists, who are mostly concentrated in the hospitals of urban centres. However, the main handicap to increased use of modern contraception, is insufficient contraceptive supply. Not only is there a lack of method choice nationally, but few of the facilities we surveyed had any contraceptives available. This situation threatens to worsen as the United Nations Population Fund (UNFPA) retracts commodities' funding. The lack of knowledge of modern contraception, lack of trained staff and poor commodity availability signals that much remains to be done for the people of Azerbaijan to achieve their fertility control goals. (author's) | We conducted a survey of health facilities and household members to determine supply and demand aspects of contraceptive use in Azerbaijan. In June 2005, we conducted interviews with 758 women and 253 men in a community-based survey in 40 communities in five districts. We also surveyed a sample of health facilities and pharmacies and conducted interviews with key informants. Both men and women in these communities desire small families, yet significant supply and demand impediments exist. Despite community interest, lack of knowledge of contraception is prevalent. Fear of side effects plays a role in non-use and discontinuation of modern methods, although little opportunity exists for counselling on side effects, since few health workers are trained. An obstacle to use is legislation that only allows contraception to be prescribed by gynaecologists, who are mostly concentrated in the hospitals of urban centres. However, the main handicap to increased use of modern contraception, is insufficient contraceptive supply. Not only is there a lack of method choice nationally, but few of the facilities we surveyed had any contraceptives available. This situation threatens to worsen as the United Nations Population Fund (UNFPA) retracts commodities' funding. The lack of knowledge of modern contraception, lack of trained staff, and poor commodity availability signals that much remains to be done for the people of Azerbaijan to achieve their fertility control goals.

We conducted a survey of health facilities and household members to determine supply and demand aspects of contraceptive use in Azerbaijan. In June 2005, we conducted interviews with 758 women and 253 men in a community-based survey in 40 communities in five districts. We also surveyed a sample of health facilities and pharmacies and conducted interviews with key informants. Both men and women in these communities desire small families, yet significant supply and demand impediments exist. Despite community interest, lack of knowledge of contraception is prevalent. Fear of side effects plays a role in non-use and discontinuation of modern methods, although little opportunity exists for counselling on side effects, since few health workers are trained. An obstacle to use is legislation that only allows contraception to be prescribed by gynaecologists, who are mostly concentrated in the hospitals of urban centres. However, the main handicap to increased use of modern contraception, is insufficient contraceptive supply. Not only is there a lack of method choice nationally, but few of the facilities we surveyed had any contraceptives available. This situation threatens to worsen as the United Nations Population Fund (UNFPA) retracts commodities' funding. The lack of knowledge of modern contraception, lack of trained staff and poor commodity availability signals that much remains to be done for the people of Azerbaijan to achieve their fertility control goals. (author's)

Favorable client perceptions of provider's interpersonal behavior in contraceptive delivery, documented in clinic exit questionnaires, appear to contradict results from qualitative evaluations and are attributed to clients' courtesy bias. In this study, trained simulated clients requested services from Ministry of Health providers in three countries. Providers excelled in courteousness/ respect in Peru and Rwanda; in India, providers were less courteous and respectful when the simulated clients chose the pill. Privacy and two-way communication were less prevalent in all three countries. The findings challenge the courtesy bias interpretation. Global results from qualitative studies may have expressed the views of the minority of clients who are not treated well by providers. (author's)

A survey intended to ascertain the rate of use and type of contraceptive methods applied by Spanish women aged 40 to 50 years, and to determine the proportion of women in this group at risk of an unwanted pregnancy, was designed and validated. To achieve representative national results for the study population, it was estimated that a sample size of 2000 women was required. Women were selected using probabilistic, stratified random sampling. The survey questionnaire was prepared by the research group with the collaboration of experts in the conduct of population studies of this type. Participants were interviewed face to face by qualified and trained staff from a specialised company external to the research group. Overall, 1039 women (52%) resorted to some contraceptive method, of which (male or female) sterilisation was the most common. We estimate that in Spain there are 840,000 women (31.8%) aged 40 to 50 years at risk of unwanted pregnancy. (author's)

The delivery of quality family planning (FP) and reproductive health (RH) care services calls for an adequate supply of appropriately trained and supervised staff equipped and empowered to meet the needs of their clients. Knowledge of contraceptive technology and clinical procedures is a fundamental aspect of safe and accessible FP service delivery; training in interpersonal communication is essential to service quality. Skills need to be built into education and training programs at the beginning of a provider's career and then kept up to date; retraining and continuous supportive supervision are essential to maintaining skills and improving services. (excerpt)

The objective was to determine the magnitude of gynaecological emergencies and the socio demographic characteristics of patients admitted at Provincial General Hospital Kakamega (PGHK). Retrospective cross-sectional study was used. The setting for the study was the Provincial General Hospital Kakamega, the referral hospital for Western Province, Kenya. The subjects for the study were four-hundred patients admitted at the gynaecological wards during the period 1st January 2002 to 3lst December 2002. In this study 80% of gynaecological patients admitted at PGH Kakamega were of an emergency nature with 45% being teenagers. The mean age was 17 +or- 3 (mean +or- SD). The majority had primary level of education or below (69%), unemployed (87%) and were rural residents (71%). Patients with abortion formed about 43% of the study group while those with inflammatory disease, pelvic abscess and ectopic pregnancy formed about 24%, 10% and 8% respectively. Most gynaecological admissions in PGH Kakamega are of acutenature, with abortion being the most common diagnosis. Hence, trained staff, equipment, supplies and drugs for management of acute gynaecological conditions should be available in hospitals in Western Kenya. (author's)

In 2004, the U.S. Agency for International Development (USAID) awarded a three-year project called the Prevention of Postpartum Hemorrhage Initiative (POPPHI) to a consortium formed by the Program for Appropriate Technology in Health (PATH), RTI International, EngenderHealth, the International Confederation of Midwives (ICM), and the International Federation of Gynecology and Obstetrics (FIGO). Management Sciences for Health's Rational Pharmaceutical Management (RPM) Plus Program is a partner supporting this initiative; other collaborators in the POPPHI project include HealthTech and Access to Clinical and Community Maternal, Neonatal and Women's Health Services (ACCESS). The POPPHI project is part of USAID's special initiative to reduce postpartum hemorrhage (PPH), the leading cause of maternal deaths worldwide, by increasing use of active management of the third stage of labor (AMTSL). In late 2005, RPM Plus initiated a study in four West African countries - Benin, Burkina Faso, Cameroon and Mali, to identify issues at the central level that might negatively affect the quality of services at the facility level, looking specifically at: Factors affecting the widespread availability of uterotonics in health facilities; Training initiatives to ensure that staff are well trained in AMTSL and the storage requirements for uterotonics; Systems to ensure quality products, maintained through a secure distribution chain. (excerpt)

A major objective of the Program of Action adopted at the International Conference on Population and Development held in Cairo in September 1994, was to make reproductive health care - including family planning - accessible to all individuals by the year 2015. The Program of Action specifically called attention to the needs of especially vulnerable populations, including displaced persons and refugees. Unfortunately, prior to this time, reproductive health was rarely considered in responses to humanitarian emergencies. Bearing this in mind, the concept of a "Minimal Initial Service Package (MISP)" was created during the Inter-Agency Symposium on Reproductive Health in Emergency Situations held in June 1995. The aim of the MISP is to reduce reproductive health-related mortality and morbidity, particularly among women, during crisis situations. This can be accomplished by providing basic reproductive health services in the early phase of an emergency, including during the establishment of refugee camps. The MISP encompasses a set of activities which must be implemented in a coordinated manner by appropriately trained staff, as well as necessary equipment and supplies. All of the following aspects are important to implementing the MISP: Appropriately trained personnel, including a coordinator for reproductive health; Guidelines and training for the implementation of selected interventions; Essential drugs, basic equipment and supplies necessary to implement the services. (excerpt)

This report covers the project's progress from October 1, 2005 through September 30, 2006. During the first year of project implementation, MITRA has: a) recruited and trained project staff; b) intensively discussed project area selection and provided updates on project baseline data; c) established, coordinated, and developed key project elements; d) presented the DIP, work plan, and internal communication/ coordination systems as well as the monitoring, evaluation, and reporting system; e) signed a technical arrangement (TA) between CII and Banten Province Health Officials (Annex 1); f) improved communication and awareness processes among government health staff who are not directly involved but are closely related to the TB program (medical unit directors, nurses and other staff); and g) socialized TB and DOTS to all sub-district and village leaders in and around selected government health centers. This first year has also served to strengthen project design elements and key relationships and thereby increase the likelihood of success. (excerpt)

As ART becomes more widely available to millions the world over, emerging issues such as contraception for clients who are living longer and more productive lives become apparent. Family Planning offers HIV-positive clients opportunities to prevent unintended pregnancies, plan desired pregnancies, prevent mother-to-child transmission and avoid potential foetal damage from the use of certain antiretroviral drugs. EngenderHealth’s ACQUIRE project, Family Health International (FHI) and the Ghana Health Service are implementing a 15-month FP and ART integration pilot at two hospitals in Ghana. A performance needs assessment (PNA) conducted at the outset of the intervention to determine the current capacity to provide FP to HIV-positive women on ART, found that 58 per cent of ART service providers did not consider contraception as part of the scope of care, and integrating FP services added complexities to service delivery. The interventions consisted of training providers to provide FP within HIV clinics, developing job aids and client brochures, documenting integrated service delivery including referrals and monitoring and supervision. An assessment after three months of integrated services noted that health talks and individual counselling to clients on FP are taking place at intervention sites. Condoms, oral contraceptives and injectables are available at the ART sites and provided to clients as they choose. However, attrition or redeployment of trained staff is a major challenge to the provision of integrated FP-HIV services. | The presentation discusses some of the weaknesses still to be overcome following the integration of ART services. Systems and training of staff include the perception of some staff that providing FP services is an added function and deserves an increase in compensation.

The purpose of the TOT is to strengthen the capacity of a team of trainers by applying principles of adult learning, steps to behaviour change, and a variety of training methodologies and facilitation skills; developing learning objectives and designing lesson plans; using audio-visuals; and practicing training sessions. The TOT is based on the principle that everyone has something to share, and by including the active input of participants, interest and efficacy is increased. The course is designed for trainers/facilitators (health care personnel and program staff) who have already been trained in Infant and Young Child Feeding (IYCF), the Essential Nutrition Actions (ENA), the Lactational Amennorhea Method (LAM), or Prevention of Mother-to-Child Transmission (PMTCT) of HIV and have acquired the necessary knowledge and skills in the content area. (excerpt)

The Commercial Market Strategies project (CMS) developed a network of youth-friendly pharmacies to provide reproductive health information and contraceptives to youth in Guanajuato, Mexico. The network involved the commercial sector in providing reproductive health and family planning services, as well respect youth's privacy and reduce their potential embarrassment when obtaining those services. The project was launched as a pilot in November 2002 in collaboration with the Centro Latino americano para Salud y Mujer (CELSAM). Two principal strategies guided the network's design and implementation: training of pharmacy staff and clerks to better serve youths' needs and the launching of a communications campaign to promote the network and provide reproductive health information. This report documents the staged process in which the network was developed, discusses its impact and replication, and highlights lessons learned from the experience. An assessment of the network indicated that it improved the quality of reproductive health services available to youth in participating retail pharmacies. The trained pharmacy staff demonstrated more knowledge about contraceptives and sexually transmitted infections and treated youth in a friendly and non-judgmental manner, as compared to a group of pharmacies not in the network. These results on the supply side, including successful institutional partnerships with the public and private sectors, supported its replication in other cities in Mexico. (excerpt)

The objective of this report is to describe two adolescent family planning and sexual and reproductive health (FP/SRH) programs that have proven to be sustainable, successful, and of high quality. These models are the PROFAMILIA Youth Center program in Colombia and the FEMAP for a Healthy Youth program in Mexico Many countries are working to provide young people with healthcare services that respond to their needs by having specially trained staff, reduced fees, outreach activities, and hours that are convenient. However, government programs are frequently unable to meet the increased demand for services, are insufficient in numbers, and have limited capacity. Increasingly, governments are turning to non-governmental organizations (NGOs) to implement adolescent FP/SRH services. Such NGOs are striving to become financially sustainable; however, this sustainability is difficult to achieve due to the limited ability of adolescents to pay for services. The programs presented here have different financial strategies for achieving sustainability. It is hoped that these models will help other organizations implement or plan locally funded adolescent FP/SRH programs. (excerpt) | El objeto de este informe es describir dos programas de planificación familiar y salud sexual y reproductiva para adolescentes que han demostrado su sostenibilidad, su eficacia y su alta calidad. Estos modelos son el programa del Centro Juvenil PROFAMILIA en Colombia y el programa de FEMAP para una Juventud Sana, en México. Numerosos países están trabajando para brindar a los jóvenes servicios de atención sanitaria que respondan a sus necesidades con personal especialmente capacitado, tarifas reducidas, actividades de promoción y horarios convenientes. Sin embargo, a menudo los programas gubernamentales no logran satisfacer la mayor demanda de servicios, no cuentan con suficientes fondos y tienen una capacidad limitada. Cada vez con mayor frecuencia, los gobiernos recurren a organizaciones no gubernamentales (ONG) para implementar los servicios de planificación familiar y salud sexual y reproductiva para adolescentes. Las ONG, por su parte, luchan por su sostenibilidad financiera; no obstante, esta sostenibilidad es difícil de alcanzar dada la limitada capacidad de los adolescentes de pagar los servicios. Los programas aquí presentados emplean distintas estrategias financieras para lograr la sostenibilidad. Esperamos que los modelos descritos ayuden a otras organizaciones a implementar o diseñar programas de planificación familiar y salud sexual y reproductiva para adolescentes con financiación local. (extracto)

CPI includes all face-to-face communication between clients and staff members. Counseling is the most important form of CPI, having a specific purpose and requiring special knowledge and skills. Clients have a right to good counseling by trained staff who provide the information they need to make appropriate, informed reproductive health decisions and who respect their dignity and confidentiality. Good CPI also has practical benefits for both programs and clients. Counseling that helps clients choose and learn to use a family planning method that suits them has a positive impact on method adoption, continuation, compliance with regimens, and resulting health outcomes. Counseling is the chief safeguard of informed choice, which is required by service delivery standards and donor policies. (excerpt)

The objective was to develop and test a distance-learning programme to improve the quality and efficiency of family planning services in Guatemala. The setting was rural family planning services in Guatemala. The study design was quasi-experimental with one intervention and one control group and with pre- and post-intervention measures. Two staff members from each of 20 randomly selected health districts were trained as leaders of the training programme. In turn, the 40 trainers trained a total of 240 service providers, under the supervision of four health area facilitators. The results were compared with 20 randomly selected control health districts. The intervention was a distance-learning programme including 40 in-class hours followed by 120 inservice practice hours spread over a 4-month period. Distinctively, the programme used a cascade approach to training, intensive supervision, and close monitoring and evaluation. Patient flow analysis was used to determine number of contacts, waiting times, and the interaction time between service providers and clients. Consultation observations were used to assess the quality and completeness of reproductive health information and services received by clients. The intervention showed a positive impact on reducing the number of contacts before the consultation and client waiting times. More complete services and better quality services were provided at intervention clinics. Some, but not all, of the study objectives were attained. The long-term impact of the intervention is as yet unknown. Distance-learning programmes are an effective methodology for training health professionals in rural areas. (author's) | El objetivo fue desarrollar y probar un programa de aprendizaje a distancia para mejorar la calidad y eficiencia de los servicios de planificación familiar en Guatemala. El entorno fueron los servicios de planificación familiar de Guatemala. El diseño del estudio fue cuasi-experimental con una intervención y un grupo control además de mediciones previas y posteriores a las intervenciones. Dos miembros del personal de cada uno de los 20 distritos de salud seleccionados aleatoriamente recibieron capacitación como líderes del programa de capacitación. A su vez, los 40 líderes capacitaron a un total de 240 prestadores de servicios, bajo la supervisión de cuatro facilitadores del área de salud. Los resultados se compararon con 20 distritos de control sanitario seleccionados aleatoriamente. La intervención consistió en un programa de aprendizaje a distancia de 4 meses de duración que incluía 40 horas de instrucción presencial complementadas con 120 horas de práctica en el servicio. El programa se caracterizó por su enfoque "en cascada" a la capacitación, además de supervisión intensiva y monitoreo y evaluación continuos. Se utilizó análisis de flujo de pacientes para determinar el número de contactos, de tiempos de espera y el tiempo de interacción entre prestadores de servicio y clientes. Se realizaron observaciones de consulta para evaluar la calidad y el alcance de la información y los servicios de salud reproductiva provistos a los clientes. La intervención mostró un impacto positivo en la reducción del número de contactos antes de la consulta y en tiempos de espera del cliente. En las clínicas participantes se prestaron servicios más completos y de mejor calidad. Se alcanzaron algunos de los objetivos del estudio. Aún se desconoce el impacto a largo plazo de la intervención. Los programas de aprendizaje a distancia constituyen una metodología eficaz para capacitar a los profesionales de la salud en las áreas rurales. (del autor)

The purpose of this document is to address some of the issues in contraception and sexual health for nurses who work in primary care. Nurses working in primary care provide a diverse range of services in the area of contraception and sexual health. This diversity reflects the wide range of experience and training among individual nurses. Many nurses have asked the Royal College of Nursing (RCN) for guidance, protocols and Patient Group Directions (PGDs) to use in providing contraceptive and sexual health services in primary care. The RCN recognises that some doctors may expect nurses to provide services, which they are not trained or competent to perform. Nurses should not extend their role if they lack the competence to practice safely. (excerpt)

Many people throughout the world remain underserved by the traditional public health care system. This is especially true where resources are lacking, the quality of equipment and facilities is poor or disintegrating, and the number of trained health care providers is insufficient. In many countries, pharmacists and pharmacy counter staff increase access to critical health information, services, and products. Even in settings where health services are broadly available, people often rely on the pharmacy or drugstore as the first and sometimes only stop for health care needs. Pharmacists and pharmacy staff are well placed to provide basic counseling and information as well as referral for clinical services that cannot be provided in the pharmacy. They also can assist clients with self-diagnosis and treatment services for a variety of conditions. The degree to which people rely on the pharmacy, and the relatively easy access pharmacies allow, makes them an important resource for health. (excerpt)