Family Health Intl Brief 7- Community-based Distribution of DMPA: The Matlab Project, Bangladesh

Publication date: 2007

BRIEF 7 Community-based Distribution of DMPA: The Matlab Project, Bangladesh KEY POINTS n Effective CBD of contraceptives, including injectables, in Bangladesh, focused on the needs of the individual client. Such programs were integrated into comprehensive reproductive health programs. n Injectable contraception has become extremely popular in Bangladesh, accounting for nearly half of all contraceptive use in some areas. n Surveys found better client satisfaction, better accessibility to services, more privacy, and better counseling in regions where CBD of injectable contraceptives was available than in control areas where it was not. SUMMARY In 1975, the government of Bangladesh, in collaboration with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), initiated community-based distribution (CBD) of condoms and oral contraceptives to 150 villages in the Matlab subdistrict. The injectable contraceptive depot- medroxyprogesterone acetate (DMPA or Depo-Provera) was made available in only six villages to assess its effect on the program. In 1977, the program was modified to make DMPA available in all participating villages and to improve the training and supervision of local providers – changes that substantially increased contraceptive acceptance and almost doubled the one-year contraceptive continuation rate. By early 1979, DMPA had replaced oral contraceptives as the most popular method, accounting for roughly half of all contraceptive use. CBD of contraceptives was successfully expanded to the Abhoynagar and Sirajganj subdistricts in 1984, more than doubling the regions’ contraceptive use, in general, and increasing injectable use, in particular, from 0.1 percent to 25 percent. CBD of contraceptives was further expanded to eight more subdistricts in 1993. Despite some flaws in provision by CBD workers, surveys found better counseling, accessibility, and client satisfaction in regions where CBD of injectable contraceptives was available. The Family Planning-Health Services Project of 1977 In 1975, the Matlab contraceptive distribution program offered home delivery of condoms and oral contraceptives in 150 villages. The 1975 program increased contraceptive use from 1.0 percent to 17.9 percent after just three months. However, over a two-year period, use fell to 11 percent because of high discontinuation rates and poor recruitment of new users. The Matlab contraceptive distribution program was followed in 1977 by the Family Planning-Health Services Project (FPHSP), which was introduced to 70 villages, with a total population of 80,000. Priority was placed on a client-focused approach. Female village health workers (VHWs) were trained to counsel clients on family planning; to provide condoms, oral contraceptives, vaginal foaming tablets, and DMPA; and to refer clients to services available at regional clinics. VHWs further enhanced the value of their service by delivering maternal and child health care, offering counseling and information on proper nutrition, and providing iron and folic acid tablets and tetanus immunizations. Increasing the role of DMPA Compared with the original 1975 program, the FPHSP substantially improved the one-year contraceptive acceptance rate and nearly doubled the one-year continuation rate. Acceptance was further improved at 18 months, with only a small decline in the continuation rate. The number of eligible women (married, ages 15 to 44 years) using contraception rose from 6.9 percent in 1977 to 33.5 percent in 1979. The FPHSP also altered the pattern of contraceptive use in Matlab, with DMPA replacing oral contraceptives as the method of choice. By April 1979, DMPA accounted for half of all contraceptive use in the study area. Expanding on the Matlab successes Based on the success of the Matlab project, similar programs were initiated in 1984 in the subdistricts of Abhoynagar and Sirajganj. By 1991, contraceptive use had increased from 21 percent to 47 percent in Abhoynagar and from 11 percent to 41 percent in Sirajganj. Notably, the use of injectable contraceptives increased from 0.1 percent at program initiation to 25 percent over the next eight years. Following this success, CBD of contraceptives was further expanded to an additional eight subdistricts in 1993. Program assessment and evaluation The Bangladesh Family Planning Programme continued to assess its CBD of injectable contraceptives. It monitored acceptance, discontinuation rates, and client satisfaction and consequently adapted the mechanisms and procedures for its CBD programs. In 1997, the ICDDR,B produced a comprehensive assessment of Bangladesh’s health and family planning program based on lessons learned from 1982 to 1996. Examples of some of the issues raised follow. Village health workers In the initial Matlab project, contraceptives were distributed and counseling provided by female VHWs who were elderly, widowed, and illiterate. In the far more successful FPHSP, female VHWs had at least a sixth-grade education, were married with children, and had personal contraceptive experience. More highly trained and qualified VHWs with a comprehensive understanding of the program – in particular, of contraceptive technologies – were better able to counsel and support clients. By the early 1990s, workers providing comprehensive reproductive health services (including contraceptives and counseling on maternal and child health) were required to have secondary school certificates. Of note, VHWs felt pride and satisfaction in being able to deliver injectable contraceptives, because doing so increased their credibility in the community. Safety of injections Infections after injections were extremely rare in the FPHSP. A 1994 study on program monitoring showed that providers maintained a “no touch” technique in more than 90 percent of injections. In almost all cases, cotton with spirit or savlon was used to disinfect injection sites. In the vast majority of cases, providers washed their hands with soap and water before giving injections. However, a problem was noted in the frequency with which providers checked drug expiration dates. A 1994 workshop on CBD of injectable contraceptives also noted concern over inadequate knowledge about and facilities for disposing of used syringes and needles. Discontinuation Most discontinuations of injectable contraceptives were due to three major side effects related to bleeding disturbances: amenorrhea, excessive menstrual bleeding, and spotting. This is consistent with findings in other countries. Counseling Some flaws in provider counseling on injectable contraception were noted. More than a third of providers did not refer to follow-up checklists used in the project. While most of the clients were told about side effects, only about a third were told about the signs of complications related to injectable contraceptives. Despite these counseling shortcomings, surveys found better client satisfaction, better accessibility to services, greater confidence in the method, more privacy, better counseling, and superior management of side effects in regions where CBD of injectable contraceptives was available than in control areas where it was not. Current provision of DMPA In the past 10 years, the Bangladesh Family Planning Programme has further evolved. To serve more clients and curb costs, it has begun to shift from conventional door-to-door family planning services to static (fixed) site-based service delivery. In urban areas, family planning services are moving to clinics; in rural areas, more women are visiting and receiving services at static sites in their communities, known as cluster spots. The willingness of women (after decades of doorstep provision) to visit static sites outside their homes reflects in part the success of Bangladesh’s 35-year-old family planning efforts. Not only are women more comfortable now leaving home to obtain services, but also studies have found that the shift to service delivery at static sites has not lowered contraceptive prevalence. In fact, in rural areas, contraceptive prevalence and DMPA use have increased. Meanwhile, the program has decreased the cost of providing services. References Ashraf A, Ahmed S, Phillips JF. The example of doorstep injectables. In Barkat-e-Khuda, Kane TT, Phillips JF, eds. Improving the Bangladesh Health and Family Planning Programme. Lessons Learned through Operations Research. Monograph No. 5. Dhaka, Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh, 1997. Bangladesh Demographic and Health Survey 1999-2000. Dhaka, Bangladesh: National Institute of Population Research and Training, 2001. Bhatia S, Mosley WH, Faruque ASG, et al. The Matlab Family Planning-Health Services Project. Stud Fam Plann 1980;11:202-12. International Centre for Diarrhoeal Research, Bangladesh. Workshop on injectable contraceptives. Glimpse Newsletter 1994;16:3-4. John Hopkins Center for Communication Programs. New era for injectables. Popul Reports 1995;23(2). Available: www.infoforhealth.org/pr/k5edsum.shtml. Rahman M, Mosley WH, Kahn AR, et al. Contraceptive distribution in Bangladesh: some lessons learned. Stud Fam Plann 1980;11:191-201. Routh S, Ashraf A, Stoeckel J, et al. Consequences of the shift from domiciliary distribution to site-based family planning services in Bangladesh. Int Fam Plann Perspect 2001;27:82-89. Available: www.guttmacher.org/pubs/journals/2708201.html. This brief was produced by the Ministry of Health and its collaborating partners with technical assistance from Family Health International's CRTU program. Financial assistance for the work was provided by the US Agency for International Development (USAID). The contents do not necessarily reflect USAID policy. For more information or additional copies, please contact: Head, Reproductive Health Division, Ministry of Health Uganda Plot 6 Lourdel Rd, Wandegeya P.O. Box 7272 Kampala Uganda Tel: 256-41-340884 Fax: 256-41-340887 E-mail: info@health.go.ug or Project Director, Family Health International Plot 35, John Babiiha (Acacia) Avenue P.O. Box 4553 Kampala, Uganda Tel: 256-312-244-730 E-mail: publications@fhi.org January 2007

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