Thank you, Carol and thank you all for being here. Today I’m going to present on the evaluation of a program aimed at training Traditional Birth Attendants or Comadronas as they are referred to in Guatemala to promote and offer family planning at the community level in rural Guatemala.
So getting started, The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: And that is that I have no relationships to disclose
The objectives of this presentation are to:-Describe the elements needed to enable Traditional Birth Attendants to offer FP, including training materials, supervision and support systems, and reporting and procurement mechanisms-to Demonstrate the impact of service delivery offered by TBAs towards demand for FP through promotion, counseling and refferals -and to Evaluate the feasibility, acceptability and sustainability of having TBAs offer family planning outside of a traditional health center setting
So to give some background on the context, Guatemala, with a population of over 14 million, is the largest country in Central America. Its population identifies itself as 60% mestizo and of European descent and 41% of indigenous Mayan descent. This is important to note because there are 21 different Maya groups and approximately 26 Mayan languages currently spoken in the country. And as you can image, this impacts accessibility to health services. About half the population live in rural and half in urban areas. Indigenous groups are mostly concentrated in the Western Highlands in small rural farming communities, which the areas of higher altitutde highlighted in this map. More than half of the population lives below the poverty line. But for indigenous people, that figure is 76%. Guatemala has one of the highest indicators for maternal mortality in Latin America with 153 deaths to 100,000 live births and one of the highest malnutrition rates in the world at 43%. Despite more than 35 years of family planning programming, contraceptive prevalence remains relatively low, at 54% and lower among rural (46%) and indigenous women (40%). Currently the most popular methods are femaile sterilization, injectables and natural methods, which in last DHS covered women using rhythm, withdrawal and other traditional methods and non-modern methods.
The Institute for Reproductive Health of Georgetown University, through its field office in Guatemala, worked with the Ministry of Health, Dept. of TBA under the National Program for Reproductive Health of to design, implement and evaluate a strategy to train traditional birth attendants to promote all family planning methods and to offer four methods in their comunities. Those methods being the Standard Days Methods, Lactational Amenhorrea Method, condoms and oral contraceptive refills. For those of you who may not be familiar with SDM, the Standard Days Method is based on monitoring the days of the woman’s mentrual cycle to see which days she is most likely to get pregnant – its considered a somewhat new modern natural fp method in Guatemala. It was decided by the Ministry that these four methods could be offered by TBAs at the community-level. The purpose of the strategy was really to operationalize one of the mandates in the Ministry’s national family planning guidelines which states that traditional birth attendants may offer family planning. Up until now this mandate hasn’t been opertationalized and TBAs haven’t been trained to offer any methods. So this strategy served to pilot and evaluate these efforts
The strategy, has 4 components, the first being the a training of trainers. In this case the trainers are auxiliary nurses, who are also responsible for supervising and supporting TBAs in their new role. That training is followed by TBA training using a low-literacy manual (food in the back?). The training covered method criteria, key messages on method use and counseling information on the 4 methods they offer, plus information on common myths and misconceptions about methods, general information on sexual and reproductive rights and HTSP. The Supervision component included using existing monthly visits to health centers as opportunities for auxiliary nurses to support TBAs, answer their questions and when necessary assess their knowledge using a competency checklist to address specific method details. The logistics and reporting component was probably the most difficult step because it required a significant change in the existing MOH system at the district level. A reporting form was developed by the MOH and TBAs used this new form to register their users and document the number and type of methods they distributed. The MOH also created procedure for supplying each TBA with additional methods, acoording to how many they had distributed and had left. Their registry was then integrated with provider records for each health center. Finally, there were efforts to promote family planning through TBAs and for health centers to promote the availablity of TBAs in the community to offer certain methods, which included invitaction cards and announcements in health centers.
So just to give you an idea of the profile of a MOH tradtional birth attendantsThey ranged from 23 to 87 years of age They were mostly female, but we did have 2 male TBAsThey identified themselves as Mayan (belonging to the Mam, Kaqchikel groups) & Mestizo (Spanish). The majority that spoke Mam and Kaqchiquel also spoke Spanish, but many didn’t read any Spanish.They are from rural and peri-urban communitiesTheir levels of education ranged from no formal schooling to completing primary-level schoolRole in communities they live in: attending births, pre and post natal care, and providing information of health issues (as provided by the MOH)
The evaluation of the intervention consisted of both quantitative and qualitative components, including focus groups with traditional birth attendants and auxiliary nurses As well as in-depth interviews with stakeholders from the ministry of health at the district, department and national level. We also analyzed district level service statistics for the three intervention sites as well as for three control sites. And we analyzed data from checklists used to assess the TBAs’ knowledge three-months after the training.
In the end we we able to train 22 auxiliary nurses who then trained 85 TBAs in in 2 districts of quetzaltenango and 1 district in santa rosa.
Using a checklist we developed, called the Knowledge Improvement Tool or KIT, we evaluated the knowledge of TBAs pertaining to topics they were trained on, again 3 months after their initial training. The results show that the majority of TBAs know the medical eligibility criteria and essential messages for all four methods, but that some additional efforts are needed to strengthen knowledge of Lactional Amenhorrea Method and oral contraceptives couseling.(We think that the TBAs prior knowledge of breast feeding practices may have created some confusion with the criteria needed to use LAM, as may providers in Guatemala often confuse LAM with breastfeeding.)
The same checklist also included questions about the conditions needed for the health timing and spacing of pregnancies. These results were expected, since these TBAs have experience discussing HTSP with their post partum clients prior to the intervention.
Using service statistics for a period of 9 months prior to the intervention and the 9-month period of the intervention, we looked at the number of total family planning users for all methods for those time frames. Here we grouped the information by quarter. We see that although the added number of FP users is moderate, there’s definitely an increase in 3 quarters of the intervention.
In these next tables we see the number of FP users grouped by the number of users for methods offered by TBAs (which again is SDM, LAM, condoms and oral contraceptives) – that the line at the bottom. Then by those methods that only health center providers offer, but TBAs promote (which include IUD, injectable and implants) – that the orange line in the center and finally the total number of users on top. Here we see that the majority of methods distributed are still those offered by providers but that there’s only an increase in SDM, LAM, condoms and pills in the intervention period. There’s also a notable dip in the number of users for what I’m going to refer to as the other methods in the couple of months – and next slide will exaplin that better.
So here we see the actual number of users by methd for the 9 months before and 9 months during the intervention. So for the first 4 methods, those offered by TBAs, we see an increased in all method users, but for the methods only promoted by TBAs, here we see a decrease. Our assumption, although it was not the intention of the intervention, women may have opted for a method that was available in their community instead of going to the health center for these othr methods.
In this final slide on service statistics we compared the number of users for 9 month period of intervention sites to the same 9 month period in 3 control sites. These results aren’t as straghtforward, but we can see that for 6 of the 9 months the number of users in the intervention or experimental site is slighly greater than the number in the control.
We also conducted some interviws and focus groups with the MOH, TBAs and auxiliary nurses to get some feedback on the strategy. When inquiring about the acceptability of the strategy, we asked stakeholders for their opinions about the strategy. We also asked TBAs about their new role as FP providers:These are some excepts of those interviews. Overall, stakeholders and TBAs had postive feedback about the strategy and TBA about their new roles.
Stakeholders and TBAs also expressed that the strategy had great potential and they saw many advantages to it, including: - it saved women time and money in not having to go to a health center regularly- FP services are expanded to communities that they don’t reachCommunity members trust TBAs and may be more likely to take their adviceTBAs can reach couples at the community level, which is rarely seen at health centers, due to lack of interest and opposition to FP by men, but lack of convenience due to their work schedulesTBAs understand cultural context of communities they serve, which may be a barrier for some providersAnd that some adolescents rather visit a TBA than go to the health center for condoms
--However, there were also many challenges that should be discussed. --Traditional birth attendants mentioned that It costs them a good deal of time to promote and offer family planningWomen ask them for oral contraceptives before going to a health center, which they are only suppose to provide refills for Women ask TBAs for methods they do not offer, such injectablesTBAs have been scolded by religious leaders for offering FPTBAs feel they are not receiving enough recognition for their work Stock outs at health center Auxiliary nurses:--Increased workload for them as they work with TBA in this new capacity, specifically because they need to help TBAs complete the registry forms as some aren’t able to do it on their own. They also need to follow-up with all TBAs on their registries and contraceptives supplies as they aren’t allowed to close their books without including this information, since it’s now consolidated.And they also mentioned that there are Stock outs at health center --Some challenges mentioned by the MOH stakeholder were that: Also that there were stock outs at health center of methods andIncreased workload for M&E staff in health centers, who are compiling this additional date to send to the dept.-level.
--Stakeholders at the department-level and district-level expressed some concern about expansion of the strategy due to level of effort and logistics matters--Central-level stakeholder were more optimistic about expansion efforts, but we awaiting evaluation results at the time of the interviews--Some stakeholders expressed that continued support from partners (like IRH) may be needed for expansion--All stakeholders agreed that contraceptive supplies issues needed to be addressed in the exsiting intervention sites before expansion, but at increasing demand and accessibility to family planning was a priority for them.
In regards to Feasibility and sustainability:- Results of evaluation need to be disseminated widely with all levels of the MOH to assess feasibility of expansion- Some cost-benefit analysis may need to be done in order to obtain a full picture of feasibility and sustainabilityIn regards to changes to the strategy itself- The method registry may need to be adapted/simplified to be more easily used by TBAs - The MOH may want to evaluate community-level needs about accessing initial oral contraceptive orders at the community level as well as the feasibility of having TBAs also offer other methds - But overall the MOH should consider TBAs a valuable resource in expanding family planning options and accesability
Taking advice from those they trust: Traditional Birth Attendants as family planning promoters and providers in rural Guatemala
Taking advicefrom those they trust:Traditional Birth Attendants as familyplanning promoters and providersin rural GuatemalaAPHA October 31, 2012 | San Francisco, CAElizabeth Salazar, Jeannette Cachan, Paola Muñoz & AlmedaAguilarInstitute for Reproductive Health, Georgetown University
Presenter disclosures Elizabeth SalazarThe following personal financial relationships withcommercial interests relevant to this presentationexisted during the past 12 months:No relationships to disclose
Objectives• Describe the elements needed to enable TBAs to offer FP, including training materials, supervision and support systems, and reporting and procurement mechanisms• Demonstrate the impact of service delivery offered by TBAs towards use of FP through FP promotion, counseling and referrals• Evaluate the feasibility, acceptability and sustainability of having TBAs offer family planning outside of traditional health center settings
Sexual and reproductivehealth in Guatemala• Population: 14.7 million• 51% rural areas & 49% urban areas• Total fertility rate 3.98• Maternal mortality rate: 153/100,000 live births• 43% of children under age 5 are chronically malnourished• Contraceptive prevalence rate: 54%• Most popular family planning methods: female sterilization (18.9%), injectables (14.7%), natural methods (10.1%)
Traditional Birth Attendants as family planning promoters and providers in rural GuatemalaProgram goal • To train TBAs to promote all family planning methods and to offer four methods (Standard Days Method (SDM), Lactational Amenorrhea Method (LAM), condoms and oral contraceptive refills) in their communitiesPartners • Georgetown University/Institute for Reproductive Health (Guatemala office) • Ministry of Health/Guatemala, Department of TBAsLocation • 3 disticts in 2 departments in Guatemala
Description of the intervention Capacity Supervision Logistics & Promotion building HMIS Intervention steps- Training of - Monthly -Supplying - Distribution oftrainers supportive methods invitation supervision through health cards by TBAs- Training of from center (optional)TBAs facilitators - Submission of - Health- Refresher -Application of user/methods centertraining of knowledge registry to promotion ofTBAs checklist health center TBA service dielivery
Traditional birth attendant profile • Ages 23 to 87 (median age = 46) • Gender: Mostly female, 2 male • Ethnicity and language: Mayan (Mam, Kaqchikel) & Mestizo (Spanish) • Communities: Rural and peri- urban • Education level: No formal schooling to completing primary-level school • Role in communities they live in: attending births, pre and post natal care, and providing information of health issues (as provided by the MOH to them)
Evaluation design• Quantitative and qualitative• Data sources: – Focus groups – In-depth interviews – District-level Ministry of Health (MOH) service statistics – Checklist of essential messages on SDM, LAM, condoms & oral contraceptives• Target groups: – Traditional Birth Attendants – Auxiliary Nurses (Training facilitators) – MOH Stakeholders
Results Quetzaltenango Santa Rosa (2 districts) (1 district) Total Facilitators 15 7 22 TBAs 53 32 85 Start EndIntervention August/September 2011 OngoingEvaluation (9 months) October 2011 June 2012
Competencies of TBAs TBAs knowledge of medical eligibility criteria and how to use the method, after receiving training % of TBAs Method (N=29) LAM 62% SDM 79% Condoms 72% Oral contraceptives 59%
Competencies of TBAsKnowledge of conditions for Healthy Timing and Spacing of Pregnancies (HTSP) HTSP conditions % of TBAs (N=29) After having a baby, a woman should wait at least two years after the birth of her baby 83% before trying to get pregnant again In order to avoid pregnany, a woman should use a family planning method continuously 82% for at least two years
Demand for family planning Number of FP users (all methods), 9-mos. before and 9 mos. during TBA intervention32003100 3175300029002800 27042700 2674 # of FP2600 users 252625002400 24272300 22462200 Qtr. 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr. 5 Qtr. 6
Number of FP users (methods offered by TBAs, methods referred by TBAs, all methods) 9 mos. before and 9 mos. during interventionPre-intervention 1200 1000 800 600 400 200 0 1200 Oct Nov Dec Jan Feb Mar Apr May JunPost-intervention 1000 Methods 800 offered by TBAs 600 Methods 400 referred by TBAs 200 All Methods 0 Oct Nov Dec Jan Feb Mar Apr May Jun
Number of FP users, 9 mos. before and 9 mos. during TBA intervention, by method7000 6652 628460005000400030002000 1028 6431000 611 6 19 24 107 338 0 31 5 4 0 Pre-intervention Post-intervention
Number of FP users (all methods) in control andexperimental group for 9-month period during TBA intervention 1800 1600 1400 1200 1000 Control 800 Intervention 600 400 200 0 Oct Nov Dec Jan Feb Mar Apr May Jun
Acceptability of the strategy:MOH and TBA perspectives“Yes, there has been a contribution “That it makes our work difficult, no.[to the FP program], above all This is what we’ve always beenbecause we have the experience doing – when we give prenatalnow. These comadronas can really care we always talk about familyoffer methods eventhough theydon’t have a great deal of technical planning.”knowledge. They can speak about -TBA, Quetzaltenangothe benefits of FP and raiseawareness about methods.” “It’s important that we as -Department-level MOH stakeholder comadronas have this information because it helps us and we can“The comadrona can take the help other women.”services of a health center to wherethey don’t reach, the community -TBA, Quetzaltenangolevel. So they are contributing toexpansion of services and improvingwomen’s health.” -District-level MOH stakeholder
Contributions and benefits of the strategy • Women save time in not going to health center for method resupply • Women save money in not traveling to health center regularly • FP services are expanded to communities that they do not reach • Community members trust TBAs and may be more likely to take their advice • TBAs can reach couples at the community level • TBAs understand cultural context of communities they serve • Some adolescents rather visit a TBA than go to the health center for condoms
Challenges experienced and concernsabout the strategyTraditional birth attendants:• Additional time needed to promote and offer family planning• Women ask TBAs for oral contraceptives before going to a health center• Women ask TBAs for methods they do not offer, such as injectables• Some TBAs were scolded by religious leaders for offering FP• Some TBAs felt they are not receiving enough recognition for their work• Stock outs at health centerAuxiliary nurses:• Increased workload for auxiliary nurses working with TBAs• Stock outs at health centerMOH stakeholder:• Stock outs at health center• Increased workload for M&E staff in health centers
Feasibility of the strategy • Stakeholders at the department-level and district-level expressed some concern about expansion of the strategy due to level of effort and logistics matters • Central-level stakeholders were more optimistic about expansion efforts, but were awaiting evaluation results at the time of interviews • All stakeholders agreed that contraceptive supplies issues needed to be addressed in the existing intervention sites before expansion • Some stakeholders expressed that continued support from partners may be needed for expansion
Recommendations • Results of evaluation need to be disseminated widely with all levels of the MOH to assessFeasibility and feasibility of expansion • Some cost-benefit analysis may need to be sustainability done in order to obtain a full picture of feasibility and sustainability • The method registry may need to beAdapatations adapted/simplified to be more easily used by TBAs to the • The MOH may want to evaluate the feasibility strategy of having TBAs offer initial OC packs and additional methods
Elizabeth Salazares336@georgetown.edu www.irh.org