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Integration of Family Planning Referral Messages into the Expanded Program on Immunization Services1

Florencia G. Apale2, Rachel T. Micarandayo3

Rosario S. Benabaye2, Leslie DP. Escalada2 and Alejandro N. Herrin4 August 15, 2013

1. Introduction

There are a number of opportunities for personal contacts with women to discuss or to inform them of family planning. These can be at the community or at the facility level, and it can be established at the point of service or at the point of referral. Such personal discussions are expected to encourage women to learn more and eventually adopt modern family planning according to their preferences and needs. Health care providers can have direct contact with women to discuss family planning when they visit the community for outreach or medical missions. They can also have direct contact with women when they provide maternal services (prenatal and postnatal) where discussion on family planning would come naturally. Direct contact is also possible during out-patient child care services where birth spacing and family planning can be discussed with the mother as well. Barangay Health Workers (BHW) and community volunteers in their visits to households can refer women to health care providers in the Rural Health Unit (RHU) or Barangay Health Station (BHS) for further information on family planning.

Table 1 Personal contacts among women to discuss FP at point of opportunity and by level

Point of opportunity

Level

Household/ Community Facility

Point of service Medical missions Maternal and Child care

Point of referral Community Health Teams, Barangay Health Workers

FP-EPI

1 This study was made possible by the generous support of the American People through the United States Agency

for International Development (USAID). The contents of this report are the sole responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. The authors wish to thank Orville Solon, Stella Quimbo, Carlos Tan, Jr., Rajeev Colaco and Vicente Paqueo for their comments and suggestions on the study design. We thank the MHO/CHOs, PHNs and BHWs in the municipalities of Aloran, Calamba, Clarin, Lopez Jaena, Plaridel and Tudela for participating in the study, and the Misamis University Community Extension Program for assistance in the field implementation of the study.

2 National Center for Disease Prevention and Control – Department of Health

3 Provincial Health Office-Misamis Occidental

4 USAID-HealthGov Project

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However, data from the National Demographic and Health Survey (NDHS) of 2003 and 2008 on contact communication between non-users of family planning and health workers/health service providers reveal low percentages (less than 15%) of women who said that: (1) a fieldworker discussed family planning with them during the fieldworker’s visit to the household (indicator of outreach); and (2) a health provider discussed family planning with them during their visit to a health facility for any reason in the past 12 months (indicator of missed opportunities). There is clearly a need to take advantage of these opportunities of personal contact to ensure that family planning is discussed. While this is being done, there is another opportunity for personal contact with women to inform them of the availability of modern family planning in the health facility. This opportunity is when mothers come to the health facility for the immunization of their children during scheduled immunization days.

Table 2

Contact communication among non-users of family planning NDHS, 2003 and 2008

National Demographic and

Health Survey (NDHS) round

Field worker discussed FP with women DURING VISIT OF FIELD

WORKER (%)

Health service provider discussed FP with WOMEN WHO VISITED A

HEALTH FACILITY in the past 12 months

(%)

DID NOT DISCUSS FP either during visit of field worker or visit

to health facility

2003 11.5 13.6 80.3

2008 9.6 12.3 82.5

Sources:

National Statistics Office [Philippines] and ICF Macro. 2009. Philippines National Demographic and Health

Survey 2008: Key Findings. Calverton, Maryland, USA: NSO and ICF Macro; National Statistics Office (NSO)

[Philippines], and ORC Macro. 2004. National Demographic and Health Survey 2003. Calverton, Maryland:

NSO and ORC Macro.

2. Additional Venue for Personal Contact: Expanded Program of Immunization (EPI

Based on the 2011 Family Health Survey, the coverage rate for Fully Immunized Child (FIC) is high in the Philippines at around 90%. Regional variation ranges from 85% to 95%. This means that one can have personal contact with a large number of postpartum mothers to discuss family planning. These mothers are more likely to be receptive to considering delaying the next pregnancy. Also one can have repeated and multiple personal contacts with these mothers over a period of several months until the completion of the immunization of their children. Furthermore, typically EPI service is scheduled on certain days in a month. During this time, quite a number of mothers would come for the scheduled immunization of their children. This is an opportunity to have personal contact with many mothers all at once. But precisely because of this, the design of the integration process needs to be tailored so that it will not disrupt the immunization process itself by taking the Rural Health Midwife (RHM) away from her primary task for the day, which is to provide immunization services.

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3. Past Studies

Past studies have suggested that providing simple family planning “referral messages” to women when they visit the health facility for the immunization of their children can effectively increase the number of women who accept modern family planning. A particular study done in Togo, West Africa has shown that the provision of family planning referral messages to EPI clients increased awareness of available family planning services by 18 percent and increased the average monthly number of new family planning acceptors by 54 percent. In the study, no additional information was provided and all questions were referred to FP services available in the same clinic. The conclusion was that “the use of referral messages can have a significant and dramatic effect on FP services in a relatively short time” (Huntington and Aplogan, 1994)5.

Locally, a similar study was conducted by the USAID-HealthGov Project in Polomolok in South Cotabato in 2009. In Polomolok, the FP-EPI integration was pilot-tested in one (1) RHU and 28 BHSs. The Polomolok study adopted the three (3) family planning referral messages used in the Togo, West Africa study which are as follows:

“Madame, your child is still young and you should be concerned about having another pregnancy too soon”

“This clinic provides family planning services that can help you delay your next pregnancy”

“You should visit the family planning services after the immunization today for more information”

Data from both baseline and end line surveys during the study period from March to December 2009 were collected. The data showed an increase in new acceptors by 38% which is equivalent to a 6-percentage point increase in the contraceptive prevalence rate (CPR) from 49% percent in 2008 to 55% percent in 2009. The provision of family planning referral messages in EPI activities did not appear to have had a negative effect on the FIC as the FIC coverage remained high at over 95 percent in 2009 as it was in 2008.

As an evaluation study, however, the pilot test in Polomolok is limited in a number of things. First is the lack of a control group to compare Polomolok with. Secondly, in addition to the family planning messages, there was also competency-based trainings for RHMs to provide counseling and FP services. The increase in new acceptors could have also been a result not only of the integration of family planning referral messages but also because of an increase in the number of trained providers. Given these two limitations, it is difficult to isolate the effect or contribution of FP-EPI integration to the improved performance in contraceptive use.

5 Huntington, Dale and Aristede Aplogan, Studies in Family Planning, Vol. 25, No. 3 (May-June, 1994), 176-183.

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4. FP-EPI Integration Study in Misamis Occidental Province

From August 2011 to July 2012, a study was conducted in Misamis Occidental Province to provide additional evidence of the effects on modern family planning use of integrating FP into EPI service. It addressed the shortcomings of the Polomolok study by randomly assigning RHUs/BHSs to treatment and control groups. To further ensure the test validity of the effects of integration, no further program interventions in the study areas were implemented, either on the demand or supply side.

Study Sites and Research Design. Of the 25 USAID-assisted HealthGov provinces, two have not yet implemented integration in August 2011 using the Polomolok Model. These are Misamis Occidental and Leyte. Of these two, Misamis Occidental was selected because of the availability of good local data on health and socio-demographic indicators from the Community Health and Living Standards Survey (CHLSS) that was used to identify municipalities that will be included in the study. The CHLSS is a complete household enumeration conducted in 2009 by the province for planning and targeting beneficiaries, among others. From the 15 municipalities and 2 (two) cities of Misamis Occidental, six (6) municipalities were chosen to be the study sites. These are Aloran, Calamba, Clarin, Lopez Jaena, Plaridel and Tudela. Based on the CHLSS data, these municipalities matched well on the basis of the size of married women of reproductive age (MWRA), size and percent of non-FP users, number of infants, performance in EPI (coverage rates of FIC) and poverty rate.

Table 3

Information on number of MWRA and children 0-11 months CHLSS-Misamis Occidental, 2009

Municipality (1)

Population of MWRA

(2)

Number of non-

pregnant and non-user of

modern FP (3)

Percent of non-

pregnant, non-user of modern FP

(4)

Population of children

0-11 months

(5) Percent FIC

(5)

Expected number of mothers who are

non-users of modern FP (6) = (4)*(5)

Aloran 3,186 1,247 39% 443 73% 173

Calamba 2,305 1,020 44% 293 71% 129

Clarin 4,235 1,803 43% 454 72% 195

Lopez Jaena 3,032 1,197 39% 397 82% 155

Plaridel 4,809 2,213 46% 627 61% 288

Tudela 3,453 1,635 47% 483 78% 227

Total 2,697 1,167

From the 2,697 MWRA, the initial expected number of MWRA as total sample for the study was 1,167 (column 6) using the percent obtained from the ratio of non-pregnant and non-user of modern FP to the total MWRA (column 4) applied to the population of children (column 5). The population of children assumes similar number of mothers who will come to the facility for the immunization of the children.

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In these municipalities, there was an RHM trained to provide family planning counseling and services, adequate family planning commodities and a referral center for services that cannot be provided by the RHM, e.g., sterilization.

The study involved all the 42 RHUs and BHSs of the six municipalities of the province. These RHUs/BHSs were randomly assigned to treatment (n=21) and control groups (n=21).

Table 4

Study Sites in the Province of Misamis Occidental

Municipality (number of RHUs/BHSs)

RHUs/BHSs

Treatment Group n=21

Control Group n=21

Aloran (6) BHS: Banisilon, Maular, Zamora RHU: Aloran BHS: Mitazan, Tawi Tawi

Calamba (4) BHS: Bunawan, Calaran RHU: Calamba Main BHS: Bonifacio

Clarin (9) RHU: Clarin Main 1, Clarin Main 2 BHS: Guba, Mialen, Kinangay Norte, Segatic

BHS: Dela Paz, Lapasan, Pan-ay

Lopez Jaena (6)

BHS: Alegria, Sibogon BHS: Burgos, Macalibre, Mansabay Bajo RHU: Lopez Jaena

Plaridel (9) RHU: Plaridel Main C BHS: Panalsalan, Sta. Cruz, Unidos

RHU: Plaridel Main A, Plaridel Main B BHS: Bato, Looc Proper, Tipolo

Tudela (8) RHU: Tudela Main BHS: Canibongan, Locsoon, Maikay

BHS: Balon, Cabol-anonan, San Nicolas, Tonggo

Tools. Three (3) sets of tools were used in the study. The first set was used to collect information about service delivery capacity of the municipalities; the second set includes the tools used for the treatment sites; and the third set includes the tools for the control sites. The first set of tools was administered by the project staff. The tools used for the treatment and control sites were provided to the RHUs/BHSs in the study sites for the duration of the study and were administered by the community health workers.

Form 1: Service Delivery Capacity Survey was administered in all six (6) municipalities included in the study. This provides supply-side information particularly the availability of services and commodities for family planning as well as the training of health providers.

Forms for Treatment Sites

Form 2: Survey on Identification of Unmet Needs is a one-page questionnaire that was used by the BHWs in the treatment sites for interviewing mothers who come to the health facility for immunization of their children. This obtains information about the mother including name, age, education, number of children, pregnancy status, desire to have additional children and use of family planning method. The survey aims to identify women with unmet need who will be given the appropriate messages.

Form 3a: FP Referral Messages 1 is a ¼ size referral message slip which includes messages for women who want to have additional children but who are not currently using modern FP method.

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Form 3b: FP Referral Messages 2 is also a ¼ size referral message slip which includes messages for women who do not want to have additional children and who are not currently using modern FP method.

Form 4: FP-EPI Integration Monitoring Form serves as the master list of all women who were interviewed during immunization day and who have unmet need. This is the form that was also used by the BHWs to monitor women who were interested to visit the health facility for more information on modern family planning but have not specified a date of their visit.

Form for Control sites

Form 5: Profile of Women of Reproductive Age serves as master list of all mothers who come to the health facility for immunization of their children. This obtains information about the mother including name, age, education, number of children, pregnancy status, desire to have additional children and use of family planning method.

The basic information collected during immunization day from the control sites is similar with the information collected from the treatment sites. The basic difference is that in the control sites, no family planning referral messages were given to the mothers.

Operations. Prior to the actual implementation of the approach, all the RHMs and selected BHWs in the treatment sites were trained in FP-EPI Integration. The protocol for FP-EPI integration was used during this training, which contained instructions for implementing the interview with the mothers and the provision of FP referral messages. The schedules of immunization for each month including the venues were also recorded for each of the RHU/BHS in the study sites.

Typically, child immunization is provided during fixed immunization days where a large number of mothers, depending on the size of the catchment population, bring their children for immunization. In such a situation, it was determined, based on qualitative time-and-motion observation, that it will not be desirable or even possible for the RHM to discuss family planning while at the same time attending to her immunization tasks. However, it is possible for trained BHWs to engage the mothers for a short interview while these mothers are waiting for their turn to have their children immunized and to provide those with unmet need with information regarding the availability of modern family planning services in the facility. In the first few rounds of interviews conducted in the treatment sites, the BHWs were asked to observe and learn from the process so that it will be easy for them to administer the tools. For the succeeding interviews, they were assisted by a Local Technical Assistance Provider (LTAP) hired by USAID-HealthGov Project in administering the tools and ensuring that forms are readily available in each of the RHUs/BHSs. For each of the sites, the steps followed in the administration of the tools and the conduct of the interviews are:

Treatment Site

Step 1: The BHW waits for mother to complete the registration. Step 2: The BHW introduces her/himself and the objectives of the survey. Step 3: The BHW asks the mother for consent to be interviewed

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a. If the mother does not want to be interviewed, the BHW thanked the mother and proceeded to the next mother and goes back to Step 1.

b. If the mother gives her consent to be interviewed, the BHW proceeded to the next step

Step 4: The BHW conducts the interviews using Form 2, Form 3a and Form 3b. Step 5: The BHW completes Form 4. Step 6: At the end of the day, the BHW consolidates and endorses the filled-out Form 1 and

Form 4 to his/her respective RHM or in some cases to the Public Health Nurse (PHN).

In the treatment sites, the mothers who were identified as having unmet need for modern family planning were provided with FP referral messages. For purpose of the study, women with unmet need for modern family planning are (1) those that want additional children after three years but are not using modern family planning, or (2) those that do not want to have additional children but are not using modern family planning. The determination of unmet needs that takes into account other factors such as sexual activity, fecundity, mistimed pregnancy, among others will be determined by the RHM and the mother during the latter’s consultation/counseling visit. To ensure that no mothers were missed in the course of the interview, those who want to have additional children within three years were also provided with referral messages.

The referral messages in the Treatment Sites are:

FP Referral Messages 1

(for those who want to delay the next pregnancy) 1. This clinic provides modern FP services that can help you delay the next pregnancy. 2. Would you like to visit this clinic and learn more about modern Family Planning

methods? 3. (If Yes) Let us set a schedule for your visit to the clinic.

FP Referral Messages 2

(for those who want to prevent the next pregnancy) 1. This clinic provides modern FP services that can help you prevent the next pregnancy. 2. Would you like to visit this clinic and learn more about modern Family Planning

methods? 3. (If Yes) Let us set a schedule for your visit to the clinic.

Control Site

Step 1: The BHW waits for mother to complete the registration. Step 2: The BHW introduces her/himself and the survey.

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Step 3: The BHW asks for the consent of the mother to be interviewed a. If the mother does not want to be interviewed, the BHW thanked the mother

and proceeded to the next mother and goes back to Step 1. b. If the mother gives her consent to be interviewed, the BHW proceeded to the

next step. Step 4: The BHW conducts the interviews using Form 5. Step 5: At the end of the day, the BHW consolidates and endorses the filled-out Form 5 to

his/her respective PHN/RHM.

Note that in the control sites, there were no FP referral messages given to the mothers interviewed during immunization day.

From August 2011 to February 2012 (excluding October6), the LTAP provided assistance to the RHUs/BHSs of the study sites. They collected all filled out Form 2 from the treatment sites and encoded them to come up with a database. Forms 4 and 5 were photocopied by the LTAP for consolidation and encoding as well. The original Forms 4 and 5 were left with the RHUs/BHSs for use in their monitoring.

From February to July 2012, the second survey was conducted among the same mothers who were interviewed in the first survey, this time the LTAP administered the survey. The tool used for the second survey is a 2-page questionnaire, which includes basic information of the mother such as name, age, address, education, desire for additional children, use of modern family planning method and access to family planning information. Database. There were two (2) databases prepared that were used for the study, the service delivery capacity data from the six (6) municipalities and data on mothers interviewed in both the first and second surveys.

5. Results of the Study

In the baseline survey, there were 2,116 mothers interviewed, 54% are from control sites, 45% are from treatment sites, and the remaining percent are mothers who brought their children to both control and treatment sites at different times (n=35). During the end line survey, only 78% of mothers (n=1,651) from baseline were available for interview. Of the 1,651 mothers, 55% are from control sites, 45% are from treatment sites and 0.7% are mothers who brought their children to both control and treatment sites at different times (n=13).

6 The interviews were temporarily suspended in October 2011 during the implementation of the Garantisadong

Pambata (GP). The GP program included a package of health services for children 0-59 months old. It also included provision of information for mothers on FP. To exclude the confounding effect of GP on family planning use, both treatment and control groups were exposed to GP but neither were exposed to FP-EPI integration in October 2011

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Table 5 Number of Mothers Interviewed in Baseline

And End Line Surveys by Study Sites

Study Sites

Mothers interviewed in Baseline

Mothers interviewed in End Line

Number Percent Number Percent

Control 1,136 53.7% 902 54.6%

Intervention 945 44.7% 736 44.6%

Control cross-study 20 0.9% 1 0.1%

Treatment cross-study 15 0.7% 12 0.7%

Total 2,116 100.0% 1,651 100.0%

Of the 465 mothers that were not interviewed in the end line, the major reasons include change in residence and transient status, which accounted for 241 mothers or 52% of the total. Another 84 or 18% could not be interviewed because they were not in the house. Another 72 or 15% were not in the house because they were reported to be working. Twenty-six (26) mothers lived far from the barangay centers and could not be reached during the period of the survey. Altogether, this information is of great interest since it shows that mothers do seek services for their children even outside their current area of residence. They get the service they need where the service is available (transients, movers). It is also interesting that some would travel far to seek services. Finally even busy working mothers have time for the immunization of their children.

Table 6

Reasons for Non-Interviews of Mothers in End Line Among Those Interviewed in Baseline

Reasons

Study sites

Total Control Treatment Control

cross-study Treatment cross-study

Unknown/transients 27 31 6 0 64

Changed residence 98 73 6 0 177

Working 37 32 3 0 72

Not in the house 34 46 2 2 84

No information 26 13 1 0 40

Cannot be reached 10 14 1 1 26

Others 2 0 0 0 2

Total 234 209 19 3 465

For the analysis that follows, the data used were that of mothers who were interviewed in both baseline and end line surveys but excluding cross-study cases (n=13) and those with incomplete information in either survey (n=45). Thus, from the 1,651 mothers in both Surveys 1 and 2, the succeeding analysis will now focus on 1,593 mothers; 719 from Treatment Sites and 874 from Control Sites.

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Interest in visiting the health facility to learn more about modern family planning. In the treatment sites and during Survey 1, mothers who reported they were not practicing modern family planning were informed that modern family planning services are available at the health facility and asked whether they wanted to visit the facility to learn more about family planning, and if yes, to set a date of the visit. The table below shows that 84% of these mothers indicated that they were interested and half of them have set a date for the visit. About 16% said they were not interested. The study was not designed to actively track the mothers’ subsequent behavior except for the conduct of Survey 2 for indications of change in behavior regarding family planning use or checking with the RHM’s facility records who among those interviewed at baseline eventually visited the health facility for counseling and services.

Table 7

Mothers’ Interest in Visiting the Health Facility to Learn More About Modern Family Planning: Treatment Sites

Interest in visiting the facility and commitment for visit Pregnant

Not pregnant

Not using any FP method

Using traditional method

Interested, with date of visit 11 30% 176 43% 36 44%

Interested, no date of visit 20 54% 166 40% 29 36%

Not interested 2 5% 65 16% 16 20%

No information 4 11% 3 1% 0%

Total 37 100% 410 100% 81 100% Note: Total number of cases for treatment site in Survey 1 is 719. Total cases shown in the table is 528. Not shown are those using modern FP method = 191.

Changes in use of modern family planning methods. In the control sites, the percent of those using modern FP method is 34.4% in the baseline and 38.1% in the end line. In the treatment sites, the percent of those using modern FP method is 26.6% in the baseline and 38.5% in the end line. The net difference is 8.2 percentage points [(38.5-26.6) – (38.1-34.4) = 8.2] percentage points. The net difference is statistically significant at 0.005 level.

Table 8 Comparison of Modern FP Use

Site Survey 1 Survey 2 Net

increase

Treatment 26.6% 38.5% 11.9%

Control 34.4% 38.1% 3.7%

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Figure 1: Comparison of Modern Family Planning Use Among Mothers in Control and Treatment Sites

Net change in CPR: (38.5-26.6) - (38.1-34.4) = 8.2

6. Summary and Conclusion

In the treatment sites where the integration was implemented, the data shows that among pregnant and non-pregnant mothers who were not using a modern method of family planning at baseline, a large number of mothers say they want to visit (84%) the health facility to learn more about modern family planning, and half of them have set a date of visit. The study was not designed to actively track the mothers’ subsequent behavior except to survey them again at some future date for indications of change behavior regarding family planning use. The subsequent survey of the same mothers interviewed at baseline show that that a larger increase in use of modern methods occurred in the treatment sites where FP-EPI integration was implemented compared to the control site. The net difference among the sites and between periods is 8.3 percentage points. This measures the net impact of the integration on use of modern methods. The study results suggest that taking the opportunity afforded by EPI services to reach mothers can be effective in meeting the needs of mothers for modern family planning. The approach to integration is simply to inform mothers of family planning service availability and giving them a chance to schedule a visit to the facility if they so desire Moreover, as the study has revealed, a number of mothers who come to the health facility for the immunization of their children are already pregnant. This provides another opportunity to inform pregnant mothers of modern antenatal care services that are available in the health facility and to encourage them to visit early. A tool for implementing such a broadened integration process, called the FP/ANC-EPI integration, is available for use by LGUs.

26.6%

38.5%

34.4% 38.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Baseline Endline

Treatment Control

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How do we interpret the results? Why would a simple provision of FP referral messages have

significant influence on behavior? One way of interpreting the results is as follows: when health

providers including BHWs talk to women, when they show interest regarding their preference and

needs, when they provide them information on where services are available and when they allow

them to set a schedule for a visit to the facility to learn more, then it is likely that they these women

will decide to learn more and eventually adopt a modern family planning method.

7. Postscript

After the study found evidence that the integration of FP referral messages in EPI services was an

effective approach to increasing modern family planning use, the approach was rolled-out to the

rest of the project sites consisting of 603 LGUs in 25 provinces. Orientation on the implementation

of the integration of FP/ANC referral messages to mothers with unmet need during immunization

services was provided during the joint CHD-PHO-MHO/CHO forum in April 2012 to update data and

plan for accelerated implementation of their current annual plans. Of the 603 LGUs, 526 attended

the forum, and 378 committed to implement the FP/ANC-EPI integration. Field monitoring showed

that 239 LGUs implemented the integration as of November 2012. Reports from two LGUs

demonstrate the extent of unmet needs identified and the services that were subsequently

provided.

From August to November 2012, 306 mothers in the municipality of Nabunturan, Compostela Valley

Province were interviewed during immunization days. Of the 306 mothers, 102 want to have

additional children and 204 do not want to have additional children. There are 139 mothers who are

currently using modern FP method (continuing users), 159 who are not using any modern FP

method and 8 who are pregnant. Of the 159 mothers who are not currently using any modern FP

method, 84 (53%) scheduled a date of visit to the facility to learn more about modern FP, 49 actually

came back based on the scheduled visit of which 33 became new acceptors. Among the 66 mothers

who did not schedule a date of visit to the facility to learn more about modern FP, 35 came back for

counseling of which 25 became new acceptors. Thus a total of 58 mothers became new acceptors in

four (4) months of implementing FP/ANC-EPI integration, a reduction of unmet need from 159 or

36% from the start of the period

In Talisay City, Negros Oriental Province, 1,000 mothers were interviewed from April to November

2012. Of the 1,000 mothers, 213 want to have additional children while 787 do not want to have

additional children. There are 372 mothers who are currently using modern FP method, 34 mothers

who are using traditional FP method, 567 who are not using any method and 6 who are currently

pregnant. In total, there are 601 mothers with unmet need for modern FP. Of these, 378 scheduled

a date of visit to the facility to learn more about modern FP, 155 of them came back of which 137

became new acceptors. Thus, from the 372 mothers who are continuing user, 137 new acceptors

were added because of the integration. Alternatively, of the 567 mothers with unmet need, 137

became new acceptors thus reducing unmet need by 24% in eight months.