Family Planning Method Mix in

two crisis affected states: Chad and DRC

Jesse RattanCARE

Women Deliver May 2013

April 12, 2023

2

Who are we? Supporting Access to Family Planning

and Post-abortion Care Initiative (SAFPAC)

• Increase access to family planning (with a focus on LARC) and post-abortion care

• Disaster or conflict-affected places: Chad, DRC, Pakistan and other acute emergencies as they arise (Mali, Djibouti)

• Integrate SRH programming throughout CARE’s emergency response work and culture

What does SAFPAC do?

Strengthen service delivery of FP and PAC at gov’t health facilities through:

• Competency-based training of providers with a focus on LAPM/LARC and post-abortion care (clinical and counseling);

• Work with gov’t district management teams to strengthen supportive supervision (both facility level and clinician follow-up);

• Strengthen health information system and data collection, analysis and use for decision-making;

• Equipment, supplies, commodities: ensure the full range of MOH approved methods- pills, injectibles, IUD, implants, condoms, female/male limiting (in DRC and Pakistan currently)

Stimulate awareness, supportive norms, and demand:

• Collaborate with women’s associations, religious leaders, formal leaders, community health workers to discuss and explore how to increase social access to FP and PAC

• Use theater groups, radio as mass media communication of what/where when3

04/12/2023

4

Where do we work? DRC

Lubero and Kayna Health Zones

Kasongo Health Zone

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Where do we work? Chad

Gore DistrictDanamadji District

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Set the stage: Why Family Planning in Chad and DRC?

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What happened? Cumulative new users (July 2011 to Dec 2012):Pills,

injectables, IUDs, implants, permanent methods

2011_06

2011_07

2011_08

2011_09

2011_10

2011_11

2011_12

2012_01

2012_02

2012_03

2012_04

2012_05

2012_06

2012_07

2012_08

2012_09

2012_10

2012_11

2012_12

0

5000

10000

15000

20000

25000

30000

35000

Monthly Total

Cumulative Total

SAF-PAC Target

Axis Title

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Dramatic increase in % of new users choosing long-acting and permanent methods (LAPM)

2011

_06

2011

_07

2011

_08

2011

_09

2011

_10

2011

_11

2011

_12

2012

_01

2012

_02

2012

_03

2012

_04

2012

_05

2012

_06

2012

_07

2012

_08

2012

_09

2012

_10

2012

_11

2012

_12

Avera

ge0.00%

10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Chad DRC

Chad

DRC

April 12, 2023

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But extremely skewed toward implants!

2011_06

2011_07

2011_08

2011_09

2011_10

2011_11

2011_12

2012_01

2012_02

2012_03

2012_04

2012_05

2012_06

2012_07

2012_08

2012_09

2012_10

2012_11

2012_12

0

200

400

600

800

1000

1200

0 0 1 1 0 0 22 57 56 41 17 34 5 22 49 36 55 55 490 0 0 0 3 1

395

886

246472

804 781693

422 360 428 423257 330

46 26 44 84 78 69

77

83

82

85

16 51

28

15 3013 20

198

56 38 49 53 50 37

72

69

105

214

60124

76

83 92 84 101

55128

0 0 0 0 0 0

1

1

1

31

2

1

0 9 1 1

1

1

Monthly total new FP users by method for CHAD

Chad - Vasectomies

Chad - Tubal Ligation

Chad - Injectables

Chad - OCP

Chad - Implants

Chad - IUD

2011_06

2011_07

2011_08

2011_09

2011_10

2011_11

2011_12

2012_01

2012_02

2012_03

2012_04

2012_05

2012_06

2012_07

2012_08

2012_09

2012_10

2012_11

2012_12

0

100

200

300

400

500

600

700

800

900

1000

3 7 16 15 14 7 22 42 36 68 47 37 42 59 66 72 86 109 9935 37 36 32 35 36152

292 317

662

473404 391

638

346 377430 407 367

52 41 40 29 53 31

57

42 65

65

6343 45

66

84 8689 75

64

11 13 12 7 16 12

36

3144

47

4149 31

95

110 6761 53

64

0 1 1 4 0 1

2

45

2

1011 5

7

14 511 3

7

Monthly total new FP users by method for DRC

DRC - vasectomies

DRC - Tubal Ligation

DRC - Injectables

DRC - OCP

DRC - Implants

DRC - IUD

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A closer look at method mix…

5%

69%

9%

16%

0%

Contraceptive Method Mix in Chad

IUD

Implants

OCP

Injectables

tublig

vas

10%

66%

13%

10%

1% 0%

Contraceptive Method Mix in DRC

IUD

Implants

OCP

Injectables

tublig

vas

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• No ideal method mix, but it can proxy for method availability and choice

• Sullivan et al, 2005: 34/96 countries >50% single method skew

• Reasons for method skew:

1. Policies/programmes

2. Provider bias

3. History of method in the country

4. Method characteristics

5. Client characteristics

What does the literature tell us about method skew?

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So based on these factors: What does our experience tell us about method skew?

• Policies/programmes• Method characteristics• Provider bias• Client characteristics

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• Extreme lack of access

• Extremely limited

availability

Combined with:• Free, high quality

contraceptives and trained staff,

• Good quality counseling

National programmes: Extremely limited access to any method

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Method Characteristics

Long-acting FP methods:• Highly effective• Utterly

“forgettable”• Long-acting… yet

reversible

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Implants: • Ease of implant insertion• Confidence with

technique• Quick process, less work

than IUD

IUDs• Concern about STIs (and

IUD insertion)• Lack of confidence with

technique

Provider bias…towards LARC but away from IUDs

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• The name: “The two sticks”…La jadelle”

• Is visible in the body• No need to disrobe or

have a pelvic exam (esp w/ male provider)

• Friends and neighbors have it and recommend it (bouche a oreille or “mouth telephone)

• Myths: • cancer• String will bother the partner

during sex• It will disappear inside the body• Baby could be born holding the

IUD

• It is invisible inside the body• In its package, the IUD looks

very long • Shame R/T undergarments in

poor condition and personal hygiene

Category 4: Client, partner, community characteristics & perceptions:

Away from IUDs Toward implants

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What did we do? Focus on choice (instead of skew): Examples of two of our strategies

1. Using a rights-based frame and work with key influencers to inform and support CHOICE

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Population Council’s Excellent counseling strategy

2. Using a rights-based frame, quality counseling (and good skills) to protect choice

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Example of one program strategy to drop barriers to expanded choice

0

10

20

30

40

50

60

70

80

37

16 15 14

7

22

4236

68

47

3742

5962

IUD

Clinical training

Counseling training

Supportive supervision training and approach

begun

Team improves messages related to IUDs, increase outreach to men

Number of new users of IUDs in DRC June 2011 to August 2012

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Final Thought from Sullivan, Bertrand Et al:

Efforts to ‘improve’ method mix ought not to be undertaken at the expense of good methods that happen

to be popular:

Our focus will continue to be on expanded availability and ensuring true choice

Terima Kasih!