India has among the highest maternal mortality ratios and infant mortality rates in the world, at 178 maternal deaths per 100,000 live births and 42 infant deaths per 1,000 live births (Sample Registration System, 2013). Among all Indian states, Uttar Pradesh, with one sixth of India’s population (200 million) has the highest maternal mortality ratio (292 per 100,000 births), and the highest infant mortality (53 per 1,000 live births). One of the main underlying causes of high morbidity and mortality among women and children is the health risk associated with early childbearing, short birth intervals and high parity, often higher than desired. In Uttar Pradesh, 13% of the births are high risk births to very young or old mothers.
As part of the global FP2020 partnership, the Government of India’s goal is to expand availability and provide modern contraception to an additional 43 million women (36% of the global FP2020 goal) by 2020. Additionally, India has committed to the inclusion of family planning as a central element in its efforts to achieve universal health coverage, with a financial commitment of 2 billion USD for family planning during the years 2012-2020, and sustained coverage of 100 million women currently using contraceptives.
Under the GoI’s RMNCH+A (reproductive, maternal, newborn, child and adolescent health) strategy, a new direction has been developed for the family planning program. FP has been repositioned to not only achieve population stabilization but also to reduce maternal, infant and child mortality. The approach emphasizes addressing unmet need for contraception (rather than a “target-based” approach), dual emphasis on spacing and limiting methods, and promotion of ‘children by choice’ in the context of reproductive health (Ministry of Health and Family Welfare, Government of India, 2013).
With a goal of supporting GoUP in achieving its FP2020 goals, the University of Manitoba and its consortium partners (India Health Action Trust, EngenderHealth, Marie Stopes India (MSI) and Janani initiated a project (November 2014 – October 2017) that creates an effective system for increasing the number and geographical spread of FP service delivery points, for increasing the quality and utilization of FP services. The project is being implemented through a technical support unit (TSU) at the public health facilities in 25 high priority districts in Uttar Pradesh with the following objectives.
Through its various efforts, the consortium aims to reduce the unmet need for contraception and increase the use of modern method of contraception. The quality improvement efforts also aim at reducing complication and discontinuation rates of family planning and thus enhancing client satisfaction.
1) Strengthening Identified Health facilities for Family Planning(FP) services
As part of this strategy 147 health facilities were identified based on the need and availability of family planning services across the 25 districts. The health facilities were strengthened on infrastructure and family planning supplies, including availability of family planning commodities like Condoms, Oral Contraceptive Pills (OCPs), Emergency contraceptives IUCD, Tubal rings etc. The facilities were also strengthened on Infection prevention protocols and Quality assurance for family planning services.
Another component of this strategy was increasing service provision at identified health facilities through training of new service providers on family planing clinical services. The approach also enabled optimization of service skills for providers who have already been trained. This resulted in an increased number of health facilities now providing family planning services either on a static basis or through fixed day services.
2) Clinical Outreach Teams for increasing family planning service provision:
The project adopted the strategy of utilizing services of Clinical Outreach Teams (COT) to reach out to underserved health facilities with limited capacity to initiate family planning services. Two types of teams were created – COT and Mini COT for sterilization and spacing methods respectively thereby expanding the scope and availability of family planning services and reducing the unmet need for family planning at rural underserved areas.
3) Community Mobilization Strategy for demand generation
The Community Mobilization Strategy aimed to streamline eligible couple tracking from the time of identification and its linkage to services as well as post method follow-up there by generating demand at the ground level. The strengthening of community platforms also enabled in tracking of eligible couple. As part of this, FP Enumeration and Tracking Tool (ETT) were developed for FLWs in order to identify and track women with unmet need. Based on the demand and information from the ETT, the FLWs generated rosters for organization of fixed day outreach services or referrals to facilities for FP services
The project resulted in reducing the unmet need for spacing methods from 37% in year 2014 to 26% in year 2016. This has been primarily due to improvement in supplies of oral contraceptive pills and Condom supplies. The HMIS data shows 100% increase in OCP cycles distribution and 15% increase in Condom distribution in the given time period. Provision of FP services with appropriate method-mix has greatly benefitted women’s health and help decrease maternal deaths.
IHAT TSU is working closely with the government of UP to advocate and help the government plan and utilize its family planning budgets and additional FP funding promised by the Government of India to fund and absorb into the public health system the personnel (at block-level, district-level and training centres) and systems (outreach clinics) used by the project to maintain the momentum of FP service delivery in the state.