OPERATIONAL RESEARCH ON INTEGRATION OF FAMILY PLANNING

SERVICES IN EPI CLINICS IN KALIKOT DISTRICT OF NEPAL

6 June 2014

Authors:

Dr. Senendra Raj Uprety, Rachel Cullen, Dr. Maureen Dariang, Dr.

Sushil Baral, Ramila Bhandari, Bishnu Dulal

Presentation Outline

• Rationale for integration• General background of the study district• Step taken for operational research• Integration model• Monitoring and evaluation model• Findings of the OR• Enabling factors for high family planning uptake• Challenges • Lesson learnt • Recommendations

Rationale for Integration

Unmet need of postpartum FP and consequences

Unmet need of Post-partum FP(low demand)

Birth to pregnancyduration of <24

months

Unwantedpregnancy

Increased maternal, newborn and

infant mortalityand poor health

outcomes

Poor awareness on fertility return; poor access to

services

Fertility behaviour, risk of pregnancy and use of family planning among post-partum women

Source: NDHS 2011 further analysis

Unmet need for Family Planning (women 0-23 months post-partum period)

33

6456

20

34 38

13 3017

0102030405060708090

100

0-5 months(N=548)

6-11 months(N=509)

12-23 months(N=973)

Total unmetneed

for Limiting

for Spacing

Source: NDHS 2011 further analysis

Unmet need among MWRA: 27%Limiting: 17%, spacing: 10%

Population: 134,000Expected under one children: 3500 MWRA: 29,350CPR: 23%

Kalikot District Background

• Kalikot district is one of the most remote and poorest district of Nepal

• Ranks 73th out of 75 districts

• Kalikot district has 30 VDCs – 1 district hospital– 1 PHCC– 13 HPs– 15 SHPs– 111 EPI outreach clinics– 68 PHC ORC clinics

Step taken for operational research

• Context specific planning in Kalikot district recommends for integration of FP services in EPI clinics

• Development of integration materials in Kathmandu in consultation with various stakeholders

• Design workshop at Kalikot district, staff training and orientation- May-June 2012

• Implementation from mid-July 2012 to mid-July 2013

• Monitoring and data collection (12 months)

• Evaluation

Group health education on HTSP to persons accompanying the child to the EPI clinic

Ask what the mother thinks of spacing/limiting during child vaccination

Need identification and individual counselling of women

Recording and Reporting.

Referral services

Mothers whose pregnancy status is not confirmed for pregnancy test

Mothers wanting long term methods

Undecided

Information and counselling during next visit

At EPI clinics

While vaccinating the child, to all mothers

Women interested in further information

Service provision

Based on the informed decision, devices provided to clients (condoms, pills and depo)

Integration Model

Monitoring and Evaluation Model

• Routine monitoring: out of 30 VDCs, a focused monitoring was conducted in EPI (Expanded Program of Immunization) clinics of 20 VDCs through three field monitoring officers

• Data collection: EPI FP (family planning) data were collected by the field monitors for FY 2068-69 and 2069-70 from the EPI, FP registers

• Evaluation: An evaluation was carried out in May-June 2013. Both qualitative and quantitative designs were used in the final evaluation

Routine Monitoring

• Collected routine service delivery statistics (related to EPI, FP and PHC-ORC)

• Exit interview with clients of EPI clinics and local stakeholders

The key objectives of routine monitoring were:• To understand the functionality and provision of FP services

• To understand the overall supply (vaccine, devices) status in the clinics and the issues encountered while providing FP services

• To record the EPI and FP services provided by EPI clinics

• To know the perception of women on integrated EPI FP services, etc.

Evaluation

The objectives of final evaluation were:

• To explore the knowledge about EPI FP integration

• To identify the clients participation in various process of integration in the EPI clinics

• To determine the use of FP services from the EPI clinics

• To explore the reasons for not using FP services

• To explore family planning history

Findings- July 2012 to July 2013

Findings – Service delivery

Findings – The model successfully increased access to family planning:

• Two-thirds of the women attending EPI clinic reported to have attended the group health education session

• 1539 clients received FP devices from EPI clinics (48% of post-partum women)

• At household interview 32% of women reported using a family planning method with 56% of them having received the method from the integrated clinics. (18% of current users of post-partum women received FP from EPI clinics)

Findings – Information is critical to the success of the integrated model especially as many women who

access EPI services are unaware that they are at risk of getting pregnant

• Majority of women knew recommended duration of birth to pregnancy interval

• 50% of women interviewed did not realise that they were at risk of pregnancy although they do not practice exclusive breast feeding during post-partum 6 months

Findings – Underserved groups are using the service:

• 26% of family planning users were Dalit (lower caste), who represent 24% of Kalikot’s population. This suggests that this group is not marginalised from the service — rather the integration increased their access to family planning services.

Findings – The integrated service did not affect the uptake of EPI

• EPI performance did not suffer as a result of the integrated family planning/EPI service, with performance remaining in line with or above the previous year’s performance for the duration of the research.

Findings – Women liked accessing family planning at the EPI clinics:

• Majority (94%) of the women mention that EPI clinic is convenient location for them to get FP devices

• The women clients reported that integration had no negative impact on their experiences of the service. In fact they reported a better experience of immunisation services.

“I prefer this integrated EPI clinic as I can complete my child immunisation as well as get FP service for myself from the same clinic” (women of Kumalgaun VDC)

Enabling factors for high family planning uptake and good service provision were:

• More than one health worker staffing the clinic;

• there being at least one female member staffing the clinic (to encourage women to adopt and use family planning methods);

• all staff having received training on this approach; and

• Support by Female Community Health Volunteers.

Challenges:

• Consistent availability of health workers to conduct EPI clinics due to retirement of Village Health Workers

• Management and motivation of health workers at local level to provide regular services – group health education, individual counselling

• Privacy difficult to maintain in crowded EPI clinics with limited infrastructure

• Availability of IEC materials (handover among HW to new recruits)

• Differentiation from the usual HMIS reporting in this pilot

Lessons learnt:

• Orientation of all health workers involved in providing EPI services is necessary

• Simple flow chart for screening for pregnancy risk would make it easier for health workers

Recommendations

• Scale up the approach in remote districts where EPI service users are small (less than 10 per clinic)

• Mobilise and enable health workers to provide quality services by assessing the availability of necessary human resources prior to implementing integrated services, orientating staff on the approach and awarding multi-year contracts to locally contracted health workers

• Develop the skills of health workers to deliver group heath education

Recommendations cont…

• Review infrastructure requirements for integrated clinics and use community networks to improve accommodation for EPI and PHC-ORC clinics

• Market the services available at integrated clinics, especially to marginalised group people.

• Involve and seek support from FCHV

• Ensure availability of LTFP methods at health facility level

• Review and revise IEC material used based on this study findings (example- focused message on timing of fertility return)

Few glimpse of pilot

Thank you