E2A Newsletter, July 2015

E2A program in Cameroon inserts postpartum implants same day as new Medical Eligibility Criteria released

On June 1, 2015, the World Health Organization (WHO) issued its revised Medical Eligibility Criteria (MEC), for the first time releasing evidence-based guidelines for the insertion of contraceptive implants within 48 hours after delivery.  Aware of the coming change, the E2A team prepared its postpartum family planning program in Cameroon to offer implants immediately after delivery—and upon immediate release of the new criteria—at the four largest hospitals in Yaoundé.

“We were waiting for the minute WHO released its revised MEC to announce it to our Cameroon team and add implants to the contraceptive mix,” said Dr. Salwa Bitar, E2A’s senior advisor for scale-up who manages the program in Cameroon and developed the strategy applied. “Offering implants counseling and services started immediately and resulted in  43 new acceptors of implants in less than two weeks.”

Implants are easier to insert than intrauterine devices (IUDs). Adding them to the postpartum contraceptive method mix offers women the choice of another long-acting method during a crucial time for making decisions about family planning. This time is crucial because many women who leave the hospital after delivery do not return for family planning services, and as a result, have another often unplanned child within one year after their last birth.

Prior to supporting the provision of postpartum implants, the E2A Project supported competency-based training with 50 providers and master trainers in January and February 2015 on the insertion of both implants and IUDs.

“Before January 2015, nobody was trained in postpartum intrauterine device insertion and did not accept the provision of implants immediately after birth,” said Boniface Sebikali, a senior clinical training advisor with Intrahealth International who led the trainings in Cameroon. He pointed out that 61% of women in Cameron deliver at the health facility and not reaching them with the full range of contraceptive methods would be a huge missed opportunity.

“I used to insert IUDs and implants, but not immediately postpartum,” said Antoinette Gousse, a nurse at Central Hospital in Yaoundé. “The training improved my technical competency, as my counseling skills on all methods have improved and I am now counseling women during antenatal care and postnatal care."

After sharing the new MEC with Cameroon’s Ministry of Health, E2A worked with the Ministry to make sure counseling on all methods, including contraceptive implants and IUDs, was taking place at four contact points: during antenatal care, in the delivery and postpartum room, at the child immunization clinic, and in the family planning unit. Clients who choose implants can then have them inserted in the delivery room or the family planning unit.

According to Dr. Salwa Bitar, the ability of providers to offer implants immediately after delivery will likely result in higher acceptance of contraceptive methods during the immediate postpartum period, higher contraceptive prevalence, lower total fertility, and reductions in maternal and newborn mortalities.

“Looking back at the countries in which I have worked to strengthen postpartum family planning, including Yemen, Uganda, and Haiti, I wish that these additional contraceptive options were available then,” said Dr. Bitar. “Certainly if the Ministry of Health and development partners would have included them in their family planning strategies and programs, many mothers and babies could have been saved.”

Although postpartum family planning counseling was taking place in those countries at high rates, postpartum contraceptive uptake remained low, due in large part to the limited contraceptive options offered for women. IUDs, the only long-acting method being offered immediately postpartum, could not easily be offered at scale due to the rigorous competency-based training requirements for the method, the medical equipment needed, and limited funding to purchase this equipment.

Dr. Bitar recommends that both the public and private sectors accelerate availability of IUDs and implants in the delivery room and train providers to offer high-quality counseling and services. She also recommends that the WHO and development partners build the evidence base around expanding method choice for all women and men.

“We know that family planning is a sensitive commodity and there is no one size that fits all,” she said.

Right place at the right time: student caravan halts a child marriage in Niger


In March, a 13-year-old Nigerien girl was about to join the many young girls in Niger who are married as children. Although it was against her wishes, she had taken part in the preliminary wedding ceremonies that would transform her from the orphan she once was into the wife of her 35-year-old husband-to-be—that is, until her friend spoke out.

During a debate organized by the E2A Project’s University Leadership for Change (ULC) Project in Madaoua, Niger, the young friend began to cry. She told them that in a week her friend would become a child bride. Despite the fact that 30 percent of Nigerien girls are married when they are younger than 15, Nigerien law sets the minimum age of marriage for girls at 16. After members of the ULC Project brought the case to the police, it went to a juvenile court judge who ordered the families of the child bride and her intended husband to stop the marriage.

ULC carries out sensitization activities to improve young people’s knowledge and practices related to their sexual and reproductive health, and the debates are a part of that effort. The debates in Madaoua were led by what the project refers to as a “sensitization caravan,” composed of 23 students from Abdou Moumouni University in Niamey, two Ministry of Public Health Officials, and a ULC program manager.  Although it wasn’t an objective of the caravan to report the child marriage, the team could not remain indifferent, particularly in a place where there are so many child brides. The two Ministry of Public Health officials and two student peer educators reported the case to the police.

At the center of the ULC Project are peer educators and student supervisors from Abdou Moumouni University in Niamey who raise awareness about sexual and reproductive information and services and lead behavior-change activities with their fellow students. The caravans are the ULC Project’s approach to develop students’ leadership and responsibility for sharing what they know about sexual reproductive health and rights with their communities.

The March caravan also traveled to Birni N'Gaoure, Dosso, Maradi, and Tahoua to hold debates and discussions with young people, other community members, and local and traditional authorities about the sexual and reproductive health challenges facing youth. The caravan visited university health centers and spoke with officials, student delegates, and administrative officials about sexual and reproductive health and rights. Screenings were held of the film Binta’s Dilemma, which was produced by ULC to spark conversations about early marriage, contraception, unintended pregnancy, and sexual and other reproductive health topics facing young Nigeriens. Members of the caravan also used a behavior-change tool developed by Pathfinder International, called Pathways to Change, to prompt reflection that might motivate changes in behavior.

More than 300 young people were directly involved in caravan debates, Pathways to Change games, and film screenings. The project was presented to key regional and district health office contacts and connections were established between health centers at the universities of Tahoua and Maradi and the respective regional health authorities to find solutions to insufficiencies in health providers and medical supplies.

Based on the caravan experience visiting the sites outside of Niamey, caravan members recommended:

  • Establishing provisions to improve the enforcement of laws and legal texts prohibiting early marriage and punish perpetrators of violence against adolescent girls;
  • Strengthening the coordination mechanisms between the Ministry of Public Health, the Ministry of Child Welfare, and NGOs for the management of cases of children's rights violations;
  • Strengthening partnerships between civil society actors working on child protection and those working in the sexual and reproductive health and rights;
  • Investing in community-awareness activities to mobilize community support and commitment in the fight against early marriage;
  • Training peer educators and government representatives involved in ULC on child protection issues to build their capacity to respond to these types of situations.

Caravan members recognize, in particular, that legal actions are only one step to addressing child marriage. Interventions seeking to change the sociocultural norms that support child marriage are equally important.

The caravans support ULC objectives of reducing the unmet need for family planning and unintended pregnancies and preparing young women to make informed decisions about delaying sexual initiation and first pregnancy, as well as spacing and limiting the number of pregnancies to ensure better health outcomes—all with the support of young men and their communities.

Read more about the ULC Project here.

Tanzania: scaling up use of evidence-based tools

In Tanzania, the E2A Project, with the East, Central and Southern Africa Health Community College of Nursing (ECSACON) and the IBP Initiative, trained 33 pre-service education tutors from 20 nursing and midwifery schools using the Training Resource Package for Family Planning (TRPFP)—a comprehensive set of materials designed to support up-to-date training on family planning and reproductive health.

The training, from July 6-10, was part of E2A’s work in building the capacity of the East, Central, and Southern Africa Health Community’s (ECSA) to demonstrate application of the TRPFP among providers and trainers in its member states. Participants learned about high-impact practices in family planning and were led through the structure and content of the TRPFP. A  Ministry of Health trainer also gave an overview of the World Health Organization’s new Medical Eligibility Criteria.

All participants built their skills in family planning counseling and communication and the use of competency-based methods to deliver family planning services. Participants worked in small groups to practice their counseling skills and prepare 20-minute training sessions on various family planning topics using a template from the Ministry of Health.

During the last two days, the E2A-IBP team leading the training posed as student nurses to give feedback after each session. Participants learned that students acquire skills from doing and not from lectures. The family planning sessions also provided an opportunity for a contraceptive technology update.

“Indeed it was a wonderful training of all the trainings I have ever attended. As time went by, my mindset towards competency-based education and training kept on changing,” said one participant.  “My humble request to all trainees: let us make sure that we keep the TRPFP fire burning, and by so doing, we shall have many clients who meet MEC using contraceptives for the health of the nation.”

In response to a request from the Ministry of Health, the Training Coordinator for Nursing and Midwifery Training launched an online Tanzania TRPFP community site on the Knowledge Gateway. One participant posted a comment to the site: “This will bring professional respect, proof to employers that you have the skills, ability and knowledge your field requires!!”

Scale-up workshop in Ouagadougou sets stage for ECOWAS Good Practices in Health Forum

More than 100 public health practitioners from across West Africa became familiar with tools and approaches they can use to systematically scale up effective practices at a workshop on July 28 held prior to the Economic Community of West African States (ECOWAS) Forum on Good Practices in Health.

The pre-conference workshop was held by the West African Health Organisation (WAHO) in collaboration with Management Sciences for Health through the E2A Project and the Leadership, Management and Governance Project; the World Health Organization; the IBP Initiative; Jhpiego; Marie Stopes International; and the International Planned Parenthood Federation. Ministry of Health officials from across West Africa attended.

“This is a great opportunity to hold a day on fostering change for scaling up good practices and how to introduce systematic approaches for scaling up in the WAHO region,” said Salwa Bitar, E2A’s senior advisor for scale-up, during welcome remarks. “We hope the effect will be synergistic to the coming three days of the WAHO Forum on Good Practices in Health.”

Although governments, donors, and implementing partners are committed to improving health outcomes in the West Africa region, many promising practices and programs have not been scaled to reach a wide swath of the population.

“An array of good practices and projects in pilot phases for maternal, newborn and child health exist in our region, but they remain largely unknown by the wider public,” said Dr. Xavier Crespin, WAHO Director General. “This workshop is an opportunity for us to showcase what we are capable of.”

The workshop focused on practices in maternal and neonatal health, family planning, sexual and reproductive health, and family planning for youth, and participants learned about key components of the scale-up process.

The workshop featured a panel discussion where panelists shared success stories about scaling up in Liberia, Mali, Niger, Senegal, and Togo, and a knowledge café that featured tools for advocacy and costing and provided information on high-impact practices.

During the afternoon, participants broke into groups to analyze three pilot interventions and apply the IBP Initiative’s Guide to Fostering Change’s principles of change and the CORRECT model from ExpandNet’s Nine steps for developing a scaling up strategy.

At the end of the day, participants identified actions they would take upon return to their countries to support scale-up of effective practices and programs. Those actions included:

  • Gauging existing pilot interventions against the principles of change to determine readiness for scale-up.
  • Reviewing projects that have been scaled up to determine gaps based on learning from the workshop and forum.
  • Using the Guide for Fostering Change and Nine steps for developing a scaling up strategy to further explore opportunities for scaling up existing interventions.
  • Sharing information with colleagues to push for innovative and effective actions.
  • Having advocacy meetings with partners on good practices that can be scaled.

A message that resonated with participants is one from Suzanne Reier’s presentation. “We chronically underestimate what it takes to make change stick and enable scale-up,” said Reier of the IBP Initiative. “Don’t leave change to chance.”