Save Lives, Alleviate Poverty, Spur Development: Invest in LAPM Services

1. Save Lives, Alleviate Poverty, Spur Development: Invest in LAPM Services Roy Jacobstein, M.D., M.P.H. John M Pile, M.P.H. Fredrick Ndede, M.B.,Ch.B. (NBI), MMed. (Ob/Gy) Joan Taylor The ACQUIRE Project/EngenderHealth 7th Annual Global Health Mini-UniversityOctober 5, 2007

2. Three Compelling Rationales for Family Planning: • Health • Program (health system) • Development

3. Health Rationale • 1 maternal death for every ~ 110 births in Africa • 1 in 16 lifetime risk of maternal death in Africa • ~ 250,000 women’s lives could be saved, each yr • 200,000 infants saved, annually, with >2-yr spacing • Reduces vertical HIV transmission (more than ARVs)

4. Program Rationale • Unmet need for FP is very high: • Only 14% of women in Africa uses modern FP • 1 of every 3 women in Africa has unmet need • 1 of every 4 in Asia and LAC has unmet need • Effective FP services reduce system costs • 350 million people have limited access to FP

5. Development Rationale • 1.5 billion more people by 2025 • 500 million in South Asia • 450 million in Africa (will ↑ 60% in < 20 years) • 75% of sub-Saharan Africa now living on <$2/day • Just to maintain current rates of contraceptive use, services need to expand 40% • Critical to national development

6. Outline of Presentation • The case for long-acting and permanent contraception (LAPM) • A holistic program model for LAPM services • The program model in action

7. The Case for LAPMs

8. Positive Method Characteristics • The most effective FP methods 995-999/1000 do not get pregnant • Very safe (minor complications <10%; major, rare) • Long duration of effectiveness (up to 3-12 yrs)

9. Language Conditions Thought What is the difference between “Long-acting” and “Long-term”?

10. Good for People • Meet needs of many categories of users • Very wide eligibility: almost all can use • Spacers / limiters / delayers • Younger / older • Postpartum / post-abortion • HIV-infected women and PLWA • Convenient (one act confers long protection) • Highly effective (why they want FP!)

11. Highly Effective Pregnancy Rates by Method

12. Good for Health Systems • Meet clients’ needs / provides choice • Reduce burden on other health services: • FP (re-supply clients) • Obstetric/maternity (unwanted births, abortions) • HIV (PMTCT) • Pediatric • The most cost-effective FP

13. Low Discontinuation Rates % Women and men using FP methods at one year: Source: The ACQUIRE Project 2007. Reality √

14. Comparison of Annual Contraceptive Commodity Costs, Short-acting, Long-acting, & Permanent Methods, Per Year of Use Cost-Effective Source: UNFPA 2005. Achieving the ICPD Goals: Reproductive Health Commodity Requirements 2000-2015.

15. Outline of Presentation • The case for long-acting and permanent contraception (LAPM) • A holistic program model for LAPM services • The program model in action

16. Data for Decision Making Fundamentalsof Care StakeholderParticipation “More More More Services People Places” to in Increased Access, Quality and Use • Service sites readied • Staff performance improved • Training, supervision, • referral, and logistics systems strengthened • Accurate • information • shared • Image of services enhanced • Communities engaged Quality client-provider interaction Supply Demand Increased knowledge + acceptability Increased availability Advocacy Improved policy + program environment • Supportive service policies promoted • Human and financial resource allocation fostered • Gender equity advanced

17. Outline of Presentation • The case for long-acting and permanent contraception (LAPM) • A holistic program model for LAPM services • The program model in action

18. The Model in Action: Kisii IUD Initiative • National effort to revitalize IUD • IUDprevalence ↓ from 4.2 [‘93] to 2.4 [‘03] • IUD share of modern method use ↓ from 21% [‘89] to 8% [‘03] • Kisii District, Nyanza Province, Western Kenya

19. Long-Acting and Permanent Methods LAPMs Underutilized Despite Need in Kenya: Contraceptive methods and limiting % Using to limit: LAPMs (28%) Source: MEASURE/DHS, Kenya DHS Survey, 2004.

20. Long-Acting and Permanent Methods LAPMs Underutilized Despite Need in Kenya: Contraceptive methods and spacing % Using to limit: LAPMs (8%) Source: MEASURE/DHS, Kenya DHS Survey, 2004.

21. Supply, Demand and Advocacy • Gaps • Demand • Low knowledge • Misinformation • Interventions • Demand • Media Campaign • Community outreach/participation • Supply • Ensuring readiness of sites to provide services • Clinical/counseling training • Supply • Less available • Providers’ not comfortable providing • Advocacy • Guidelines revised • Services expanded to health centres and dispensaries • Advocacy • Eligibility • Where provided

22. The Model in Action: Kisii IUD Initiative Providers trained • CTU/Basic FP counseling: 51 • IUD Insertion and Removal: 28 • Comprehensive Family Planning Counseling: 18 • Sites Upgraded (equipment): 13

23. Mass Media Radio spots & interviews National and local radio station spots over 5 months Primary: Women 25-45 IEC materials 900 posters 6000 brochures 10,000 leaflets Secondary: Their partners Experiential 4 Roadshows –11,000 people Ladies Clubs, Men’s barazas Community Outreach 72 Peer Educators 375 CBD Agents Reaching the Community

24. Promotional Campaign Message: “Stand Up” Fahamu ukweli wa mambo “Now you know the truth”

25. Post-campaign Household Survey: 45% reported exposure to IUD messaging

26. Kisii IUD Initiative:122% Increase in IUD use IUD Uptake 579% Higher than Jan. 2005 Baseline April 2007 2nd IUD Skills Training Oct. 06 December is historically a slow month for FP clients – IUD trained providers were on holiday – Increased Uptake in Jan. 06 FP Counseling Training & TOT for CBD Supervisors Feb. 06 IUD Clinical Skills Training Oct. 05 IUCD Campaign Launch July 06 Stakeholder Meeting Feb. 05 CBD Agent and Peer Ed. Training April & May 06 CTU Trainings Aug. & Sept. 05 Project Ends Dec. 2006 Depo Stockout Jan.-Feb. 2007 PNA May 05 District Restructuring, Staff TransfersMay-Jul. 2007 Supply Demand Advocacy

27. What Makes A Difference: Reaching the Community • Sites with peer educators/CBD agents • Provider’s perspective is that peer educators/CBD agents • ↓ client fear of providers • Give messages in villages and bring clients to facilities • Remove myths • Create a link between providers & community

28. Action was a Strong Output of Community Sessions

29. What Makes a Difference: Quality Counseling -- Critical for LAPMs • Counseling Training - “Made us change our attitudes; we give clients all the information” • Providers identified counseling as important component of CTU and IUCD skills trainings • Intensive one-week FP counseling training • Providers seemingly made even more CPI changes

30. What Makes a Difference:Facilitative Supervision: From ‘Policing’ to ‘Friendly’ • “Improved Approach” in supervision: impact beyond FP • “Friendly” “Supportive” “Appreciating Work”

31. What Makes a Difference: Engage Men in Family Planning • Over 21,000 men reached in the community by peer educators • Male champions emerged • Men called into radio program • Men began talking about FP in public and with providers

32. Summing up • Demand for FP (both met and unmet) is significant and growing • FP programs need to expand by ____ in the next 10 years just to maintain current CPRs 40%

33. Summing up LAPM service programs need to be holistic, integrating • S • D • A program elements • Supply • Demand • Advocacy

34. Summing up • LAPMs are • fesa • vefeectif • eptableacc • dlabaffore • underutilized • endede • safe, • effective • acceptable, • affordable, • underutilized, and • needed • LA(P)Ms are excellent for spacing (& limiting)

35. Thank You!