Community-based Distribution Serves Unmet Needs

Network: Vol. 19, No. 3, Spring 1999

By reaching out into rural communities and isolated city neighborhoods, community-based distribution (CBD) programs can serve unmet needs for contraception. Where contraceptive prevalence is very low, community programs can also generate demand for family planning.¹

While there are many variations, community-based distribution programs in general seek to take contraceptive methods and family planning information to people where they live, rather than requiring people to visit clinics or other locations for these services. The approach often involves community members who are trained to become family planning workers.²

That community services can increase contraceptive use has been observed throughout the world. Contraceptive use is further enhanced when CBD workers can offer clients a wide variety of methods, either directly or by referral.

In Turkey, CBD workers distribute combined oral contraceptives (OCs) and condoms, and make referrals for clients desiring intrauterine devices (IUDs) or voluntary sterilization. In an Ankara settlement of 110,000 low-income people, the percentage of women using modern contraceptives has risen to 74 percent after four years, from 36 percent. In other areas served by the Family Planning Association of Turkey, similar increases have been seen: to 62 percent from 21 percent in Adana-Mersin, and to 50 percent from 32 percent in Istanbul.³

In a CBD program in Mali, contraceptive use nearly tripled in villages where OCs were added to barrier methods, which were already available. No health centers or commercial contraceptive sales were available in the area being served. Before OC introduction, contraceptive prevalence was about 12 percent in 54 villages where condoms and spermicides had been offered. Contraceptive prevalence increased to 31 percent in 18 villages six months after OCs were also offered, while prevalence increased less, to 21 percent, in the remaining 36 villages where OCs were not offered. Prior to the program, which included activities to motivate potential clients, contraceptive prevalence was only 1 percent.⁴

"After training, Malian CBD workers were able to give accurate information about OC use to new clients, identify contraindications to OC use, prescribe pills safely, and monitor all clients taking the pill," says Dr. Seydou Doumbia, a Mali-based Population Council program associate who helped analyze the impact of this CBD project in Mali.

Introduction of injectables to the CBD mix remains limited. But, in Mexico, the monthly combined injectable Cyclofem has been distributed by CBD workers. Higher continuation rates were observed among some 650 rural women served by the CBD workers than among approximately 2,800 urban and suburban women who visited health centers: 37 percent versus 24 percent after one year, respectively.⁵ In Ghana, the three-monthly injectable depot-medroxyprogesterone acetate (DMPA) was offered by CBD workers to over 1,000 women in a pilot study by the Navrongo Health Center.⁶

Two pioneering studies conducted in rural Bangladesh between 1975 and 1981 concluded that a CBD program offering a wide choice of methods, skilled counseling, rigorous follow-up, care of side effects and good referral systems was more effective than one based on one or two methods distributed by unskilled workers. Moreover, higher acceptance and continuation rates were maintained over time.⁷

When OCs and condoms were distributed to men and women in 150 villages primarily by illiterate, elderly and widowed women, only 17 percent of female clients reported using pills three months after distribution. After 18 months, pill use prevalence had declined to 9 percent. Knowledge of condoms increased over time, but the method never became popular. In the second study in 70 villages, injectables were added to the mix of methods and literate, married women from the villages distributed contraceptives. A referral system for helping clients with side effects also was established, since side effects from pills were common and discouraged some users. After a year, contraceptive prevalence had risen to 32 percent, from 10 percent. The one-year continuation rate for DMPA was 69 percent. (A project to replicate this initial success with DMPA was less encouraging, with a one-year continuation rate for DMPA of 30 percent. This decrease was attributed to staff shortages, unpredictable client-worker contact, lack of medical backup and training, and lack of technical support.)⁸

-- Kim Best

References

1. Phillips JF, Greene WL, Jackson EF. Lessons from community-based distribution of family planning in Africa. Presentation at the IUSSP Seminar on Reproductive Change in Sub-Saharan Africa, Nairobi, Kenya, November 2-4, 1998; Simmons R, Baqee L, Koenig MA, et al. Beyond supply: the importance of female family planning workers in rural Bangladesh. Stud Fam Plann 1988;19(1):29-38.
2. Bertrand J. Recent lessons from operations research on service delivery mechanisms. In Seidman M, Horn M, eds. Operations Research: Helping Family Planning Programs Work Better. New York: Wiley-Liss, Inc., 1991.
3. Gürses D. Community-based distribution projects in Turkey. Progress in Reproductive Health Practice. Entre Nous 1997;36-37:17-18.
4. Doucouré A, Djeneba D, Touré F, et al. The effect of a family planning CBD project in Mali. In Foreit J, Frejka T, eds. Family Planning Operations Research: A Book of Readings. (New York: Population Council, 1998)113-18.
5. Garza-Flores J, del Olmo AM, Fuziwara JL, et al. Introduction of Cyclofem once-a-month injectable contraceptive in Mexico. Contraception 1998;58(1):7-12.
6. Overcoming cultural constraints to family planning and reproductive health in Ghana. Alternatives 1996;5:11.
7. Phillips JF, Stinson W, Bhatia S. The Demographic Impact of Two Contraceptive Service Projects in Matlab Thana of Bangladesh: A Compendium of Findings for the 1975-1980 Period. Dhaka, Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh, 1981.
8. Phillips JF, Hossain MB, Huque AA, et al. A case study of contraceptive introduction: domiciliary depot-medroxy progesterone acetate services in rural Bangladesh. In Segal S, Tsui A, Rogers S, eds. Demographic and Programmatic Consequences of Contraceptive Innovations. (New York: Plenum Press, 1989)227-48.

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