Contraceptive Introduction Strategies Raise Key Questions

These issues focus on three aspects: the method itself, the service delivery system, and the potential users. The many characteristics of a method's technology, such as whether it requires a trained provider to begin or discontinue, are important to understand and evaluate. The method's side effects and duration are factors. How the new option fits in with the users' needs and preferences, as well as the community's culture, should be considered. Service delivery concerns, such as additional training or staff requirements, are also essential considerations.

When contraceptive methods move into large-scale use without careful evaluation of these basic concerns, problems can arise. Providers may not be adequately informed or trained, and users may not receive essential counseling and information. The method's characteristics may not be well understood, including side effects and how to manage them. Misunderstandings and false rumors can circulate, damaging the method's credibility.

Logistical and economic issues must also be anticipated. A dependable way of supplying commodities must be organized, and additional services needed for the method ought to be planned, such as removal of implants or IUDs. Adding a method may affect how previously available methods are used. The cost of providing the method, and what users are willing to pay, may be decisive.

Several organizations, including FHI, have developed strategies for introducing or expanding use of a contraceptive method. FHI has two decades of experience with contraceptive introduction. Introduction strategies have continued to evolve as more is learned about how methods, users and service delivery systems interact.

In 1993, FHI's work in this area was synthesized in a written strategy for DMPA. While it focuses on the three-month injectable as a case study, it is designed for use with any method. It involves a needs assessment and addresses regulatory issues, service delivery policies and procedures, information and training, evaluation and other concerns.1

A similar approach, developed by a World Health Organization task force, seeks to identify the method mix that is most desirable for local circumstances. Whether a new option should be introduced at all is a key decision. "What would an ideal method mix look like?" asks Martha Brady of the Population Council, which is collaborating with WHO to test its model. "We need to look at who can provide which methods, where, and to whom. All of these levels have to fit. It would not be practical or necessarily desirable to offer every method in all settings."

Good contraceptive introduction strategies seek to improve the overall quality of family planning programs rather than simply expanding choices. They also recognize that even a very good contraceptive technology requires careful planning before it is widely used. "Scientists have continued to seek longer-acting, more effective methods that are easy to use, easy to deliver and have fewer side effects," a report by the WHO task force says. Introducing an attractive new method without careful planning, however, may only magnify existing problems. "Every method has a different side effect pattern, and places a different potential burden on the service delivery setting."2

Most strategies tend to plan and evaluate in steps, beginning with the use of existing data and selective interviews with policy-makers, providers, users, women's health advocates and others. More thorough research may be done at a later stage, before a method is introduced throughout a country. The new method may be offered on a limited basis at a small number of clinics, for example, to evaluate service delivery concerns and user perspectives.

All of the many concerns regarding service delivery, user perspectives and method technology are closely intertwined and are shaped by local circumstances, including rates of sexually transmitted diseases.

The following articles describe recent contraceptive introduction efforts involving Norplant, DMPA and barrier methods and provide lessons on approaches that have worked well. They show the importance of proper planning and a careful evaluation of how users, service delivery systems and the technology of the method itself interact with each other.

-- William R. Finger and Sarah Keller


Footnotes