APCRSHR10 Virtual abstract presentation of Dr Neeta Shrestha
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This is the abstract presentation of Dr Neeta Shrestha, which was made as part of the 10th session of #APCRSHR10 Virtual, on the theme of "Innovations and changing norms around sexual and reproductive health and rights (SRHR) in Asia and the Pacific". C H A I R Dr Eden R Divinagracia Executive Director, Philippine NGO Council on Population, Health and Welfare (PNGOC) P L E N A R Y S P E A K E R Beth Schlachter Executive Director, Family Planning 2020 (FP 2020) "Family planning progress to date and a collective vision for family planning post-2020" A B S T R A C T P R E S E N T A T I O N S Dr Neeta Shrestha | Visiting Service Provider Approach: reaching the unreached with Family Planning services Dr Pramesh C Bhatnagar | Peer lead approach for Promoting change in socio-Cultural Norms in a conservative rural community so as to reduce child marriage and promote youth friendly SRHR: An Intervention from Khalikote Ganjam Rural area of Orissa India Mehrin Shah | Increasing Lady Health Workers’ knowledge of sexual and reproductive health and rights: addressing knowledge gaps and improving linkages within rural communities in Pakistan Elisa Oreglia, Camille Tijamo | Smartphone use and reproductive health in Cambodia: A qualitative, multi-disciplinary exploratory study For more information on the session, please visit www.bit.ly/apcrshr10virtual10 Official conference website: www.apcrshr10cambodia.org Thanks
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APCRSHR10 Virtual abstract presentation of Dr Neeta Shrestha
- 1. Visiting Service Provider Approach: reaching the unreached with Family Planning services APCRSHR10 Virtual -10 October 26, 2020 Dr. Neeta Shrestha UNFPA Nepal
- 2. Context: FP Scenario in Nepal • One of four married women have an unmet need for FP • mCPR rate has plateaued at 43% • Half of pregnancies were unintended and 1/3rd ended in abortion (CREPHA 2014) Source: NDHS 2016
- 3. Context: FP Scenario in Nepal • Adolescent birth rate has increased • Adolescent (15 to 19 age) have highest unmet need for FP (35%) • 14.5% of married adolescents use a modern method of contraception • 41 percent of Nepali girls are married before the age of 18 Source: NDHS 2016
- 4. Context: FP Scenario in Nepal 8 7 15 16 46 61 Unmet need Met need Total demand For limiting For spacing Unmet Need, Met Need, and Total Demand Percent of married women age 15-49 with unmet need, met need, and total demand for family planning Source: NDHS 2016
- 5. Context: FP Scenario in Nepal 18 14 32 Unmet need for spacing Unmet need for limiting Total unmet need Unmet need for Postpartum Family Planning Source: NDHS 2016
- 6. Context: FP Scenario in Nepal Source: NDHS 2016 53 43 15 9 6 5 4 3 1 10 Any method Any modern method Female sterilization Injectables Male sterilization OCP Male condoms Implants IUCD Any traditional method Current Use of Family Planning Percent of married women age 15-49
- 7. Context: FP Scenario in Nepal 100 1.5 98 98 49 44 59 5 5 0 20 40 60 80 100 Male Condoms Female Condoms Oral Contraception Injectables Emergency Contraception IUDs Implants Female Sterilization Service Male Sterilization Service Percent of Service delivery points offering Family Planning method Source: Facility Based Assessment for Reproductive Health Commodities and Services in Nepal, 2018 1 in 10 FP service providers are trained on LARC (Nepal Health Facility Survey 2015)
- 8. Context: FP Scenario in Nepal 99.6 88.9 44 No stock out of at least one method No stock out of at least three method No stock out of at least five method Stock status of Family Planning commodities Source: Facility Based Assessment for Reproductive Health Commodities and Services in Nepal, 2018
- 9. Barriers to FP Gender Inequality Women’s autonomy in making Healthcare decisions Early marriage and pregnancy Myths and misconceptions related to FP methods Geographical Barriers Inequalities Migration Cultural/Religious beliefs
- 10. The Visiting Service Providers Approach Who are Visiting Service Providers (VSP): Trained health service providers (Staff Nurse/Auxiliary Nurse Midwife) who visit primary level public health facilities on a scheduled day to deliver long acting reversible contraceptive (LARC) services where trained/competent health service providers are not available Provides onsite coaching/mentoring to service providers for providing LARC services Quality Improvement: Monitoring of the FP services and FP Quality Improvement assessments VSP are mobilized to increase the access to and uptake of Long acting reversible contraceptives – expand the coverage especially in hard-to-reach areas
- 11. The Visiting Service Providers Approach Planning with local administration to identify priority areas/geograp hical region Identification of hard to reach areas and lower utilization of FP services Assess support needed for LARC services/VSP/ commodities/ supplies/traini ng Mobilize VSP in selected health facilities in a fixed schedule Demand generation and information dissemination and referral for FP services through Female Community Health Volunteers
- 12. Key achievements A total of 540 health facilities in eleven low CPR districts support with Visiting Service Providers 61 Visiting Service Providers mobilized in these health facilities Trained 449 Health Service Providers on competency-based training of LARC services
- 13. Key achievements 4826 7998 8993 5864 200 448 711 418 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 2017 2018 2019 2020 (until September 2020) Implant IUCD Constitutes 50% of the total LARC uptake in the district Uptake of LARC services through VSP
- 14. Key achievements 20% 30% 20% 6% 21% 3% Dalit Janajati Madhesi Muslim Brahmin/Chettri Others LARC Uptake among different ethnic groups 56% of the users were from marginalized communities
- 15. Key achievements Visiting Service Provider providing information session about family planning to men staying at a quarantine centre in Baitadi District
- 16. Ensuring continuity of LARC services from the primary level health facilities Engaging with provincial/local authorities and sensitizing need for FP services; advocacy to increase financing Provision of LARC services by the VSP Competency based training for Health Service Providers Onsite coaching and mentoring of trained Health Service Providers by VSP Monitoring and FP QI assessment by VSP Female Community Health Volunteers acting as a bridge between the community and the health facility Ensure commodities are in place Ensuring continuity of service post VSP support: Sustainability
- 17. Conclusion • VSP approach has been successful in expanding choices for FP and ensure FP demands are met • Focuses on the key elements of right to health - availability, accessibility, acceptability and quality • It has contributed in expanding coverage of FP services – reaching the most marginalized and furthest behind both at stable and unstable times such as the COVID-19 pandemic
- 18. Thank You Acknowledgement ● Family Welfare Division ● DFID ● Marie Stopes International/Sunaulo Pariwar Nepal ● ADRA Nepal ● UNFPA colleagues
Editor's Notes
- Nepal has made tremendous progress in relation to promoting reproductive health and rights and commitment to promoting universal access to reproductive health including family planning – it is one of the few countries in the region to have progressive standards and committed to improving the rights of women and girls in the region. Nepal is one of the countries that made early commitments to the FP2020 global partnership in 2015 with a pledge to increase funding for family planning as well as to address the systemic barriers to family planning services.
- Despite the positive policy environment, there are persistent gaps. In the next few slides, I will take you through the current FP scenario in Nepal. One in four married women have an unmet need for FP. The use of any method of family planning by married women has nearly doubled in the last two decades. Similarly, modern method use has increased from 26% to 43% during the same time period but it has not changed since 2006 with half of the users discontinuing within 12 months of starting. Furthermore, half of pregnancies were unintended and 1/3rd ended in abortion. Fewer than half (42%) of all abortions were provided legally in government-approved facilities which gives a clear indication to unsafe abortions among women and girls. This indicates that Nepal needs to further strengthen the family planning program to achieve its commitments to global family planning goals.
- Further, a group that deserves special attention is young people - adolescent motherhood continues to be a key health concern in Nepal. In fact the adolescent birth rate has increased since the last DHS in 2011 (81 per 1000 to 88 per 1000 in 2016). Unmet need for family planning among adolescents aged 15-19 years is 35 percent - the highest of any age group. Early marriage is a key factor in Nepal and according to the Demographic Health Survey, 41 percent of Nepali .girls were married before the age of 18
- In terms of unmet need while 24% of married women in Nepal have an unmet need for family planning: 8% want to delay childbearing, while 16% want to stop childbearing.15% of married women want to delay childbearing (delay first birth or space another birth) for at least two years. Additionally, 61% of married women do not want any more children. Women who want to delay or stop childbearing are said to have a demand for family planning and the total demand for family planning among married women in Nepal is therefore 76%.
- The unmet need among Postpartum women is 32% which is higher than the national average.
- While More than half (53%) of married women age 15- 49 use any method of family planning—43% use a modern method and 10% use a traditional method. Further if we look at the method mix, 15% of married women resort to sterilisation, followed by 9% using injectable contraceptives, with all other modern available methods at negligible levels. As such, there is a need to improve the method mix over time, with a balance between permanent, long acting reversible methods and short-acting methods.
- In terms of availability of FP services in the health facilities, we can see in this graph that short acting methods such as oral contraceptive pills and injectables are available in almost all service delivery points. However, less than half provide IUDs (44%) and 59% of the service delivery points provide Implants services. And……just over 1 in 10 family planning service providers have ever received in-service training on long-acting reversible contraceptive methods.
- There are different barriers related to family planning in Nepal and there is a need to turn our attention to address these barriers. When we look at the national indicators, we also recognize that inequalities exists and disparities are widening – the rural, minority ethnic groups, the socially excluded and the young are especially at a disadvantage in terms of accessing FP services. Culture and religious ties also serve as substantial barriers to increasing FP use FP among migrants and their spouses is further likely to be impacted in the current situation of COVID-19 with high number of migrants that are returning and will be returning in the near future. Lack of women’s empowerment to make decisions, myths and misconceptions related to FP methods and limited choices. Early marriage and early fertility is also a concern - early marriages often mean the end of girl’s education, setting aside her chances of a career and undermining her life choices and her human rights. Girls who marry young are pressurized to have children right away which pose risks to their health and wellbeing including unwanted pregnancies and adverse outcomes related to child birth. Post abortion and Post partum FP is an issue.
- Against this backdrop, Ministry of Health and Population/Family Welfare Division along with partners including UNFPA supported the introduction of VSP approach. At this point, I would also like to take this opportunity to acknowledge DFID who is supporting this initiative as a part of a four year family planning program which ends in 2020. This initiative is also being funded through UNFPA Supplies which is UNFPA’s thematic fund program dedicated for Family planning programs. VSP are mobilized to increase the access to and uptake of Long acting reversible contraceptives– expand the coverage especially in hard-to-reach areas. So who are Visiting Service Providers? Visiting Service Providers as the name suggests are trained health service providers who visit primary public health facilities on a schedule day to deliver Long acting reversible contraceptive services where trained/competent health service providers are not available. They provide onsite coaching and mentoring support to health service providers for providing quality LARC services – these Visiting Service Providers also support monitoring of FP services and quality improvement assessments of the health facilities. And the picture above is that of a Visiting Service Provider travelling with her bag pack with the FP supplies to a health facility in one of the remotest parts of the country – some requiring travel on foot up to 6 to 8 hours.
- So, how are Visiting service providers mobilized in the health facilities….. This figure outlines the overall process which starts with coordination and planning at the provincial and local level, identification of priority areas; identification of hard to reach areas and sites with lower utilization of FP services; further health facilities requiring support for LARC service; training needs of health services providers; commodities/supplies are then assessed – based on this, health facilities are selected and agreed upon at the local level following whichs Visiting service providers are mobilized in selected health facilities. Additionally, Female community volunteers are mobilized to provide information and referrals for FP service.
- Over the period 2017 to September 2020, a total of 540 health facilities in eleven low CPR districts were supported with this approach of Visiting Service Provider – 61 Visiting Service Providers were mobilized to these facilities in a scheduled basis. Additionally, over 400 health service providers were trained in providing Implant and IUCD services. In the current context of COVID-19 pandemic, the VSP have continued to provide FP information and services. These VSPs are also providing support in provision of FP services in the current situation of restricted mobility/lockdown in the current pandemic.
- If we look at the trend in use of long acting reversible contraceptives, Implant and IUCD, it clearly shows that the uptake of LARC service is increasing over the years. And these figures constitutes approximately half of the total LARC service uptake in the district.
- In this picture you can see a Visiting Service Provider providing information session about family planning to men staying at a quarantine center in one of the remotest districts.
- While talking about sustainability of this approach……n order to ensure continuity of service following Visiting Service Provider support from the primary level health facilities, a holistic approach is being followed– UNFPA is continuously engaging at the provincial and local level to sensitize the need for Family planning services; advocacy for adequate financing for FP including adopting the VSP approach by local government until all health service providers are trained; training for health service providers; coaching mentoring of service providers; ensure quality improvement assessments; ensuring commodity support and disseminating information at the community level.
- The findings suggests that the Visiting Service Provider approach has been successful in expanding choices for family planning and ensuring that family planning demands are met. This approach particularly focuses on the key elements of right to health – i.e. availability, accessibility, acceptability and quality And it has contributed in expanding coverage of family planning services – reaching the most marginalized and furthest behind both during stable and unstable times such as the current COVID-19 pandemic. I would like to end by saying that The FP2020 has brought a lot of attention to these issues and really created a momentum to refocus on FP. The policies are in place to address the reproductive health and rights of women in Nepal but there is a need to strengthen the implementation. Especially, in the changed federal context and the rapidly evolving situation due to the COVID-19 pandemic our major challenge is sustaining the gains and achieving the aspirations and targets of Sustainable Development Goals particularly in achieving universal access to sexual and reproductive health services and tailoring our efforts towards reaching the unreached.