FP-EPI Integration as an Approach to Reduce
Unmet Need for Modern Family Planning[1]
Alejandro N. Herrin[2], Rosario S. Benabaye2, Leslie DP. Escalada2,
Florence G. Apale[3] and Rachel T. Micarandayo[4]
November 20, 2012
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) and 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 Barangay Health Station (BHS) or the Rural Health Unit (RHU) for further information on family planning.
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 the children during scheduled immunization days.
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.
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. 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 BHS. The Polomolok study adopted the three (3) family planning referral messages used in the Togo, West Africa study which is as follows:
- “Your child is young and you should be concerned about having another pregnancy”
- “Your health facility provides FP services that can help you”
- “You should visit our FP services after your immunization today for more information”
Data from for 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 training of RHMs to provide counseling and FP services. The increase in new acceptors could have also been a result of an increased numbers of trained providers and not only the integration of family planning referral messages. Given these two limitations, it is difficult to isolate the effect or contribution of FP-EPI integration to the improved performance in contraceptive use.
4. FP-EPI Integration Study in Misamis Occidental
From August 2011 to July 2012, a study was conducted in Misamis Occidental 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 or control groups. To further ensure the test validity of the effects of integration, no further treatments in the study areas were implemented, either on the demand or supply side.
Study Sites and Research Design. The USAID-HealthGov Project is assisting 25 provinces. Of these, Misamis Occidental and Leyte are among the provinces that have not yet implemented FP-EPI integration as of August 2011 using the Polomolok model. Misamis Occidental also has good local data on hea.lth 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 other purposes.
From the 15 municipalities and 2 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. To ensure enough cases for the study, municipalities with larger MWRAs and infants were given priority for inclusion
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).
Municipality / Treatment Groupn=21 / Control Group
n=21
Aloran / Banisilon, Maular, Zamora / Aloran, Mitazan, Tawi Tawi, Tonggo
Calamba / Bunawan, Calaran / Bonifacio, Calamba
Clarin / Guba, RHUC1, RHU2, Mialen, Kinanga, Sigatic / Dela Paz, Lapasan, Pan-ay
Lopez Jaena / Sibogon, Alegria / Burgos, Lopez Jaena, Macalibre, Mansabay Bajo
Tudela / Canibongan, Locsoon, Maikay, Tudela / Balon, Cabol-anonan, San Nicolas
Plaridel / RHU-A, Panalsalan, Unidos, Santa Cruz / Bato, Look Proper, RHU-B, RHU-C, Tipolo,
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.
· 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.
- 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 their immunization tasks. But 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, a Local Technical Assistance Provider (LTAP) assisted the BHWs in administering the tools and providing additional copies of the forms.
For each of the sites, the following were the steps followed in the administration of the tools and the conduct of the interviews.
- Treatment Site
Step 1: The BHW waits for mother to complete the registration.
Step 2: The BHW introduces herself and the objectives of the survey.
Step 3: The BHW asks the mother for consent to be interviewed
a. If mother does not want to be interviewed, the BHW thanked the mother and proceeded to the next mother and starts with Step 1.
b. If mother gives consent to be interviewed, the BHW proceeded to Step 4.
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 PHN/RHM.