In the northwestern Indian state of Rajasthan, the past 60 years have seen a three-fold surge in population, increasing to an estimated 65 million people. Women on average have at least three children, and less than 60 percent of women of childbearing age or their partners use contraception. The need for focused family planning services was never more strongly felt here.
To help meet that need, Jhpiego joined with the Government of Rajasthan, the Norway India Partnership Initiative (NIPI) and other partners to provide family planning services immediately after childbirth, with a focus on the intrauterine contraceptive device (IUCD). This collaboration is already showing encouraging results in helping Rajasthani women plan smaller families. At three small hospitals, in less than three months, nearly 300 women decided to have an IUCD implanted immediately after delivering their babies.
The joint venture is building capacity among health providers in Rajasthan and strengthening the health system, a model partnership for family planning services that other states in Indian can adopt as their own.
Dr. M.L. Jain, Director of the Reproductive and Child Health Program, said that the focus of family planning in Rajasthan has shifted from sterilization to birth spacing methods because “Jhpiego helped us to show the importance and correct timing of family planning counseling [in antenatal care] and services [in immediate postpartum].”
“Before training of trainers we were not convinced about IUCD, specially the IPPIUCD (Immediate Postpartum Intrauterine Contraceptive Device) program, which had failed miserably in the past. But after attending the training, I have noticed palpable changes among all trained staff as their approach and vision is quite different now,” added Dr. Vimla Jain, Head of the Department of Gynecology-Obstetrics at Sawai Man Singh (SMS) Medical College, Jaipur. “The way the program has started again shows that training provided by Jhpiego is worthwhile and we are confident that the current approach will be successful.”
The focus on services for postpartum family planning and immediate postpartum IUCD (PPFP/IPPIUCD) began in earnest in 2009. The goal was challenging: The Government of India wanted to reach a contraceptive prevalence rate of 68 percent by the year 2016. In this vast state known for its forts, camels and legendary rulers, women marry at an early age and literacy rates are low. According to the National Family Health Survey-3 (2005–06), only about 1.6 percent of married women ages 15–49 in Rajasthan use IUCDs, and there was a huge unmet need for family planning (14.6 percent).
With the help of Jhpiego and partners, a strategy to increase the use of PPFP/IPPIUCD services was developed: establish nodal education sites for health providers, strengthen family planning services, create awareness, generate demand for services and evaluate the work done.
LAYING THE GROUNDWORK
The Government of Rajasthan identified three NIPI focus districts in the northeastern part of the state (Dausa, Alwar and Bharatpur) for the introduction of these services to be phased in, under the national Reproductive and Child Health Program II. After an evaluation of the performance there, the services are to be expanded over the entire state of Rajasthan.
The education of health providers took place at SMS Medical College (through its affiliates, Mahila Chikitsalaya and Zenana Hospital) and the District Hospital in the capital city of Jaipur. Those providers will in turn share their skills with colleagues at the district hospitals and support implementation of the government-approved IPPIUCD performance standards.
Recognizing that public health services are best utilized when clients and prospective patients are not only aware of, but actually demand the services being offered, the PPFP/IPPIUCD project developed counseling materials for community- and facility-based health workers who strive to link residents with the services they need. The demand-generation activities were undertaken in collaboration with the state’s Information, Education and Counseling Unit and the Indian Institute of Health Management Research (IIHMR), Jaipur.
Another important component of the PPFP/IPPIUCD project is the establishment of a robust documentation and monitoring and evaluation system to measure and disseminate results. The goal is to generate useful information based on family planning service statistics and trends for policymakers, program managers and relevant stakeholders.
JHPIEGO’S PROJECT ACTIVITIES
For its part, Jhpiego was actively involved in a number of activities between June and November 2010. At the start, the India team co-hosted a stakeholders’ meeting on May 31 at the Health Directorate in Jaipur. During the meeting, stakeholders shared their opinions and ideas for designing a strategy to revitalize PPFP/IPPIUCD services. With a strategy and plan approved, it was time to build a platform to support PPFP/IPPIUCD services among the providers who would be directly involved in implementation—gynecologists. An orientation for these providers from all district hospitals and medical colleges was held on July 12, 2010.
Five days later, coinciding with Population Week, Ashok Gehlot, the Chief Minister of Rajasthan, along with Ghulam Nabi Azad, the Union Minister for Health and Family Welfare, and other dignitaries formally inaugurated the PPFP/IPPIUCD services in the state.
To identify areas for improvement and direct specific actions, a baseline assessment of training sites was done at Mahila Chikitsalaya, Zenana Hospital, Kawantiya Hospital and District Hospital in Dausa. Clinical skills and standards for PPFP/PPIUCD service delivery were examined. Following the baseline assessment, 24 service providers from Zenana Hospital, Mahila Chikitsalaya and Kawantiya Hospital attended seminars on PPFP/IPPIUCD services at Safdarjang Hospital in Delhi.
Jhpiego then supported Mahila Chikitsalaya and Zenana Hospital with equipment, teaching materials, anatomic models and other logistics so they could begin to offer the services and hold subsequent education courses.
Recognizing that India has one of the largest private health sectors in the world, Jhpiego’s India team knew that involving private practitioners in PPFP/IPPIUCD services would help generate broader awareness and create an environment for such services to be incorporated within the private health sector. In November, 27 private practitioners attended an orientation program.
To further the success of the project, Jhpiego is now developing packages for PPFP/IPPIUCD counseling, which will be used by community health workers—Yashodas, ASHAs (Accredited Social Health Activists) and AWWs (Anganwadi Workers). These packages will be integrated with existing education packets for Yashodas and home-based postnatal care services provided by ASHAs.
The packages will be a joint collaboration with the Government of Rajasthan and IIHMR, and discussions about the work plan and scope of the materials have already been initiated with IIHMR.
For accountability, Jhpiego helped develop a monitoring and evaluation framework and identified a set of indicators to be integrated with the regular family planning reporting system. The state has also assigned a nodal officer and a training and state program officer to collect, compile and analyze project data on a routine basis.
After launching this project, the state has shown a good start-up with nearly 300 IPPIUCD insertions in just two months. “There was a serious apprehension among service providers about success of this initiative, which has a bitter experience in previous attempt three decades back. But after technical assistance from Jhpiego and support from NIPI, new guidelines for insertion have been prepared and early stage expulsion is comparatively very low, which shows that strategy which has been adopted this time will result in successful implementation of the program,” said Dr. S. P. Yadav, State Program Officer, Rajasthan for NIPI.
Jhpiego India continues on-site support through regular visits to the SMS Medical College and District Hospital, Jaipur. Through supervision, the India team strives to integrate PPFP/IPPIUCD with maternal and child health services, and motivate health care providers to maintain their enthusiasm.