This document summarizes the integration of family planning services into maternal and child health programming in Liberia. Key points: - Family planning services were introduced in 2011 and integrated into the existing community health program after external funding ended in 2012. Services were integrated into immunization outreach activities. - Integration trained community health workers to provide family planning counseling and some methods. It increased modern contraceptive use from 2% to 61% and decreased unmet need from 68% to 22%. - While challenges included increased workload, integration had benefits like utilizing existing resources and a network of community health volunteers to scale up comprehensive services. Lessons included applying family planning messaging to all users and clarifying return dates for integrated services.

1. NANCY WARREN, MPH
CURAMERIC AS GLOBAL
MARCH 7, 2014
Integration of Family Planning
Services into MNCH Programming
in Liberia
Additional collaborators: Allen Zomonway, BSN, Ganta United Methodist Hospital;
Jean Capps, MPH, BSN

2. Liberian Context
 Total population: 3,989,703
 Over 14 different ethnic groups
 Median age is 17.9 years
 Total Fertility Rate (TFR): ~5
children/woman
 Maternal mortality: 770/100,000
live births
 Infant mortality: 71/1,000 live
births
 FP Unmet need: 36%

3. Overview of Nehnwaa Child Survival Project
 Nehnwaa – “struggle of the child”
 USAID-funded for five years (2008 – 2013)
 Local partner: Ganta United Methodist Hospital (GUMH)
 Located in Nimba County, Liberia
 Targeted WRA, U2 mothers, and U5 children
 Six intervention teams:
 Maternal and Newborn Care (MNC)
 HIV/AIDS
 Immunizations (EPI)
 Water and sanitation (WatSan)
 Integrated Mgmt of childhood illnesses (IMCI)
 Community Support Services (CSS)

4. Overview (continued)
 Program Design combines the Community-Based
Impact-Oriented Methodology (CBIO) and Care Groups
to provide community-based primary health care
services
 Over five years, 120
general Community
Health Volunteers
(gCHVs) and 120 Trained
Traditional Midwives
(TTMs) trained
 One gCHV and one TTM
per community

5. Introduction of Family Planning Services
 In 2011, introduced 1-year FlexFund award for
Community-Based Family Planning Services
 Hired additional FP staff to establish Community
Depot at GUMH and integrate FP into community
visits (additional intervention team)
 Trained all staff, gCHVs, and TTMs for community-
based distribution and counseling
 Established supply chain and procurement system
for MOH-provided family planning commodities

6. Integration Process and Procedure
 After funding ended in August 2012, FP services
were integrated into the original Nehnwaa structure
as a part of EPI service provision
 EPI staff were fully trained in counseling and service
provision, including administration of Depo Provera
 EPI staff were trained in supply chain management,
reporting, and recordkeeping

7. Integration Process and Procedure
 While technically FP/EPI integration, family planning
became a topic of most intervention teams:
 HIV team counseled on safe sex and provided condoms
 MNC and IMCI teams counseled on LAM and birth spacing
 CSS team trained and mentored gCHVs on counseling,
distribution, and recordkeeping of FP services

8. Description of Family Planning Clients
 Between September 2012 and January 2014, 3,866
office visits
 2% male and 98% female
 Male clients range from 18 to 50 years old
 Female clients range from 13 to 50 years old
10-14 yrs 15-19 yrs 20-30 yrs 31+ yrs
Female 11 802 2128 850
Male 0 5 25 45

9. Family Planning-Specific Outputs
Key Result Objectives Baseline
(2008)
June
2011
July
2012
Final
(2013)
Increase the percentage of
Contraceptive Prevalence
Rate among WRA
2.0% 15.20% 61% 61%
Decrease the percentage of
Unmet Need among WRA -- 67.90% 22% --
Increase the percentage of
WRA who report discussing
family planning with a health
or family planning worker or
promoter
-- 25.3% 97% 97%

10. Indirect Improvements - Additional Indicators
 Improvements in other indicators may be influenced
by integration of family planning services:
Indicator Baseline (2008) Final (2013)
Exclusive Breastfeeding 39.4% 52.9%
At least 4 ANC visits 24.7% 73.9%
Postpartum visit for mother 9.3% 58.1%
Children with PENTA1 vaccine 40.1% 100%
Children with PENTA3 vaccine 24.5% 99%
Children with Measles
vaccination
45.3% 97%

11. What was the difference maker?
 Family Planning counseling and service provision
made possible by network of community health
volunteers
 Increase in peer education and social acceptability
 Supply is able to meet demand
 Client has options
 Community v. facility
 Wide variety of commodities
 Trust and rapport with Nehnwaa Staff
 Involvement of men in BCC programming

12. Limitations with Survey Data
 All data is self-reported
 Urban bias
 Sample size less than 5% of beneficiary pool
 Recall bias
 Interviewer bias: beneficiary wanted to please the
interviewer
 FP indicator may be related to availability of
commodity

13. Conclusion: Benefits to Integration
 Cost effective - utilizes existing staff and resources
 Scaling up of comprehensive service provision
 Synergy of efforts
 Meets demands for services
 Potential continuum of FP service provision by
current implementing partner
 Utilizes a robust community mobilization &
intervention system

14. Conclusion: Challenges to Integration
 Increased workload of all staff, particularly EPI
 Combining FP & EPI data collection & reporting tools
 Logistics
 Commodity Stock-outs

15. Lessons Learned
 FP integration into MNCH community outreach
activities is feasible
 FP/EPI integration reaches multiple types of
beneficiaries
 BCC messaging should apply to the spectrum of FP
users
 All CBPHC teams should modify the service
provision setting to address confidentiality
 Clarify return-to-clinic dates (particularly with EPI
and FP service provision)

16. Looking Forward
 Currently, post-funding, GUMH has scaled back their
FP services to Facility service provision and minimal
CBD by community volunteers and staff
 GUMH continues to regularly receive commodities
from MOH despite national restructuring of
distribution
 New agreement with Planned Parenthood
Association of Liberia (PPAL) to provide community
SRH services
 Continued external support from private donors to fill
gaps as needed

17. Questions
?
For more
information on
FP/EPI
integration,
visit:
http://www.k4h
ealth.org/toolkit
s/family-
planning-
immunization-
integration

18. Thank you!