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Key Points
- Comprehensive interventions increased the use of LAPMs
- After the interventions ended, the use of LAPMs declined
- Long-term strategies are needed to sustain higher levels of LAPM use
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Interventions to expand contraceptive choice by improving access to long-acting and permanent methods (LAPMs) can be effective, but long-term strategies are needed to sustain the results of these efforts.
This was one of the lessons drawn from a recent assessment of interventions to increase the use of LAPMs in Kenya. The findings of the assessment will help guide the design of future efforts to revitalize LAPM use.
Rationale
Since the 1980s, the proportion of Kenyan women using LAPMs has declined, while the proportion using oral contraceptives and injectables has increased. The result is a trend in use that is skewed toward short-acting methods. For example, according to the Kenya Demographic and Health Survey from 2003, fewer than 3 percent of married contraceptive users were using the intrauterine device (IUD). More than 14 percent were using injectables.
The current mix of contraceptive methods in Kenya is not considered cost-effective or sustainable. As a greater number of donors expect governments to provide their own contraceptive commodities, countries like Kenya need to ensure a more balanced method mix that includes LAPMs.
Under the Ministry of Health's leadership, several interventions have been launched in Kenya since 2000 to increase the use of LAPMs. The Ministry of Health decided to assess three of them: the AMKENI Project, the ACQUIRE Project, and the AMUA network.
These three interventions were chosen because they all used a comprehensive approach that included advocacy, creation of demand for LAPMs, and improvement in the delivery of LAPM services. The multi-organizational AMKENI Project sought to improve the overall provision of reproductive health services, including LAPMs. The ACQUIRE Project, managed by EngenderHealth, worked to increase uptake of IUDs in the Kisii District. The AMUA network of "social franchises," managed by Marie Stopes Kenya, worked to improve access to clinical methods of family planning among rural couples (a social franchise is a partnership among private-sector organizations that tries to help a public-sector organization reach a social goal they all share).
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More Experiences
Ghana
From 1994 to 2004, EngenderHealth trained more than 300 medical teams to perform female sterilizations. The number of facilities providing female sterilizations nearly tripled, and more than 27,000 women chose the procedure.
Mali
Male was among the first African countries to obtain regulatory approval for Norplant. The number of women using implants increased from fewer than 3,000 in 1987 to more than 10,000 in 2001.
Nepal
Through Population Services International/Nepal's Sun Quality Health Network of more than 200 private health clinics, providers inserted nearly 2,000 IUDs and performed 6,000 vasectomies and female sterilizations at both stationary and mobile clinics from 2003 to 2006.
Tanzania
Through the Choice Initiative, Marie Stopes International operates mobile teams of providers who offer free LAPM services at Ministry of Health posts in rural areas. In 2006, more than 30,000 implants and 47,000 female sterilizations were provided.
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Results
All three interventions resulted in large increases in the use of LAPMs. For instance, the number of female sterilizations performed at 96 AMKENI-supported facilities increased from 750 in 2001 to 3,318 in 2005. The number of IUDs inserted at the same facilities increased from 510 in 2001 to 1,169 in 2005. The provision of contraceptive implants also increased, but implant use varied from year to year depending on availability.
Despite large increases in LAPM use, direct comparisons of the interventions were difficult because they were conducted at different sites and targeted different methods. To facilitate comparisons, a small number of sites that were providing IUDs were selected to represent each of the three interventions. During the AMKENI intervention, the number of IUDs that were provided at the eight sites included in the assessment rose from one per month to a peak of six per month; a year later, that number had fallen to four per month. The AMUA project is still under way, but results from the ACQUIRE intervention were similar, with IUD use dropping after the initial intervention.
At its midterm evaluation, the AMUA network found that its costs were much higher than planned. The AMKENI and ACQUIRE interventions did not track their costs. However, given the large number of activities they involved and the modest increases in IUD provision observed, these interventions were also likely expensive relative to their achievements.
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LAPM Provision in Eight Former AMKENI Sites in Western Province, Kenya |
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Lessons learned
A task force is using the lessons learned from these interventions to develop a comprehensive strategy for revitalizing LAPM use in Kenya. Some of the lessons identified by the assessment include the following:
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Involving decision-makers early and assessing needs before an intervention starts are critical for gaining the support of providers and managers at the facility and district levels.
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Sustaining a trained work force is important for reducing provider bias against LAPMs. Continued training is also needed because providers are often transferred to different facilities following an intervention.
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Assuring consistent supplies of commodities and equipment is crucial. Supplies quickly decline after an intervention ends, and stockouts can force clients to choose methods they do not prefer.
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Community-based volunteers can effectively promote and refer clients for LAPM services. If funds are available, it may be cost-effective to maintain a core group of highly motivated community-based volunteers by providing them with regular incentives rather than constantly training new volunteers.
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Method-specific marketing efforts that use the mass media seem to reach potential clients more effectively than broader information campaigns about LAPMs.
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Resources
Long-Acting and Permanent Methods: Addressing an Unmet Need for Family Planning in Africa
This set of eight advocacy briefs examines the benefits of LAPMs and the rationale for introducing or revitalizing their use within national family planning programs. It also offers ideas about how to improve and expand LAPM provision. Four of the briefs were prepared as part of the Global Health Technical Brief series produced by the INFO Project at the Johns Hopkins Bloomberg School of Public Health. Each brief provides the most current information about a specific LAPM. Available here.
The IUD Toolkit
The IUD Toolkit is a comprehensive source of up-to-date, evidence-based information about the IUD. This online resource for program managers, policy-makers, family planning providers, and potential clients was developed by the Maximizing Access and Quality Initiative of the U.S. Agency for International Development. It offers guidance on best practices, training materials, case studies, and tools to help increase access to IUD services and to improve the delivery of those services. Available in English, French, and Spanish here.
Implants Toolkit
The types of resources provided by this online toolkit about contraceptive implants are similar to those found in the IUD Toolkit. They include guidance on best practices and tools to help make implant services more accessible, acceptable, and effective. Information is organized by topic and by the intended audiences: program managers, providers, policy-makers, logistics managers, communications professionals, trainers, researchers, and implant users. Available here.
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