Fall Global Health Practitioner Conference 2017 Thinking Differently about the Complexity of Unmet Need for Family Planning and Improving Maternal & Child Health Outcomes: Why Understanding Your Body Matters Sandra Chipanta, Gabrielle Nguyen, Shannon Pryor, Lauren VanEnk

1. Thinking differently about the complexity of unmet need
for family planning and improving MCH outcomes:
Why understanding your body matters

2. Family planning contributes to:
• Reduction in maternal and child mortality rates
• Increases in women and men’s secondary
education attainment (enrollment rates)
• Increases in women’s participation in the labor
force
• Improvements in the nutrition and health of
children
• Increases in the livelihood and economic
productivity of families

3. THE PROBLEM
Women want to delay and space births, but aren’t using family planning.
!

4. Top 3 reasons for not using family planning
health concerns/
fear of side effects
oppositionmisconceptions
of pregnancy
risk
?!

5. They misunderstand their
risk of pregnancy.
?!

6. “You know, before I got married to my husband now, I slept
with him just once—when we were young girls and boys—but I
got pregnant and my parents had forced him to marry me.
That’s how I got my first son and how I got married.” UGANDA

7. “You cannot know whether you are pregnant
unless you see the stomach growing and
movement. Then you wonder what could be
happening to you? Of course, in this time you
know you cannot get pregnant because the periods
have not yet come, but you realize that you are
pregnant all of the sudden. That is what they call
in ‘Nga’karamojong, Ikungut,’ meaning a child you
get without bleeding or menstruation.” UGANDA

8. They experience cultural,
religious, or social barriers
to family planning use.

9. “They comment that she has been using such temporary
devices even when her husband is not around and suspect
that she is not pure and has another sexual partner.” NEPAL

10. They fear side effects from
currently available family
planning methods.

11. “If we use an injectable, later we may not conceive a child.
Also, blood gets collected in the stomach and we may get
fat. Women [in my community] said these things, so I was
afraid to take medicine or get an injection.” NEPAL

12. WHY DOES THIS MATTER?

13. WHAT DO WE MEAN BY
FERTILITY AWARENESS?

14. TRUE or FALSE
A woman will get pregnant only if she has
sex on the same day she ovulates.

15. TRUE or FALSE
After having a baby, a woman can only get
pregnant again when her periods return.

16. actionable information about female and male
fertility throughout the life course, and an
understanding of how this knowledge applies
to one's own circumstances and needs
(specifically: basic information about the menstrual cycle, how pregnancy occurs, the likelihood of
pregnancy from unprotected intercourse at different times during the cycle and at different life
stages; how family planning methods work with the body to prevent pregnancy)
FERTILITY AWARENESS DEFINED

17. Intervention Development Phases
1
• Formative Research
• Qualitative study to explore factors influencing FP use
2
• Solution Design Workshops
• A series of workshops with communities to discuss the results of the formative research and brainstorm
possible community - driven interventions
3
• Proof of Concept
• To test the intervention and its monitoring and evaluation system for modification based on lessons
learned
4
• Pilot
• To implement the revised intervention based on lessons learned from the proof of concept and determine
its effectiveness through an endline evaluation activity
5
• Positioning for Scale
• Proven solution available for scale up; lessons learned available to be applied

18. EDEAN
UGANDA
2016-2017
Radio Drama
RWANDA
2014-2015
Pragati
NEPAL
2017-2018

19. We believe: that fertility awareness
allows people to understand their
bodies and their risk of pregnancy so
they can take action to prevent
unintended pregnancy.
1

20. 2
We believe: that by engaging in a
user-centered design process,
communities can better address and
overcome local norms that keep
people from using family planning.

21. 3
We believe: that providing accurate
information about family planning
methods and how to manage their
side effects will dispel myths and
support family planning use.

22. Serial Radio Drama
“IMPANO N’IMPAMBA,” RWANDA

23. Year-long 104
episode drama
based on social
learning theory
• Family planning/
healthy timing and
spacing of pregnancy
• HIV/AIDS prevention
• Youth reproductive
health
• Gender-based violence
• Maternal and child
health
SERIAL RADIO DRAMA RWANDA
WHO
WHERE
WHAT Population Media Center,
Institute for Reproductive Health
Nationwide

24. Addressing misunderstanding of pregnancy risk: HOW?
“Ketia”
Adolescent, unmarried girl
• Sign of onset of fertility – boys
• Sign of onset of fertility - girls
• Definition of the menstrual
cycle
• When during the cycle is a
woman fertile
• Menstrual hygiene
management
“Bacyenga”
Newly married male
• When during the cycle is a
woman fertile
• Sign of onset of fertility – boys
“Kagaju”
Mother of multiple children
• Risk of pregnancy postpartum
• LAM criteria
• Menstrual hygiene
management
SERIAL RADIO DRAMA RWANDA

25. SERIAL RADIO DRAMA RWANDA
Adjusted for sex, age, education, marital status, children, and wealth * p<.05, ** p <.01, *** p <.001
I know first menstruation is
sign a girl is now fertile.
I know ejaculation/wet dreams
is sign a boy is now fertile.
I know first day of the menstrual
cycle is first day of bleeding.
3.0 
odds (1.3 – 7.2)*
2.5 
odds (1.4 - 4.4)**
1.7 
odds (1.4 – 4.0)*
LISTENERS HAD A BETTER UNDERSTANDING OF
FERTILITY AWARENESS THAN NON-LISTENERS.

26. FERTILITY AWARENESS
SERIAL RADIO DRAMA RWANDA
“If you do not know your menstrual cycle or how your body
functions, a man can tell you a lie that if you have sex you will not
get pregnant. I heard in Ketia’s story that a man can impregnate
a woman whenever she is in her fertile period.” UNMARRIED FEMALE

27. SERIAL RADIO DRAMA RWANDA
ORs Adjusted for sex, age, education, marital status, children, and wealth, * p<.05, ** p<.01
I know where to go to access
family planning
I think unmarried women
use family planning.
I discussed family planning
with friends/family
2.2 
odds (1.1 – 4.4)*
1.4 
odds (1.0 – 1.8)*
1.6 
odds (1.2 – 2.1)**
LISTENERS WERE MORE LIKELY TO HAVE POSITIVE ATTITUDES,
SELF-EFFICACY, AND COMMUNICATION AROUND FAMILY PLANNING.

28. SERIAL RADIO DRAMA RWANDA
DISCUSSION ABOUT THE RADIO DRAMA
“I talk to my husband about knowing the fertile period…[The radio drama]
encouraged me very much; before I used to be ashamed…since I acquired information
about reproductive health I got more and more encouraged to talk and plan. We were
in bed. I was in my fertile period. I became bold and told him that if we had sex I
could get pregnant and we could fail to space our pregnancies.” MARRIED FEMALE

29. EDEAN
“Come Together to Strengthen Child Spacing,” UGANDA

30. EDEAN UGANDA
Community
engagement through
peer learning, theatre,
and reflection
• Couple
Communication
• Menstruation
• Fertility
• Family Planning
WHO
WHERE Karamoja, 6 Villages (ECCD Centers)
WHAT Save the Children,
Institute for Reproductive Health

32. ORs Adjusted for sex, age, education, marital status, years married, education, and employment, * p<.05, ** p<.01, ***p<.001
Higher fertility
awareness
Improved self efficacy
about family planning
More supportive family
planning norms
Communicated with
partner about family planning
2.6 
odds (1.7, 3.9)***
2.3 
odds (1.4, 3.7)**
1.8 
odds (1.1, 2.9)**
4.2 
odds (0.9, 19.5)
IMPROVEMENTS IN NORMS, SELF-EFFICACY, COMMUNICATION
IN INTERVENTION COMPARED TO CONTROL COMMUNITIES
EDEAN UGANDA

33. Pragati
“Fertility Awareness for Quality of Life,” NEPAL

34. PRAGATI NEPAL
Package of 9 games developed
to diffuse information on:
• Fertility awareness
• Side-effects and misconceptions
about FP methods, and
• Social and gender norms around FP
use (son preference and delaying
first birth)
Implemented by Female
Community Health Volunteers,
Health Mothers Group
Champions, Male Champions
WHO
WHERE Five districts in Nepal
WHAT Save the Children,
Institute for Reproductive Health

35. PRAGATI NEPAL
REFLECTION AFTER PLAYING SIDE EFFECTS PUZZLE
“I came to know that [sterilization] doesn’t make women
weak or decrease sexual desire. These are myths. I will get
a Minilap in the upcoming sterilization camp rather than
take Depo every three months.” WOMAN FROM SIRAHA

36. Let’s Play!

37. WHAT’S NEXT

38. LEARN MORE
For briefs, reports, updates, visit:
www.irh.org/FACT_Project
Twitter: @IRH_GU

39. Thank You