Community-based Postpartum Family Planning Through Integrated Public Delivery Systems in India
The Population Council supported the Government of India in designing, testing, and scaling up a community-based intervention to encourage healthier birth spacing in India through increased knowledge and use of postpartum family planning.
The Indian Family Welfare Program, though successful in increasing contraceptive use among couples who have achieved desired family size, has been less successful in educating people about the use of contraceptive methods for spacing births.
Recent Indian Demographic and Health Survey results show that 77 percent of sterilized women did not use any family planning method before sterilization, suggesting that the concept of spacing was not utilized, and that couples, after having children in quick succession, opted for sterilization.
Currently, the median birth interval in India is 31 months; this interval is only 25 months for girls aged 15–19 years. An increase to 3–5-year birth intervals could improve infant and maternal survival by more than two and a half times that of children born at intervals of 2 years or less. To achieve this, effective use of family planning during the extended postpartum period is particularly important, especially following the first pregnancy.
To respond to this need, the Population Council implemented a series of activities to better understand birth-spacing practices in India and to develop and then scale up interventions to encourage longer birth spacing through increased use of postpartum family planning (PPFP). The studies were conducted in the Meerut District of Uttar Pradesh.
The project components included:
- Phase 1: Operations research study. The operations research (OR) study (definition) tested the feasibility and impact of a focused behavior change communication intervention using community health workers to promote PPFP among low-parity women and their partners. This study was conducted from 2006 to 2008 under the Council’s USAID-funded FRONTIERS program.
- Phase 2: Scale up. In 2008, encouraged by the results of the OR study, the Council received a grant from the USAID-funded Extending Service Delivery (ESD) project of Pathfinder International for a second phase to create conditions for scaling up the intervention by institutionalizing the model and widening its implementation to a larger area in Meerut District. This phase also incorporated additional interventions for increasing access to and use of antenatal care, institutional delivery, and postnatal care services.
- Phase 3: Expansion. District health authorities requested that Population Council provide further technical assistance for expanding this strengthened model throughout Meerut District. Consequently, ESD extended the funding and duration of the project to allow the Council to implement a third phase through providing the requested technical assistance as well as organizing two dissemination meetings to share lessons learned.
Phase 1: Operations research study
For the OR study, the Council collaborated with the Ministry of Health and Family Welfare and the Lala Lajpat Rai Memorial Medical College. A formative study using qualitative approaches was undertaken to identify factors encouraging early first births and barriers to accessing and using family planning during the postpartum period. The results were then used to develop a community-based behavior change communication (BCC) intervention that was implemented through existing government programs, primarily by community health workers (CHWs), which was then rigorously tested and its impact on family planning behaviors documented.
The intervention used a quasi-experimental control, pre-, and post-test research design. For each study group 600 women were recruited, and they, their husbands, and their mothers-in-law were interviewed at multiple points throughout the prenatal and postpartum periods. The intervention consisted of a comprehensive outreach model: CHWs received training in family-style counseling and conducted an educational campaign through which women, husbands, and mothers-in-law were engaged in discussions about healthy timing and spacing of pregnancies and PPFP. Messages were delivered and reinforced through group meetings with men, individual meetings with target audiences, and distribution to women of contraceptive methods and educational storybooks (which women were encouraged to share with their husbands and mothers-in-law). Some messages were developed specifically for men, mothers-in-law, and other stakeholders to address the unique barriers facing each group. Additionally, coordination and support among district health authorities and among CHWs was enhanced.
The results of the OR study were very encouraging. Use of modern contraceptives for spacing the next pregnancy at 9 months postpartum was 57 percent of women in the intervention area compared with 30 percent of women in the control sites. 84 percent of women in the experimental area could correctly describe IUD placement and use of oral contraceptive pills, although condom use was the main method used in (44 percent). The intervention also successfully increased spousal communication; 60 percent of women shared the information, education, and communication (IEC) materials—a storybook—with their husbands and, in many cases when women were illiterate, their husbands read it to them, creating an additional opportunity for discussion. However, only one-third of women reported sharing the information with their mothers-in-law, known to be key influencers of use of PPFP.
Phase 2: Scale up
During this phase, the BCC model developed during the OR study was expanded to a larger area in Meerut District. The model was also improved to include interventions for increasing access to and use of antenatal care, institutional delivery, and postnatal care. PPFP counseling emphasized the lactational amenorrhea method (LAM) and injectable contraceptives in particular. As with the OR study, this phase used a pre- and post-test research design. 820 women were interviewed at baseline in September 2009, and with a response rate of 98 percent, 807 were successfully followed up at endline.
In addition to scaling up the key intervention of an educational campaign carried out by CHWs, this phase of the study also conducted capacity building to create conditions for further scale up by the Uttar Pradesh government, including one-day orientations and planning meetings with district officials, and two-day trainings of auxiliary nurse midwives and community workers (CWs). A total of 630 health workers were trained using a combination of classroom studies and role-playing sessions.
The interventions were shown to be simple and highly effective. At baseline, only 7 percent of women knew when fertility returns after birth, but this figure increased to 44 percent at endline. Correct knowledge of LAM rose from 2 percent to 79 percent, and the percentage of women who reported receiving general counseling from CWs on PPFP increased from 44 percent to 93 percent.
Phase 3: Expansion
The project's third phase continued these efforts by enhancing personnel capabilities (e.g., for monitoring and analyzing services, institutionalizing procedures and systems, and involving state officials) and expanding the reach of the intervention. TA was provided to the district authorities in building their training capacity by working together and organizing joint training of CHWs in the remaining seven areas of the district. The Council also provided TA for monitoring and checking service statistics in printed work registers of CHWs and performing occasional "spot checks" in households of pregnant women.
With this assistance, district health authorities were able to extend the comprehensive BCC model to all of Meerut District. As a result of these activities, correct knowledge among CHWs on topics covered in training rose from 32 percent to 91 percent.
The Council assessed various indicators that revealed the project's impact on behavior change, including levels of knowledge of CHWs, women, their husbands, and their mothers-in-law with regard to correct contraceptive method use, return to fertility postpartum, and risks associated with short-spaced pregnancies. Across all phases, most indicators consistently revealed that the majority of CHWs, women, and their families were more knowledgeable about these issues. Contraceptive use among women postpartum was also assessed as an indicator of BCC success.
Project successes include:
- Two separate governmental structures—the Department of Integrated Child Development Services and the Department of Health and Family Welfare—were able to successfully coordinate their work at the community level.
- The district administration was keenly interested in ensuring that revised delivery procedures and supportive resources produced were integrated into the district health system, and structured their budgets for the upcoming year accordingly.
- Two large-scale dissemination meetings were held in 2011 to share the findings with all stakeholders, including senior program managers of Uttar Pradesh and the Government of India, state and central government officials, donors, NGOs, and researchers.
- Ultimately, the interventions reached all of Meerut District, covering more than one million people.
The project also demonstrated:
- The community-based PPFP BCC model not only is feasible and effective, but was introduced in a way that has enabled it to be institutionalized for sustainability and scale-up. Expansion and scale-up were planned and implemented by district authorities with limited technical assistance from the Council, thus minimizing additional human resources and organizational changes needed to existing health structures.
- Combined (rather than isolated) efforts of CHWs from different health departments is much more effective; reinforcement of the same messages by different types of health workers has helped to increase perceived message authenticity and trigger behavior change.
- The BCC strategy is more effective when it focuses on the family as unit rather than women only. Involving husbands and mothers-in-law yielded significant results in promoting postpartum contraception.
- Message development is most effective and acceptable when it involves community opinion leaders, messages are most effective when they are tailored to local audiences.
Increasing postpartum contraception in rural India: Evaluation of a community-based behavior change communication intervention (abstract) (HTML)
Sebastian,Mary Philip; Khan,M.E.; Kumari,Kaushal; Idnani,Rukma
International Perspectives on Sexual and Reproductive Health 38(2): 68-77
Publication date: 2012
Promoting healthy timing and spacing of births in India through a community-based approach (PDF)
Khan,M.E.; Sebastian,Mary Philip; Sharma,Usha; Idnani,Rukma; Kumari,Kaushal; Maheshwari,Bharati; Ashraf,Shahid
FRONTIERS Final Report
Publication date: 2008
Location: India (Meerut, Uttar Pradesh)
Duration: 2/2006 - 10/2010
India Ministry of Health and Family Welfare
Lala Lajpat Rai Memorial Medical College, Meerut
Meerut Office of Integrated Child Development Services