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

Infants are twice as likely to survive if the previous birth interval is at least 2 years Mali 177 149 162 Rwanda Cambodia Timor Leste 112 104 88 79 71 71 71 71 54 61 78 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

20% 21% DHS 2005 DHS 2000 DHS 1992 14% 13% 13% 10% 9% 4% 3% RWANDA

Source-IntraHealthFP-Rwanda Dec 2007

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

245

Mortality ratio per 1000

170 79 149 113 53 88 90 48 71 72 138 47 78 71 143 < 2 years 2 years Post Neonatal Mortality Rate Child Mortality Rate Source: Rwanda DHS-III, 2005 3 years 4 years + Infant Mortality Rate Under five Mortality Rate

Intended

Integrating HTSP into HIV Programs

Pregnancies in 132 Women After Testing HIV+

GoR managed Faith-based managed Total 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

Use Among HIV-infected Women 3 rd Pregnancy, Pregnancy Desires, and Contraceptive Pediatric HIV Conference Dec 2007

p=.02

Reported Contraceptive Use in 97 Cases of Unintended Pregnancy

Modern GoR managed 25 (56%) Natural None 2 (4%) 18 (40%) Total 45 (100%) Faith-based managed 17 (33%) 10 (19%) 25 (48%) 52 (100%) Total 42 (43%) 12 (12%) 43 (44%) 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

450 400 350 300

Number of Health

250

Facilities

200 150 100 50 0

365 133 62

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 Contraceptive Prevalence Rate-All Methods Baseline 2000 13.2% 2005 15.1% 2010 2020 26.3% 45.2% Contraceptive Prevalence Rate-Modern Methods Infant Mortality Rate(deaths/1000 live births) Maternal Mortality Ratio Number of HIV +ve women counseled on FP 4.3% 107 1071 7.1% 113,000 18.5% 36.1% 70 700 25 350 Number of HIV +ve women using modern methods Women’s Total Fertility Rate Population Growth Rate 5.8

146,000 2.6

5.5

2.3

4.5

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

partners; : Development/Strengthening of guidelines in HTSP, development of tools, dissemination of revised guidelines, policies, tools to relevant officials and •

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

Men Civil Society,

ADVOCACY

Policy Makers Program Planners

Women

ADVOCACY

Couples Grand mothers/fat hers 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% 80% 100% 60% 40% 28% 31% 31% 34% 21% 20% 0% HCW talked to Client on HTSP Clients could identify 2 benefits of HTSP Clients could state 2 methods of FP Clients could state adequate birth interval Clients on modern FP method on day of survey Responses from clients Clients could identify where to go for FP services

0.4

0.35

0.3

0.25

Percentage of clients interviewed

0.2

0.15

0.1

0.05

0

FP

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% 25% 25% 12.50% 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