STRATEGIES FOR OFFERING LONG ACTING METHODS
Reproductive Health/Family Planning Symposium Sept 19-20, 2011Amman- Jordan
ENRIQUITO LU, MD. MPHRH/FP/Cervical Cancer Prevention UnitTechnical Director Jhpiego/Baltimore
Session Outline
Situational Summary of Key Indicators Jordanian MWRA characteristics Unmet Needs
Long-Acting Methods and Injectables (LAMI)
What are they? Why are they essential? Issues and Challenges
Selected opportunities for expanding LAMI
Summary
2
Jordan and its MWRA
3
Population of 6.6 m 1.6 m MWRA (est)
TFR 3.8 1:3 with parity > 5
Urban Dwellers 4:5 Method Type
Modern – 41 % Traditional – 15 %
FP Source – 2:3 private 4 Primary Reasons not using
Fertility Related -2/3 Method Related-1/4 Opposition to Use – 6% No Knowledge – 0.3 %
Poorest
3rd Quintile
2nd Quintile
4th Quintile
Richest
0% 10% 20% 30% 40% 50%
28%
35%
36%
42%
47%
MODERN METHOD USE BY INCOME
UNMET FP NEEDS
Demand for FP to:1. Limit
Urban – 7 % Rural – 7 %
2. Space Urban – 5 % Rural – 7 %
4
IMPACT OF LAMI ON CPR:USING CYPs
METHOD CYPTL 8 CYP (per procedure)
CuT IUCD 3.5 CYP (per IUCD)
Implanon 2.0 CYP (per implant)
Jadelle 3.5 CYP (per implnat)
DMPA 1.0 CYP (per 4 injections)
Pills 1.0 CYP (per 15 cycles)
Condom 1.0 CYP (120 condoms)
Couple Years Protection Estimated protection
during a one-year period Estimates coverage and
allows comparison of FP methods coverage
4 DMPA injections for 1 CYP versus 2.0 CYP for every Implanon Implant
5http://www.usaid.gov/our_work/global_health/pop/techareas/cyp.html, 2009
Long-acting and Permanent Methods of ContraceptionLA/PM
Long-Acting Methods IUD Implants
Permanent Methods Bilateral Tubal Ligation Vasectomy (NSV)
Most effective – > 99 % Safe Convenient – 1 action = years
of effective protection
SAFETY & EFFECTIVENESS: FP METHODS
7Decision Making Tool (adapted), WHO, 2005
Most effective and nothing to
remember.
Effective but must be carefully used.
Fewer side-effects:
Very effective but must be carefully
used.
More side-effects:
Pills Injectables
Vaginal methods
Male and female condom
IMPORTANT!Only condoms protect against both pregnancy and STIs/HIV/AIDS
Fewer side-effects, permanent:
More side-effects:
Implants
IUD
Fewer side-effects:
LAM
Femalesterilization Vasectomy
Fertility awareness-
based methods
LAMI and MWRA Reproductive Intentions
DDelaying first births-Youth
SSpacing between
births-Postpartum-Postabortion
H
HIV+ can use any LAM
8
LLimiting births
after desired fertility goals are reached
Impl
ants IU
Ds
Figure Adapted from Bakamjian, ESD 2010
BARRIERS TO LAMI
ENVIRONMENTAL- Social-cultural norms, gender
issues- Misconceptions and Myths
9
HEALTH SYSTEMS- Policy and Guidelines- Access, commodities, supplyPROVIDER/FACILITY- Bias, scheduling,provider type- Knowledge and skillsCLIENT- Lack of awareness, cost- Side effects and complications
LACK OF ACCESS IS POSSIBLY THE PRIMARY BARRIER
STRATEGIES FOR LAMI
10
Advocacy at all levels Work with communities to address
barriers, including gender norms Focus on essentials of service
delivery: access, choice, safety and quality
No missed opportunities: - postpartum, postabortion, interval - static and mobile outreach - private and public Ensure contraceptive security
New Mother in Albania (photo credit G. Stolarsky)
US Nurse Practitioner - SOP
11
Diagnosing and managing acute/chronic diseases Ordering and doing diagnostic studies Prescribing physical/rehabilitation treatments Prescribing drugs for acute and chronic illness
Providing prenatal and family planning services Well-child care Primary and specialty care services, health-
maintenance care for adults, including annual physicals
Care for patients in acute and critical care settings Performing minor surgeries and procedures Counseling and educating patients
TASK SHARING FOR EXPANDING ACCESS
Task sharing - allowing appropriately trained health workers with less formal medical education to deliver the same services as those with more education, where appropriate.
Global Examples of Task sharing Nurses/midwives in HIC inserting IUDs,
implants Midwives in Indonesia inserting Implants Surgical nurses in Thailand performing
postpartum TL CHW provision of DMPA (> 12 countries)
12
FPSERVICES
Issues in implementing task shifting
Overloading - always seem to shift to the same cadres
Inadequate support for those “receiving” new tasks Incentives/motivation/salaries Making it easy to progress through levels Educational system that permits re-entry Competencies described at all levels Having a clinical career ladder Need buy-in from professional association Dealing with regulation of practice
Why Community Based FP Provision?
Expanded points of service are critical for progress
Close the gap on providers shortage Diminish issues with long distances/wait time
at overburdened facilities Evidence shows community provision
increases FP uptake Essential to reach underserved peri-urban
urban and rural population
CHW AND INJECTABLES: POLICY RECOMMENDATIONS
Overall conclusions and policy implications: Trained CHWs can initiate and reinject DMPA CHW expands choice and access for underserved
and increases uptake Sufficient evidence exists for national policies to
support introduction, continuation, and scale-up
Programmatic guidance: Monitoring and supervision of CHW is needed Auto-disable syringes should be used WHO guidance should be followed regarding
eligibility
WHO,USAID,FHI, Technial Consultation, 2009
Key approaches for Community Access to FP
Trained midlevel (nurses/midwives) and community health worker provision of FP services such as including injectables, implants and IUDs.
Outreach or mobile clinics/teams to provide FP particularly LAMs - implants
Increased access to FP services at clinics and outposts
Pharmacy/drug shop sales and provision of FP methods including injectables
CBD of DMPA/FP in Afghanistan
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
200000
2005 2006 2007 2008 2009 (two quarters)
21Non-USAIDProvinces
13 USAID-Supported ProvincesThe WholeCountry
DMPA CBD in AFGHANISTAN
PPFP/PA FAMILY PLANNING ISSUES
Generally, FP is not being provided to amenorrheic women
Providers have misconceptions about fertility return and often make assumptions about sexual activity- limits service access
Challenges for counseling-based methods- LAM takes time
Contact with women limited; providers are busy; Need to provide additional staff for FP when integrated in larger, busy clinics
18
PPFP Best Practices: Global Experience
1. Offering FP information and services immediately postpartum and at multiple points during maternal care.
2. Initiating LAM-very effective method for up to six months; LAM users transition to other methods.
3. Providing a variety of contraceptive options including short and long acting methods.
4. Attention to postpartum long-acting and permanent methods.
5. Integrating PPFP into mother and child care—such as immunizations.
Women waiting outside for servicesPhoto credit: Barbara Deller
FP/RH Package Provided by MNH CHW: Bangla Desh
20
41% of women at 12 month postpartum used any modern method in intervention arm compared to 25% in comparison arm
P-value: <0.05Contraceptive Use at 3,6,12 mos PP
Gender Approached to Reduce Unintended Pregnancies
Encouraging male partners to take more responsibility Encouragement of joint decision-making and shared responsibility
for FP Institutionalization of gender into both private and public sector RH
services, including accreditation Advocacy with religious leaders and policymakers Integration with development activities (water and sanitation) Use of established male networks to diffuse information, refer to
services and expand method choice Empowering female providers
21IGWG, SUMMARY REPORT, 2011
GENDER INTEGRATION: RH OUTCOMES
Greater contraceptive knowledge and approval; Increases in positive attitudes toward contraceptive
methods; Increased communication between partners or couples
about health; Longer birth spacing; Increased use of long-acting contraceptive methods; Increased health-provider knowledge of family planning;
and Improved quality of care in health facilities.
22IGWG, SUMMARY REPORT, 2011
TAKE HOME MESSAGE
LAMI have high potential to: Correct the method skew Fulfill unmet need for contraception Revitalize stagnating CPR
Lessons from other countries opens up opportunities for increasing access to LAMI: Task shifting Community base approaches Incorporating Gender Based Approaches Maximizing utilization of PPFP
23
