1. STRATEGIES FOR OFFERING LONG ACTING METHODS Reproductive Health/ Family Planning Symposium Sept 19-20, 2011 Amman- Jordan ENRIQUITO LU, MD. MPH RH/FP/Cervical Cancer Prevention Unit Technical Director Jhpiego/Baltimore

2. Session Outline  Situational Summary of Key Indicators  Jordanian MWRA characteristics  Unmet Needs  Long-Acting Methods and Injectables (LAMI)  What are they?  Why are they essential?  Issues and Challenges  Selected opportunities for expanding LAMI  Summary 2

3. Jordan and its MWRA 3  Population of 6.6 m  1.6 m MWRA (est)  TFR 3.8  1:3 with parity > 5  Urban Dwellers 4:5  Method Type  Modern – 41 %  Traditional – 15 %  FP Source – 2:3 private  4 Primary Reasons not using  Fertility Related -2/3  Method Related-1/4  Opposition to Use – 6%  No Knowledge – 0.3 %

4. UNMET FP NEEDS Demand for FP to: 1.Limit  Urban – 7 %  Rural – 7 % 2.Space  Urban – 5 %  Rural – 7 % 4

5. IMPACT OF LAMI ON CPR:USING CYPs METHODCYP TL8 CYP (per procedure) CuT IUCD3.5 CYP (per IUCD) Implanon2.0 CYP (per implant) Jadelle3.5 CYP (per implnat) DMPA1.0 CYP (per 4 injections) Pills1.0 CYP (per 15 cycles) Condom1.0 CYP (120 condoms) Couple Years Protection  Estimated protection during a one-year period  Estimates coverage and allows comparison of FP methods coverage  4 DMPA injections for 1 CYP versus 2.0 CYP for every Implanon Implant 5 http://www.usaid.gov/our_work/global_health/pop/techareas/cyp.htmlhttp://www.usaid.gov/our_work/global_health/pop/techareas/cyp.html, 2009

6. Long-acting and Permanent Methods of Contraception LA/PM  Long-Acting Methods  IUD  Implants  Permanent Methods  Bilateral Tubal Ligation  Vasectomy (NSV)  Most effective – > 99 %  Safe  Convenient – 1 action = years of effective protection

7. SAFETY & EFFECTIVENESS: FP METHODS 7 Decision Making Tool (adapted), WHO, 2005 Most effective and nothing to remember. Effective but must be carefully used. Fewer side-effects: Very effective but must be carefully used. More side-effects: Pills Injectables Vaginal methods Male and female condom IMPORTANT! Only condoms protect against both pregnancy and STIs/HIV/AIDS Fewer side-effects, permanent: More side-effects: Implants IUD Fewer side-effects: LAM Female sterilization Vasectomy Fertility awareness- based methods

8. LAMI and MWRA Reproductive Intentions D Delaying first births -Youth S Spacing between births -Postpartum -Postabortion H HIV+ can use any LAM 8 L Limiting births after desired fertility goals are reached Implants IUDs Figure Adapted from Bakamjian, ESD 2010

9. BARRIERS TO LAMI ENVIRONMENTAL -Social-cultural norms, gender issues -Misconceptions and Myths 9 HEALTH SYSTEMS -Policy and Guidelines -Access, commodities, supply PROVIDER/FACILITY -Bias, scheduling,provider type -Knowledge and skills CLIENT -Lack of awareness, cost -Side effects and complications LACK OF ACCESS IS POSSIBLY THE PRIMARY BARRIER

10. STRATEGIES FOR LAMI 10 Advocacy at all levels Work with communities to address barriers, including gender norms Focus on essentials of service delivery: access, choice, safety and quality No missed opportunities: - postpartum, postabortion, interval - static and mobile outreach - private and public Ensure contraceptive security New Mother in Albania (photo credit G. Stolarsky)

11. US Nurse Practitioner - SOP 11  Diagnosing and managing acute/chronic diseases  Ordering and doing diagnostic studies  Prescribing physical/rehabilitation treatments  Prescribing drugs for acute and chronic illness Providing  prenatal and family planning services  Well-child care  Primary and specialty care services, health- maintenance care for adults, including annual physicals  Care for patients in acute and critical care settings  Performing minor surgeries and procedures  Counseling and educating patients

12. TASK SHARING FOR EXPANDING ACCESS  Task sharing - allowing appropriately trained health workers with less formal medical education to deliver the same services as those with more education, where appropriate.  Global Examples of Task sharing  Nurses/midwives in HIC inserting IUDs, implants  Midwives in Indonesia inserting Implants  Surgical nurses in Thailand performing postpartum TL  CHW provision of DMPA (> 12 countries) 12

13. Issues in implementing task shifting  Overloading - always seem to shift to the same cadres  Inadequate support for those “receiving” new tasks  Incentives/motivation/salaries  Making it easy to progress through levels  Educational system that permits re-entry  Competencies described at all levels  Having a clinical career ladder  Need buy-in from professional association  Dealing with regulation of practice

14. Why Community Based FP Provision?  Expanded points of service are critical for progress  Close the gap on providers shortage  Diminish issues with long distances/wait time at overburdened facilities  Evidence shows community provision increases FP uptake  Essential to reach underserved peri-urban urban and rural population

15. CHW AND INJECTABLES: POLICY RECOMMENDATIONS Overall conclusions and policy implications:  Trained CHWs can initiate and reinject DMPA  CHW expands choice and access for underserved and increases uptake  Sufficient evidence exists for national policies to support introduction, continuation, and scale-up Programmatic guidance:  Monitoring and supervision of CHW is needed  Auto-disable syringes should be used  WHO guidance should be followed regarding eligibility WHO,USAID,FHI, Technial Consultation, 2009

16. Key approaches for Community Access to FP  Trained midlevel (nurses/midwives) and community health worker provision of FP services such as including injectables, implants and IUDs.  Outreach or mobile clinics/teams to provide FP particularly LAMs - implants  Increased access to FP services at clinics and outposts  Pharmacy/drug shop sales and provision of FP methods including injectables

17. DMPA CBD in AFGHANISTAN

18. PPFP/PA FAMILY PLANNING ISSUES  Generally, FP is not being provided to amenorrheic women  Providers have misconceptions about fertility return and often make assumptions about sexual activity- limits service access  Challenges for counseling-based methods- LAM takes time  Contact with women limited; providers are busy; Need to provide additional staff for FP when integrated in larger, busy clinics 18

19. PPFP Best Practices: Global Experience  Offering FP information and services immediately postpartum and at multiple points during maternal care.  Initiating LAM-very effective method for up to six months; LAM users transition to other methods.  Providing a variety of contraceptive options including short and long acting methods.  Attention to postpartum long-acting and permanent methods.  Integrating PPFP into mother and child care—such as immunizations. Women waiting outside for services Photo credit: Barbara Deller

20. FP/RH Package Provided by MNH CHW: Bangla Desh 20 41% of women at 12 month postpartum used any modern method in intervention arm compared to 25% in comparison arm P-value: <0.05 Contraceptive Use at 3,6,12 mos PP

21. Gender Approached to Reduce Unintended Pregnancies  Encouraging male partners to take more responsibility  Encouragement of joint decision-making and shared responsibility for FP  Institutionalization of gender into both private and public sector RH services, including accreditation  Advocacy with religious leaders and policymakers  Integration with development activities (water and sanitation)  Use of established male networks to diffuse information, refer to services and expand method choice  Empowering female providers 21 IGWG, SUMMARY REPORT, 2011

22. GENDER INTEGRATION: RH OUTCOMES  Greater contraceptive knowledge and approval;  Increases in positive attitudes toward contraceptive methods;  Increased communication between partners or couples about health;  Longer birth spacing;  Increased use of long-acting contraceptive methods;  Increased health-provider knowledge of family planning; and  Improved quality of care in health facilities. 22 IGWG, SUMMARY REPORT, 2011

23. TAKE HOME MESSAGE  LAMI have high potential to:  Correct the method skew  Fulfill unmet need for contraception  Revitalize stagnating CPR  Lessons from other countries opens up opportunities for increasing access to LAMI:  Task shifting  Community base approaches  Incorporating Gender Based Approaches  Maximizing utilization of PPFP 23