Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions

Abstract

BackgroundFamily planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society - Pakistan implemented an operational research project - ‘Evidence for Innovating to Save Lives’, to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan.MethodsWe conducted a quasi-experimental (pre - and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, 1) Suraj model (meaning ‘Sun’ in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and 2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls.Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata® version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model.ResultsThe Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14 % percentage points, current contraceptive use by 5 % percentage points and long term modern method - intrauterine device (IUD) use by 6 % percentage points. The CMW model significantly increased contraceptive awareness by 28 % percentage points, ever use of contraceptives by 7 % percentage points and, IUD use by 3 % percentage points. Additionally the Suraj intervention led to a 35 % greater prevalence (prevalence ratio: 1.35, 95 % CI: 1.22–1.50) of contraceptive use among MWRA.ConclusionSuraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

“…The Impact Matrix comprehensively summarizes existing findings on the impact of broad categories of FP interventions on contraceptive use using a single comparable metric. The Bankole and Adewuyi 1995;Kim et al 1996;Weinman 1997;Kane et al 1998;Jato et al 1999;Rogers et al 1999;Storey et al 1999;Valente and Saba 2001;Boulay, Storey, and Sood 2002;Gupta, Katende, and Bessinger 2003;Sood et al 2004;Babalola and Vonrasek 2005;Hutchinson and Wheeler 2006;Hutchinson and Meekers 2012;Speizer et al 2014 Excluded for Insufficient Evidence Mobile Outreach Thomas and Maluccio 1996;Casey et al 2013 Social Franchising Hennink andClements 2005;Agha et al 2007;Azmat et al 2013;Azmat et al 2016 Ngure et al 2009;Kosgei et al 2011;McCarraher et al 2011;Bradley et al 2010 medians allow for comparisons of the relative effectiveness of different intervention categories, while the ranges illustrate the potential variability in impact within each category. In addition, within the Impact Matrix, intervention categories are divided between those that can be implemented among the general population of women of reproductive age and those that are focused on a specific subpopulation (e.g., postpartum women).…”

Vouchers: A Hot Ticket for Reaching the Poor and Other Special Groups With Voluntary Family Planning Services

“…A review of available literature and implementation experience shows that vouchers can be an effective programmatic tool as well as a financing mechanism for family planning and reproductive health. 2 , 7 , 9 , 13 , 14 Key benefits and comparative advantage of voucher programs are summarized in the Table and outlined in more detail below.…”

“…In Uganda, single-service family planning vouchers have operated with success, including alongside other types of health vouchers. 9 , 13 , 14 , 21 Most voucher programs, however, offer integrated services, such as a program in India that included a package of antenatal, institutional delivery, postpartum, and family planning services. 1 In Zimbabwe, a voucher program for youth initially included only family planning services, but later added screening and treatment for sexually transmitted infections after receiving feedback from clients who were interested in and needed more services (personal communication with Anna Mackay, Deputy Director, Support for International Family Planning Organizations [SIFPO-MSI] Project, Feb. 2016).…”

Women’s decision versus couples’ decision on using postpartum intra-uterine contraceptives

“…Step tion for less than three years and having fewer children were more inclined to using PPC. This trend suggests the success of fertility awareness programmes that have been implemented by the government and certain nongovernment organizations (20,21).…”