Helping Women Achieve Optimal Birth Intervals Through Linking Community-based Postpartum Family Planning with Maternal Health Services in Egypt
In Egypt, Population Council research helped providers integrate birth spacing and postpartum family planning messages into antenatal and postpartum care through a community-based approach.
To respond to the challenge of supporting women in achieving healthier birth intervals of at least two years, the Population Council's USAID-funded FRONTIERS program, in collaboration with the Egyptian Ministry of Health and Population (MoHP) and the NGO Social Planning, Analysis and Administration Consultants, conducted an operations research (OR) study to compare the acceptability and effectiveness of two clinic and community-based behavior communication change (BCC) and service-delivery models:
- The "health services" model communicated birth spacing and postpartum family planning (PPFP) messages to women via health workers during their prenatal and postpartum care visits.
- The "community awareness" model, in addition to providing messages to women, involved an awareness-raising component that focused on men and trained community leaders to communicate birth spacing and PPFP messages.
The study used an experimental design in 20 health facilities in six health districts, three each from Assiut and Sohag Governorates of Upper Egypt. One district in each governorate was randomly assigned to implement a model or to serve as a control site by providing standard care only.
Sources of data for this study included:
- Exit and home interviews with low-parity pregnant women at 4 months and 10–11 months postpartum (1,416 women total);
- Structured interviews with physicians, nurses, and family planning outreach workers;
- In-depth interviews with local Ministry of Health and Population (MoHP) managers and supervisors;
- Focus group discussions (FGDs) with community leaders;
- FGDs with husbands of low-parity women; and
- Service statistics on utilization of maternal and child health and family planning services.
The study demonstrated that using these models to provide birth spacing and PPFP messages to low-parity women and their husbands was both feasible and acceptable. Both models proved effective in changing knowledge and attitudes toward healthy timing and spacing of pregnancy (HTSP) and in enhancing use of PPFP at 10–11 months postpartum. Both models were associated with increased utilization of services, especially of family planning, by women who had only one child. However, a fear of contraceptive side effects continues to be a major concern among women and men in all groups and is an obstacle in achieving healthy birth intervals.
To build upon the success of the OR study, the Council was awarded additional funding in 2009 by the USAID-funded Extending Service Delivery (ESD) project. The purpose was to scale up the original intervention to all of Assiut and Sohag Governorates. Activities occurred in two phases: Phase 1 (June 2009–November 2010 ) aimed to scale up the intervention to eight additional districts, and Phase 2 (December 2010–April 2011) aimed to scale up into the remaining districts and build MoHP capacity for scale-up in other governorates.
- Revising and updating protocol for providing messages around HTSP for pregnant and postpartum women;
- Training of trainers for family planning and maternal and child health managers and supervisors;
- On-the-job training and job aids for clinic staff;
- Providing information, education, and communication materials to clients;
- Monitoring and supervision;
- Educational seminars for husbands;
- Steering committee meetings; and
- A national orientation and dissemination workshop.
The results of the OR study, in addition to information, education, and communication materials, have been widely produced and disseminated in the two study governorates. They have been shared with senior MoHP officials in the population and family planning and the maternal and child health sectors, cooperating agencies, donors, and researchers.
In addition, messages on HTSP have been integrated into service-delivery guidelines for antenatal and postpartum care, and discussions are underway with MoHP officials to enhance the effectiveness of the day 40 postpartum visit by providing more maternal and child health services along with PPFP. At the end of the study, the Council received requests for technical assistance from officials at MoHP and at health directorates, leading to the ESD project.
The ESD-supported scale-up project further improved birth spacing and use of PPFP. It was successful in scaling up the intervention in eight districts in Assiut and Sohag and creating conditions for scaling up the project in the remaining 16 districts, as well as in other governorates. Phase 2 was delayed and modified as a result of the Egyptian revolution and subsequent strikes by health workers. Nevertheless, activities were conducted in a total of 543 facilities in Assiut and Sohag, far exceeding the initial target of 394. More than three-quarters of managers and supervisors and two-thirds of pregnant and postpartum women were made aware of HTSP and correct PPFP information. In addition, there has been an increase from 25 percent to 47 percent in family planning use in the eight original intervention districts.
The main achievement, however, was securing the support and investment of senior MoHP officials at the central level, as well as the support and commitment of managers and supervisors at governorate and district levels. Moreover, partnerships with other cooperating agencies (e.g. Takamol and Communications for Healthy Living) and with the USAID mission have been instrumental in influencing service-delivery guidelines in favor of HTSP and standardizing messages across projects.
It is expected that the MoHP will take this intervention to a national level in Egypt. With the rise of more conservative forces and concern over negative reactions against family planning in Egypt, adopting the HTSP approach to providing family planning messages may prove more useful and politically acceptable.
Scaling up the provision of family planning messages in antenatal and postpartum services in Upper Egypt (PDF)
Extending Service Delivery Final Report
Publication date: 2011
Location: Egypt (Assiut and Sohag Governorates)
Duration: 7/2005 - 4/2011
Population Council researchers:
Amal Zaki (Egypt Ministry of Health and Population)
Amal Zaky (Egypt Ministry of Health and Population)
Hanaa El-Kholy (Egypt Ministry of Health and Population)
Khaled Nasr (Egypt Ministry of Health and Population)
Sahar El-Sonbaty (Egypt Ministry of Health and Population)
Sarah Loza (Egypt Ministry of Health and Population)