Integrating Immunization and Family Planning Services:

the Polomolok Experience in the Philippines

Strengthening Governance for Health Project (HealthGov)

June 20111

Acronyms• LGU: Local Government Unit• FP: Family Planning• EPI: Expanded Program on Immunization• MCH: Maternal and Child Health• RHU: Rural Health Unit • BHS: Barangay Health Stations

• DMPA: Depo medroxyprogesterone acetate injection• IUD: Intrauterine Device• BTL: Bilateral Tubal Ligation• LAM: Lactational Amenorrhea Method

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Millennium Development Goals

• Goal 4: Reduce child mortality rates– Target: Reduce by two-thirds, between 1990 and 2015, the

under-five mortality rate • Children’s immunization

• Goal 5: Improve maternal health– Target: Achieve, by 2015, universal access to reproductive

health • Contraceptive prevalence rate• Adolescent birth rate• Unmet need for family planning

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Why integrate Immunization and Family Planning in Philippines?

• 90% of women within first year after delivery want to space or limit pregnancy, high unmet need for FP

• Multiple contacts with mothers at service delivery point: 4-5 visits over newborn’s first 11 months

• High access and awareness of EPI services - at least 85% children fully immunized

• Immunizations and FP provided by trained midwives: on different days and times (referrals made)

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Polomolok Municipality, Province of South Cotabato (Mindanao)

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Lake Sebu

SOUTH COTABATO

Tiboli

Surralah

TupiBanga

Sto. NinoKoronadal

TantanganNoralla

Tampakan

To Isulan

To Tacurong

To GeneralSantos City

Philippines Map

Implementation• 10 month pilot test in one local government unit (LGU): Polomolok

Municipality• 1 Rural Health Unit (RHU -- municipal health center) & 28 Barangay Health

Stations (BHS) involved• Began integration with 1-day orientation of all medical personnel –

explained purpose, approach & key messages• Developed map of facilities and FP and MCH service providers• Pre-tested 3 verbal messages (translated in local dialect)

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• Messages:– “Your child is young & you should be concerned about having

another pregnancy”– “Your health facility provides FP services that can help you”– “You should visit our FP services after your immunization today

for more information”

• Trained 25 rural health midwives (RHMs-based in BHS), 56 barangay health workers (BHWs), 2 RHU nurses and 1 doctor in FP messages

• Study did not collect special immunization data but data available from routine reporting to government

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• Baseline & end-line survey questionnaire was developed to measure changes in women’s knowledge, attitudes & practices (KAP)

• Data collected on new FP acceptors, method mix & CPR (from same monthly period during 2008 and 2009)

• KAP survey administered in 28 BHS – randomly selected mothers bringing children in for immunizations were surveyed (baseline: n=269; end-line: n=183)

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• BHW—administered survey, registered children for immunization & delivered messages

• RHM – administered immunization & delivered same messages

• “Innovations” in Poblacion-4 BHS: Stapled 3 FP messages to immunization records & posted messages in entry way

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Key Findings

38% increase in New FP acceptors after 10 months, Polomolok Municipality

YEAR

MAR

APR

MAY

JUN JULAUG

SEPOCT

NOV

DEC

TO-TAL

2008 151 136 164 149 123 113 151 136 164 149 1,405

2009 176 205 235 178 191 164 176 205 235 178 1,943

%increase

16.6 50.7

43.3

19.5 55.3

45.1

16.6 50.7

43.3 19.5

38.3

(March-December, 2008 vs 2009)

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CPR Increased by 6 percentage points

46%49%

55%

40%

45%

50%

55%

Percent

2007 2008 2009

CPR by Year

Contraceptive Prevalence Rate, Municipality of Polomolok, South Cotabato

CPR

Source: FHSIS

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Shift in Method PreferenceHigher preference for modern methods, lower preference

for traditional methods after six months (June 2009 vs Dec. 2009, Polomolok)

0

5

10

15

20

25

30

FP Methods

Per

cen

t

Jun-09

Dec-09

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Health centers are increasingly important as primary source of FP information

47

1912 10

87

4 5

010

2030

4050

6070

8090

100

Health Center Family / Relative Friend / neighbor None

Source of Information

Perc

ent Jun-09

Dec-09

(among FP users)

(June 2009 vs December 2009, Polomolok)

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126% increase in new FP acceptors over 3 months in

Poblacion-4 BHS (written FP messages & posters provided in

addition to oral messages)

YEAR MAR APR MAY JUN TOTAL

2008 8 7 12 16 43

2009 40 20 14 23 97

% 400.0 185.7 16.7 43.7 125.6

(March-June, 2008 vs 2009)

Immunization Data(Polomolok Municipality—source: FHSIS)

• No adverse impact on children’s immunization

• Fully Immunized Child (FIC) coverage rates – 2008: 96%– 2009: 99%

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Potential Best Practices & Processes Needed for Effective Integration

• Local ownership and support (from local government and health officials)

• Posted and take-home written messages along with verbal messages

• Client follow-up to prevent FP drop outs• Assuring the availability of FP commodities to meet

increased demand• Ongoing performance monitoring (at facility & LGU

levels)

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Potential Barriers to Integration

• Lack of local political (elected) & technical (health officials) support

• Lack of contraceptive and immunization supplies

• Lack of trained providers (in both services)

• Social, linguistic norms that pose barriers in some communities to accessing services (e.g. indigenous populations)

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Priority Next Steps• Measure impact of FP integration with other MCH

services: postpartum care, vit A supplem.

• Tracking availability of FP commodities and services (since creating demand)

• Implementing Data Quality Control trainings for project staff to assure data reliability

• Study outcomes will determine methodologies to scale up integration interventions

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