Integrating EPI and Family Planning Service Delivery in Liberia Background, Rationale, Integration Model 1

THE NATIONAL CONTEXT: POSTPARTUM FAMILY PLANNING 2

41% of birth-to-pregnancy intervals in Liberia are too close for healthy outcomes 3 Source: MCHIP Re-analysis of 2007 Liberia DHS

At Risk of Pregnancy 4 Risk of Pregnancy Among Sexually Active Women Across Postpartum Periods Factors Affecting Return to Fertility Among Postpartum Women Analysis of 2007 Liberia DHS FP Data

WHAT DOES IT MEAN TO “INTEGRATE” SERVICES? 5

WHY INTEGRATE EPI AND FAMILY PLANNING? 6

7 Both immunization and family planning save lives… …and are part of a comprehensive approach to MNCH

 Family planning helps couples to achieve healthy timing and spacing of pregnancies; prevent unintended pregnancies  Immunizations are one of the most effective and highly used child health preventive services Increasing access to postpartum family planning contributes to achievement of child health goals.

9 EPI provides multiple opportunities to reach postpartum women during an important period.  Through child immunizations, mothers have multiple contacts with health providers in the year after birth  During the 12 months following birth, women may be very open to hearing messages about FP

10 Why are FP Services for Postpartum Women a High Priority?  During the first year after birth, or the extended postpartum period, most women want to delay or avoid future pregnancies but many are not using a modern FP method  Pregnancies spaced too closely can lead to health risks for the mother and child

11 Potential Benefits for Service Providers  Saves time by maximizing opportunities to provide multiple services on same day (rather than having a client return multiple times on different days)  Increased efficiency, improved client flow  Increased communication, flow of information across service areas  Builds providers’ technical skill & confidence

12 The Global Dialogue  Growing interest in FP/immunization integration  Emerging program experiences in Rwanda, Ghana, Zambia, Mali, Philippines  Limited documentation exists on effects of integration on FP & immunization outcomes, (especially for immunization outcomes)  FP/Immunization Working Group established in 2010 to exchange experiences, resources, identify successful integration strategies

Integrated EPI/FP service delivery Possible effects on immunization Positive: - Secure support for EPI by using it as platform to serve another program - By increasing convenience to caregivers through “one stop shopping” increase utilization of services and vaccination coverage Negative: - Deter mothers who accept EPI but not FP - Create confusion that EPI is really FP and a masked attempt to sterilize women or children

Precedent: possible concerns  Cameroon & Philippines (early 1990s) – halted EPI 2-3 years  Madagascar ( ) – confusion during MCH Weeks with FP and tetanus toxoid for women  Northern Nigeria ( ) – oral polio vaccine viewed as sterilizing agent  Pakistan (2012– ) – rumors that vaccination sterilizes children  disruption of polio campaigns, disruption of routine immunization, many measles outbreaks  Most problems associated with political conflict or mass immunization campaigns Indicates need for careful planning and monitoring with attention to effect on immunization

Positive effects of EPI/FP integration for EPI?  Not consistently documented  Rwanda ( ): improvement in FP and immunization coverage remained high  Togo (1994): 54% increase in new contraceptive acceptors and immunization coverage remained high  Liberia: MOHSW/MCHIP has actively monitored effect on immunization 15

Possible strategies for engaging immunization community 16 Reducerisks Design approaches that address hazards Actively measure effects on EPI Show benefits Design approaches with win/win appeal Share data that demonstrate gains Share experienc e Disseminate experience to date Engage country level immunization staff in both designing and sharing FP/Imm experiences

Overview of MOHSW/ MCHIP EPI/FP Integration Approach 17

Background  MoHSW and MCHIP tested an approach to link EPI and FP services in 5 facilities in Bong County and 5 facilities in Lofa County  Pilot phase of implementation lasted 9 months (March 2012-November 2012) 18

Site Selection  Participating health facilities included:  Bong County: Phebe Hospital, Garmu Clinic, Zoweinta Clinic, Salala Clinic, Fenutoli Clinic  Lofa County: Curran Lutheran Hospital, Borkeza Clinic, Kpaiyea Clinic, Ganglota Clinic, Gbonyea Clinic  Rationale for selection:  Counties with stronger EPI performance  Facilities in various proximities to the road  1 hospital and 4 clinics in each county 19

The Integration Model  Combined service provision, with same-day referrals from the vaccinator to co-located FP services  Focus on fixed facilities  Strategically designed materials reinforce key messages (job aid, leaflet, poster) 20

Sequence of Activities 21 Advocacy & Stakeholder Meetings Formative Assessment Model Design (including patient flow) Message Development & Materials Design Field Testing of Materials Finalize and Print Materials Trained Providers & Oriented Supervisors Implementation + Ongoing Supportive Supervision Mid-term Process Assessment + Adjustments Endline Assessment Reflect on Findings &Share with Stakeholders Adaptation & Scale-up

THE PROCESS 22

Role of Vaccinators During routine child immunization sessions, at the completion of each immunization visit, vaccinators will:  Remind mothers when they need to bring their child back for the next vaccination  Use a simple job aid to share brief, targeted FP messages with caregivers  Ask mothers whether they are interested in going for family planning services that day 23

For caregivers who ARE interested in seeking family planning on the same day:  Vaccinators give them a referral card and tell them to give it to the FP provider  Vaccinators direct them toward the FP room  Record on the register that the caregiver was referred (using the supplemental EPI/FP register) 24 Role of Vaccinators

For caregivers who are NOT interested in going for FP on the same day:  Vaccinators give them the leaflet about the benefits of FP  Vaccinators encourage them to discuss FP with their partner and family members  Vaccinators encourage them to return to the facility soon 25 Role of Vaccinators

Role of Family Planning Providers Family planning providers:  Collect the referral card from the clients referred from EPI  Provide FP counseling and services to women referred  Record in their legers (in the comments section) that the woman was referred from EPI, and whether she selected an FP method ( = referred, counseled and chose a method, = referred, counseled and did not choose a method)  Return the referral cards at the end of the day to the vaccinators’ room 26

Variations in Approach Across Facilities  Registration  Referral processes – Expedited referrals?  Privacy screens for facilities where EPI is provided in open waiting area 27

Key Inputs Required 28 START-UP Initial stakeholder meetings Formative assessment to inform design Initial training + practical exercises for Vaccinators & CMs (3 days) Orientation for Supervisors (1 day) Pre-testing Materials Printing Materials RECURRENT Refresher training for service providers and supervisors (1-2 Days) Re-print materials as needed Monthly supportive supervision visits County and National-level advocacy to ensure sufficient commodity supply Semi-regular stakeholder meetings to share progress

Questions? 29

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