Wednesday, 7 January 2015

Mobile Family Planning Unit: An innovation for expanding accessibility to family planning services in Bihar



"Mobile Family Planning Unit: An innovation for expanding accessibility to family planning services in Bihar"

Accessibility to cost effective and quality Family Planning services in remote and hard to reach area which are not well connected to the block and district towns is a major reason for poor uptake of family planning services in Bihar.Contraceptive prevalence is mere 33.3% percent in rural Bihar below national figure of 56.3%.(1) Female sterilization is being adopted for family planning purpose since long as the major contraceptive method(29.4%). Other methods used here are Condom(1.6%),OC-Pill(1.5%),IUCD(0.5%),Vasectomy(0.3%) and natural or traditional methods(3.7%).There is a huge unmet need for spacing(21.3%) and limiting(17.9%) in Bihar above the national figure of 6.2% and 6.6% respectively.(2) Major reasons for poor acceptance in Bihar where IUCD coverage is a mere 0.4% in rural areas are due to lack of trained personnel,lack of connectivity and lack of awareness among Front Line Workers(ASHAs and AWWs)  & community.In this context,the Bill and Melinda Gates Foundation’s Integrated Family Health Initiative Project(IFHI) proposed an innovation of Mobile Family Planning Unit(MFPU) into piloting in Patna district which hypothesised that through MFPU along with trained and highly skilled providers the gaps can be minimized and Goal for spacing can be achieved.(3)  A study was conducted to assess the effectiveness of MFPU in improving accessibility and acceptance of IUCD services and minimizing the gap between target and achievement.This kind of MFPU for IUCD insertion was first of its kind for family planning services in Bihar.
The MFPU is a fully equipped and air conditioned ambulance with all facilities for examination of the client and IUCD insertion.The staffs in MFPU consist of one Van nurse who is trained for IUCD insertion,one Van Manager who looks after the organisation of camp and registration of clients,one female attendant who conducts pregnancy test and assists van nurse and one van driver.The unit travelled a distance of 10 to 100 kilometres in any van day from Patna to outreach areas and provided “Interval IUCD” insertion services to the identified clients.The micro plan for camps and travel route were prepared by IFHI team in advance in preceding month and shared among the unit staff.The required numbers of IUCD insertion sets were pre-sterilized.Every Front Line Worker of the piloting block was using a screening card to screen and send the women for IUCD insertion by van nurse.Guidelines were mentioned in this card for selection and rejection of any woman for IUCD insertion.

On camp day, the clients were mobilised by FLWs.The clients after reaching at camp went for a pregnancy test of their urine samples.Clients who were negative in pregnancy test got registered by Van Manager and counselled by the Van Nurse before IUCD insertion.The Van Nurse inserted the IUCD under all aseptic measures by using “no touch technique” of insertion.All aseptic measures and techniques of insertion from Government of India Guidelines were strictly followed.(4)
63(97%) camps could happen against 65 camps planned over a period of 6 months. The MFPU provided services for 7-11 days per month in remote areas of the pilot district.A total of 1508 women attended the MFPU in 63 van days averaging 24(23.9) per day.Out of 24 women attending the MFPU on any van day, 15 could be inserted,5.5 women could be followed up and 3.5 women were rejected on average.A total of 929(80.2%) women availed IUCD insertion from MFPU averaging 15 per day.230(19.8%) women were rejected for IUCD insertion who were found unsuitable for the procedure for reasons like positive pregnancy test,unexplained vaginal bleeding,foul smelling vaginal discharge,denial from woman after counselling, etc.349(37.5%) women out of 929 could be followed up subsequently after insertion.Number of IUCD insertions that happened was inversely proportionate to the distance of the camp site from the district headquarter.On some days, women had to return home without insertion due to lack of time.Most of the women were followed up at home by FLWs after 7 days of insertion.Women reported about spotting, menorrhagea, pain in abdomen etc  as complaints during follow-up.After counselling about effectiveness,Cu T-375 with contraceptive effectiveness of 5 years was accepted by 53 women(5.7%).Cu T-380A with contraceptive effectiveness of 10 years was accepted by 876(94.3%) women from MFPU.
Only 10.4% women with one child opted IUCD as a method of spacing.Majority of women(89.6%) who have two or more children had IUCD insertion.Indepth interview with these women revealed that most of them were not ready to accept permanent sterilization as a method to limit their family size.They were afraid of surgery needed for tubectomy.Rather they prefered Cu T-380A to be a safe non surgical method which could protect them aginst pregnancy over a longer period.Women who are in late reproductive phase(40-49 years) and afraid of surgery, opted Cu T-380A only to pass over their fertilty period.Women with 2 or more female children without a son,were not in favour of irreversible terminal sterilization. Some women with two or more children who were interested for a permanent method but got IUCD insertion.On the other hand the proportion of women(10.4%) with at least one child opting IUCD as a spacing method is less. These happened due to inappropriate selection and inadequate counselling of women with 2 or more children for long term IUCD.An exit interview with the women,who availed IUCD from MFPU,revealed that they had to cover a distance of less than 1 kilometer to 7 kilometers to reach the MFPU.Some clients came by walking while others were dependent on vehicular transport.It cost them about 10 to 15 rupees.All of them reported that they were informed by their ASHA/AWW about IUCD, Camp Date and Camp Site earlier.The camp used to start at 11.00 am and close at 5.00 pm on each camp day.Approximately, 15 minutes or more were given to each client for counseling and insertion.The van Nurse informed that, sufficient time was not available to give quality counselling to each of the client.Pre-procedural counselling on IUCD by the FLWs during the home visits could have decreased counselling time by the van Nurse and increased the number of insertions on camp day.
            Issues identified from this piloting were inadequate pre-insertion counselling of women, improper Client Selection, failure in detecting anaemia before insertion, huge client load of 18-30 per day against anticipation of 15-20 per day, less number of follow-ups, no system for complication identification and referral services after insertion, inadequate van days to meet unmet need for spacing and limiting through MFPU in the district of Patna and high operating cost of van.The objectives of the piloting were successfully achieved in reaching at door steps of the client in hard to reach areas of Bihar. Increasing accessibility to quality family planning services was proved feasible through this piloting.Taking the current piloting and huge unmet need into consideration, it is suggested that each district should have a MFPU for outreach family planning services at least 15 to 20 days a month.It is suggested that one nurse from each block PHC could be given hands on training on IUCD insertion in the van itself to increase access to IUCD insertion at PHC.
Reference
1.Census of India,2011: http://nrhm-mis.nic.in/familywelfare2011.html.
2.National Family Health Survey-III,2005-06.
3.Implementation Design for Integrated Family Health Initiative(IFHI) in Bihar,Final Document,September,2011,p:11-15.
4.IUCD Reference Manual for Nursing Personnel, Family Planning Division, Ministry of Health & Family Welfare, Government of India, December 2007,p:22-23.

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