“A small family, Oh friend, is a happy one
A large family, my friend, burdens our lives!
(A family with) two children, can eat good food,
(A family with) five children, hardly manage to eat!
Think hard, my sister, what it will take for a happy life
A small family, my friend, is a happy one!”
Sangeeta Kumari, a community health activist in India’s Bihar State, sings the above song in her local dialect when she meets with women in her community to inform them of the merits of family planning. “Many women are not yet aware how to protect themselves from repeated pregnancies,” says Kumari, an Accredited Social Health Activist (ASHA) in her village of Kumarpur. “Others who are aware also need to be convinced that adopting a family planning method is good for them, their children and the entire family.”
Kumari is a part of an extremely crucial workforce established to link women with the public health system. In a state that produces the largest number of children per couple (total fertility rate of 3.7) and where every year, 8,000 mothers die while giving birth and 150,000 babies die before they reach their first birthday, these grassroots workers are the first level of contact. They spread the message of healthy timing and spacing of pregnancies, discuss the positive impact of family planning on maternal and child health and provide these women with access to a range of family planning choices.
With technical assistance from Jhpiego and support from the David and Lucile Packard Foundation, the Government of Bihar is training ASHAs and Mamtas (former traditional birth attendants who now work in hospitals to care for mothers and newborns) to sensitize and inform women about postpartum family planning (PPFP) options. The strategy calls for integrating these messages and counseling into existing maternal, neonatal and child health service delivery platforms, including immunization sessions, village health and nutrition days, and antenatal and postnatal care visits.
The need for family planning information is great. A large number of women in Bihar’s remote and underserved communities are unaware of how soon they can get pregnant after childbirth. As a result of India’s Janani Suraksha Yojana conditional cash transfer scheme, more and more women are opting for institutional deliveries, providing a large window of opportunity to reach these women while they are still in the facility—within 48 hours of childbirth—and to provide them the information and opportunity to adopt a family planning method.
The Government of Bihar’s PPFP strategy stresses the importance of the immediate postpartum period and puts special emphasis on increasing the utilization and provision of quality and comprehensive PPFP services to clients at all possible levels of contact with the health system. The desired outcomes of this strategy are: 1) more clients receiving quality messages on return to fertility and healthy timing and spacing of pregnancies, and receiving postpartum counseling services; 2) a wider basket of postpartum contraceptive methods; 3) increased awareness of the importance and availability of PPFP services among communities; and 4) improved capacity to provide these services.
Kumari is one of 425 ASHAs trained during the first phase of this initiative, which uses a unique, practice-based, one-day training package that aims to increase the involvement of ASHAs and Mamtas in promoting PPFP. The training course highlights the importance of the postpartum period, the recommended gap between childbirths and the various PPFP methods that can be adopted in the postpartum period. Trainees are also provided job aids to help them counsel women in their communities.
Anupam Kumari, an ASHA from Maheshi village who also attended one of the training courses, had this to say, “We were not aware that the postpartum period is such an important time to inform women about family planning. This training has taught us a lot about the family planning methods available to postpartum women. I hope many more of my ASHA sisters can attend this training and learn from it.”
The next phase of this initiative will target additional ASHAs for training in 18 facilities across the five districts of Bihar State, including districts that are known to have high levels of institutional deliveries and a high unmet need for family planning.
By informing women in their communities about postpartum family planning, ASHAs and Mamtas—the Hindi words for hope and motherhood, respectively—will save mothers and children in Bihar State from needless deaths and, in turn, keep families and communities healthy and happy.