Jesse rattan care women deliver 2013 method skew presentation
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Jesse rattan care women deliver 2013 method skew presentation
- 1. Family Planning Method Mix in two crisis affected states: Chad and DRC Jesse Rattan CARE Women Deliver May 2013
- 2. Who are we? Supporting Access to Family Planning and Post-abortion Care Initiative (SAFPAC) • Increase access to family planning (with a focus on LARC) and post-abortion care • Disaster or conflict-affected places: Chad, DRC, Pakistan and other acute emergencies as they arise (Mali, Djibouti) • Integrate SRH programming throughout CARE’s emergency response work and culture 1 January 31, 2014
- 3. What does SAFPAC do? Strengthen service delivery of FP and PAC at gov’t health facilities through: • Competency-based training of providers with a focus on LAPM/LARC and postabortion care (clinical and counseling); • Work with gov’t district management teams to strengthen supportive supervision (both facility level and clinician follow-up); • Strengthen health information system and data collection, analysis and use for decision-making; • Equipment, supplies, commodities: ensure the full range of MOH approved methodspills, injectibles, IUD, implants, condoms, female/male limiting (in DRC and Pakistan currently) Stimulate awareness, supportive norms, and demand: • Collaborate with women’s associations, religious leaders, formal leaders, community health workers to discuss and explore how to increase social access to FP and PAC • Use theater groups, radio as mass media communication of what/where when 2
- 4. Where do we work? DRC Lubero and Kayna Health Zones Kasongo Health Zone 3 31/01/2014
- 5. Where do we work? Chad Gore District 4 January 31, 2014 Danamadji District
- 6. Set the stage: Why Family Planning in Chad and DRC? 5 January 31, 2014
- 7. What happened? Cumulative new users (July 2011 to Dec 2012):Pills, injectables, IUDs, implants, permanent methods 35000 30000 Axis Title 25000 20000 Monthly Total 15000 Cumulative Total SAF-PAC Target 10000 5000 0 6 January 31, 2014
- 8. Dramatic increase in % of new users choosing long-acting and permanent methods (LAPM) 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% DRC Chad 7 January 31, 2014 DRC Average 2012_12 2012_11 2012_10 2012_09 2012_08 2012_07 2012_06 2012_05 2012_04 2012_03 2012_02 2012_01 2011_12 2011_11 2011_10 2011_09 2011_08 2011_07 2011_06 Chad
- 9. But extremely skewed toward implants! Monthly total new FP users by method for CHAD 1200 1 69 83 1000 3 214 800 600 1 72 77 400 395 200 0 886 0 56 46 0 0 38 26 0 0 49 44 0 1 0 53 84 0 1 0 50 78 3 0 0 37 69 1 0 22 1 105 82 1 60 16 2 124 51 1 76 28 781 472 56 41 17 34 9 92 30 1 84 13 422 804 360 428 423 22 49 36 55 693 5 Chad - Tubal Ligation 1 101 20 0 83 15 85 246 57 Chad - Vasectomies 1 128 8 Chad - Injectables 257 330 Chad - Implants 55 49 Chad - IUD 1 55 19 Chad - OCP Monthly total new FP users by method for DRC 1000 900 800 700 600 500 400 300 200 100 0 7 95 66 2 47 65 10 41 63 4 31 42 0 11 52 35 3 8 January 31, 2014 1 13 41 37 7 1 12 40 36 16 4 7 29 32 15 0 16 53 35 14 1 12 31 36 7 2 36 57 152 22 5 44 65 292 317 662 36 5 31 45 5 67 86 11 61 89 3 53 75 430 407 404 346 391 367 86 109 99 7 64 64 DRC - vasectomies DRC - Tubal Ligation DRC - Injectables 638 473 42 11 49 43 14 110 84 377 66 72 DRC - OCP DRC - Implants 68 47 37 42 59 DRC - IUD
- 10. A closer look at method mix… Contraceptive Method Mix in Chad Contraceptive Method Mix in DRC 1% 0% 0% 0% 17% 10% 5% 10% 13% IUD IUD 9% Implants Implants OCP OCP Injectables Injectables tublig tublig vas vas 69% 9 January 31, 2014 66%
- 11. What does the literature tell us about method skew? • No ideal method mix, but it can proxy for method availability and choice • Sullivan et al, 2005: 34/96 countries >50% single method skew • 1. 2. 3. 4. 5. Reasons for method skew: Policies/programmes Provider bias History of method in the country Method characteristics Client characteristics 10 January 31, 2014
- 12. So based on these factors: What does our experience tell us about method skew? • • • • Policies/programmes Method characteristics Provider bias Client characteristics 11 January 31, 2014
- 13. National programmes: Extremely limited access to any method • Extreme lack of access • Extremely limited availability Combined with: • Free, high quality contraceptives and trained staff, • Good quality counseling 12 January 31, 2014
- 14. Method Characteristics Long-acting FP methods: • Highly effective • Utterly “forgettable” • Long-acting… yet reversible 13 January 31, 2014
- 15. Provider bias…towards LARC but away from IUDs Implants: • Ease of implant insertion • Confidence with technique • Quick process, less work than IUD 14 January 31, 2014 IUDs • Concern about STIs (and IUD insertion) • Lack of confidence with technique
- 16. Category 4: Client, partner, community characteristics & perceptions: Away from IUDs Toward implants • Myths: • The name: “The two sticks”…La jadelle” • Is visible in the body • No need to disrobe or have a pelvic exam (esp w/ male provider) • • • • cancer String will bother the partner during sex It will disappear inside the body Baby could be born holding the IUD • It is invisible inside the body • In its package, the IUD looks very long • Shame R/T undergarments in poor condition and personal hygiene 15 January 31, 2014 • Friends and neighbors have it and recommend it (bouche a oreille or “mouth telephone)
- 17. What did we do? Focus on choice (instead of skew): Examples of two of our strategies 1. Using a rights-based frame and work with key influencers to inform and support CHOICE 16 January 31, 2014
- 18. 2. Using a rights-based frame, quality counseling (and good skills) to protect choice Population Council’s Excellent counseling strategy 17 January 31, 2014
- 19. Example of one program strategy to drop barriers to expanded choice 80 Team improves messages related to IUDs, increase outreach to men 68 70 59 Number of new users of IUDs in DRC June 2011 to August 2012 60 50 47 42 36 40 62 37 42 IUD 30 22 20 10 16 7 15 14 7 Counseling 3 0 18 January 31, 2014 Clinical training Supportive supervision training and approach
- 20. Final Thought from Sullivan, Bertrand Et al: Efforts to ‘improve’ method mix ought not to be undertaken at the expense of good methods that happen to be popular: Our focus will continue to be on expanded availability and ensuring true choice Terima Kasih! 19 January 31, 2014
Notas do Editor
- SLIDE 1WHO: I am the lead for an initiative called Supporting Access to Family Planning and Post-abortion careWHEREAs you can see we work in unstable, crisis-affected settings, and, inside of that, in areas based where refugees or internally displaced people are. In DRC as many of you know,, we work in North Kivu that has suffered through decades of violence and is suffering from increased violence even as we speak, In Chad we are in districts that are home to permanent refugees from CAR, and over the past several months of instability in CAR, we have seen several thousand refugees move across the border.In Pakistan, we work in South Punjab in disrtricts that have experienced massive flooding and people displaced by those floods in 2010/2011 and experiences seasonal flooding. Today I will be focusing on method mix in Chad and DRC only because what happened in those countries was so acute and so similar… I also won’t be talking about our post-abortion care work, although it is worth mentioning here that we offer and advocate for family planning during post-abortion care services. And finally, I just want to emphasize here that we support access to ALL FP methods, but within that full range of FP methods we focusing on under-utilized long-acting and to some extent permanent methods too.
- SLIDE 2: -- Our main activities are -- service delivery strengthening of government facilities, and that includes support competency-based training with a focus on LARC and to some extent permanent methods, and post-abortion care, supporting the district teams to provide good supervision of clinicians and the overall functioning of the facilities, strengthening district and facility team’s ability to record information, look at it critically and make decisions based on it, Provision of supplies, equipment and the full range of modern FP methods– pills, injectibles, IUDS, implants, condoms and permanent methods (tubal ligation and vasectomy)– but as I said, we are striving to increase inside of that full range of FP, access to long-acting methods. -- our supporting interventions are working with communities to build awareness of family planning in the community, strengthen the connection between the community and the health center, and at the same time as building awareness of family planning and post-abortion services, raise and explore norms that are barriers to women’s access to FP (and PaC)
- So today I am going to be talking about our first phase, which ran about 18 months from July 2011 to December 2012Here is Congo, an enormous country– the land mass as big as Western Europe and a popuation of about 70 million people. During our first phase, we worked in 19 health facilities in 3 health zones of two provinces in Eastern Congo, Maniema and North Kivu (Maniema province being extremely remote but peaceful, but North Kivu as I said before, relatively remote, but also suffering from decades of political instability and violence. Kasongo: 1 generalhospital, 8 CdS (entire zone is about 200,000 people)Lubero: 1 generalhospital and 4 CdS (entire zone is about 340,000 people)Kayna: 1 generalhospital and 4 CdS (Kayna zone is about 362,000 people)
- Chad has a much smaller population of abou 11.5 million and geography characterized by Sahelian desert in the northeast, and wooded Savanah in the South, were work. It is for the moment, a stable oasis of relative peace in the Sahelian region, although there was an attempted coup just a few weeks ago. As with DRC it is a fragile state and some would say « failed »…. In Chad we work in two separate districts in two regions, Moyen Chari adn Logone Oriental that are also home to Central African Repbulic refugee camps in 14 health facilities14 health facilities :10 health centers2 districts hospitals2 regionals hospitals ,Logone oriental region:Gore Health district Doba regional hospitalMoyen Chari region:Danamadji Health district Sarh regional hospital
- -- this is graph is from a March 2013 Lancet article published by the United Nations Population Division and the University of Singapore on global estimates of CPR and unmet need. -- For me it tells a compelling story of the global trends– the green and blue points are CPR in 1990 and 2010 and the red and purple points are unmet need. As you can see, the points form a “Y”. The CPR rising and the unmet need moving down in the last decade. While central and west africa have also seen positive change, they lag significantly behind the rest of the regions, the only regions with aggregate CPR around or below 20% and the only regions where the percentage of unmet need is higher than the contraceptive prevalence rate. -- The last national survey in Chad in 2004 found a modern contraceptive prevalence rate of 1.8%, and the most recent survey in DRC in 2010 finding a 5.5% modern CPR. So from our perspective, we had our work cut out for us, especially since we were not only hoping to increase the overall use of FP, we hoped to at least to make long-acting methods avaiable and begin the process of making people aware of their availability and advantages. - So keep this in mind as we look at the next slide
- -- This slide is a snapshot of our cumulative users over time compared to what our target was for all three countries-- just to give you an idea of how far off our estimates of new users was– we estimated a very rapid increase from baselines Health center numbers, and assumed we would generate about 10,000 new users over an 18 month period. -- Our analysis of this in a nutshell– in these settings, the issue was not so much about low demand, but the reality that supply was so low and so inconsistent, very very few women were contracepting, many fewer than even the national survey suggested. ----- Meeting Notes (5/27/13 05:46) ------ So this graph shows the percentage of new users of long acting and permanent methods over the first phase of our project- as you can see we had a very surprising and rapid uptake of long-acting and permanent methods by about month six of the project and this very high percentage of clients choosing long-acting continued until the end of the first phase of this project.
- - So this graph shows the percentage of new users of long acting and permanent methods over the first phase of our project- as you can see we had a very surprising and rapid uptake of long-acting and permanent methods by about month six of the project and this very high percentage of clients choosing long-acting continued until the end of the first phase of this project.-
- So this slide is a break down of the last slide000 but shows you the breakdown by method, and again, as you can see, the vast majority of women were choosing implants, although you can see a small uptick in IUDs there at the bottom in DRC. Training commenced in both countries around November 2012 – January 2013Stock-out
- -- just another view of this trend– implants accounting for almost 70% of method mix in both countries in about one year period.
- So you can imagine this was all very surprising to us, and we wanted to figure out what was going on, because our first impression was “this is bad”. One article informed our thinking: A great overview by Tara Sullivan and Jane Bertrand et al from 2005And a couple key elements from that article have helped inform how we are understanding and approaching our own program method skew:No ideal method mix, but it is an available proxy or red flag for availability and true choice When a single method commands more than 50% of total method mix, you can officially say you’ve got a skewed mix, and it’s really worth investigating reasons wheyYou can break down method skew into 5 categories: 1) national policies and programmes that influence availability and access to a full range of methods, 2)provider bias, 3) actual time the method has been around 4) positive and negative characteristics of the method, and 5) client characteristics– client perceptions but here I would also include partner and community perceptions, understanding and norms around family planning and fertility
- --So we felt there are four categories of reasons for method skew that are influencing uptake of long-acting, specifically implants and IUDs in our program
- - We believe our method skew is based on the foundation of a huge national supply issue—extremely limited availability of any method: -- In DRC and Chad, in the remote areas we work in, there was little to no supply of contraceptive, significant distances to reach facilities to get family planning, situations in which there was no guarantee there would be any methods, and often uncertain, informal costs to get them if they exist-- combine this with free, high quality contraceptives and staff trained to deliver them and you have the foundation for rapid uptake of any method (in this kind of context).
- The second category influencing method mix is the method characteristics: And here we have the positive features of long-acting methods: 1) highly effective: less than 1 woman in a 100 will get pregnant in one year of use2) utterly forgettable– once they are in place you can forget them– no appointment to remember, no long distances to travel to get resupply3) long-acting yet totally reversible-- and with the copper T IUD– immediate return to fertility.
- -- We have noted some provider bias– the good news is that it is obviously not bias against highly effective, long-acting methods, But we’ve been talking to providers, and here is what they say about the two methods- Review the the issues on the slide
- Category 4 of common reasons for method skew is related to client and community perceptions, understanding and attitudes towards particular methods:-- Because we are focusing on dropping barriers to long-acting methods, and achieving a healthy balance between the two– we have been trying to understand the high skew toward implants compared to IUDS:As you can see, -- a range of common myths about IUDs but I wanted to point two points: Once the IUD is inside the body– it is completely invisible compared to the implant which one can see the outline of under the skinShame not only related to disrobing, but also shame about the poor or dirty condition of one’s undergarments and lack of hygieneFor implants– especially in Chad, we have not only the visibility of method in the skin, but the easy to remember name “la jadelle” (like a trusted girffriend) and the nickname “the two sticks”
- Because we know that skew is not bad in and of itself, but as a red flag for poor or coerced choice, our focus has to be not on fixing the skew, but on ensuring choice: reinforcing a woman’s right to use family planning at all, and dropping barriers related to knowledge and perceptionsSo one way we are trying to do that is working with opinion leaders, connectors, the powerful– this is a photo of policemen in Southern Chad… We worked with these guys because a few months into the project, husbands of women who had come to our supported health centerswere going to the police to complain that they were getting family planning without the husband’s knowledge. When our team went to talk to the police, they brought along the reproductive health policy that Chad adopted a few years ago, to reinforce that women had a formal right to seek family planning without anyone’s permission. And these these guys said– we didn’t know anything about that policy… and by the way we don’t know anything about family planning… what are the methods? How do they work? Our teams also did a short workshop on family planning in generalIn this case we were able to do two things– reinforce the idea of women’s right to family planning and also to drop some of the awareness and knowledge barriers about family planning methods in general
- Here I want to emphasize two basic strategies to try to protect choice: 1. Ensuring providers are competent and confident about their skills through training but also follow-up and coaching 2. Using a really excellent counseling strategy called Balanced Counseling Strategy Plus which uses a a simple algorithm and family planning method cards which does two great things: 1) Early in the discussion, asks the client what methods she definitely does NOT want (keeping her right to choose her method at the center of the discussion), but keeps all the other methods on the table. 2) Uses touchable, visual family planning method cards that have basic facts about each method on the back including effectiveness, which helps the long-acting methods to stay on the table and in the discussion much longer than traditional counseling strategies do.
- So Hereisjust a quick snapshot ofmodestincrease in IUD use and better balance of methods in DRC, and whatwethinkwerefactorsinfluencingit1) Clinical training and counseling training in the earlymonthsprompted the initial increase in use of IUDs and thenlater in the yearthen in latermonthsbetterfollow-up of providers to improvetheir confidence in bothclinicalskills and use of the counseling technique, and improved messages and engaging men to dispelmyths about methods in general and especiallyrelated to IUDs
- -- In SAFPAC our focus will continue to be not on fixing skew but expanding availability at the program level, dropping social and information barriers in the community and ensuring true choice at every client-provider interaction.