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Family Planning Method Mix in
two crisis affected states: Chad and DRC
Jesse RattanCARE
Women Deliver May 2013
April 12, 2023
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
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 post-abortion 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 methods- pills, 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 when3
04/12/2023
4
Where do we work? DRC
Lubero and Kayna Health Zones
Kasongo Health Zone
April 12, 2023
5
Where do we work? Chad
Gore DistrictDanamadji District
April 12, 2023
6
Set the stage: Why Family Planning in Chad and DRC?
April 12, 2023
7
What happened? Cumulative new users (July 2011 to Dec 2012):Pills,
injectables, IUDs, implants, permanent methods
2011_06
2011_07
2011_08
2011_09
2011_10
2011_11
2011_12
2012_01
2012_02
2012_03
2012_04
2012_05
2012_06
2012_07
2012_08
2012_09
2012_10
2012_11
2012_12
0
5000
10000
15000
20000
25000
30000
35000
Monthly Total
Cumulative Total
SAF-PAC Target
Axis Title
April 12, 2023
8
Dramatic increase in % of new users choosing long-acting and permanent methods (LAPM)
2011
_06
2011
_07
2011
_08
2011
_09
2011
_10
2011
_11
2011
_12
2012
_01
2012
_02
2012
_03
2012
_04
2012
_05
2012
_06
2012
_07
2012
_08
2012
_09
2012
_10
2012
_11
2012
_12
Avera
ge0.00%
10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
100.00%
Chad DRC
Chad
DRC
April 12, 2023
9
But extremely skewed toward implants!
2011_06
2011_07
2011_08
2011_09
2011_10
2011_11
2011_12
2012_01
2012_02
2012_03
2012_04
2012_05
2012_06
2012_07
2012_08
2012_09
2012_10
2012_11
2012_12
0
200
400
600
800
1000
1200
0 0 1 1 0 0 22 57 56 41 17 34 5 22 49 36 55 55 490 0 0 0 3 1
395
886
246472
804 781693
422 360 428 423257 330
46 26 44 84 78 69
77
83
82
85
16 51
28
15 3013 20
198
56 38 49 53 50 37
72
69
105
214
60124
76
83 92 84 101
55128
0 0 0 0 0 0
1
1
1
31
2
1
0 9 1 1
1
1
Monthly total new FP users by method for CHAD
Chad - Vasectomies
Chad - Tubal Ligation
Chad - Injectables
Chad - OCP
Chad - Implants
Chad - IUD
2011_06
2011_07
2011_08
2011_09
2011_10
2011_11
2011_12
2012_01
2012_02
2012_03
2012_04
2012_05
2012_06
2012_07
2012_08
2012_09
2012_10
2012_11
2012_12
0
100
200
300
400
500
600
700
800
900
1000
3 7 16 15 14 7 22 42 36 68 47 37 42 59 66 72 86 109 9935 37 36 32 35 36152
292 317
662
473404 391
638
346 377430 407 367
52 41 40 29 53 31
57
42 65
65
6343 45
66
84 8689 75
64
11 13 12 7 16 12
36
3144
47
4149 31
95
110 6761 53
64
0 1 1 4 0 1
2
45
2
1011 5
7
14 511 3
7
Monthly total new FP users by method for DRC
DRC - vasectomies
DRC - Tubal Ligation
DRC - Injectables
DRC - OCP
DRC - Implants
DRC - IUD
April 12, 2023
10
A closer look at method mix…
5%
69%
9%
16%
0%
Contraceptive Method Mix in Chad
IUD
Implants
OCP
Injectables
tublig
vas
10%
66%
13%
10%
1% 0%
Contraceptive Method Mix in DRC
IUD
Implants
OCP
Injectables
tublig
vas
April 12, 2023
11
• No ideal method mix, but it can proxy for method availability and choice
• Sullivan et al, 2005: 34/96 countries >50% single method skew
• Reasons for method skew:
1. Policies/programmes
2. Provider bias
3. History of method in the country
4. Method characteristics
5. Client characteristics
What does the literature tell us about method skew?
April 12, 2023
12
So based on these factors: What does our experience tell us about method skew?
• Policies/programmes• Method characteristics• Provider bias• Client characteristics
April 12, 2023
13
• Extreme lack of access
• Extremely limited
availability
Combined with:• Free, high quality
contraceptives and trained staff,
• Good quality counseling
National programmes: Extremely limited access to any method
April 12, 2023
14
Method Characteristics
Long-acting FP methods:• Highly effective• Utterly
“forgettable”• Long-acting… yet
reversible
April 12, 2023
15
Implants: • Ease of implant insertion• Confidence with
technique• Quick process, less work
than IUD
IUDs• Concern about STIs (and
IUD insertion)• Lack of confidence with
technique
Provider bias…towards LARC but away from IUDs
April 12, 2023
16
• 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)
• Friends and neighbors have it and recommend it (bouche a oreille or “mouth telephone)
• Myths: • 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
Category 4: Client, partner, community characteristics & perceptions:
Away from IUDs Toward implants
April 12, 2023
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
April 12, 2023
18
Population Council’s Excellent counseling strategy
2. Using a rights-based frame, quality counseling (and good skills) to protect choice
April 12, 2023
19
Example of one program strategy to drop barriers to expanded choice
0
10
20
30
40
50
60
70
80
37
16 15 14
7
22
4236
68
47
3742
5962
IUD
Clinical training
Counseling training
Supportive supervision training and approach
begun
Team improves messages related to IUDs, increase outreach to men
Number of new users of IUDs in DRC June 2011 to August 2012
April 12, 2023
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!
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