Taking Action to Strengthen Family Planning Service Delivery in Liberia

By Chelsea Cooper and Holly Blanchard

Vaccinator sharing family planning information during a child's immunization visit, an example of integrating maternal health services. (Photo by C.Cooper)

Bong County, Liberia – During a routine immunization visit for her infant at Phebe Hospital, a mother listened intently as the vaccinator shared information vital to the woman's health. Mothers who delay pregnancy for at least two years after giving birth are better able to care for themselves and their families, the mother was told.

Interested to know more, the woman was referred that day to family planning services where she met midwife Anna Flomo.

At 41, this mother had been pregnant 10 times, given birth to eight children and had seen seven survive. As Flomo counseled the woman on the family planning methods available at the hospital, the mother knew she didn't want to be pregnant again. The woman chose a tubal ligation, expressing relief that she wouldn't have to face another unwanted pregnancy.

More than half of the women who brought their children for vaccinations on this day sought family planning services, following a conversation with a vaccinator. For Flomo, this was her first opportunity to provide such family planning education and counseling in an integrated service setting since attending a capacity-building workshop on this innovative approach.

Phebe Hospital is among 10 health facilities in Liberia where the Ministry of Health and Social Welfare has integrated family planning with routine infant immunization services through the U.S. Agency for International Development's global Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego. Supported by MCHIP, the ministry embarked on this pilot project to addressLiberian women's unmet need for family planning, build skills among health providers and strengthen the country's health system. MCHIP partners, Jhpiego and JSI, participated in this work.

The latest Liberia Demographic and Health Survey (DHS 2007) reported contraceptive prevalence among married women at 10.3 percent for modern methods, a total fertility rate of 5.2 and a maternal mortality ratio of 994 per 100,000 live births, one of the highest in the world. According to an MCHIP analysis of Liberian health data, 82 percent of Liberian women who are within two years of giving birth report an unmet need for family planning services.

An integrated approach to meeting this need is not only innovative, but has shown promise in other countries. Through routine child immunizations, caregivers have multiple contacts with mothers in the year after birth. These frequent contacts present a clear opportunity to reach women with family planning services while they are already at the health facility.

Vaccinators provide a few short, targeted family planning messages to mothers during routine immunization visits. For women who express interest in learning more about family planning options on the same day, vaccinators provide referrals to nearby services. Targeted job aids and information, education and counseling materials have also been developed to support the process of integrating services.

MCHIP began working in Liberia in 2010 to strengthen family planning services. It is part of Jhpiego's ongoing efforts to help countries build the capacity of health workers to deliver skilled and comprehensive care, strengthen health systems and innovate to save lives.

One of the facilities where MCHIP is working is Redemption Hospital, the largest free maternity hospital in Liberia, located in an urban slum of Monrovia. When MCHIP first began working there in 2010, the midwives required clients to show proof of current menses to rule out pregnancy before starting them on a modern contraception. This mandate undermined women's ability to obtain contraception.

Vicky Youqui and Anita K. Kollie, midwives at the Redemption Hospital's family planning clinic, participated in capacity-building family planning workshops, sponsored by MCHIP/Jhpiego. During these sessions, they learned about effective counseling skills, provision of long-acting methods, infection prevention practices and postpartum family planning. They now know how to be reasonably sure that a woman isn't pregnant by asking her six simple questions. And they have seen success.

MCHIP family planning advisor Comfort Gebeh (center) discusses integration of family planning and child immunization services with Redemption Hospital midwives Vicky Youqui (left) and Anita K. Kollie (right). (Photo: H.Blanchard)

To highlight the hospital's achievements, Youqui proudly showed an MCHIP trainer the family planning register. Between October 2011 and January 2012, she and Kollie have seen an average of approximately 1,100 clients per month. Kollie shared the reaction of one of many clients to whom she provided a long-acting contraceptive implant.

"The woman really appreciated the care, saying that she had an [unsafe] abortion and promised herself that she would never do that again. Now she can breathe easy."