To give you a bit of background, IRH was founded in 1985 and we’re currently working on a 5 year project with USAID funding which goes until 2012. With this funding we are focusing on research to scaling up into program implementation in five countries: Rwanda, DRC, Mali, India, and Guatemala. With this and prior funding, IRH has also provided technical assistance to countries that want to add fertility awareness based methods to their programs. Many of these countries are in conflict and post-conflict settings, and to name just a few, in 2009 alone, IRH provided technical assistance to projects in Pakistan, Afghanistan, Nepal, Angola, East Timor, and Burundi. And by FAM methods, I am focusing on three the institute has developed: the standard days method or SDM which tracks a woman’s fertile period through color-coded beads called CBs, the lactation amenorrhea method or LAM which is a post-partum method which is most effective when a women breastfeeds exclusively for six months without seeing the return of her menstrual period. And, finally, the two day method or TDM which uses cervical secretions to track fertile days.
So to look at FAM method use in crisis settings, we see the advantages as being that the LAM and TDM methods require no commodities to purchase or supply and CBs used for SDM can last an average of four years before they need to be replaced. So issues of frequent commodity replenishment along with high cost do not impact use or program implementation. Furthermore, those displaced do not have to worry about taking, losing, or needing to replace the commodity, as they would with some others. Furthermore, there is no need for frequent trips to a health facility, movement which we know puts women at risk in insecure areas and with health facilities often located far away from their homes. With FAM methods women also do not need to make repeated visits for follow up. For example, once they have received an initial SDM counseling session of 15 to 20 minutes, a time which has proven sufficient to teach the method, a woman or couple is equipped with the knowledge and tools to use it in the long-term. The LAM method can also be integrated into pre and post-natal consultations so as to minimize women’s needs to undertake risky travel and is free as well. And LAM encourages exclusive breastfeeding which is an added advantage for the babies’ health and cuts down on refugee, IDP, or impoverished women having to seek out other nutritional supplements that they cannot afford or find, particularly if they are uprooted from their homes. IRH’s innovations include using low literacy and low technology approaches (such as completely pictorial instructions for use of CBs for women who may be illiterate and don’t have easy access to a provider for counseling) to train local health facility, CHWers, and users. This also reduces the vulnerability of NGO or other external organization staff members making frequent travel into high risk areas for trainings and supervision. IRH also works through local community groups on all our projects – from conflict through development – but this can be even more crucial in crisis settings because reliable information regarding security issues often comes from community members and without their acceptance, buy in, and support, this added protection is missing. Finally, local as well as national support must be in place and engagement with all parties to the conflict is often necessary in order to create an overall supportive environment allowing for better access to the population in need. If one chooses to assist only a certain group, this creates risks because all other groups may then feel they are being excluded which opens up vulnerability to insecure situations.
Now, to look a bit at the Haiti and DRC contexts. These two countries – although far apart geographically – share a lot of similarities in their histories, cultures, and reproductive health needs. To talk a bit about their shared experiences, both have been through long-lasting dictatorships (Papa and Baby Doc in Haiti and Mobutu in Congo) which led to almost complete destruction of infrastructure and extreme civil unrest (a series of coup d’états in Haiti and prolonged civil war in the DRC). Both countries have also been through terrible natural disasters – the series of hurricanes in 2008 and of course the January earthquake in Haiti while volcanic eruption destroyed nearly all of the DRC’s North Kivu provincial capital, Goma, and continues to pose a risk due to its very active state. Both countries have populations accustomed to violence, extreme poverty and poor health and they have also had fluctuations in degrees of outside intervention, which has been not only humanitarian (UN and INGOs) but military (US and UN forces in Haiti; UN, African, and European forces in the DRC) Finally, both have a lack of state and civil society rebuilding due to donor dependence and the on-going crises
Good data is difficult to find, but DHS, UN, and a C-Change project data found that only 6% of women use a modern contraceptive method in the DRC and most of these users are in the western part of the country where access is easier. Because there are so many short term, emergency focused projects they do not include FP in their activities which also contributes to a lack of use/access in the east. In 1990, 16% of the population used a method and data shows 50% unmet need as of the 2005 DHS so clearly the demand is there but the descent into war led to a tremendous decrease in use. Also traditional method use is fairly high, particularly in Haiti, so adding a natural, modern, evidence based method to the mix could be an easy way to meet the needs of this population and draw in new users. In Haiti, according to 2007 DHS data, modern method use is higher at nearly 25%, but there is still great unmet need and with the recent earthquake this number has almost certainly gone drastically up as regular supplies are depleted and disappear.
These are some of the findings from work IRH has done with partners in eastern DRC, the area most touched by the conflict: There are many values of adding it to the method mix and with brief provider trainings and short counselling sessions, that makes it an appealing method for programs and clients. In GTZ areas of intervention, an evaluation found that the SDM was the most popular commodity after male condoms, and represented 33% of FP commodities sold . This area was in eastern DRC (South Kivu) during period of conflict (2007) -Continuation is high (at 66%?) and this point illustrates that. MSI project came in after a USAID-funded project which introduced CBs and MSI found many couples still using beads years after due to the simplicity and the fact that they can make them locally and that they reduce the need for risky movement to/from clinics for provision of other birth control methods -A variety organizations – be they NGO, FBO, or CBO – have had interest and success in integration the SDM and LAM into their services. In North Kivu the Catholic church provided training as they saw it as the best option for their context of high insecurity, etc - FAM methods can be easily integrated into new and existing FP programs as well as – in LAM’s case – maternal and child health programs which are often more common in conflict programming. For example, the Merlin – Care project added FAM methods due to these reasons as well as those Sarah mentioned earlier (relating to commodities, cost, training, and ease of use)
IRH implemented these programs in partnership with MSH and HHF between 2005 and 2007, which was continued period of civil unrest in Haiti (elections, increasing incidence of GBV, etc). With the aftermath of the earthquake, the advantages of IRH methods are even more appealing for introduction and continuation in FP programming. Unlike DRC which is a dedicated focus country for IRH, Haiti received only limited technical assistance and funding. As the first bullet point demonstrates IRH and HHF were able to work with 14 clinics in urban settings, bringing 600 new users to SDM. This also shows that couples – both urban and rural, educated and less so – find the method appealing IRH and partners also developed IEC materials in Creole and French to accompany the trainings undertaken with local NGOs and Haitian providers. This building of local capacity ALSO HELP COMMUNITIES TO START MAKING A CRISIS TO DEVELOPMENT TRANSITION.
Some things we’ve learned from research in development focused settings, but we believe these would hold true in conflict settings and further research is envisioned to look more deeply at these issues and settings: - GBV tolerance goes down among both men and women when the SDM is offered as part of a comprehensive package of FP services Couple communication goes up which leads to improved gender equity majority of women who chose the method are first time users of FP so it doesn’t take away users from other methods rather it reaches a population wouldn’t otherwise be using FP services For more info, you can look at IRH’s website, which was recently updated so there are a lot more resources and info than we previously had available online. You can also e-mail Sarah at firstname.lastname@example.org. We also have some CBs and literature (including in Spanish) if you’d like to take some after the end of the panel.
Use of Fertility Awareness Based Family Planning Methods in Areas of Conflict and Civil Unrest :
Annual Meeting of the Inter-agency Working Group on Reproductive Health in Crises Santo Domingo, Dominican Republic May 24 – 26, 2010
Use of Fertility Awareness BasedFamily Planning Methods in Areas of Conflict and Civil Unrest : Examples of Haiti and the Democratic Republic of Congo Presenters:Sarah J. Terlouw, IRH/Georgetown University Jewel Gausman, USAID
IRH Background• Founded in 1985 and focuses on: • Fertility awareness based methods (SDM, TDM, and LAM) of FP • Fertility awareness and body literacy among youth • Reducing stigma and discrimination to improve HIV prevention and care
FAM Method Use in Crisis SettingsAdvantages: Innovations:• Few to no • Train providers using commodities low literacy and low- needed technology approaches• No need for • Work with and frequent trips to through local health facilities community groups• Short counseling • Create a supportive sessions to explain policy environment use
Haiti and DRC: Shared Experiences• Long-lasting dictatorships• Natural disaster• Donor dependence• Populations accustomed to violence, extreme poverty and poor health• Outside interventions – military and humanitarian• Lack of state and civil society rebuilding
Haiti and DRC: Family PlanningContraceptive Unmet Need for Prevalence: Family Planning,• Modern methods Women 15 – 49: – Haiti: 24.8% – Haiti: 37.5% – DRC: 6% – DRC: 50%• Traditional methods Total Fertility Rates: – Haiti: 7.2% – Haiti: 3.5 – DRC: 15% – DRC: 6.1 Contraceptive Prevalence: 2005-2006, DHS Haiti , 2007 DHS DRC Unmet Need for FP: 2009 JSI Haiti Report, 2007 DRC DHS Fertilty Rates: Human Development Index, 2005 - 2010
IRH Work in the DRC • GTZ evaluation found that the SDM was the most popular commodity after male condoms, and represented 33% of FP commodities sold • MSI found couples continuing to use CBs 2 to 3 years after initial introduction to SDM • Catholic church trained couples in CB use • Joint Merlin – CARE project included SDM and LAM in FP method mix due to simplicity GTZ, “Family Planning End of Project Report”, 2007Marie Stopes International, Maniema Province, 2009 (based on findings from USAID-funded CARE project, 2007)
IRH Work in Haiti• IRH work with the Haitian Health Foundation (HHF) resulted in 600 new accepters of SDM between December 2004 and August 2007• MSH and HHF provided training to providers and CHWs in various regions of Haiti IRH, “Awareness Project Haiti Country Report 2005 – 2007”, January 2008
Conclusion • FAM methods work well in crisis settings and offer distinct advantages over many other FP methods www.irh.org email@example.com