By Dr. Claire Watt Rothschild, Senior Research Advisor, Sexual and Reproductive Health (SRH), PSI D.C. and Dr. Hambulle Mohammed, Division of Reproductive and Maternal Health, Kenya Ministry of Health
In designated “underserved or hard-to-reach” areas, making contraceptive methods available only through facilities poses a major barrier to contraceptive accessibility and uptake.
“Even if the doctor will come over, still the CHV is the pillar”
–Community health volunteer from a focus group discussion in Sokoke Sub-Country, Kilifi County
In coastal Kilifi County of Eastern Kenya, for example, use of modern contraceptive methods is substantially lower than the national average – just 44 percent of women of reproductive age (15-49-years-old) report currently using a method, compared to over 60 percent nationally.
Specifically:
- In Kilifi, and in Kenya as a whole, contraceptive injectables and implants are the most popular methods of contraception.
- Contraceptive injectables, implants and intrauterine devices are also among the methods that are typically only administered by medical personnel at health facilities.
- In contrast, consumers can often access short-acting methods such as oral contraceptive pills condoms from a variety of sources: health facilities, pharmacies, and through lay health workers such as community health volunteers.
To increase consumer choice, improvements to community-based distribution models are needed. In 2018, Population Services Kenya and PSI, in partnership with the Kilifi County Department of Health and the Division of Reproductive and Maternal Health of the Kenyan Ministry of Health, sought to determine whether community-based distribution models could increase community access to a wider range of contraceptive options and strengthen social and policy environments supportive of informed contraceptive choice.
What did we learn? We outline, below.
Our research
Our formative qualitative and quantitative research aimed to:
- Understand current roles and responsibilities of existing cadres of community health workers in Kilifi County – including community health extension works (CHEWs) and community health volunteers (CHVs)
- Assess community perspectives toward community-based distributions
- Evaluate current trends in contraceptive practices and their key behavioral drivers among women of reproductive age and their partners
Our findings?
- Geographic inaccessibility and overburdened facilities presented as the primary barriers to contraceptive access
- Entrenched social norms for large family sizes were deeply entwined with ideals of masculinity and social status. As one Ministry of Health key informant succinctly put it, “When you have many children, you are taken as a hero.” Correspondingly, male community members described women’s contraceptive use as a “sin” or as a perceived threat to the social fabric – a “mode of doing promiscuity.”
- Many men and women alike expressed deep concerns about the health effects and impacts on long-term fertility of modern contraception
And still, female community members brought diverse perspectives, describing women’s desire to use contraception to avoid the stress of multiple closely-spaced pregnancies and the need to engage men in community dialogue about the benefits of contraception.
The opportunity is there.
Engaging Community Health Workers Increases Consumers’ Contraceptive Access
The Riziki (meaning “sustenance” or “livelihood” in Swahili) Demonstration Project was designed to address both upwards and downwards barriers to informed contraceptive choice.
On the supply-side, non-medical CHEWs – professional community members already employed by Kilifi County – underwent an intensive training to prepare them for community-based contraceptive counseling and method provision. For the first time, CHEWs would be authorized to administer contraceptive injectables and implants to community members in their homes or in community settings outside of health facilities. CHVs, who received an enhanced training to deliver comprehensive community-based counseling and to engage community leaders in dialogue, were tasked with addressing social norms and positioning contraception as a tool that can benefit family health.
The pilot received critical support from the national Division of Maternal and Reproductive Health, which supported training of the CHEWs using an adapted version of the national FP curriculum, and from the Kilifi Department of Health, which granted temporary authorization for the expanded duties of CHEWs under the Riziki Project. Three years later, the County is still working with this authorization, and CHEWs and CHVs continue to work together to engage communities and to deliver a wider range of contraceptive products directly in people’s homes.
To evaluate the program, PSI and Population Services Kenya reviewed contraceptive service delivery data from every public health facility in the County and conducted qualitative research with community members, leaders, and other key stakeholders. Health facilities with affiliated CHEWs who participated in the Riziki project (and whose client delivery numbers were included in those of the facility) had a 14 percent higher increase in implant clients (equivalent to an average of 6 additional implant clients per month per facility) after, compared to before program implementation than those facilities that did not have CHEWs in the program. Similarly, the program increased provision of injectables by 11 percent (an average of 13 additional clients per facility per month). Method provider increased overall, with no decreases observed for any of the short-term methods with existing community-distribution delivery models. Importantly, no safety concerns were reported during and after implementation.
Our Learnings:
- Multilevel programming is critical: Formative research highlighted access issues to the full range of methods (including the most popular method types), but also highlighted engrained social norms that limited male support for FP. Riziki intervened to improve contraceptive access and informed choice at three levels of the health system: at the individual level, home-based distribution removed transportation, cost, and time barriers associated with accessing facility-based contraceptive services; at the community level, social education and dialogue about norms that engaged community and religious leaders position FP as aligned with community values; and at the policy level, deep engagement by regional and national government allowed for a critical policy change that authorized high-quality training and support to expand the role of CHEWs.
- With appropriate support, administration of contraceptive implants by lay health workers is feasible and safe. While ongoing research is critical to understand which FP interventions can be safely shifted to lay health workers and in what contexts, evidence from Riziki suggests that community-based distribution of contraceptive methods – including contraceptive implants – by lay health workers is an effective strategy in hard-to-reach areas. While task-shifting of contraceptive injectable provision has been demonstrated to be safe and effective in a number of countries, Riziki is the first project, our our knowledge, to extend task-shifting to implant insertion. While Riziki’s CHEWs have only be trained in implant insertion, developing programs for community-based removal of long-acting reversible methods is also critical.
- Additional research is needed to ensure that community-based distribution programs safeguard contraceptive autonomy. While many women interviewed at the formative research stage expressed the need for greater male engagement in FP, male engagement may come with unintended consequences – in settings where men are often viewed as the “head of the household,” greater male engagement can come at the expense of female contraceptive autonomy. Programs that engage men need to carefully plan for ways to safeguard women’s contraceptive decision-making and bodily autonomy.
To further explore the research, drop a note – Claire Rothschild ([email protected]).
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This article is a part of PSI’s ICFP 2022 Impact Magazine. Explore the magazine here.
