Integration of family planning referrals into immunization clinics in Zambia and Ghana June 14, 2011 Gwyneth Vance, John Stanback, Barbara Janowitz, Mario Chen, Brooke Boyer, Prisca Kasonde, Gloria Asare, and Beatrice Kafulubiti

Why Prioritize FP Services for Postpartum Women?  Unmet need very high among postpartum women  Pregnancies spaced too closely together can pose serious health risks for the mother and child Photo: Society for Family Health/PSI, Zambia

Why is unmet need high among postpartum women? 1. Lack of knowledge – Confusion about when at risk for pregnancy. – May not fully understand the health consequences of births spaced too closely together. 2. Denial of some popular methods due to lack of menstruation

Intervention Tested: Referral Model Fixed health facilities with an immunization and FP clinic to ensure convenience. Vaccinators assessed a mother’s risk of pregnancy based on LAM criteria using a job aid. Messages attempted to: – address confusion about pregnancy risk factors following delivery – explain benefits of birth spacing

Intervention Tested Provider training: Study coordinators trained vaccinators at each intervention facility. Training took one half day. Providers were asked to use the job aid with women individually and not as part of group counseling. Follow-up: Study coordinators and senior level health staff made regular visits to facilities. Family Planning Clinics: Introduced the “pregnancy checklist” to ensure non- menstruating women access to methods.

Low resource intervention Why? Future scalability and sustainability in mind. Immunization days in child health clinics are busy! Provider time is limited. Research in Togo from 1994 showed positive results (a 54% increase in FP service utilization) due to delivery of simple messages by vaccinators.

Robust Research Design Cluster randomized experiment:  Pre/ Post intervention evaluation  Interviewed women 9-12 months post partum  Primary outcome: Non-condom modern method use Qualitative:  In depth interviews with vaccinators Process:  Interim Assessment: exit interviews on use of job aid

Results: No Change in Primary Outcome Percentage of women 9-12 m postpartum using a non-condom, modern FP method

Results: No Change in Referrals Percentage of women 9-12 m postpartum who reported having been referred to FP by a vaccinator

Qualitative Findings  Providers reported using the job aid with most of their clients; however a large proportion (particularly Zambia) used the tool in group health talks as opposed to providing one –on- one risk screening with clients.  In Zambia, the tool conflicted with current training. Photo: FHI, Zambia

Interim Assessment Results Approximately two months after the intervention was introduced exit interviews with women were completed In Ghana, low use of the tool. Greater “push” necessary. In Zambia (n=118),  82 % of women reported their vaccinator talked about FP  98 % of women reported seeing the job aid  90 % of women reported receiving information when they were waiting for services to begin.

Feedback from in-Country Stakeholder Meetings Is integration of FP and child immunization services a good idea? What would make our approach better?

Conclusion: Integration isn’t easy! Intervention was not implemented as planned. Embedding processes deeper into all program components necessary for the effective delivery of a service. - Integrated child health cards - Documentation of referrals Effectiveness of messages. Functionality of the health system may be a limitation (stock-outs, high provider turnover, overburdened health staff).

Programmatic Experiences Experiences highlighted in a new online map:online map  Burundi  Ghana  India  Indonesia  Kenya  Madagascar  Malawi  Mali  Nigeria  Pakistan  Philippines  Rwanda  Uganda  Zambia