Successful Elements of Family Planning

Interview with Habib Sadauki, Pathfinder International

Conducted on April 30, 2008 by Katie Richey

Katie Richey: Can you tell us a bit about your background and how you became interested in reproductive health and family planning?

Habib Sadauki: I am a medical doctor and am trained as a gynecologist/obstetrician and I have practiced for about 30 years now. In the course of my clinical work, I found that you can treat women individually and you can make impacts, but you find that women with pregnancy problems do arrive and the major causes of maternal mortality are not unrelated to frequency and interval of delivery, the number of deliveries. If you are to make an impact reducing maternal mortality the perfect effort is to not have pregnancy. But you can space your children, and you can have fewer children. So you do it only a few times during that interval. It makes sense. Not only do the children and mother survive, but also economically, socially, governmentally, it is more advantageous to have just enough children that you can look after and manage, like healthy and you can see them grow onto adulthood. This characteristic attracted me to family planning and working at a wide level, not just talking one-on-one counseling.

Talking to the community, working on policies, ensuring appropriate policies of family planning, how do we get communities to understand the rationale behind family planning, how do you get them to accept family planning. These are larger issues than you can deal with in the clinical room and that brought me over, talking about national level, community level, trying to promote reproductive health at all levels and ramifications. Seeing a woman going through pregnancy, the complications, seeing how many women die, things that we an prevent. Seeing if they really needed this pregnancy (the 10th pregnancy). I’ve seen almost the 17th pregnancy. She is taking a risk every time she exceeds beyond the 5th child. That really took my interests outside the clinic. Since, for the last 10 years I’ve mixed the community and national activities with clinical work, I spend a lot of time doing more policy-level and community-level stuff protecting good reproductive health.

KR: In your words, please define a successful family planning program? What contributes to success?

HS: If you say what is a successful family planning program, it’s one that provides access to the services, to a well-motivated individual and communities. There’s the intent and the desire, people are motivated to accept it and see a reason for it, and then the services are available easier and affordable to them. They have an opportunity to receive the services.

KR: Why is government support of FP programs so important?

HS: I should be talking about the governments I know, that of Nigeria. At present level of development of Nigeria, everything you want to do must get the blessing of the government. The government controls all the resources of the country, they give the policies, they provide ability for everything that you do. So governments support in every activity is very important—without that you cannot succeed. If you bring a program, for example a FP program, and you are going to implement it in the community, ultimately the health facilities. The majority of the health facilities belong to the governments, so you can see clearly that if there is no support from the government, it will fail. So we need government’s policy makers, the technocrats within the governments to appreciate what we’re talking about, to appreciate that there is need for child spacing, maternal services support, if we’re to bring down maternal mortality. Maternal mortality will continue as long as women are having 10 children, as long as women have short birth intervals. A good example is postpartum hemorrhage, a condition that can affect anybody unannounced and the woman can die suddenly from that. So there is need to have a successful FP program that addresses frequency of birth at high priority. On top of that is to have efficient maternal services, where women have access to safe delivery, and access to safe family planning. They should go hand and hand.

KR: In your opinion, who are the actors in developing supportive government policies?

HS: We should look at it from different levels of government. First of all you have the technocrats, the professionals, who know it all so-to-speak and they are the people that should give the technical advice and also can formulate policy. But for policy to become reality, you need the top management of any government, especially the political side of management. They are the people that make decision and they need to be aware. The role of the technocrats here is to feed the right information to the politician.

A lot of the problems in Nigeria is that the leadership does not appreciate what we are talking about. A lot of us will gather and talk about maternal mortality and safe abortions, no access no skilled delivery. But what does it take to have skilled delivery, trained FP providers, in our environment of human resources? So the right policy must be there for the trainer of these providers, for the training of the trainers and for the supply of the hospital. If the people in the management don’t appreciate this, then you have problem, you are only speaking to yourself. The actors, the policy makers, the decision makers, they are there and we should always advocate on them to make sure that they understand what we are talking about.

When they do, and they are converted, things become very easy. They prepare the right amount of money for your programs. And unless you do that, you don’t have the right money, you don’t have the right resources, personnel to provide the services. So the actors: the technocrats, the policy makers and the political part of the management. They all need to come in.

At another level is the community itself. The community knows what they want and they ask from the government. So there is need to remember that a good portion (especially community leaders) at a different level—religious leaders, traditional leaders, some opinion leaders within the community—who have access to the government at a different level. They say “Look, our children are dying, our children are not able to go to school, our women don’t have access to skilled delivery.” But what is skilled delivery, Then they can come to a technical group to provide the answers and provide guidelines. Then you will find that the right policy will be there.

There are levels of involvement in the government and we all must advocate at different levels, especially the players that are promoting safe delivery, reproductive health, rights and issues. We need to bring everybody on board.

KR: Can you give examples of where leadership and policies have negatively affected FP programs? And where have positively affected programs?

HS: Negative side is difficult to in point who is doing what where. But in the state of Nigeria, where you do not have the governments or the people in power (especially the policy formulator in support of any program), you find that that can impact negatively on the supply of commodities for instance, even training of personnel, or support for the facilities in every environment. You find that if those group of people aren’t interested, there is no success at all—that can bring negative impact.

A positive impact on FP program is where you have the right place, where people are committed, who are interested, who are converted to appreciate the value of family planning and child spacing for health reasons. You find that you can get a tremendous amount of support. Where we had that in Nigeria, I wanted to provide access to skilled delivery. You had the technocrats from the ministry, the politicians in support of it, and it became a huge success to delivery. All we did was provide three maternal delivery services and they provided all the funds required, provided the supplies, the equipment and support the program that provided services to women who came to clinic to deliver in government hospitals. The year before that program, you know it was the largest hospital in the state (about 5000 deliveries each). But when this service was introduced, the following year they did about 11700 women. So you can see how supportive government can impact on a program.

Now the advantage of that, when the women came out, that was a good opportunity for her to be counseled. “OK, now there is also a need for health reasons for you to space your child.” Then we did it frequently because it was free. They were counseled and had access to family planning. And if you set up good family planning along side this type of program, you are bound to succeed. So yes, key players must be converted. People must have the right attitude and knowledge, so that they can develop the right policies and implement them.

KR: Why is a community-based approach so important for success in FP programs?

HS: The community should always own a program. They are the users of the program, They say “The person that wears the shoes knows where it pinches.” Community is key to success in family planning program.

The involvement of the community has really helped some of the services that we have achieved in family planning program under the COMPASS project. There was a good community mobilization and people came out. The community members, if they appreciate what you are doing and they take on the aspects of your program, then it will succeed. We were in a situation where they provided support for a clinic, they bought equipment, water transport and commodities for the facilities because they are interested. They believe that every man, every woman should support child spacing and should have access to the facility that has been renovated and that this program and this project. The community is very important in the success of family planning programs.

KR: In your experience, what role should the community play in the planning and implementation phase of these programs?

HS: First of all, we need to involve them to appreciate what we are talking. And when we do that, we create a situation where they own the program, and they tell us what they need, not what we think we want to give them. We should be able to find out from the community what their needs are. Sometimes we go an we tell them, “What we want to do for you is to build a school, a health center.” But then they say, “that’s not our problem, our problem is that there’s no water in this town. So what is a hospital for if we cannot even get anything to drink?” So involving the community and understanding them and let them also understand the program and let them own the program, let them decide how they want to run each. So we provide the guidance, provide the skills for them to appreciate. The health reasons, the economic reasons, let them appreciate that. Once it has sunk in that family planning can promote health, you are there. Or family planning is good for the educational success of my daughter, so she doesn’t get married at 13 and can go to university, she can become a doctor, an engineer, a nurse, she will be able to fend for herself and is economically independent. If you create that kind of environment to understand and appreciate, and they own the program, it will succeed.

KR: Can you tell use about your experience training clinical staff on post-abortion care and some of the most important messages emphasized?

HS: Certain post-abortion care services in Kanua state of the 36 states of Nigeria, the largest in terms of population. We train all of our 200 midwives and 50 doctors in post-abortion care, including the use of manual vacuum aspirator (MVA) in every secondary care centers and primary care centers of post-abortion care. One component of post-abortion care was a post-abortion family planning corner—where a woman who have had abortions can be counseled and provided with family planning counseling and also services if they desire at once (otherwise they are referred to nearby FP clinics). In the course of this work, we found that among women who have abortion, they have to travel long distances to get services, have to wait which wastes a lot of time (in some cases, they will spend 2-3 days waiting for an evacuation which is normally conducted in a theater with anesthesia). But with introduction of the post-abortion care program, where we were using MVA, it was easy to train staff nurse-midwife to be able to provide the services, they can counsel, they can examine and diagnose incomplete abortions and refer to doctors or can do evacuation themselves. It was really such an excellent program that was scaled-up in the state. What happened was that we were able to put in place the State Services program, which meant that the state government supported the services and women had access to post-abortion care, available and within their environments. There were some rural hospitals that were able to provide some basic services and there was no need for a doctor, no need for electricity for the services and were using high level disinfection to sterilize the instrument. And this was really a successful program.

Of course there were challenges. In Nigeria, abortion is illegal and there were laws, and people felt we were training people to do abortions in public facilities. That was investigated and it was not found to be true—it was that people were providing services to women who needed it, who really desired them, and would have had to travel long distances to services to get services. I think it was good. There were lots of challenges in terms of attrition of staff. We trained staff and after awhile they leave. One thing we emphasized with that, we encouraged on-the-job training, so we train you and when you go back to work you train others on-the-job as well. The services were comprehensive. We talked about infection prevention, we talked about the care itself, post-abortion and family planning of course as well. The post-abortion unit became the family planning unit as well, so women came there for their FP services, not only for post-abortion care. Earlier on they didn’t have a FP clinic, and then we discovered that there was a need and no one was providing it. That’s how it goes.

KR: How important is motivated staff in FP delivery systems? Problems with attrition? How can FP programs strive to keep staff motivated?

HS: Staff that are not motivated will not do that work. I will give an example of a state of Nigeria where the staff in charge of the family planning was badly badly motivated and she collected supplies and lugged them up in the toilet until they expired. To her that was nothing, that was no problem. So you can see what motivation can do—she was disinterested. Meanwhile, women we not getting services, she didn’t care. She was disinterested in family planning, FP was not for her or for anyone who’s just into population control. So we need the right staff top have the right attitude and they need to be motivated.

This motivation has many aspects and will include their pay. They have to be paid properly. It may be a question of training, it may supervision. All this must be taken into consideration. Somebody must be there to appreciate what they’re doing—the supervisors—to say “oh you’re doing well” for encouragement.

There’s need for other incentives, like training, going out to meet other providers in other facilities that are providing similar services can help in giving them a boost to see what they doing right and what they’re not doing right, or they doing it this way or that way. These things must be considered in all our programs: we need to keep our staff well motivated. Not necessarily in terms of payment but in terms of other activities that will encourage them to provide the services appropriately and be nice to the clients, because that is one other problem with providers—because of lack of motivation. They do not communicate well with the clients and instead of promoting family planning, they actually end up sending the patient out of the clinic and they don’t come back because of the way they were handled there. Take the youth for instance, they have no access to services, and if they should go into a clinic and ask for a condom that’s a serious issue. If a youth has come to you and ask for a condom, it means that they have decided to use it. Whether you provide it, that’s doing the right thing (counseling and providing it) or whether he will go out and buy it and use it. The same thing for when teenagers come in seeking abortion. You counsel them, you counsel them, they just want safe abortion somewhere. These are the things that providers should be very good at—interpersonal communication. They should be highly motivation, training, supervision and then whatever encouragement and recognition from them providing good services.

In Bangladesh, family planning providers are given honors, awards and that helps the motivation and encourage. And some regular interaction between different providers at different organizations can also create that type of encouragement. These are some aspects that we need to consider in all the programs.

KR: Why is it important to integrate education and health, as the COMPASS project does? How does Pathfinder integrate health and family planning into that?

HS: As you know the COMPASS is the first project that has provided health and education side by side, and reproductive health and child survival side by side basic education. There’s a strong interface between health and education, because the common factor to both is community. The community needs access to health and they need access to education. The decision makers in the community decide what kind of health and what kind of education, and whether they go to school at all. So the COMPASS project has had a lot of interest in integration of health and education.

Look at PTA (parent teacher association) on the side of the school, that’s a good opportunity to discuss reproductive health with parents, and husbands. If you just use that forum to discuss family planning, reproductive health, access to antenatal care, skilled delivery, delaying next child, delaying the age of marriage—isn’t that talking about reproductive health. That is the linkage. And how you come back to the health facility where people are bring their children for immunization, that’s an opportunity to talk about school, “she or he will grow up to be like me”, you know, provide good role models in the community. So that’s a forum where you can discuss education and health.

The most important thing is the community. Community is one. They look after health, they need health, and education. The community component of COMPASS was formation of community coalition. These were exertives of community based organizations that come together to form a coalition to discuss how to promote health and education within that community. Within that group, there is another group formed called Quality Improvement Team. The Quality Improvement Team address issues in schools, they determine what is quality in terms of education. This component is usually the PTA. For health, the Quality Improvement teams usually involve providers and members of the community who will come and see how to we integrate our services. Women have to come for family planning clinic today and come back for child immunization tomorrow—isn’t it possible to do that concurrently, so that the woman that comes only once and get family planning and child immunization. The integration is good, especially when you look at the community component of the project because you’re dealing with the community members. In the community, they choose health and education. Of course there are other things—you might talk about water, about agriculture, about microcredit to improve the society. But education and health are very key to any community. If you’re healthy and you receive good education, you are empowered. That is why I think COMPASS is a very good project, bringing programs together in health and education.

KR: What are some of the challenges COMPASS has faced when integrating programs?

HS: Well of course they become large. When you have a large program, large management and large structure, in terms of cost you’re looking at huge amounts of money. And then of course sometimes if you are just focusing on one protocol alone, and put all our efforts alone in one place (like child immunizations for example), you make impact there. But the challenge is bring all together, because what you have now is a large structure. But programs that are running vertical are just: “OK, child survival is my only concern, reproductive health is not my area of concern.” That’s a challenge.

It was difficult. I wouldn’t say that we succeeded completely at integrating the programs. At some stage you find that it becomes a little vertical, but of course the strings can always pull people back and say “Oh no come back, don’t just do family planning, reproductive health. There’s a component of education. What are you doing to promote education aspects in your program and training and interpersonal communication to midwives? Are you talking to them and reminding them that the child needs to go to school? Do they tell the woman the need for that?” Or if you’re doing education you say, “Are you talking about health? Water supply and nutrition? Are you talking about nutrition for the pregnant mother?” These are things that can be discussed in PTA. “Under the COMPASS project, the facility has been renovated, and providers have been trained so that they can have skilled delivery. Are you asking the parents to remind their wives to go to receive care and deliver in the facility?”

I know at some stage, as you’re going along, we move a bit more towards our own area, we’re more comfortable with our own area. The teacher is more comfortable talking about education. But we try as much as possible to bring people back to the right course when that happens.

KR: Can you speak to the role of community in the COMPASS program?

HS: Community is key to the success of any project. For two reasons. One they are the users of the services. Two, sustainability is very important. There’s no use renovating a facility, putting in the equipment, training providers, if the community members are not motivated enough to use the services. Access is there but they are not willing to use the services. When you cure the access, you know how to move the community to access the services.

Two, if at the end of the program the community is not involved, that would be the end of the program, there is no sustainability. Nobody to carry on, supervise the providers, ensuring the systems are still running. But the community members need to be carried along from the beginning and feel a sense of belonging and ownership, then you are on the right path to disengage at some point, with them continuing it on. Many years after they will still be there carrying on because they’ve appreciated the value of what they get, they appreciated the need for them to contribute, they own the services, it is their own. If you are only there to say “we are only here to improve your services, make access to you” that’s fine, they will use it. But when you go, if there’s a failure in there, no one will fix it and the services will stop. For ownership, for sustainability, there is need from the beginning to create feeling in the community that it is their program. With or without any program support, they should be able to sustain it.

That’s why the COMPASS program granted the community coalitions annual money, they were encouraged to seek their own funding, they were encouraged to provide support, or counter-funding to health facility or a school. When we assessed facilities, we said “this facility will require so much to renovate and provide equipment. What will the coalition will do?” And they say, “We will provide labor. We don’t have money but we have people, we will provide the labor.” So the cost of labor is taken off. If you have something that you have labored on, it’s more likely to have a feeling that it belongs to you because you’ve made a contribution and you have a stake in it. So the community has a very very significant role on any program, and they have to have that ownership. If you don’t have the ownership, there will be no sustainability. If they’re not involved, even the services will not be utilized here.

KR: Is there anything else you would like to add?

HS: Let me emphasize the need for integration. I think the integration is very good and whatever we do we should take cognizance of the culture, the religion, the approaches of the community. We should respect those and involve the community opinion leaders and the various leaders in the community. We should carry them along to have a sense of belonging and to feel that this program is for their benefit. It’s not someone bringing a program for any reason, but to improve them. If they accept that, then we have succeeded and people will use the programs. But if we see that program as alien, then no matter what, it will only last for the period of the program and it will not last.