Bill & Melinda Gates Foundation

5 Lessons on Integrating Family Planning and Maternal Health

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January 29, 2014

Jacaranda Health is working to change the way that maternity care is provided in Africa. We are developing a replicable model to provide affordable, high-quality maternal health services to low-income women worldwide. Our goal is to become a global laboratory for some of the most exciting innovations in maternal and child health service delivery.

Family planning is one of the most cost-effective ways to reduce maternal mortality, and at Jacaranda we are committed to integrating high quality family planning services to the spectrum of our maternity services. We hope to contribute to the community by sharing what we are learning about providing postpartum family planning services in resource-constrained settings.

1. Integrate family planning into maternity services

Pregnant women have so much to think about during pregnancy – where to deliver, how to save for the costs, the baby clothes – that preventing the next child is often the last thing on their mind. But studies from around the world have shown that nearly 80 percent of women do not want a pregnancy in the two years following a delivery. Half of these women would like to start contraception within six weeks after delivery. In Kenya, 90 percent of women in the three months postpartum and 68 percent of women at one year postpartum still have an unmet need for family planning. Most health care facilities design maternity care and family planning as separate services; we believe the two should be married.

Integration of family planning into antenatal, postpartum, and child wellness services is proven to help women meet their contraceptive desires. At Jacaranda, we’ve integrated family planning cues into documentation so that providers do not have to struggle with multiple forms, and can respond to built-in prompts to initiate family planning dialogue throughout the continuum of care. We’ve also designed educational materials for our antenatal clients to take home, which plant the family planning seed early and equip clients with the knowledge they’ll need to make a decision after delivery. The postpartum period is often a missed opportunity for family planning, so we’re also considering helping our antenatal clients build a personal postpartum contraception plan, analogous to a “birth plan,” to encourage them to start planning early.

 Evidence from Kenya and other countries suggests that once women have been fully counseled on family planning usage and side effects, satisfaction and uptake increases while unmet need drops.2. Get efficient

Task-shifting to lower level providers can increase access to family planning.

Nurses are overburdened and under-resourced, and often lack the time (and the skills) to provide adequate education and products. Recent national data from Kenya reveal that that 88 percent of women who are not using family planning have not discussed it with a field-worker or health facility staff at a health facility. Moreover, evidence from Kenya and other countries suggests that once women have been fully counseled on family planning usage and side effects, satisfaction and uptake increases while unmet need drops. Stronger counseling benefits women, and training auxiliary health care workers to provide the counseling can take a tremendous burden off of primary care providers – especially when integration is the name of the game. 

At Jacaranda, we are training patient care assistants (PCAs) and community health workers (CHWs) to use the “Balanced Counseling Strategy,” an algorithmic counseling technique that ensures quality counseling. They use this technique during delivery discharge and postpartum home visit to help women decide on their family planning options early. Task shifting helps our clinicians manage their clinical priorities, and can subsequently improve family planning uptake while decreasing client wait time and improving overall efficiency.

 

3. Bust myths

Family Planning is about more than the commodities: It’s also about knowledge, education, and counseling.

You could write a book with all the myths and misconceptions out there about family planning. Some women think that hormonal contraceptives will cause infertility, or that the IUD will move around in the body. Good counseling is rare, and as a result many women seek information through informal social networks or simply decide against family planning altogether.

Taking tools off the shelf – and tailoring them for your specific setting – is a good way to make sure providers have the tools to bust myths and build knowledge. We’ve adapted existing family planning counseling tools – the WHO Decision-Making Aid, Population Council’s Balanced Counseling Strategy, the Government of Kenya’s medical eligibility checklists – to help nurses and patient care assistants provide high-quality, customized counseling. In the interest of encouraging equity in our service provision, our in-house family planning curriculum addresses bias against male and unmarried clients. We are also exploring the possibility of family planning group education sessions to take advantage of empty wait times and build community among our clients.

Text messaging is another effective way to link informal community dialogue about family planning to the formal health sector. We are currently using community feedback to develop postpartum family planning SMS and voice messages in order to convey key health information, dispel myths, and encourage women to seek further information.

4. Target men

Male involvement is key to increasing access to family planning.

Male partners are probably the greatest source of pressure in women’s reproductive health decisions, especially in terms of when, how, and whether they choose family planning. More often than not, men in resource-constrained settings are bringing in more income than women, and thus control resources for maternity care or family planning.

We’ve engaged in human centered design exercises to understand male views on maternity and birth spacing in Kenya: Who is responsible for deciding how many children a couple will have, where the woman will deliver, or how do couples save for delivery? Most importantly, where does the perceived responsibility for reproductive health choices lie? We learned that many of our clients choose not to start postpartum family planning until they’ve decided on a method with their partner, but that male partners largely lack knowledge about the options – and even when they have questions, they do not feel comfortable asking them. We also learned that men are primarily concerned about financing maternity care and family planning. In response to these insights, we designed waiting room materials and financial saving tools targeted specifically at men, as well as a family planning decision-making aid for women to use at home with their partners.

5. Think outside the box

Getting creative by working with both public and private providers is the only way to ensure that contraceptives make their way into the hands of those who need them.

Many resource-constrained countries suffer from commodity stockouts and poor inventory management, particularly in rural areas. If a woman from a smallholder farming family travels for two hours to get family planning at the nearest health center only to find it out of stock, can we really expect her to make a trip back anytime soon? 

In Kenya, the Government of Kenya is the primary public provider of family planning, and private providers fill commodity gaps when the government falls short. Here and beyond, we need to cement proper inventory management (at the local level) and improve supply chain systems (at the regional and national levels). We’ve found that government support and training can help private providers access cheaper training and commodities and build good relationships at the district level. For contraceptive security we think it’s best to hedge your bets with multiple suppliers, so we’ve linked up PSI to ensure that our commodity supplies stay constant.

 
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