Integrating EPI and Family Planning Service Delivery

in Liberia

Background, Rationale, Integration Model

1

THE NATIONAL CONTEXT: POSTPARTUM FAMILY

PLANNING

2

41% of birth-to-pregnancy intervals in Liberia are too close for healthy outcomes

3Source: MCHIP Re-analysis of 2007 Liberia DHS

At Risk of Pregnancy

4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-5.9 6-11.9 12-23.9

Sexually active Return to menses

Excl. Bfeeding Predominant Bfeeding

5%

10%14%14%

6% 1%0%

20%

40%

60%

80%

100%

0-5.9 Mos 6-11.9 Mos 12-23.9 Mos

Modern FP Use Predominant BF

Risk of Pregnancy Among Sexually Active

Women Across Postpartum Periods

Factors Affecting Return to Fertility Among Postpartum

Women

Analysis of 2007 Liberia DHS FP Data

WHAT DOES IT MEAN TO “INTEGRATE” SERVICES?

5

WHY INTEGRATE EPI AND FAMILY PLANNING?

6

7

Both immunization and family planning

save lives…

…and are part of a comprehensive approach to

MNCH

Family planning helps couples to achieve healthy timing and spacing of pregnancies; prevent unintended pregnancies

Immunizations are one of the most effective and highly used child health preventive services

Increasing access to postpartum family planning contributes to achievement of child health goals.

9

EPI provides multiple opportunities to reach postpartum women during an important

period.

Through child immunizations, mothers have multiple contacts with health providers in the year after birth

During the 12 months following birth, women may be very open to hearing messages about FP

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Why are FP Services for Postpartum Women a High Priority?

During the first year after birth, or the extended postpartum period, most women want to delay or avoid future pregnancies but many are not using a modern FP method

Pregnancies spaced too closely can lead to health risks for the mother and child

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Potential Benefits for Service Providers

Saves time by maximizing opportunities to provide multiple services on same day (rather than having a client return multiple times on different days)

Increased efficiency, improved client flow

Increased communication, flow of information across service areas

Builds providers’ technical skill & confidence

12

The Global Dialogue

Growing interest in FP/immunization integration

Emerging program experiences in Rwanda, Ghana, Zambia, Mali, Philippines

Limited documentation exists on effects of integration on FP & immunization outcomes, (especially for immunization outcomes)

FP/Immunization Working Group established in 2010 to exchange experiences, resources, identify successful integration strategies

Integrated EPI/FP service delivery Possible effects on immunization

Precedent: possible concerns

Cameroon & Philippines (early 1990s) – halted EPI 2-3 years

Madagascar (2004-2005) – confusion during MCH Weeks with FP and tetanus toxoid for women

Northern Nigeria (2004-2006) – oral polio vaccine viewed as sterilizing agent

Pakistan (2012– ) – rumors that vaccination sterilizes children disruption of polio campaigns, disruption of routine immunization, many measles outbreaks

Most problems associated with political conflict or mass immunization campaigns

Indicates need for careful planning and monitoring with attention to effect on immunization

Positive effects of EPI/FP integration for EPI?

Not consistently documented Rwanda (2011-2012): improvement in FP

and immunization coverage remained high Togo (1994): 54% increase in new

contraceptive acceptors and immunization coverage remained high

Liberia: MOHSW/MCHIP has actively monitored effect on immunization

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Possible strategies for engaging immunization

community

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Overview of MOHSW/ MCHIP EPI/FP

Integration Approach

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Background

MoHSW and MCHIP tested an approach to link EPI and FP services in 5 facilities in Bong County and 5 facilities in Lofa County

Pilot phase of implementation lasted 9 months (March 2012-November 2012)

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Site Selection

Participating health facilities included: Bong County: Phebe Hospital, Garmu Clinic,

Zoweinta Clinic, Salala Clinic, Fenutoli Clinic Lofa County: Curran Lutheran Hospital, Borkeza

Clinic, Kpaiyea Clinic, Ganglota Clinic, Gbonyea Clinic

Rationale for selection: Counties with stronger EPI performance Facilities in various proximities to the road 1 hospital and 4 clinics in each county

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The Integration Model

Combined service provision, with same-day referrals from the vaccinator to co-located FP services

Focus on fixed facilities

Strategically designed materials reinforce key messages (job aid, leaflet, poster)

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Sequence of Activities

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THE PROCESS

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Role of Vaccinators

During routine child immunization sessions, at the completion of each immunization visit, vaccinators will:

1)Remind mothers when they need to bring their child back for the next vaccination

2)Use a simple job aid to share brief, targeted FP messages with caregivers

3)Ask mothers whether they are interested in going for family planning services that day

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For caregivers who ARE interested in seeking family planning on the same day:

Vaccinators give them a referral card and tell them to give it to the FP provider

Vaccinators direct them toward the FP room

Record on the register that the caregiver was referred (using the supplemental EPI/FP register)

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Role of Vaccinators

For caregivers who are NOT interested in going for FP on the same day:

Vaccinators give them the leaflet about the benefits of FPVaccinators encourage them to discuss FP with their partner and family membersVaccinators encourage them to return to the facility soon

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Role of Vaccinators

Role of Family Planning Providers

Family planning providers:

(1)Collect the referral card from the clients referred from EPI(2)Provide FP counseling and services to women referred(3)Record in their legers (in the comments section) that the woman was referred from EPI, and whether she selected an FP method ( = referred, counseled and chose a method, = referred, counseled and did not choose a method)(4)Return the referral cards at the end of the day to the vaccinators’ room

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Variations in Approach Across Facilities

Registration

Referral processes – Expedited referrals?

Privacy screens for facilities where EPI is provided in open waiting area

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Key Inputs Required

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START-UP

•Initial stakeholder meetings•Formative assessment to inform design•Initial training + practical exercises for Vaccinators & CMs (3 days)•Orientation for Supervisors (1 day)•Pre-testing Materials•Printing Materials

RECURRENT

•Refresher training for service providers and supervisors (1-2 Days)•Re-print materials as needed•Monthly supportive supervision visits•County and National-level advocacy to ensure sufficient commodity supply•Semi-regular stakeholder meetings to share progress

Questions?

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Thank you!

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