Balanced Counseling

Strategy Plus – Overcoming

Barriers to FP Services

Sexual, Reproductive and Maternal Health

(SRMH)

Kamlesh Giri – Senior Advisor, Clinical Training

CARE

Jan 9th 2013

222 Million Women Report Unmet

Need for Contraception Worldwide

• A number of barriers contribute to this unmet need

• Medical Barriers

• Process Barriers

• Access Barriers

Source: Susheela Singh & Jacqueline Darroch, Guttmacher Institute, 2012. 2

Barriers

Medical Barriers

• Inappropriate contraindications or eligibility criteria: age, parity, marital status, etc.

• Lack of trained provider

• Provider bias

• Restrictions on where services can be provided

Process Barriers

• Unnecessary barriers to initiation – e.g. Menstruation, STI, etc.

• Rest periods required

• Unnecessary procedures required – Pap smear, pelvic exam, lab tests, etc.

• Inappropriate follow-up schedule – IUD follow-up, only 1 pill cycle given, etc.

3

Mean Parity Required Among Providers Who

Report Restrictions on Injectable Use Based

on Parity

1.9

2.8 2.9 2.93.4

0

1

2

3

4

5

6

Kenya Botswana Burkina

Faso

Zanzibar Senegal

Source: Population Council, 1998.

# c

hild

ren

Percentage of Providers Who Restrict Injectable

Use Based on Minimum Age*

in Four African Studies

Source: Population Council, 1998.

* Minimum age = 13 or above

Percentage of Providers Who Restrict Injectable

Use Based on Maximum Age*

in Four African Studies

* Maximum age = 45 or below

Source: Population Council, 1998.

Compliance Is Critical to the

Contraceptive Equation

• Among pill users, every 1% decrease in

effectiveness represents ~ 100,000 unintended

pregnancies

• If two methods are equally efficacious but one

has better compliance/continuation, the net

effectiveness will be higher for that method

7

Receiving Contraceptive of

Choice Increases Continuous Use

0

20

40

60

80

100

Injection Condom Pill

Received

Denied

Source: Pariani, Studies in Family Planning, Nov/Dec 1991.

Indonesia

% of

Continuous

Use

Menstrual Requirement is a Major

Access Barrier in Kenya

100 Women

Seek FP Services

55

Menstruating

45

Non-Menstruating

55 Registered

as Clients

10 Registered

as Clients

35 Sent Home

to Await Menses

Source: Stanback, 1999.

9

Breaking

Barriers

10

Practices to Break Down Barriers

•Providing client’s method of choice to

enhance continuation and compliance

• Avoiding unnecessary medical restrictions

and tests

•Improving counseling and client-provider

interaction (CPI)

11

Avoiding Provider Bias

• Often, well-intending providers think they know

best - so do not elicit client preferences

• Provider needs to consider client’s specific

situation and let client select method

• Programmatic pressures favoring certain

methods (e.g., provider targets) may influence

providers

12

"How to be reasonably sure woman is not

pregnant" Checklist use for non-menstruating

clients can improve access

0

100

200

300

400

500

7 Checklist Clinics

7 Control Clinics

*12/97 – 1/98

excluded due to

national nurses’

strike in Kenya

*

*

Feb-

Mar

96

Jun-

Jul96

Oct-

Nov

96

Feb-

Mar

97

Jun

-Jul

97

Oct-

Nov

97

Dec

97-

Jan

98

Apr-

May

98

New Client Volume

Contraceptive Counseling:

Including Partner Improves Continuation Rates

0

10

20

30

40

50

Partner Involved in

Counseling

Partner Not Involved in

Counseling

33%

17%

% o

f C

ouple

s C

onti

nuin

g

Contr

acep

tive

Aft

er 1

2 M

onth

s

Terefe A, Larson CP. Am J Public Health. 1993;83:1567-1571;Herndon N. Network. 1998;18:13.

14

Structured counseling groupStructured counseling group

Routine counseling groupRoutine counseling group

Counseling About Side Effects Decreases

Discontinuation

0

10

20

30

40

50

BaselineMonth 3

Month 6Month 9

Month 12

Source: Zhen-Wu Lei et al, Contraception, Vol 53, 1996.

Percentage

of clients

discontinuing

100

15

BCS+: Improving Client-Provider

Interaction

• Uses interactive and client-friendly approach for

improving FP counseling

• It uses key job-aids for counseling clients

• It integrates counseling and services for other

related services (e.g. antenatal care, STI/HIV,

immunization services)

• It incorporates latest international guidance from

the WHO

Frontiers/Population Council Inc. 2011 16

Counseling Approaches

• Two other FP counseling approaches • GATHER

• REDI

• Both GATHER and REDI take a longer time for

training providers and for providing counseling at

service delivery

• Both of these approaches rely on personal

memory (or third party memory tool) to transfer

the information to clients on FP

• BCS+ is streamlined, with own job-aids,

minimizes memory burden 17

BCS+ Toolkit

The Toolkit consists of the following:

• BCS+ User’s Guide: It explains how to use the

job aids

• BCS+ Job Aids: these are tools used during the

counseling process

• BCS+ Trainer’s Guide: Supervisors can use this

guide to train providers on how to use the BCS+

counseling approach

18

BCS+ Counseling Stages

BCS+ is divided into four counseling stages:

• Pre-choice Stage:

• Method-choice Stage:

• Post-Choice Stage:

• Systematic Screening for Other Services

Stage:

These stages are outlined in the BCS+ algorithm

19

BCS+ Job Aid

20

• Establish and maintain a warm and cordial

relationship with client

• Rule out pregnancy - ‘pregnancy checklist’ card

• Find out woman’s reproductive goals – does she

want to have children in the future?

• Set aside counseling cards from the table that

are not relevant to the client

The Counseling Cards

21

• Ask client if there is preference for a certain

method

• Provide method effectiveness for cards still on

the table

• Use method brochures to check for medical

conditions not suitable for client

• Discuss chosen method with client and provide

method or refer to another center

The Counseling Cards (contd..)

22

• CARE adapted the BCS+ training to a 3-day and

5-day training package to meet program needs

• Included skills for client-provider interaction and a

contraceptive technology update (from WHO)

• 5-day agenda has further expanded CTU component

• The 3-day and 5-day training package available

in English and French including the job-aids

Adapting BCS+ Package for CARE

23

• Barriers to contraceptive use exists at different

levels

• An effective counseling approach is at the core of

any successful family planning program

• Program managers and providers can help to

reduce many of these barriers

• Programs must empower the providers to take

steps to reduce these barriers at the clinic level

Conclusion

24