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Operationalizing
Healthy Timing and
Spacing of Pregnancy
(HTSP) in Child Health
Services: BASICS
Experience in Rwanda
Gloria Ekpo, MD, MPH
Issakha Diallo, MD, MPH, DrPH
Diana Silimperi, MD, MPH
Mathias Yameogo, MD, MPH
Moses Ahabwe, MD MPH
May 24, 2008
Justification for On-going Advocacy and
Implementation of HTSP
Infant Mortality Rate per 1000
Infants are twice as likely to survive if the previous birth interval is at
least 2 years
Mali
Rwanda
Cambodia
Timor Leste
177
162
149
112
104
88
79
78
71
71 71 71
54
61
59
29
< 2years
2 years
3 years
4year +
Source: Rwanda, Mali, Cambodia, Timor Leste DHS data
RWANDA: BACKGROUND
Population: 8,648,248 (PGR:
2.43%)
Fertility Rate: 6.1
Knowledge of a method of FP:
98%
Contraceptive Prevalence:10%
Unmet Need for pregnancy
spacing: 41%
HIV Prevalence: 3.6% (women
and 2.3% in men)
Life Expectancy at birth: 47.3
years
Source: Rwanda DHS III 2005
Week in Review
After So Many Deaths, Too Many Births
Laura Hoemeke/Twubakane Decentralization and Health Program
BABIES, NOT GHOSTS A crowd at a health campaign rally in northern Rwanda.
Population control has been controversial because survivors of the genocide have felt it was a family’s right to
replenish what was lost. By STEPHEN KINZER Published: February 11, 2007
Modern contraceptive use
1992 to 2005
DHS 2005
21%
20%
DHS 2000
DHS 1992
14%
13%
13%
10%
9%
4%
RWANDA
Source-IntraHealthFP-Rwanda Dec 2007
3%
Urban
Rural
% women in union, age 15 to 49
Important proportion of women have
short birth intervals – case of Rwanda
23% Birth Interval < 2 years
41% 2 < Birth Interval < 3 years
36% Birth Interval ≥ 3 years
Source: Rwanda DHS-III, 2005
Children are paying the Highest Toll from the
Short Birth Intervals In Rwanda
Mortality ratio per 1000
245
170
149
143
138
113
88 90
79
53
< 2 years
48
2 years
71 72
3 years
78 71
47
4 years +
Post Neonatal Mortality Rate
Infant Mortality Rate
Child Mortality Rate
Under five Mortality Rate
Source: Rwanda DHS-III, 2005
Integrating HTSP into HIV Programs
Pregnancies in 132 Women After Testing HIV+
GoR managed
Faith-based
managed
Total
Intended
24 (35%)
10 (16%)
34 (26%)
Unintended
45 (65%)
52 (84%)
97 (74%)
Total
69 (100%)
62 (100%)
131* (100%)
* Excluding one case of no reply
Source; Livinus Bangendanye, FHI/Rwanda Pregnancy, Pregnancy Desires, and Contraceptive
p=.02
Use Among HIV-infected Women 3rd Pediatric HIV Conference Dec 2007
Reported Contraceptive Use in 97 Cases of
Unintended Pregnancy
GoR managed
Faith-based
managed
Total
Modern
25 (56%)
17 (33%)
42 (43%)
Natural
2 (4%)
10 (19%)
12 (12%)
None
18 (40%)
25 (48%)
43 (44%)
Total
45 (100%)
52 (100%)
97 (100%)
Context of Family Planning in Rwanda
• 365 (81%) out of 450 health facilities offer Family Planning services
• FBOs own 133 (30%) health facilities of which 47% (62) of these offer FP
services (i.e 17% of total FP facilities are owned by FBOs)
•
FP services are not offered daily in most health facilities
•
FBO facilities willing to counsel clients for FP but may not offer full
package for FP at their facilities
• Secondary FP Post erected to accommodate clients needs from FBO
facilities
• High client demand for long-term methods (Implants and injectables)
• Most services are free
• Incentive-Motivation: Performance-based Financing for FP services
Health Facilities and Family Planning Services in Rwanda
449
365
450
400
350
300
Number of Health
Facilities
250
133
200
62
150
100
50
0
1
Category of FP Facility
Total number of Health Facilities
Number of Health Facilities owned by FBOs
Number of Health Facilities with FP services
Number of FBO facilities providing FP services
Rwanda Government Objectives and Targets
for Family Planning 2006-2020
Indicator
Baseline
2000
2005
2010
2020
Contraceptive Prevalence Rate-All Methods
13.2%
15.1%
26.3%
45.2%
Contraceptive Prevalence Rate-Modern
Methods
4.3%
7.1%
18.5%
36.1%
Infant Mortality Rate(deaths/1000 live
births)
107
-
70
25
Maternal Mortality Ratio
1071
-
700
350
Number of HIV +ve women counseled on FP -
113,000
-
-
Number of HIV +ve women using modern
methods
146,000
Women’s Total Fertility Rate
5.8
-
5.5
4.5
Population Growth Rate
-
2.6
2.3
2.2
Enabling environment for a successful
Integration: the Case of Rwanda
– Readily available quality and complete data from the DHS III
2005
– Functional PHC activities with increasing performance for the
essential MCH package
– Political will and Partnership in management and leadership
functional structures
– Partnership and collaboration in HTSP activities
– Appropriate tools and approaches for quality assurance
– Training and capacity building of health care workers on
HTSP integration
– Supportive supervision, mentorship and monitoring
Programmatic HTSP Integration Strategies
•
Advocacy: Encouraging governments and partners to adopt integration strategy,
guidelines, or policy;
•
Integration: Development/Strengthening of guidelines in HTSP, development of
tools, dissemination of revised guidelines, policies, tools to relevant officials and
partners;
•
Implementation: Training of trainers and on-the-job-training of service providers on
integration of HTSP in child health at central and district levels;
•
Supervision, mentorship and Monitoring: Supportive supervision and mentoring
of HTSP service providers;
•
Expansion and Scale-up: To improve coverage in additional districts and
provinces in the countries.
•
Partnership and Collaboration: Global and Country level




USAID, ESD, ACCESS-FP, IMMbasics
Ministry of Health and Maternal and Child Health department of ;
Intrahealth/Twubakane project; Intrahealth/Capacity project;
Extended Impact Project (EIP: IRC, WorldRelief, Concern), EGPAF, Population Council
Platforms for HTSP integration in child
health programs
– IMNCI-Sick baby clinics at MCH (Rwanda, Malawi)
– Immunization and Well baby clinics (Rwanda)
– Essential newborn and postnatal care (Swaziland, East
Timor, Cambodia)
– PMTCT programs (Malawi)
– Pediatric HIV care and support services (Rwanda)
– Pre-service and In-service training curriculum (Rwanda,
Malawi)
Tools in Support of HTSP Programming
1. Advocacy and Capacity Building in HTSP
2. Methodological guide for HTSP integration at child health
entry points to care
3. Rapid Facility Functionality Assessment Guide
4. Supervision and Mentorship checklist
5. Framework for monitoring and evaluation at global and
country level of HTSP results
6. Training Manual for integration of HTSP into child health
programs
HTSP Key Messages at Immunization Sites
HTSP:
• You have just given birth, waiting at least 24 months before
trying to become pregnant again, but not more than five years
is better for your health and your children’s health;
• Choosing a secure and effective contraceptive method that
you can easily use is the best way to prevent unplanned
pregnancy;
• This facility provides support for healthy timing and spacing of
pregnancy and for more information about how you can
access these services, please meet with our counselors
before you leave this facility today.
Rwanda: Preliminary integration process at
Immunization sites
• Key messages developed for use at group education
sessions for women/parents/guardian
• 5 Pilot sites identified for the implementation of HTSP
integrated messages
• Explore holding Immunization and FP services on same
days
• Use of Secondary FP posts for close to FBO health facilities
• Conduct mobile FP clinic during community immunization
outreaches and campaigns
• Expectations:
–
–
–
–
One-stop shop for child and maternal health needs in IMM and FP
Mothers looking forward to immunization days
Access FP services in addition to child immunization
Increased in uptake and retention of services
ADVOCACY
Policy Makers
Program Planners
Men
Civil Society,
ADVOCACY
Couples
Grandmothers/fat
hers
Women
Health Care
Workers
On-The-Job-Training on HTSP
Accomplishment at Country Level
Rwanda:
1. Integration and strengthening HTSP in:
•
•
•
•
IMCI Training Manual,
pre-service nursing curriculum,
pediatric HIV job aids and tools
Comprehensive referral form for health facilities
2. Development of key HTSP messages for utilization at immunization sites
3. Training of trainers on IMNCI-HIV -HTSP integrated manual
• 275 HCWs and 25 Supervisors
• 42 Health Facilities
• 15/30 Districts in the country
4. Supervision and quality assurance visits to monitor integrated services
5. Partners: MOH, TRAC, MCH, EPI, IntraHealth Twubakane, CAPCITY
project.
Rwanda: Exit Interview results from clients
visiting health centers in two districts
Exit Interview results from clients visiting health centers in two districts in Rwanda
120%
100%
Clients interviewed
100%
80%
60%
40%
28%
31%
31%
34%
21%
20%
0%
HCW talked to Client on Clients could identify 2
HTSP
benefits of HTSP
Clients could state 2
methods of FP
Clients could state Clients on modern FP
adequate birth interval
method on day of
survey
Responses from clients
Clients could identify
where to go for FP
services
Rwanda: Entry points to care where HTSP
messages are delivered at health facilities.
Result of Exit Interview on HTSP messages to clients at health facilities
38%
0.4
0.35
0.3
25%
25%
0.25
Percentage of clients
0.2
interviewed
12.50%
0.15
0.1
0.05
0
FP
ART/PMTCT
IMCI
Sites where clients received HTSP messages
Admission Ward
Challenges
Constraints & Issues:
– Engaging child health providers to integrate preventive measures such
as HTSP activity into their daily busy child survival activities
– Limited human resources for implementation of activities- Point person
is required to facilitate program implementation, data collection and
supervision of HTSP activities at all levels of care in the country
– Limited funds for expansion and scale up of HTSP integration in child
health programs
– Monitoring impact of activities through partners who have other
multiple activities and programs
Conclusion
• Integration of HTSP in child health services is crucial to
reinforcing child and maternal health services
• HTSP in child health contributes to expand the access and
use of FP services by reducing the missed opportunities to
educate women/couples in contraception for birth spacing
• HTSP is an essential component of the Repositioning FP
Initiative and should receive more attention and commitment
from the FP program managers, policy makers and donors
Acknowledgement
USAID Washington
USAID Mission-Rwanda
MCH/MOH Rwanda
BASICS HTSP Partners- ESD, IMMbasics, ACCESS-FP
Implementing Partners:
Intrahealth Twubakane, CAPACITY Project
BASICS Country and HQ HTSP Team
Photo credit: Intrahealth/Twubakane