E2A newsletter March April 2017

RISE-FP: E2A to integrate family planning into resilience programming in Niger’s Sahel

E2A, with Pathfinder International/Niger, recently began supporting family planning interventions in three health districts of Niger’s Zinder region—Matamèye, Magaria and Mirriah—that will be integrated into ongoing resilience programming. The integrated resilience initiative, referred to as the “Resilience In the Sahel Enhanced” Program—or RISE—is funded by the USAID Sahel Regional Office and includes efforts in Burkina Faso and Niger to strengthen institutions and governance, increase sustainable economic wellbeing, and improve health and nutrition of vulnerable Sahelian communities.

As in much of Niger, family planning and reproductive health services are largely inaccessible in Zinder. In rural areas of Niger like Zinder, women have an average of 8 children in their lives and most women (75 percent) marry before they become adults.

Increasing access to contraceptives

Through RISE, E2A aims to increase demand for and access to family planning services in the three districts through a combined strategy of community- and facility-based services. RISE will train community-based distributors (CBDs) to: counsel on a full range of contraceptive methods, refer clients to health posts and health centers for implants, injectables and IUDs; and provide Cyclebeads, condoms, and oral contraceptive pills.

Trained facility-based providers will counsel on family planning and provide a full range of contraceptive methods, including long-acting reversible contraception. Additionally, facility-based providers will conduct outreach visits to communities each month to support CBDs’ demand-creation  activities by offering a full range of contraceptives in communities, including injectables and implants.

Demand generation via scale-up of behavior change interventions

In addition to strengthening the delivery of family planning services, E2A’s strategy for RISE adopts some interventions from the University Leadership for Change (ULC) Program, implemented by E2A from April 2014 to June 2016 in Niamey. Like ULC, RISE will engage peer leaders from a local university to lead behavior change activities in communities. The peer leaders will play an especially important role in building the capacity of youth from RISE communities to reach their peers.

“Today's young people are the adults of tomorrow,” said Mohamedine Souleymane Issoufou, 26, a peer leader from University of Zinder that will work with RISE. “If they are well informed, it will ensure a succession with responsible men and women.”

The behavior change interventions led by the peer leaders, which began at Abdou Moumouni University in Niamey, were scaled up to three additional universities in Niger—including the University of Zinder—after testing their feasibility and developing plans for scale-up with Niger’s Ministry of Public Health and Ministry of Higher Education. The interventions at University of Zinder, which engage student peer leaders to raise awareness among the student body about sexual and reproductive health, will now move to communities in Zinder.

Seidou Moussa Aboubacar, 24, says that his sensitization efforts are already changing lives.

“I have a friend from the same village as me, married to two women who give birth every year. He has such a large family that he has trouble feeding them despite his savings as a small trader. He was ready to abandon these women, to go on exodus, but I talked to him about contraception and the possibility of spacing births,” said Seidou. “Now, he says he will even pay money if necessary for these women to benefit from contraception to finally have a stable family.”

Family planning systems strengthening

In addition to demand generation through engagement of the peer leaders, RISE will strengthen the health system in the three districts by improving: the management of family planning commodities, data collection and reporting, and supportive supervision and shared learning to improve performance. The project is currently in its start-up phase. Ongoing data collection will inform the selection of intervention communities.

Crucial as classwork: peer counseling on campus

By Sophia Mwende, Peer Counselor, Kenyatta University

Reposted from Pathfinder International’s Blog


Photo courtesy of Maren Vespia, Pathfinder International

When I met my friend, Marie*, she had recently arrived at university and just learned she was HIV positive. She had lived her entire life with the infection, but it wasn’t until she went to campus health services that she learned about her status.

Shortly thereafter, Marie’s mother revealed that she also had HIV. The medicines she took and had given to Marie for her whole life were for HIV. Now, the mother and daughter attend support group together and set their alarms at the same time every day to take their pills.

Marie approached me because I am a peer counselor at Kenyatta University—in fact, I am the lead peer counselor of a group of seven. There are 100 of us who counsel at the main Nairobi Campus—60 females and 40 males—and we work in groups of seven, each supported by one professor who gives us advice and support. I spend three to four hours each day as a peer counselor—talking and texting with students about their relationships, contraception, sexually transmitted infections, and, really, anything related to their sexual and reproductive health.

When Marie came to me, she had little confidence, a lot of stress, and hatred in her heart. But she trusted me to walk her toward a freer and happier life. I introduced Marie to other students who are HIV positive and when she heard their stories, she felt less alone. Every time we met for counseling sessions, she seemed to be more inspired, and after a while, she joined our group as a peer counselor too.
Stories like this are why I spend almost as much time in classes as I do as a peer counselor.

Because I am a lead peer counselor, I was recently selected to participate in research led by Pathfinder’s USAID-funded Evidence to Action (E2A) Project on our university on sexual and reproductive health. E2A examined service statistics from the campus youth-friendly sexual and reproductive health services program and talked to students, university administrators, guidance counselors and sexual and reproductive health providers and residential hall housekeepers and wardens for their insights on the factors that influence student demand for sexual and reproductive health services, and their experiences with university life.

That research confirmed much of what I already know: that students, for the first time living away from home, are faced with enormous pressure to not only succeed academically, but also fit in at university and explore their newfound freedom. This often means having sex, or negotiating condom use for the first time.  First-year students and students who don’t have a lot of money—some who engage in transactional sex to support their education—are the most vulnerable.

One female student told the researchers: “If you tell a friend you are a virgin, they may go around mocking you about the same. So, if you want to fit in that group, you will find yourself having sex just because you want to be a friend to so-and-so or fit in a particular category.”

They are concerned with their sexual and reproductive health, particularly pregnancy, sexually transmitted infections, and HIV, yet certain fears—such as other people knowing that they are sexually active—prevent them from accessing the services they need.

“There are those who don’t want to go to anything here in school—they fear being seen—so they end up going outside the campus,” said one male student.

Students who unintentionally become pregnant, because they did not know about contraception, couldn’t access it, couldn’t negotiate with their partner to use a condom or abstain from sex, or believed a myth—like implants are only for married women—will have a hard time succeeding at university if they do not have the requisite support to deal with their situations. A student like Marie who finds out she is HIV positive may feel so stressed out and isolated by her news that she may find it hard to concentrate on her studies and may risk failing out of university.

E2A’s study findings are being used by the university to improve the sexual and reproductive health services offered at Kenyatta University’s 11 campuses. Based on the findings, E2A offered several recommendations to the university including:

  • Include students as leaders and resources of the sexual and reproductive health program who can reach students and foster positive gender norms, attitudes, and sexual and reproductive health behaviors.
  • Given the multi-faceted context of sexual and reproductive health issues, build participatory, accountable, and responsive stakeholder networks to provide input.

As our university acts on these recommendations, I would like to reiterate the need to involve us—the peer counselors—in not only the outreach activities themselves, but also in decisions about how youth-friendly sexual and reproductive health services are run. We need more resources to reach out to the growing student body at Kenyatta University—now 70,000 students large—especially nonresident students who are scattered all over. We need to talk to more students like Marie, so they feel confident and comfortable with us—so they can be proactive in ensuring their own sexual and reproductive health.

It is important to make sure everyone knows us. Because if they know us, they will come to us.

*Names have been changed.

Read this research brief developed by E2A based on the studies at Kenyatta University.

For midwives in Togo, counseling clients on contraceptives is often a balancing act

By Stembile Mugore, E2A's Senior Advisor for Performance Improvement

Reposted from IntraHealth International's Blog


Graphic courtesy of IntraHealth International

When Mrs. Iwu arrived at the maternity ward at Atapkame Regional Hospital in Togo, she was bleeding heavily—experiencing her second miscarriage. It may have been the result of multiple closely spaced pregnancies.
At 43, Mrs. Iwu had seven children between the ages of 20 months and 10 years.

Despite the risk that she might become pregnant again too soon, Mrs. Iwu left the health center without a contraceptive method.

“She did not want a method because she is a recent widow who has been inherited by her husband’s brother, who has another wife,” said Ms. Akor, the in-charge of the maternity ward at the health center and the most experienced midwife on staff. “She therefore needed to get pregnant as soon as possible to secure her place in the family.”

In Togo, data on unintended pregnancies and unsafe abortion are limited; a 2002 survey of family planning clinics in Lomé determined that 39% of women aged 15–24 who had been pregnant at least once reported having had an abortion. And 34% of married women do not desire a pregnancy in the next two years, yet they are not using a modern contraceptive.

Ms. Akor had diagnosed Mrs. Iwu with anemia, prescribed her iron tablets, and assessed her for possible referral to a hospital for a blood transfusion after fellow midwife Fauzia performed the manual vacuum aspiration to treat her miscarriage—known in medical terms as an incomplete abortion—and midwife Marie had engaged her in family planning counseling that honored the concept of voluntary informed choice.

“This is a new husband,” Ms. Akor said. “Culturally, she is expected to have children with the new husband or else she will not be fully accepted in the family, and besides she is also getting old.”

According to Ms. Akor, the recommended timeframe of six months would be too long for her to wait before trying to get pregnant again, particularly now that she had a miscarriage.

Although the midwives had learned in their clinical training that multiple pregnancies—too early, or too closely spaced—put the health of both mother and baby at great risk, they also learned to honor a client’s voluntary informed choice when it comes to contraceptive decisions.

This type of counseling, which all providers should be trained to conduct, ensures the right of the client to make informed decisions based on her personal reproductive health needs, desire for timing of subsequent pregnancy and family size, and the socioeconomic and cultural context. In counseling for voluntary informed choice, the health worker becomes a facilitator, allowing the client to exercise her autonomy.

As facilitators, health workers are trained to be unbiased, provide accurate information tailored to the client’s needs, respond to the client’s questions, respect and support the client’s choice, and make sure they do not unduly influence the client’s decisions. They skillfully help the client examine the available information and weigh the potential health benefits and consequences against their individual needs, as well as the opinions and beliefs of their families and communities.  Typically, a health worker takes a client’s history, performs an exam, reaches a diagnosis, and prescribes a method. Normally, this is simple and straightforward.

Counseling that honors voluntary informed choice, however, is personal and complicated, and clinical training, guidelines, and protocols do not always prepare health workers to handle that complexity.
The midwives at Atapkame Regional Hospital were torn between their clinical knowledge and their understanding of the client’s cultural circumstance. Their empathy for Mrs. Iwu and her risk of not being accepted into her new family was palpable.

I pointed out that even if Mrs. Iwu becomes pregnant again, she might still not be accepted if she cannot carry a subsequent pregnancy to term, has a premature or low-birth-weight baby, or worse, dies in pregnancy or childbirth.
Fauzia let out a heavy sigh. After Mrs. Iwu mentioned that she wanted to try for pregnancy as soon as possible, Fauzia discussed the need to wait for at least six months and the benefits of spacing soon after the miscarriage, but did not dwell on the family planning methods. Fauzia felt that Mrs. Iwu would not be interested.

“It is her voluntary choice, but a risky choice,” said Ms. Akor.

The midwives had done the right thing in respecting Mrs. Iwu’s autonomy in her decision. But informed choice also means making sure the client is fully aware of the medical repercussions of her choice. Such conversations—where a midwife must tell a client she might die if she follows a certain plan of action—are difficult.

This was a perfect example of how health workers in Togo and beyond need more support and practice in having such difficult conversations.

My question to them was: “What is Mrs. Iwu’s uterus telling us?”

The uterus has had enough pregnancies and needs a break, the midwives agreed.

Marie mentioned that Mrs. Iwu’s desire to have a healthy baby with her new husband and her being healthy enough to look after her children should have been the focus of the discussion.

“That might have helped her to make the decision to wait before trying too soon,” Ms. Akor said. “After nine pregnancies and two of them resulting in miscarriages, the uterus is clearly tired!”

We then discussed a few examples of similar cases, not just among postabortion clients, but also postpartum clients and clients with chronic illnesses that are likely to worsen with pregnancy or threaten the mother’s life. The midwives said that in some of these situations, they just do not know what to do.

New resources from E2A

E2A recently released detailed documentation of its University Leadership for Change Program in Niger. The report is available in English and French.

This new program brief, Uplifting rural communities: Building a scalable model for community-based family planning in Democratic Republic of the Congo, describes E2A’s USAID/DRC-mission supported interventions in three rural provinces. The interventions include outreach events where nurses join community-based distributors to ensure communities can access a full range of contraceptives close to home, including injectables and implant insertion and removal services.

E2A’s Community of Practice on Systematic Scale-Up of Family Planning and Reproductive Health Best Practices has updated its bibliography on scale-up literature. The new version, updated by E2A's core partner ExpandNet,  includes a clickable table of contents for easier use!

If you were not able to catch it, listen to the recording from the webinar "Beyond Bali: shifting from thought to action." The webinar is the first in a four-part part webinar series led by the working group advancing the use of the Global Consensus Expanding Contraceptive Choice for Adolescents and Youth to Include Long-Acting Reversible Contraception. Read more about the four-part series here.