Repositioning Family Planning in West Africa Repositionnement de la Planification Familiale en Afrique de l’Ouest Sponsored by: U.S. Agency for International Development (USAID), World Health Organization (WHO), Action for West Africa Region Project - Reproductive Health (AWARE-RH), Advance Africa, the POLICY Project Community-based Programs: Introducing the Standard Days Method Lessons Learned Candide Agbobatinkpo Caroline Blair

The Standard Days Method Family planning method for women with menstrual cycles between 26 and 32 days Identifies days 8-19 of the cycle as fertile Helps a couple prevent or plan pregnancy by knowing which days they should avoid unprotected intercourse Uses CycleBeads™ as a tool to track her cycle days, monitor cycle length, and identify her fertile period.

SDM Efficacy Study Results Couples used the method correctly in 97% of cycles Of the 478 women in the study, 43 got pregnant With correct use, the failure rate is 4.8 With typical use the failure rate is 12.0

Why Offer the SDM?  Can be offered by community-based providers  Community-based mobilizers can refer to clinics  Teaching does not require clinical skills  Addresses an unmet need  Increases choice and expands coverage  Empowers women and involves men  Offers a low-cost method

240 Condoms 30 Pill Packets 8 Depo injections.58 IUD = 2 CYPs 1 set of CycleBeads/SDM Adapted from USAID Office of Sustainable Development, Bureau for Africa, Health and Family Planning Indicators Volume I, July 1999.

Type of Providers Trained SDM O/R Study* n=333 * IRH Operations Research Study, Ecuador, El Salvador, Honduras, Benin, India, Philippines, Data currently being analyzed.

Clinic-based v. Community-based Provider Technical Competence – The SDM Provider Type Training/ Supervision AttitudesNeeds Professional/ Para clinical Less intensiveBias against NFP Discomfort discussing sex Couple communication Motivation Community health workers More intensiveBias towards SDM More comfort discussing sex Refresher training or closer individualized feedback Emphasis on eligibility criteria Mentoring Source: Final Operations Research study report

Competency Improvement Over Time – By Provider Type Results of analysis of supervision guide in El Salvador, Honduras and India

Competency Improvement Over Time – By Provider Type 12 months after training Results of Supervision Guide in El Salvador, Honduras and India Volunteers (n=76) Clinicians (n=46) Eligibility Criteria83%92% User Instructions96%95% Couple Aspects92%91% Total84%93%

Why women and men want to receive info from CHWs Access-related factors Time Distance (to clinic) Cost (transport to clinic) Method-related factors Non-medical Non-hormonal Simple (easy to use) CHW-related factors Feasibility Capability (able to offer method) Credibility (client confidence/trust in CHW) Benin OR study Data currently being analyzed.

Cumulative 6 Month Continuation Rates SDM O/R Study: 5 Programs (n=1240) IRH Operations Research Study, Data currently being analyzed.

Results: Male Involvement SDM continuation in villages targeting male participation vs. women focused villages CARE India, OR Study p <.05

PrePost SDM El Salvador45%58% India49%58% Results: Suggested increase in Contraceptive Prevalence Rate following SDM introduction into community programs Source: 1) Project Concern International, El Salvador, 2002; 2) Project Reports: CEDPA 2004

Results: Suggested Increase in Dual Protection Couples and Condom Use AdmissionExit Rural India30%35% Urban India87%98% El Salvador25%34% Philippines22%30% Project reports, IRH

BCC through Community Outreach - Benin Health providers (clinic or community-based) were primary source of information. Media (flyers, poster, radio, TV) primary source for half of Beninese users. Family and community outreach played larger role in rural areas

Demand Generation The feasibility of long-term provision of the SDM depends on the ability of organizations to stimulate demand for the SDM.

Successfully Offering the SDM in Africa through CHWs and CBDs Zambia Mobilizers and Providers Benin Mobilizers and Providers Rwanda Mobilizers and Providers Ethiopia Providers DRC Mobilizers and Providers

Programmatic Recommendations CHWs and CBDs can play a role in SDM service delivery Community-based workers’ competencies were similar to those of clinicians’ CHWs/CBDs require more technical training and more intense supervision (initially) than clinicians Best to use an existing CHW network rather than create a parallel system