Integrating Family Planning Into CSHGP and MCH Programs

Integrating Family Planning Into CSHGP and MCH Programs Victoria Graham (USAID) April 29 2010

Presentation Overview
Contribute of FP to MCH Programs
Historical Perspective of Flex Fund Program
Integration of FP into MCH Programs
Increasing Community Access to FP
Youth
Birth Spacing
Postpartum
Abortion Prevention and Post Abortion Care

Contributions of Family Planning to MCH Programs

Saving Lives by Meeting Unmet Need for Contraception, 2005-2015

Estimated Total Contribution of Unintended Pregnancies to Maternal Mortality
Total Unintended Pregnancies = 79 Million
Abortions = 46 million
Abortion deaths = ~ 70,000
Unintended Births = 33 million
Maternal Deaths = ~ 110,000
Total Maternal Deaths = ~180,000
% Contribution = 34% among 529,000 maternal deaths

Why is it essential that family planning be an integral part of Community-Based PHC?
Family planning –
Is a service wanted by the women themselves
Directly affects maternal and child survival
Promotes family welfare by preventing unintended pregnancies
Facilitates social development by slowing population growth
Increases the capability to women to participate in the development process

Health Workforce Needed to Meet the MDGs
To meet MDG goals, 2.5 health workers/1000 pop. are needed
An additional 2.4 million professionals needed globally
Sub-Saharan Africa has the largest need gap – requiring an increase of 140%
Community-based provision of injectables can reduce the burden on clinic-based staff as well as extend the reach of services.

Historical Perspective of the Flexible Fund Supporting Integration and Innovation in Family Planning

The Flexible Fund Goals and Critical Inputs Critical Inputs Flex Fund will support CA’s to provide Technical Assistance to Fund Recipients: 1) Monitoring and Evaluation 2) Program Strengthening Flex Fund will support centrally funded CAs to promote shared learning among Fund recipients Flex Fund will support PVO Programs through the CSHGP Shared Learning Goal #2 Increase Shared Learning of SOTA on community-based FP/RH approaches Goal #1 Increase access to quality FP/RH services through NGO/PVO Activities. Flex Fund will support PVO Programs through the CSHGP

Breakdown of Flexible Fund Support by Fiscal Year Fiscal Year US$ (000)

PVO and NGO Programs
US-Based PVOs
ADRA/Ethiopia
ADRA/Guinea
ADRA/Madagascar
CEDPA/Nepal
HAI/East Timor
MIHV/Uganda
MCDI Madagascar
Plan/Ethiopia
Plan/Guinea
Save/Ethiopia
Save/Uganda
Save/Guatemala
Local NGOs
AHS/Malawi
ASDAP/Mali
COCIN/Nigeria
GSPS/Mali
Fair Foundation/Bangladesh
Organizational Integration
Child Fund
International Youth Foundation
Save the Children
World Vision

CSHGP Projects w/ Flexible Fund Support
Project Hope Uzbekistan
2003-2007
Navoi, Uzbekistan (target 94,000)
Cost XT $1,300,000 (FP $430,000)
Program Level of Effort
30% Maternal Child Health
30% Family Planning
10% Breastfeeding
10% Control of Diarrheal Disease
10% Pneumonia Case Mgmnt
10% Nutrition
Strategies:
Focus on school program for youth
Train peer educators
Develop training materials for adolescents
World Vision India
2003-2008
Uttar Pradesh State (Target 1.2m)
Expanded Impact:$2.5 mil (FP $830,000)
40% Immunization
30% FP/Birth Spacing
20% Breastfeeding
10% IMCI/Vitamin A
Strategies
Performance improvement AWW & ANM
Early registration of all pregnant women
Time and Targeted BCC for families
Improve block and village level planning and use of data

CSHGP Projects w/ 100% Flexible Fund Support
ADRA/Nepal
2004-2009
Eastern Region (target 500,000)
Expanded Impact for $2.5 million (FP)
100% Family Planning
Strategies
BCC and Community Mobilization: training peer educators and FCHV, advocacy through religious leaders and decision makers
Training for FP Service Provision: public service providers (LAPM), VHW and CHW, FCHV refresher
System Strengthening: quality improvement through COPE and PDQ; strengthen referral system; strengthening contraceptive logistics management; improved M&E systems
Increasing Access to LAPMs: Mobile LAPM service provision
Save the Children/Mali
2004-2009
Segou Region (target 184,000)
Program Strategies
Behavior Change: messages through individual and group; advocacy through religious leaders and decision-makers; radio
Training for FP Service Provision; health care providers, CBDs
System Strengthening: logistics management; improved M&E
Training; strengthening referral system for LAPMs; PDQ
Increasing Community Access: Establishing network of CBD and youth PE to sell contraceptives in villages w/o health centers

CSHGP Projects with a Portion of Family Planning Support
Project Hope Uzbekistan
2003-2007
Navoi, Uzbekistan (Targeted 94,000)
Cost XT $1,300,000 (FP $430,000)
30% Maternal Child Health
30% Family Planning
10% Breastfeeding
10% Control of Diarrheal Disease
10% Pneumonia Case Mngt-
10% Nutrition
Strategies:
Target youth and adolescents with messages on about SRH
Train peer educators
Develop training materials for adolescent for use in schools
Scaled-up to national level
World Vision India
2003-2008
Uttar Pradesh State (1.2m targeted)
Expanded Impact:$2.5 mil (FP $830,000)
40% Immunization
30% FP/Birth Spacing
20% Breastfeeding
10% IMCI/Vitamin A
Strategies
Performance improvement AWW & ANM
Early registration of all pregnant women
Time and Targeted BCC for families
Improve block and village level planning and use of data

CSHGP Projects with 100% Family Planning Support
ADRA/Nepal
2004-2009
Eastern Region (targeting 500,000)
Strategies
BCC and Community Mobilization: training peer educators and FCHV, advocacy through religious leaders and decision makers
Training for FP Service Provision : public service providers (LAPM), VHW and CHW, FCHV refresher
System Strengthening: quality improvement through COPE and PDQ; strengthen referral system; strengthening contraceptive logistics management; improved M&E systems
Increasing Access to LAPMs : Mobile LAPM service provision
Save the Children/Mali
2004-2009
Segou Region (targeting 184,000)
Program Strategies
BCC and Community Mobilization: individual and group messaging; advocacy w/ religious leaders and decision-makers; radio
Training for FP Service Provision ; health care providers, CBDs
System Strengthening : logistics management; improved M&E, strengthening referral system for LAPMs; PDQ
Increasing Access to FP : Establishing network of CBD and youth PE to sell contraceptives in villages w/o health centers

Birth Spacing Messages

Healthy Timing and Spacing of Pregnancies
A child born three to five years after the birth of its sibling is about 2.5 times more likely to survive than children born at shorter intervals and less likely to be malnourished
Too young, too late, and too closely spaced result in high risk for the mother and child
Sources: Conde-Agudelo, 2000: 2005-2006; DaVanzo, 2004; 2008; Razzaque, 2005; Rutstein, 2005. All studies adjusted for 10-15 confounding factors.

Birth Spacing Recommendations
Wait 24 months before attempting the next pregnancy after a live birth (a birth-to-birth interval of 33 months) to reduce the risk of adverse:
Maternal
Perinatal and
Infant outcomes
Wait six months after a miscarriage or induced abortion to reduce the risks of adverse
Maternal and
Perinatal outcomes

Postpartum Family Planning An Essential Component of MCH Programs

Postpartum Need for FP
99% of women postpartum want to delay or avoid the next pregnancy
A 36 month birth-to-birth interval improves health of mother and child
50% of births occur outside a hospital
70% of women receive no postpartum care
Reaching postpartum women has the potential to provide FP information and services to over 90% of women of reproductive age!

Key Postpartum FP Messages
Antenatal Period
LAM and immediate & exclusive BF
Reproductive intentions
Return to fertility
Pregnancy spacing for women who want another child
Contraceptive options including (LAPM – IUD, tubal ligation, and vasectomy) for women who have reached their desired family size.
Immediate Postpartum
(1 week)
All of the above +
LAM and Exclusive breastfeeding
Importance of postnatal care for the mother and the newborn
Post Natal Care Contact
(within 6 wks)
LAM and exclusive breastfeeding
Reproductive intentions
Return to sexual activity
Return to fertility
Pregnancy spacing for women wanting another child
Appropriate contraceptive options for women who do not want another child.
Importance of well baby care.
Child Health Contacts during
1 st year (immun., sick child, etc.)
All of the above +
Exclusive breastfeeding through first six months, then breastfeeding with complementary feeding

What are the Appropriate Post Partum Contraceptives Options?

World Vision’s Strategy Timed and Targeted Counseling: Getting the Right Messages to the Right People at the Right Time

World Vision’s Timed and Targeted Counseling Strategies and Results
Provide a set of standard messages for counseling at designated timeframe
Utilize registers to track conception and birth
Identify and track pregnant women over time
Train Community Volunteers NFHS: Uttar Pradesh India 1998/99 2005/06 1998/99 2005/06 Total Fertility Rate 4.1 3.8 2.9 2.7 Contraceptive Use 28% a 44% 48% 56% Unmet need for FP 25% b 22% 16% 13% Infant Mortality 89 c 73 68 57 a Among married women aged 15-49 b Among married women aged 15-49 who want to delay next pregnancy or want no more pregnancies c per 1,000 live births

Increasing Community Access to Family Planning Bringing FP services to underserved and rural populations

Community-based Strategies for Increasing Community Access to FP
Community-based Distribution Programs* (shorter term methods including DepoProvera)
Community volunteers
Trained health workers
Mobile Services for LAPMs* (implants, IUD, female and male sterilization)
Establishment of Depots
Pharmacy Sale and Administration

Community-based Distribution Networks
Community health workers:
Volunteers from public or private sector
Paid providers typically from the public sector
Possible Roles
Awareness and disseminating messages
Counseling on FP
Referrals (active and passive)
Provision of FP (condoms, pills, injectables*, SDM)

Issues for Establishing Networks
Selection Criteria
Training
Commodities and Logistics
Supervision and Reporting
Incentives/Motivation
Retention
Sustainability

The Rationale for Using Community Health Workers to Administer Injectable Contraception
It is safe and effective
Expands access beyond health facilities to reach underserved populations (rural and urban)
Alleviates some of the burden on declining numbers of professional health care providers
Increasing access to injectable contraception has increased contraceptive prevalence rates at the national level in many countries
MDGs and country-specific FP and other health goals cannot be met without increasing access to FP

Provision of Injectables by Community Health Workers is Safe, Effective, Feasible
Research and programmatic evidence from Africa, Asia, and Latin America: Provision of Depo-Provera by trained CHWs is extremely effective
June 2009 Technical Consultation at WHO: Evidence supports provision of injectables by trained CHWs
CHWs repeatedly demonstrate they:
Provide injections safely and maintain supplies
Know when to refer to a clinic
Counsel about side effects
Administer injectables using a regular schedule
Provide services satisfactory to clientele

Adding injectables to the Method Mix has Increased CPR in some African countries

Status of Paramedical Provision of Depo-Provera by CHWs in Africa 2004 TUNISIA MOROCCO SAHARA ALGERIA MAURITANIA MALI NIGER LIBYA CHAD EGYPT SUDAN ETHIOPIA DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC CENTRAL RWANDA GABON EQUATORIAL ANGOLA CONGO NIGERIA BENIN DTVOIRE SIERRA SENEGAL GHANA THE GUINEA LIBERIA CAMEROON MALAWI ZAMBIA MOZAMBIQUE MADAGASCAR ZIMBABWE BOTSWANA SWAZILAND LESOTHO NAMIBIA ANGOLA WESTERN UGANDA OF THE CONGO REPUBLIC BURUNDI GUINEA REP. OF TOGO COTE BURKINA FASO GUINEA LEONE GAMBIA BISSAU SOUTH REPUBLIC AFRICAN THE AFRICA Pilot or limited program implementation with MOH approval; national policy restrictions remain in place

Countries are pilot testing CHW provision of injectables and instituting policy change National policies now permit scale-up. Scale-up in planning or implementation phase. Countries where pilots are being conducted or will be conducted by 2010 Potential for introduction of a demonstration project and/or policy change TUNISIA MOROCCO SAHARA ALGERIA MAURITANIA MALI NIGER LIBYA CHAD EGYPT SUDAN ETHIOPIA DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC CENTRAL RWANDA GABON EQUATORIAL CONGO NIGERIA BENIN SIERRA LEONE SENEGAL GHANA THE GUINEA LIBERIA CAMEROON MALAWI ZAMBIA MOZAMBIQUE MADAGASCAR ZIMBABWE BOTSWANA SWAZILAND LESOTHO NAMIBIA ANGOLA WESTERN UGANDA OF THE CONGO REPUBLIC BURUNDI GUINEA REP. OF TOGO COTE D’VOIRE BURKINA FASO GUINEA GAMBIA BISSAU SOUTH REPUBLIC AFRICAN THE AFRICA

A Promising New Technology – Depo-SubQ in Uniject
A new all-in-one single-use delivery system that combines
the needle and a pre-filled dose of Depo-Provera
formulated for subcutaneous injection (Depo-SubQ) into
one device.
Designed to give subcutaneous injections safely by all
trained providers including doctors, nurses, and CHWs.
Product may be available for purchase in 2011. However, cost of the commodity is still unknown. USAID has not committed to purchase Depo-SubQ in Uniject.
For now, programs are encouraged to move forward with the promotion of Depo-Provera delivered intramuscularly.

Abortion Prevention and Post Abortion Care An Opportunity for Integration through MCH Programs

Induced Abortions The Extent of the Problem
205 million pregnancies worldwide:
One third are unintended and 20% will end in abortion
20 million unsafe abortions annually:
Developing countries: 55% of abortions are unsafe
Developed regions: 8% are unsafe
68,000/yr women die unnecessarily from unsafe abortions (13% of all maternal deaths):
Africa: 650 deaths per 100,000 unsafe abortions
Developed regions: 10 deaths per 100,000 unsafe abortions

Mobile Services
Methods: implants, IUD insertions, male and female sterilizations, male circumcision
Community-level Tasks: scheduling services, preparing sites, inform client base, creating monitoring plan, and follow-up.
Mobile Team Tasks: appropriate team of trained providers, securing commodities, ensuring quality services and follow-up plan.
FP services provided by a mobile team of trained providers in an area with limited or no FP services.

Community Actions to Establish Mobile Services
Conduct needs assessment to determine demand for mobile services
Establish partnerships with local organizations that perform mobile services in your program area
Negotiate with public sector facilities to periodically bring services to a lower level facility

Abortions Result in Lost Lives
Legal restriction do not affect abortion incidence:
Africa abortion is illegal – abortion rate is 29
Europe abortion is legal – abortion rate is 28
Causes of death due to unsafe abortions:
Hemorrhage
Infection
poisoning from substances used to induce abortion
Dangerous
Abortion Practices
Drinking turpentine, bleach or tea made with livestock manure
Inserting herbal preparations into the vagina or cervix
Placing foreign bodies, such as a stick, coat hanger or chicken bone, into the uterus
Jumping from the top of stairs or a roof

Abortion Prevention and PAC Life-Saving Community-based Actions
Prevention:
Increase access to FP to address the unmet need for FP and reduce unintended pregnancies
Inform men and WRA of dangerous unsafe abortion practices
Provide messages to promote care-seeking behaviors for danger signs following an abortion
Post Abortion Care:
Advocate for availability of PAC at the community level (emergency treatment and FP)
Counsel patients to seek care immediately following abortions*
Mobilize transport to facilities for emergency care
Provide FP counseling and methods immediately following abortion
Counsel women wanting pregnancy to wait six months before becoming pregnant after an abortion

Danger Signs Following an Abortion
Heavier than normal bleeding
Monthly bleeding
Fever
Dizziness or fainting
Severe stomach or abdominal pains
Bad smelling discharge from their vagina
Immediately refer women to the clinic that has PAC services if they have:

http://info.k4health.org/PAC

Youth Programming at the Community Level Addressing Health Care Needs of Youth in MCH Programs

Why are Youth Important?
1.5 billion youth aged 10-24
1.3 youth are living in developing countries
Youth Bulge of Today
The largest generation to transition to adulthood
Impact national security and civil conflict
Results in poverty, urban sprawl and slums
Values and decisions are impacted by norms, expectations, peers, parents and other adults

Integrating Youth Issues into MCH Programs
Clinic Services:
Advocate for clinic services that meet the health care needs of youth
CHW/Vs:
Sensitize CHWs to serve youth
Disseminate messages on SRH
Behavior Change Efforts
Design custom messages for youth
Involve religious leaders and other adults to share accurate information and discuss RH/FP issues
Engage youth in community mobilization
Systems:
Include indicators for youth in monitoring systems to measure progress
Health Care Needs
of Youth
Privacy
Confidentiality
Supportive health care providers
Range of quality services (FP/RH, MCH, PAC, STI, HIV VCT, treatment and care)
Customized messages on FP/RH (delay sexual debut and first pregnancy)

Integrating Family Planning Into CSHGP and MCH Programs

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Integrating Family Planning Into CSHGP and MCH Programs — Presentation Transcript