Maximizing Community Outlets and reaching the Hard -to -Reach with Family Planning in Benin

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Maximizing Community Outlets and reaching the Hard -to -Reach with Family Planning in Benin

Benin
Project Summary
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The Standard Days Method (SDM) or "m?thode du collier" is a fertility awareness-based method of family planning that requires users to avoid unprotected intercourse during cycle Days 8 through 19. The SDM is appropriate for settings where there is high use of traditional contraceptive methods, high levels of unmet need, and a chronic shortage of contraceptive supplies because it is a low-cost alternative and does not require re-supply. Benin is an appropriate country in which to offer the SDM. The unmet need for family planning has led to many unintended pregnancies in Benin, which poses risks for women, their families, and society. The estimated unmet need for family planning is 27% in Benin, with most of it related to birth spacing (PRB 2005). Modern contraceptive prevalence is only 7% and 12% of women of reproductive age using contraception are using natural or traditional methods. The SDM is a simple fertility awareness-based method which relies on a "standard rule" or a fixed "window" of fertility that makes it easy for women to know when they are likely to become pregnant. The SDM was developed through scientific analysis of the fertile time in the woman?s menstrual cycle. More than 95% effective for women with cycles between 26 and 32 days long, the SDM is easily provided by a wide variety of programs. To use the SDM, a couple tracks the woman?s menstrual cycle and avoids unprotected intercourse on fertile days 8 through 19 ? if they want to avoid a pregnancy. Most users of the SDM rely on CycleBeads, a color-coded string of beads, to help them track their cycle and identify the days when pregnancy is most likely. CycleBeads are made with 32 oblong plastic beads. A small black ring slides along the tool starting on red bead, which represents the first day of a period; through brown beads, which represent non-fertile "safety" days when pregnancy is unlikely to occur; to white beads that glow in the dark, which represent the days when a woman is most likely to conceive if she has unprotected sex. CycleBeads are a small, one-time investment that can yield years of effective protection from unwanted pregnancies.

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Your idea
Focus of activity

Reproductive Health

Start Year

2004 (following the operation research (OR) conducted in 2001-2002)

Positioning in the mosaic of solutions
Main barrier addressed

High cost of providing quality health products and services

Main principle addressed

Introduce novel uses of technologies

Innovation
Description of health product/service offering:

The Standard Days Method (SDM) or "m?thode du collier" is a fertility awareness-based method of family planning that requires users to avoid unprotected intercourse during cycle Days 8 through 19. The SDM is appropriate for settings where there is high use of traditional contraceptive methods, high levels of unmet need, and a chronic shortage of contraceptive supplies because it is a low-cost alternative and does not require re-supply. Benin is an appropriate country in which to offer the SDM. The unmet need for family planning has led to many unintended pregnancies in Benin, which poses risks for women, their families, and society. The estimated unmet need for family planning is 27% in Benin, with most of it related to birth spacing (PRB 2005). Modern contraceptive prevalence is only 7% and 12% of women of reproductive age using contraception are using natural or traditional methods. The SDM is a simple fertility awareness-based method which relies on a "standard rule" or a fixed "window" of fertility that makes it easy for women to know when they are likely to become pregnant. The SDM was developed through scientific analysis of the fertile time in the woman?s menstrual cycle. More than 95% effective for women with cycles between 26 and 32 days long, the SDM is easily provided by a wide variety of programs. To use the SDM, a couple tracks the woman?s menstrual cycle and avoids unprotected intercourse on fertile days 8 through 19 ? if they want to avoid a pregnancy. Most users of the SDM rely on CycleBeads, a color-coded string of beads, to help them track their cycle and identify the days when pregnancy is most likely. CycleBeads are made with 32 oblong plastic beads. A small black ring slides along the tool starting on red bead, which represents the first day of a period; through brown beads, which represent non-fertile "safety" days when pregnancy is unlikely to occur; to white beads that glow in the dark, which represent the days when a woman is most likely to conceive if she has unprotected sex. CycleBeads are a small, one-time investment that can yield years of effective protection from unwanted pregnancies.

Description of innovation:

The SDM is an exciting development in the field of mainstream family planning and is an important addition to the contraceptive method mix. Years ago, the natural family planning options available to couples in Benin were widely regarded by many providers and by some family planning programs as ineffective, complex and time- consuming. Access to and information about these methods was limited, making it especially difficult for hard-to- reach groups to use them ?especially women with less education and rural women, among whom levels of unmet need are highest. The SDM is innovative because, although a natural method, it is modern, it is easy to provide and easy to use, it is of low cost, and it serves the hard to reach rural community. It can be offered as part of a multi-method program and does not require long training periods for either the provider or the client. A provider can usually be trained to offer the method in one day, while a client requires about 20 minutes. The SDM is a modern method of family planning: it is 95% effective as determined by the Institute for Reproductive Health at Georgetown University through a prospective multi-center efficacy study that was published in the scientific journal Contraception. With a first year pregnancy rate of less than 5% with correct use, it is comparable to other user-controlled methods currently available through reproductive health and other programs. The method is now included in reference documents such as the WHO?s Medical Eligibility Criteria for Contraceptive Use, the IPPF Medical Bulletin, and Contraceptive Technology. The SDM is easy to use and easy to provide: The SDM can be included in a wide variety of programs and offered by different levels of providers without significant additional resources. It has the potential to expand contraceptive prevalence by bringing new users to family planning. In Benin, the SDM services are provided through a variety of public and private sector programs, including those offered by the Ministry of Health (MoH), community based family planning programs, non-governmental organizations, faith- based groups and non health programs such as micro credit and fishing programs. Because the SDM involves using condoms or abstaining from intercourse on days 8?19 of the cycle, it necessarily involves men. This has given the Benin program an opportunity to involve men in family planning. The SDM is low in cost: Given the increasing demand for family planning in Benin, the need for reaching a growing population, and the limited donor resources to fund the needed supplies, a low-cost, effective method like the SDM is becoming an addition welcomed by policy makers, program managers, and clients. The supplies required for the Standard Days Method are relatively inexpensive. Recent figures indicate that the U.S. Agency for International Development pays 6.6 cents per condom, 22 cents per cycle of pills, 97 cents per injection of Depo-Provera and $1.45 per IUD. In contrast, the one-time cost of a set of CycleBeads, which can be used for several years, is about $1. Once a woman has learned to use the SDM, she can rely on it whenever supplies for other methods are unavailable. Hence, the method could be introduced as a stopgap measure for returning clients during times of stock depletion. In programs that are chronically out of stock, the SDM is both an alternative option and a solution to an ongoing problem that can undermine program efforts. In addition to being a low-cost, the SDM serves hard to reach populations and is attracting people who previously had not used family planning. More than 90 percent of the method acceptors in Benin had never used any method of family planning. In Benin, providers had never seen so much interest in family planning among men until the SDM was introduced.

Operational model:

The AWARENESS Project/Benin has used the ?Maximizing Community Outlets? model to disseminate the SDM. This model capitalizes on improving access and the quality of services at the same time. The quality of counseling, informed choice, and the attitudes of providers toward their clients are key elements of access and quality. Access: in Benin, many rural residents do not use family planning services because of unnecessary or inappropriate requirements for examinations and tests, eligibility exclusions, and provider biases that constrain the client's choice of methods. The SDM program has helped solve these problems by developing simple guidelines and simplifying clinic procedures, by making more use of nonmedical programs, and by providing more distribution modes and outlets. The AWARENESS Project/Benin works with 8 major partner organizations with presence in rural and hard to reach areas. For example, The Fondation Regard d?Amour (FRA), a faith-based organization that protects abandoned children and promotes family wellbeing has introduced the SDM into their clinic in Abome-Calavi and into their community- based distribution program serving the Tofinu people, a hard-to-reach population living in a floating village of the Ganvi lake. FRA workers, who understand the community dynamics of this unique fishing village, are agents of change moving by canoe from one household to another to educate women and men about family planning. Those eligible for the SDM are given the method and others are referred to nearby clinics. The AWARENESS Project/Benin trained SDM trainers pooled from these partner organizations at the initial stage of the program. These trainers trained providers. Quality of services: In order to improve the quality of services, the AWARENESS Project/Benin chooses and works with partners who understand the social, physical and administrative environment in which their grassroots level providers work, function and provide the services. In the SDM training we stress the importance of respect for all clients. Every client visiting the program has a right to access, choice, safety, privacy, confidentiality, dignity, and comfort. In addition, the client has the right to information from the program and to express an opinion.

Human resources:

The AWARENESS Project/Benin has one locally-recruited country representative who has a public health background and a Washington DC based backstop Program Officer. In addition, more than 30 trainers from NGOs, FBOs, and the MoH and 303 providers from partner organizations have been trained on the SDM. The project has focused on building local capacity to ensure sustainability.

Key operational partnerships:

The SDM expansion project in Benin has been carried out by a strategically-chosen core of non governmental organizations, faith-based organizations, and public clinics selected through consultations among the MoH and its in-country family planning cooperating agencies. Seven partners, including the MoH, OSV/Jordan, ABPF, HOMEL, PSI, FRA, and ProFam are involved in the SDM expansion. These partners come from both primary health care programs, as well as from organizations that have no experience providing family planning and reproductive health services and together they have introduced the method into 131 clinics, pharmacies and community distribution channels. The AWARENESS Project/Benin primary partner is the Ministry of Health. The Ministry of Health/Benin has included the SDM in 21 government clinics throughout the country and made it an essential part of its family planning service because it meets the needs of large traditional subgroups that prefer natural methods over hormonal family planning methods.

Impact
Financial Sustainability:

<ul><li class="entry-label">Fees charged to clients?: <span class="entry-text">Yes</span></li><li class="entry-label">How do you assure affordability?: <span class="entry-text">CycleBeads are sold for the price of 500 CFA (Around $ 0.80). This minimal charge of 500 CFA was set by the ministry of health after consultation with it reproductive health partners and price has not been a problem since. There is no earned income on the SDM expansion program in Benin but there is a cost recovery of 500 CFA for commodities sold. </span></li><li class="entry-label">Earned incomes as a percentage of operating costs: <span class="entry-text">6%</span></li><li class="entry-label">Other funding sources: <span class="entry-text">The AWARENESS Project/Benin?s work is financed by USAID. For sustainability reasons, the Ministry of Health was involved early in the program and has made the SDM an essential part of their family planning service. They have included the SDM in national RH norms, policies and training protocols, and have added the CycleBeads to their procurement list. </span></li><li class="entry-label">Strategy for long-term sustainability: <span class="entry-text">The AWARENESS Project/Benin strategy for long-term sustainability includes continuing to work closely with Ministry officials, NGOs and social marketing agencies to give them ownership of the SDM. In this effort the AWARENESS Project/Benin has trained a cadre of government trainers, participated in the development of the reproductive health norms and in the drafting of the demographic and health survey module to include the SDM. Also CycleBeads have been introduced into the FP procurement list. The AWARENESS Project/Benin has also supported the Ministry of Health to develop prototype curricula for including the SDM in medical, nursing, midwifery, and public health education. The curricula have been introduced in four Beninese educational institutions. </span></li></ul>

Current and Future Impact:

<ul><li class="entry-label">Total number of clients: <span class="entry-text">over 5000 </span></li><li class="entry-label">Clients in the past year: <span class="entry-text">Over 1500</span></li><li class="entry-label">Percentage of low-income clients: <span class="entry-text">90%</span></li><li class="entry-label">Impact: <span class="entry-text">The project has provided people in Benin with an additional choice that is contributing to reducing unmet need for FP. More than 30 trainers and 303 providers have been trained to offer the SDM in 131 sites and through numerous community distribution channels in 11 departments. In the family planning services provided by one partner organization, SDM users represent 14% of new family planning acceptors. Ongoing montoring suggest that similar results are being seen by other partners and efforts to collect additional evidence continue. SDM services have also been integrated into non-health programs including micro-credit and youth programs. In the ABPF youth center, for example, more than 2,000 youth have been taught how to track their fertile days using CycleBeads. In addition, a culturally sensitive project in the Muslim dominated area of Parakou has helped to increase the support of community and religious leaders and understanding and acceptance of family planning among men.</span></li><li class="entry-label">Overall "market": <span class="entry-text">More than 90% of women who choose the SDM have not used a modern family planning method before; others have been dissatisfied with other methods. Almost all women who choose the method do so because it is "natural" and does not have side effects. Programs are very satisfied with offering the SDM and they report that SDM counseling presents an opportunity?and a comfortable context?to encourage and discuss condom use. Operation research and long term follow up data now being analyzed suggest high level of correct method use. ? Overall "market": Benin?s population is estimated to be about 8.4 million with an annual population growth of 2.9%.(PRB 2005 World Population Data Sheet). Contraceptive prevalence is low and the number of abortions and its risks remain high. Cultural beliefs and traditional lifestyles place a strong value on fertility and large families. The Beninese population is young and almost half are less than 15 year of age. As this group enters the reproductive years, the need for family planning services will increase. </span></li></ul>

Scaling up strategy:
Stage of the initiative:

<i>Scaling Up</i> stage.

Expansion plan:

The AWARENESS Project/Benin is at the growth phase and has registered many successes. Efforts to enhance the sustainability of the SDM program in Benin include support for internal policy commitment, a focus on building the capacity of local partners including the MOH, integrating the SDM into the national reproductive health norms and educational curriculums, and developing a sustainable CycleBeads distribution channel. IRH will continue emphasizing continuous quality improvement of management and service delivery. Successful leveraging of additional resources and, in collaboration with the MOH, building an SDM functioning cost recovery system, are priorities. Future Plans ? Continue field monitoring and supervision of active sites. ? Intensify and disseminate IEC activities undertaken by partners. ? Intensify collaboration with the MoH and other CA?s working to develop the national RH norm to include the SDM. ? Work with educational institutions including nursing schools, medical schools, and schools of midwifery to integrate the SDM into their curriculum. ? Train additional SDM providers thus expanding services within existing government sites. Continue activities in behavior change communication, including reproduction of materials and organization of community-based social mobilization activities.

Origin of the initiative:

The SDM was developed by Georgetown University's Institute for Reproductive Health with support from USAID. The SDM was introduced in Benin in December 2001, through an OR study. This study took place in two urban centers (Cotonou and Parakou) as was requested by the MOH and where its partners, the Beninese Association for Family Promotion (ABPF) and the NGO "OSV-Jordan" were implementing reproductive health activities. The results from the OR study determined that strong demand for the method existed in Benin; that the SDM could be offered effectively to the community through existing service delivery channels; there was a high degree of acceptability and continuation with use of the method; and the SDM could be used correctly and consistently by Benin. The OR results dissemination meeting was held at the MOH in April 2002. The MOH requested additional assistance to expand the program and increase service delivery through its existing sites throughout the country.

Sustainability
Policy change:

The Ministry of Health has fine tuned its policy and has integrated the SDM into it national reproductive health norms. The SDM have been included into the national RH norms, policies and training protocols, and has added the CycleBeads to their procurement list. However, constant turnover in the MoH complicated our advocacy work. The Beninese government historically has given little attention to family planning; as a result, programs in Benin have suffered from a weak central organization and coordination. Since the start of the SDM expansion program in Benin, the Director of Reproductive Health (DSF) has been changed at least five times. These constant changes in the Ministry of Health have hindered the program?s progress. The MoH?s recent inclusion of SDM as a distinct modern method in the demographic and health survey (DHS) instruments indicates its recognition of the SDM as a mainstream choice. It is expected that when the DHS data is collected and analyzed, program impact will be validated.