Priority Strategies for Improving Contraceptive Use Among First-Time Parents

Purpose: This tool is an approach to reach first-time parents (FTPs) through frontline health workers or Urban Accredited Social Health Activists (ASHAs) to increase correct knowledge on modern contraceptive methods and improve contraceptive use among them.

Audience:

  • Joint Director/Additional Director
  • Chief Medical and Health Officers (CMHO/CDMO/CMO)
  • Chief Medical Superintendents (CMS)
  • Divisional Urban Health Consultant
  • Nodal Officer-Urban Health, Family Planning, Rashtriya Kishor Swasthya Karyakram (RKSK)
  • Urban Health Coordinator/Assistant Program Manager, NUHM
  • Medical Officer In-Charge

 Background: The National Family Planning Health Survey (NFHS 4, 15-16) provides a growing body of evidence that the age group with the lowest contraceptive prevalence rate are married women between 15-29 years of age, more specifically young married first time parents. This age group of 15-29 years face a unique set of challenges different to those faced by older married women with regards to accessing and availing family planning services. 

Evidence of Impact

The Challenge Initiative for Healthy Cities (TCIHC) experience from five cities (Firozabad, Varanasi, Gorakhpur, Allahabad, and Saharanpur) revealed that when ASHAs are coached and mentored to periodically update urban health index register (UHIR), segregate and list women based on age and parity, they are able to prioritize young and low parity women, specifically first time parents for family planning. This practice also aids to maintain a registry of young married first-time parents (FTPs) 15-24 years, and prioritize the category for household visits. The coaching enables them to easily identify FTPs with an unmet need for FP methods and counsel them to avail family planning services on FDS days/Antaral diwas.

The strategy is showing promise as data from a population level survey among FTPs from the five AYSRH intervention cities indicate a 17% increase in modern contraceptive prevalence rate (mCPR).

Figure 1: Findings from two-rounds of Population based survey conducted by TCIHC

[1] TCIHC conducted two rounds of population based output tracking survey between September 2018 and September 2019.

Guidance on Scaling Up This Intervention

The following steps can facilitate a successful scale up of FTP interventions in a state:

Making FTP data visible

To amplify how health systems must focus and prioritize this group, data from population level studies, HMIS and project health information systems must be triangulated and discussed at both city and state level family planning monitoring meetings. Family planning uptake data disaggregated by age/ parity and method choice is critical for a city to plan its strategy to reach women with unmet need for family planning. Making FTP data visible in city level monitoring meetings such as family planning review meeting/NUHM review meeting is therefore important.

Coaching & mentoring ASHAs

Coaching and mentoring ASHAs is an important step towards elevation / visibility of young first-time parents, so that FTPs are seen and served at UPHCs with the right, appropriate service including contraceptive methods.

ASHAs must to be coached to:

  1. Update population register: The importance of updating her survey record or population register, specifically section-2 of UHIR (ASHA diary), termed as ‘slum/gram survey’ periodically. An updated survey reveals the total number of population to be served by an ASHA.
  2. Develop a priority list of FTPs: Once the ASHA updates her UHIR, she then updates /completes section 8 of the UHIR, which is an aggregation of all eligible couples in the community. From this section, the ASHA can extract number of FTPs in the population she serves. Further, segregation of lists of FTP women based on age and user/non-user, helps frame a priority list of young first-time non-user parents for counselling.
  3. Prioritize visit to FTP (listing of FTP and integration in routine contact plan): When an ASHA extracts FTP list from her existing eligible couple (EC) section of the UHIR, it gives her a clear picture of potential women who are in high need of contraception for spacing between children. The list is shared with Anganwadi workers for better coordination. ASHAs precedence to this list during household visits.  Also, the list is categorized into users and non-users; the ASHA is encouraged to devise a plan with her supervisor to meet non-users first and refer them to FDS. As for users, she provides continuation support including both reassurance counselling, and also resupply of commodities such as condom and pills.
  4. Leverage benefits of government schemes related to their work: ESB is a government scheme to promote spacing between births. It is important that an ASHA feels motivated to work for FP for first-time parents. Hence it is important to coach ASHA on this scheme, specifically on how to fill the form, when to claim, what are the criteria on which this incentive is given and where it is to be deposited (Refer to ESB scheme).
  5. Follow up: To ensure retention of the adopted method by the client, ASHAs must follow up with clients in the proposed interval.
Sensitization of the influencers (i.e., family /community) on the benefits of family planning

In many communities, it is still a taboo for a 20-22-year-old woman to adopt a family planning method (Hall, Stephenson, Juvekar, 2008). Therefore, ASHA must sensitize both FTPs and key influencers on the benefits of contraception for a young mother (and child), and this could include:

  • Counsel FTPs on one-on-one basis to explain the benefits of spacing. IEC material may be used, if available.
  • Educate influencers of FTPs including mother-in-law, sister-in-law, husband and, peers on the benefits of contraception for a young mother.
  • Conduct meeting of FTPs where non-users can seek inspiration from the users and where couples can interact and discuss family planning amongst themselves.

 

Whole-site orientation

To mitigate provider bias if any caused by inadequate knowledge on methods or the latest medical guidelines about them, it is critical to conduct ‘whole-site orientation’ of all staff working at the UPHCs on specific needs for FTP and the importance of offering them all methods and support them to choose a method of their choice.

 

Designate a day for FDS marked for FTPs at UPHCs

Fixed day static/Family planning day (FDS)/Antaral diwas (spacing day) approach assures quality family planning services at a pre-fixed time known to the community. The Chief Medical Officer (CMO) can designate a day from FDS calendar to be marked as FTP FDS day. A medical/facility in-charge can also request permission to conduct FTP FDS. In accordance mobilize community and ensure facility readiness. In addition, facilities can be decorated to appeal young adolescents. In facility readiness, ensure that counselling services are offered in person to maintain confidentiality.

Learn more about how to organize FDS.

 

Inaugurate FTP activity in a new city

In a new facility or a city where a ‘Special FDS for first-time parents’ if is being done for the first time then getting this inaugurated from the Chief Medical Officer (CMO) can garner attention from neighboring facilities, local media and boost the morale of that particular UPHC staff.

 

Roles and Responsibilities

Role
Responsibility
Joint Director/Additional Director
  • Include FTP as an agenda in the NUHM/FP review/Divisional review meeting.
  • Review the progress of work for FTP in NUHM/FP review meeting/Divisional review meeting.
  • Issue guidance to all the cities to refer this FTP tool as one of the guidance documents to increase improved contraceptive use among FTPs.

CMHO/CDMO/CMO

 

  • Participate/ensure participation in the CCW.
  • Issue a directive to UPHCs to conduct WSO.
  • Issue a directive to designate one FDS for FTPs.
  • Proactively plan and organize FDS for FTPs by taking all necessary measures into account in the district.
  • Issue directive to train facility staff on service provision and counselling on all methods.
  • Proactively engage with DQAC for quality assurance of UPHCs.
  • Monitor quality and outputs of each FDS for FTPs.
CMS 
  • Establish FDS/ FPD teams.
  • Supervise facility readiness.
  • Ensure that informed choice and method-specific counseling is done as per guidelines.
  • Ensure that clients are appropriately screened. In case, they are not eligible for their preferred method, clients should be counseled about other appropriate contraceptive alternatively.

 

Nodal Officer-Urban Health and FP

 

  • Lead in planning and organizing FDS for FTPs in the district.
  • Lead in organizing WSO for all UPHCs.
  • Manage the FDS/ FPD operations including team deployment and logistics.
  • Coordinate and oversee all quality parameters and work as an interface between district leadership and facilities.
  • Ensure smooth supply of commodities and supplies.
  • Monitor quality of FDS for FTPs and ensure data validation and reliability of collected data.
Medical Officer-In-Charge 
  • Develop FDS/FPD calendar.
  • Ensure supplies and commodities for FTP-FDS day and Supervise facility readiness.
  • Provide FP job aids, IEC material, supplies to ASHA.
  • Inform ASHA on the FTP-FDS schedule.
  • Release timely payment of ASHAs.
  • Ensure that clients are appropriately screened and that staff nurse offers informed-choice-counselling as per the government norms.
  • In case the client is not eligible for their preferred method, counsel them on other appropriate contraceptive alternatives.
  • Ensure that methods are provided with appropriate quality of care including recommended infection prevention practices.
  • Monitor the quality of FDS/FPD services and ensure correct reporting in HMIS.
ASHA, Mahila Arogya Samiti (MAS), NGO, Outreach Workers
  • Generate awareness and mobilize clients for family planning through home visits and group meetings.
  • Prepare prioritized client list and reach them before each FDS/FPD.
  • Use IEC materials to provide information to young adolescents and influencers about family planning and specific contraceptive methods.
  • Support post-procedure follow-up of clients.

Monitoring Benchmarks

  1. Number of FTPs identified by ASHA
  2. Number of FTPs reached by ASHA
  3. Number of FDS for FTPs organized
  4. Contraceptive uptake by FTP in each of the facilities
  5. Number of WSOs organized
  6. Number of meetings organized to influence non-users by users
  7. Number of one-to-one meetings with FTPs to brief them about benefits of family planning methods

Cost Elements

The elements required for ‘reaching FTPs and improving their contraceptive behavior’ are mentioned below along with their Program Implementation Plan (PIP) codes for easy reference. They may be covered under existing budget line items, but if not, they should be incorporated through the PIP in the next cycle. Besides, any additional support can also be sought from the flexi-pool.

Cost elements/PIP budget head FMR code
Demand generation, strengthening service delivery 1.1.3.2.1; 3.2.1
IEC, Mid Media, Mass Media 11.6.1; 11.6.3; 11.6.4; 11.6.5; 11.6.6
Inter personal communication U.11.3; 11.6.2
Necessary Kits, surgical equipment and supplies U.6.1.1 & U.6.1.2; 6.1.1.3.a till 6.1.1.3.f
Printing of FP manuals, guidelines 12.3.1 till 12.3.5
Training & capacity building, additional manpower U.8.1.8.1.2; U.9.5.1 till U.9.5.8; 3.1.2.5; 9.5.3.1; 9.5.3.1 till 9.9.3.27
POL for family planning/others (including additional mobility support to surgeon’s team if required) 2.2.1
Drop-back scheme 7.3
Quality assurance U.16.2.1; U 13.1.1 & U.13.2.1

Source: NHM PIP Guideline, 2018-19

Note – The table above is indicative and illustrates the manner in which cost elements are provided in a government PIP, thus giving guidance on where to look for elements related to a particular task.

Sustainability

AYSRH approaches can be sustained by organizing regular FDS for FTPs by ensuring all providers of the facility and community provide family planning services to young FTPs. Moreover, the rising demand amongst FTPs for family planning services will indicate sustenance of this approach.

Take An Assessment and Get a Certificate

Other India Program Areas