1

ImprovingMaternal Health

through Postpartum

Family Planning

MINISTRY OF HEALTH

2

MUBENDE

YUMBE

ARUA

OYAM

GULU

KATAKWI

KAABONG

MOROTO

NAKAPIRIPIRIT

ABIM

KOTIDO

KITGUM

AMUDAT

BUNDIBUGYO

KANUNGU

REPUBLIC OF SOUTH SUDAN

KENYA

TANZANIA

DEMOCRATICREPUBLIC OF CONGO

N

S

EW

Target Districts

UNFPA TARGET DISTRICTS

3

4

FOREWORDUganda’s reproductive health and family planning landscape has changed dramatically over the past five years. We have seen impressive efforts geared towards strengthening health systems to deliver quality reproductive health services, increased commitment to ensure reproductive health and family planning (RH/FP) commodity security, and additional efforts to train health workers to provide a wide range of family planning methods to women who wish to delay, space or limit their pregnancies.

Uganda still has a long way to go in ensuring that the unmet need for family planning is greatly reduced. The country has one of the world’s youngest populations and faces unique challenges in meeting

these adolescents’ health needs, including their sexual and reproductive health. We need to enable our health providers and health care system to be responsive to the needs of our young population.

Our partnership with Jhpiego on the “Capacity Building for Family Planning Providers” project has resulted in 439 health workers being equipped with cutting-edge skills to deliver quality family planning (FP) services and 160 health facilities receiving the necessary equipment to provide long-acting reversible contraceptives including the postpartum intrauterine device in the 15 United Nations Population Fund (UNFPA) target districts1. 1 UNFPA target districts for this project included Mubende, Katakwi, Abim, Amudat, Nakapiripirit, Moroto, Kotido, Kaabong, Oyam, Gulu, Kitgum, Bundibugyo, Kanungu, Arua and Yumbe.

5

Additionally, we worked with 18 midwifery insti-tutions to revise their family planning curriculum to include postpartum family planning so that new midwives will be competent in this strategy upon graduation. These activities have contributed toward achieving 80,190 couple years of protection over 12 months.

This success story book highlights the investments made through the work of Jhpiego, the Ugandan Ministry of Health, and 15 district local governments. These stories provide evidence to build upon and scale up what this project has started. It is critical that Uganda continues to tap into these resources and build RH/FP competent communities that will tackle reproductive health challenges, especially for young people.

On behalf of the Ministry of Health, I would like to express our appreciation to UNFPA for providing financial resources that have made it possible for us to extend these critical services to the women and families of Uganda. We look forward to continued partnership with Jhpiego and other development partners as we work to increase access to family planning services.

Prof. Anthony MbonyeDirector Clinic and Community ServicesMinistry of Health - Uganda

6

The government of Uganda is dedicated to improving access to and utilization of family planning services. The five-year National Development Plan (2010/11–2014/15) acknowledges that limited access to family planning (FP) services hinders overall development of society in general and women in particular. One of the goals outlined in the plan is to reduce unmet need for family planning by ensuring access to FP services, especially in rural areas.

FP services are the range of informational and medical interventions that allow women to decide if, when, and how to grow their families. They include counseling, administration of a family planning method, and follow-up care. Postpartum family planning (PPFP) is a service delivery strategy that expands access to family planning through integration within the

existing continuum of maternal, newborn and child health services. To effectively deliver PPFP services health care providers must be trained to provide tailored counseling and correct information on all family planning methods, including long-acting reversible contraceptives (LARCs), a category of family planning methods which provide extended protection from pregnancy (between 1 – 10 years dependent upon the method) and can be removed when a women wishes.

With support from the United Nations Population Fund (UNFPA), over a one and a half year period, Jhpiego worked with the Ugandan Ministry of Health to strengthen the capacity of health care providers in 15 target districts and future midwives from 18 institutions to deliver high-quality postpartum

OVERVIEW

777

Our partnership with Jhpiego and UNFPA has been fundamental in ensuring an increase of highly skilled health workers offering family planning services. Our

hope at the ministry is that this capacity building program is scaled up to all referral hospitals and health centers country-wide, so that we have many more women accessing postpartum family planning.”

- Dr. Mihayo Placid, Family Planning Focal Person, MOH

8

family planning services with an emphasis on the immediate postpartum period (0-48 hours after delivery).

During the project implementation, Jhpiego used three capacity building approaches:

1. Train providers from the Antenatal Care (ANC) and labor/delivery units to deliver PPFP services, including the administration of LARCs with a special focus on the PPIUD.

2. Train providers from the existing health center and hospital FP units to deliver PPFP services, including the administration of LARCs with a special focus on the PPIUD.

3. Revise FP planning curriculum to include PPFP service provision, including the administration

of LARCs with a special focus on the PPIUD, and build the capacity of midwifery teachers, tutors, preceptors and clinical training sites to offer this pre-service training to current and future midwifery students.

In addition to building health worker capacity, Jhpiego delivered training and medical equipment to the health centers, hospitals, and training institutions so that health care providers and students can continue to practice and perfect their skills after the project.

Finally, recognizing the importance of demand generation for PPFP services to their success as an intervention, Jhpiego trained and provided supportive supervision for members of village health teams (VHTs) from the 15 target districts. These VHTs

9

are now empowered to promote PPFP services at a community level and refer women interested in receiving these services to health care workers who can provide additional counseling and administer a FP method.

This comprehensive project, has provided training and tools for communities, health centers, hospitals, and training institutions to increase access to FP planning services, especially PPFP services, for Ugandan women. The stories captured in this booklet highlight the different strategies and interventions employed in this project and provide evidence for their future scale-up.

9

80,190 COUPLE YEARS OF PROTECTION

THO

USA

ND

160 HealthFacilities reached

15 districts

10

114 health care providers trained on

PPIUD.

11

According to Uganda’s Demographic and Health Survey (DHS), contraceptive prevalence for modern contraceptives in Uganda moved from 14% in 2000–01 to 17.9% in 2006 and to 25.9% in 2011. As women increasingly seek FP services it is important that they have access to a wide-range of methods that fit their varied desires and needs. Jhpiego, with support from UNFPA, trained 631 current health care providers at 160 health facilities in 15 districts to provide PPFP services, including counseling on and the administration of LARCs.

Jhpiego’s training reached beyond the classroom to ensure that health care workers were empowered provide services at the facilities where they work and that they have a local resource for follow up

questions. First Jhpiego trained two “trainers of trainers” from each district in FP service provision. Then, with support from Jhpiego, these trainers led training for other health workers from facilities in their district. In these trainings the health care workers developed their skills and knowledge through classroom-based training and practice on humanistic models. Finally, Jhpiego conducted supportive supervision visits to the trainees’ health facilities to continue training and identify barriers to FP service provision.

Following these trainings, the 15 target districts have reported 80,190 couple years protection have been achieved and 694 PPIUDs have been inserted.

EMPOWERING HEALTH WORKERS TO PROVIDE PPFP SERVICES, WITH AN EMPHASIS ON LONG-ACTING METHODS

12

My first encounter with Jhpiego’s clinical training on PPIUD was last year and it has been very good for me and my colleagues. We had been offering family planning services

like use of contraceptive pills, injectables and to a small extent IUDs. We are currently pushing for the PPIUD method because we have realized that many women are now able to space their children. We have gone on to mentor other providers in health centers in Arua and constantly supervise them to ensure they are providing these services effectively. We hope that next time we can target VHTs in order to reach more women in communities who are not able to come to the health centers.””

- Jane Angucia, Nursing officer, Arua Regional Referral Hospital

1313

14

15

Training current health care workers to provide PPFP alone will not address Uganda’s growing demand for FP services. To provide for the future provision of services both within the 15 target districts where current health care workers were trained and also throughout Uganda, Jhpiego, with support from UNFPA, worked with the Ugandan Ministry of Health and 18 midwifery institutions to revise the FP curricula across the country to include PPFP services, including the administration of LARCs.

Beyond revising the curricula, Jhpiego trained 118 tutors, clinical instructors and preceptors in maternal and newborn health updates, PPFP, and effective teaching and clinical skills training to improve the quality of education that midwifery students receive in PPFP. Additionally, Jhpiego provided humanistic

models and medical equipment to the midwifery institutions which will enable their students to practice the methods and skills they learn in the classroom.

This support and investment in the education of midwifery students supports graduates so that they have the knowledge and skills to provide quality PPFP services to Ugandan women.

SUPPORTING PRE-SERVICE TRAINING FOR MIDWIFERY INSTITUTIONS

To date, 18 midwifery schools have

participated in thepre-service training.

16

“Jhpiego Uganda has provided us with equipment and models that enable us to give practical lessons to our students. Initially, we only taught about family planning in theory and our students only practiced what was taught when they went to the field. We can now offer practical lessons at schools and all midwifery students are required to do a placement in health center IIIs and IVs before graduation. This reinforces their training and confidence to offering family planning services”

- Tumwesigye Richard, Tutor, Nyakibale School of Nursing, Rukungiri.

“We ensure that the midwifery course is mandatory for all students at the nursing school, so that there can be an increase of health care providers equipped with knowledge and skills in family planning. Theoretical study and clinical experience cover all aspects of antenatal, labor, postnatal and neonatal care. We are happy that Jhpiego Uganda provided us with the PPIUD kits, ‘Mama U’ and ‘Mama Natalie’ models. These tools enhance learner experience especially when our students go for clinical training.”

- Ogarubo Mary, Tutor, Lira School of Comprehensive Nursing, Lira

17

18

19

In order to retain their newly acquired skills and knowledge, health workers must have the tools and resources to continue practicing after training. To facilitate this continuing education, Jhpiego, with support from UNFPA, purchased the same humanistic models used during training and distributed them to districts and midwifery institutions so that providers and students can continue to perfect their abilities.

Additionally, Jhpiego identified that health facilities lacked the specialized forceps to insert the PPIUD. To fill this gap, Jhpiego, with support from UNFPA, purchased and distributed 755 PPIUD kits containing the reusable forceps and other materials necessary for PPIUD administration to all of the health facilities and midwifery institutions that it trained providers

at during this project. Without these tools providers would have been unable to insert the PPIUD and women would have continued to lack access to this innovative family planning method.

EQUIPPING HEALTH CENTERS TO PROVIDE FAMILY PLANNING SERVICES

“Jhpiego Uganda has been very instrumental in building capacity of our health workers and moved a step further to provide the necessary tools required to provide family planning services effectively. Initially, family planning services were only available at the regional referral and district hospitals, health center IVs but now we have scaled them up to health center IIIs with at least one health care provider trained in long-acting and reversible methods.”

- Dr. Sebudde Stephen, DHO Kanungu

20

160 health facilities &

18 midwifery schools were equipped with PPIUD kits for

continuous practice as a means of buiding on the competences and health confidence of health providers.

21

22

Training current and future health care workers is critical to expanding access to FP services; however, women must also be made aware of the different FP services and methods available to them. To build this knowledge within communities, Jhpiego trained 154 village health team members to inform women of their FP service options, including PPFP and LARCs, and where they can access them. So far 694 PPIUDs have been inserted, suggesting that women are receiving information about its availability and are following up with health care workers for counseling and insertion.

MAKING THE CHOICE TO ADOPT A LONG-ACTING FAMILY PLANNING METHOD

23

Akwiya Consi, is a 30 year old mother of seven, married to a polygamous husband. Over a year ago, her husband who had been living with his second wife came home unexpectedly, and she remembered that she had no protection whatsoever. Knowing that her husband was against family planning, she snuck away from him and rushed to the health center to talk to a nurse about available contraceptive options. She did not know that her husband had followed her to see why she had gone to see the nurse. He was very upset and asked her to leave immediately-threating to divorce her if she used any family planning method. Distraught and feeling desperate, she went back home and promised herself to return to the health center a few days later. She didn’t. She discovered she was pregnant a month later and had her 7th baby in early 2015.

23

694women provided with PPIUD

services across the 15 target districts.

“During my antenatal trips at Angaya health center III in Gulu, the midwife advised me to try the PPIUD family planning which would offer me protection from unwanted pregnancies and my husband would not know about it. She counseled me and as soon as I delivered my baby, the PPIUD was inserted. I am delighted to say that it has not given me any problems and as a farmer, I am now able to work all year round, tend to my crops and sell my produce. I can now afford to take care of my children better,” says Consi.

24

“I am happiest when I get couples coming for antenatal together, I give them all the information I can on family planning and encourage them to adopt a family planning method. We always encourage these men to talk to their fellow men when they are in the bar or church so they feel free to come to the health center with their partners and access family planning services.”

- Koriang Mariam, Midwife, Moroto Regional Referral Hospital

158

VHTs trained in PPFP advocacy and linking to

service delivery points.

25

26

ACKNOWLEDGEMENTS

Jhpiego would like to thank all partners for their contributions which made this project a success. Special thanks go to the health workers in the facilities and training institutions we worked with to achieve our project goals. We appreciate the Government of Uganda through the Ministry of Health for their continued guidance and the United Nations Population Fund for their financial support.

We greatly appreciate the individuals who agreed to share their personal stories and photographs for this publication.

CONTACT: EMILY KATARIKAWE, COUNTRY DIRECTOR, JPHIEGO - UGANDAPROGRAM IMPLEMENTATION: TONNY KAPSANDUI AND JOSEPHINE NABUKEERA

Jhpiego @jhpiego

uganda.countryoffice@jhpiego.org

27

“I“am blessed to have been trained by Jhpiego on the PPIUD. The best part for me is the use of practical tools and kits that enhance our learning ability.”

- Amono Jennifer, Senor Nursing Officer-Midwifery, Gulu

Regional Referral Hospital

28

Jhpiego—an affiliate of Johns Hopkins UniversityPlot 36, Lower Naguru, East roadKampala, UgandaTel: 0393 202 937www.jhpiego.orgwww.facebook.com/Jhpiego