1. Increasing rational use of modern contraceptives in Bangladesh: Experiences from an operations research Md Mahabub-ul Anwar Ubaidur Rob Ismat Ara Hena 139th APHA Annual Meeting & Exposition in Washington, DC October 31, 2011

2. Background  Low contraceptive use rate and high regional variation  Overall 55.8%,  Rajshahi 65.9% and Khulna 63.1  Sylhet 31.5% and Chittagong 43.9%  Contraceptive use tilted towards temporary methods  30% of oral contraceptive users completed desired family size  Over three-fourths of women with four or more living children want no more children, and yet only 10 percent use LA/PMs  56.5% of all contraceptive users stop using their chosen method within 12 months of initiation (Source: NIPORT, Mitra and Associates, and ORC Macro 2009) Cont’d…………..

3. Background  Community identification and prioritization of family planning (FP) and reproductive health (RH) problems study identified that...  Lack of in-depth knowledge about FP methods  Misconceptions about FP methods  Social and religious barriers  Training needs assessment survey identified that...  Providers need training on contraceptive methods and counseling technique  Providers need training on syndromic management of RTI/STI  Providers tend not to use behavioral change communication (BCC) materials

4. Objectives Overall objective  The aim of the study is to examine the impact of a service delivery model to enhance the rational use of modern contraceptives Specific objectives  Increase acceptance of modern contraceptives by 10%  Decrease discontinuation of modern contraceptives by 10% Rationale Considering the problems and needs an operations research study “Increasing rational use of modern contraceptives” was introduced

5. METHODOLOGY

6. Study design Experimental groupO1 XO2 Nonequivalent control group O3O4 Quasi-experimental nonequivalent control group design  Enhancing technical capacity of service providers  Strengthening physical infrastructure and supply system of health facilities  Involving community through community support group and peer promoters  Creating awareness of family planning and reproductive health issues 12 months

7. Timeline  Study duration : July 2007 to March 2009  Pre-intervention data collection : July - September 2007  Intervention : October 2007 - September 2008  Post-intervention data collection : October - December 2008

8. Study site Intervention sites  Two unions from Nabiganj Upazila of Habiganj District  Two unions from Raipur Upazila of Lakshmipur District Control sites  One union from Bahubal Upazila of Habiganj District  One union from Ramganj Upazila of Lakshmipur District

9. INTERVENTIONS

10. Enhancing technical capacity of service providers  Service providers (9)  Four-day training on modern contraceptives and counseling  Five-day training on syndromic management of RTIs/STIs  Field workers (48)  Four-day training on modern contraceptives and counseling  Service providers and field workers  Orientation on team building and appreciative inquiry

11. Strengthening physical infrastructure and supply system of health facilities  Ensured necessary supplies and equipments  Improve physical environment  Garden, pond  Tables, chairs, fans  Signboard displayed available services and service hours  Co-ordination between service providers

12. Involving community through community support group and peer promoters  36 community support groups  Formed  Trained  Monthly meeting  139 peer promoters  Selected  Trained  Refresher training  Monthly evaluation

13. Creating awareness of family planning and reproductive health issues  BCC activities  Interpersonal communication  Cultural program  Raffle draws at health facilities

14. FINDINGS

15. Observations on community support groups monthly meetings ObservationsRaipurNabiganj Category of members attending meeting Male UP member 45.274.8 School teacher 36.063.1 Religious leader 47.890.2 FWA/HA 90.689.5 Information about meeting Held on time 89.791.9 Held on schedule date 80.383.7 Meeting minutes discussed 65.899.2 Peer promoters activities discussed 71.699.2 Specific agenda for the meeting 82.997.6 Discussion held according to agenda 88.998.4 Service-related issues discussed 100.099.2 Total number of observations 117 123

16. Performance of peer promoters IndicatorRaipurNabiganj Greeted participants82.6100.0 Created friendly environment58.798.7 Explained topic clearly58.769.8 Summarized key findings of the session14.984.9 Provided correct information76.083.0 Provided information on sources of FP and STI/RTI services 96.791.8 Used BCC materials91.766.7 Distributed BCC materials47.956.6 Number of peer promoters observed121159

17. Percent distribution of respondents by knowledge on modern contraceptives Methods M RaipurNabiganj InterventionControlInterventionControl PrePostPrePostPrePostPrePost Know seven modern methods 64.781.9***65.574.9***52.473.0***46.752.6 Pill100.099.9100.0 99.9100.099.8 100.0 Condom94.997.1*97.599.4*78.886.4***79.1 Injectables99.699.799.4100.097.9 98.5 98.9 Norplant87.6 91.9**92.593.491.8 95.2**85.194.6*** IUD95.396.295.697.091.8 94.183.2 90.2** Vasectomy75.290.0***69.580.9***65.384.7***53.365.3*** Tubectomy95.599.0***97.794.994.898.1***89.8 94.8** N956 941 478 467 815 858 469460 M Multiple responses; Significant at *p<0.05; **p<0.01; ***p<0.001

18. Percent distribution of respondents by current use of contraceptives Methods RaipurNabiganj InterventionControlInterventionControl PrePostPrePostPrePostPrePost Any method73.876.360.5 62.268.571.264.657.2** Temporary methods 63.9 59.0*48.6 45.254.253.960.446.5** Pill44.4 31.1***32.6 21.3***44.039.2*45.533.5** Condom 2.8 3.32.53.83.7 5.31.42.5 Injectables 16.7 24.6***13.5 20.1***6.59.4**13.510.5 LA/PMs5.810.0***6.18.412.115.3*8.78.2 Norplant1.33.9***0.2 1.8***5.6 4.03.32.5 IUD3.7 1.8 2.52.34.4**1.20.7 Sterilization0.82.4***4.1 4.26.9**4.25.0 Not currently using 26.223.739.5 37.831.528.829.442.8*** N 896 882438 442736 799429439 Significant at *p<0.05; **p<0.01; ***p<0.001

19. Percent distribution of respondents by current use of LA/PMs and parity Number of alive children RaipurNabiganj InterventionControlInterventionControl PrePostPrePostPrePostPrePost 1 0.40.70.20.00.80.90.5 2 1.12.30.20.91.82.31.91.1 3 and above 4.27.0*5.77.59.412.1*6.36.6 N956 941 478 467 815 858 469460 Significant at *p<0.05

20. Future intention to use of contraceptives

21. Percent distribution respondents discontinued the use within 12 months after beginning its use Method RaipurNabiganj InterventionControlInterventionControl PrePostPrePostPrePostPrePost Pill70.780.776.785.439.341.333.735.2 IUD35.931.175.072.820.017.633.331.2 Injectables56.449.872.070.160.356.064.461.2 Condom70.768.376.775.039.338.133.732.0

22. LESSONS LEARNED

23. Lessons learned  Organized involvement of stakeholders in FP activities, such as through CSGs and peer promoters, is an effective strategy for raising community awareness about family planning and increase knowledge and use of modern contraceptives, especially LA/PMs  Increasing technical skills of service providers through training, along with strengthening of health facilities, considerably enhanced the quality of services provided, resulting in increased use of LA/PMs  Training on informed counseling can enable service providers and fieldworkers to give appropriate information on a method and to ensure an effective follow-up mechanism Cont’d…………..

24. Lessons learned  If properly trained, service providers can screen FP clients based on life-cycle considerations  Peer promoters, in general, are effective in disseminating information on FP/RH issues among their peers and motivating them to accept modern contraceptives  Selecting satisfied longer acting method acceptors as peer promoters can be an effective strategy to motivate the potential acceptors for longer acting methods  BCC sessions jointly conducted by the fieldworkers and peer promoters are effective in motivating potential clients to accept modern contraceptives  Since the CSG members and peer promoters work on a voluntary basis, a mechanism of supporting and facilitating their activities on a regular basis is necessary to sustain their involvement and interest

25. Limitations  Individual effect of the interventions  Some vacancies of service provider in intervention areas  One NGO worked on LT/PM in one control area

26. Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Md Mahabub-ul Anwar “No relationships to disclose ”

27. Acknowledgements  Canadian International Development Agency (CIDA)  United Nations Population Fund (UNFPA)  RTM International  International Centre for Diarrheal Disease Research (ICDDR,B), and  John Snow Institute (JSI) Deliver Project, Bangladesh  National Institute of Population Research and Training (NIPORT)