Plugging the Leaking Bucket Ramakrishnan Ganesan March 4, 2016 Good morning! My name is Ram Ganesan and I work with Abt Associates. Thank you for coming to this session, titled PLUGGING THE LEAKING BUCKET. This session focuses on use of mHealth to address contraceptive discontinuation. Before I start, could we do a quick show of hands, please? How many of you are currently managing family planning projects? Thank you!

The Leaking Bucket phenomenon Anrudh Jain of the Population Council used the analogy of the ‘Leaking Bucket’ to draw attention to the contraceptive discontinuation. FP programs aim to reach women who want to regulate their fertility, but are not using contraception. Most programs address this “unmet need” by helping these women to initiate contraceptive use—opening the tap to fill the bucket with water. Yet many users of reversible contraception stop using their method and leave the pool of current users, just like the water leaking through the hole in the bucket. Clearly, programs must not only ‘open the tap’, but must also minimize leakage from the bucket. A simple and effective analogy to draw our attention to discontinuation.

Why do users discontinue? Pause here. Elicit responses from the

Reasons for contraceptive discontinuation Not in need In need, stopped In need, switched Wants to become pregnant Infrequent sex / partner away Infecund Failure (became pregnant during use) Health concerns / side effects Method related factors Cost, access issues Opposition (partner, family, religion) Switched to a more effective or less effective method? Of these three groups, whom should we be more concerned about? Purpose of family planning programs is to help people achieve their reproductive goals. So, #1 is not a concern. Neither is group #3 – they are using another method. #2 is at risk of unwanted/unplanned pregnancy Sometime or the other, all of us have bought a product that did not meet our expectations. What do we do then?

Case study A telephone-based mechanism to improve contraceptive continuation For users of DMPA – a 3-month, progestin only, injectable contraceptive

About DMPA A three-month injectable contraceptive Effective and easy to use Very safe, can be used by lactating women Causes changes in monthly bleeding, delayed return to fertility

DMPA in India A “new” method Not available in the public sector Available through private sector doctors for just over a decade Low use rates (~ 1%): Low community knowledge of the product Nearly 80% of women discontinue using the method within the first year, mostly after the 1st injection

Why is the discontinuation rate so high?

Mystery client surveys show high quality of counseling

Formative research findings Women need confirmation / reassurance when experiencing the effects Many of those concerned about the side effects they are experiencing do not return to their doctor Real and opportunity costs, distance, waiting time at clinic Some forget when the next injection is due, and go late

Potential ways to reassure and remind Communication route In-person follow-up Mass media Moblie phone Advantages Personal touch, Interactive Dis-advantages Could be intrusive Low scale High reach, ease of management Not targeted, could increase health concerns Interactive High reach Technology, connectivity limitations

The mHealth mechanism Call-back to new adopters of DMPA who own mobile phones Voice calls preferred over text messages (SMS) Outsourced to a call center Monthly training and on- site mentoring by the project team

Call-back elements DMPA users call to enroll Reassurance call: 22 days from 1st injection Users can request additional call-back at any time by giving a “missed call” Reminder calls before subsequent injections are due Follow-up through the first year of use

Promoting enrollment Promoted as a “careline” DMPA users call a toll-free number to enroll Careline promoted in clinics offering DMPA; recommended by doctors and paramedics to their clients

First year continuation rates 38% of DMPA users who received support from the Careline continued using the method for a year compared to 23% observed in an earlier survey

Factors to consider in adopting this approach Reason for discontinuation and underlying cause Importance of interactive communication Acceptability of receiving calls on contraception Ownership rates? Is it a family phone or the client’s individual’s phone? Do people switch service providers / phone numbers often? Infrastructure available: Can we use an existing call center, or do we need to set up one?

Questions? Ramakrishnan Ganesan ram_ganesan@abtassoc.com