Promoting Healthy Timing and Spacing of Births in India through a Community-based Approach

This 32-page report details an operations research (OR) study carried out in India to assess the feasibility and effectiveness of using behaviour change communication (BCC) as a strategy for promoting the lactational amenorrhoea method (LAM) and postpartum contraception among pregnant women with a parity of zero or one. Funded by the United States Agency for International Development (USAID), the study is a collaborative undertaking by the Population Council's Frontiers in Reproductive Health Program (FRONTIERS), the Lala Lajpat Rai Medical College, Meerut, and the District Directorates of the Health and Family Welfare and Department of Women and Child Development. These partners were motivated by the observation that the Indian Family Welfare Program has failed to educate people about the importance of using contraceptive methods for spacing births rather than adopting sterilisation after having children in quick succession. This was found to be true in rural areas of the Meerut district, located in the western part of Uttar Pradesh, where the study was to be carried out. According to the authors of this report, "it is globally recognized that Healthy Timing and Spacing of Pregnancy (HTSP) is an important family planning intervention to improve maternal and child health - the focal points of the Millennium Development Goals (MDGs) 4 and 5."

In this context, researchers began in July and August 2006 by carrying out baseline data collection as well as a formative study that included focus group discussions (FGDs) held with newly married and first-time-parent men and women, mothers-in-law, community leaders, and family planning providers. In addition, 30 in-depth interviews of newly married and first-time-parent men and women were conducted. Based on the findings of the formative study, simple, unambiguous messages on the risks of early- and short-spaced pregnancies and the benefits of maintaining at least a 3-year interval between births were developed. These messages were then incorporated into a series of communications products including: 4 types of posters, 3 wall paintings at strategic village locations, a pocket counselling guide for providers (which also served as an information booklet for the women and their family members), and leaflets on temporary family planning methods (intrauterine device [IUD], condom, and pills) developed by the State Innovations in Family Planning Services Project Agency (SIFPSA). The intended audience pre-tested all of these information, education, and communication (IEC) materials and counselling aids, evaluating the clarity of the messages, use of words, cultural acceptability, familiarity of the audience with the context, relevance, layout, use of pictures, typeface, and colours.

The educational campaign was implemented by 267 community workers (CWs) who - having been divided into groups of 25 trainees - were first reoriented in pre- and post-natal care, LAM, and postpartum contraception, and then trained in counselling skills to manage young couples' reproductive health needs and use job aids to make their counselling more effective. All teaching materials were written on large (3 ft x 2.5 ft) sheets, and those were used as a flipchart during the training, which consisted of both classroom and role-play sessions. According to the authors of this report, "[r]ole plays by the workers acting as the pregnant women, a CW, and a mother-in-law were not only entertaining but also showed the problems they would face in the households and how they could manage such situations and explain the topics amicably and patiently." Researchers point to the importance of inter-sectoral coordination in this training exercise, since the CWs hailed from 2 different ministries (the Ministry of Health and Family Welfare (MoH&FW), and the Integrated Child Development Services (ICDS) of the Department of Women and Child Development). The authors claim that "[c]oordination and support among the district authorities of the two departments and among the village level CWs was enhanced to create a synergic effect in their educational efforts." A printed work register was given to CWs to ensure systematic coverage of all relevant topics during counseling and to support their supervisors' monitoring work."

Having been trained and then provided with a printed work register to ensure systematic coverage of all relevant topics during counselling, CWs visited each eligible woman individually to explain postpartum care, including LAM and postpartum contraception. As part of these visits, the CWs gave each woman a printed, pocket-sized HTSP booklet, instructing her to share it with her husband and mother-in-law. As another example of this interpersonal communication strategy, pregnant women and older women were invited to attend group meetings at the Anganwadi centre (a government-sponsored child-and-mother-care centre). To raise awareness among men, group meetings were organised among husbands, community elders, and the Pradhan (village leader). This approach was designed to raise the community's awareness about the risks associated with closely spaced pregnancies and to stress why postpartum contraception is important. During the first male group meeting in each of the study villages, the HTSP booklet was made available; attendees were encouraged to take one.

In addition to qualitative findings from the formative research (which highlight social constructs and pressures that influence young couples' early reproductive lives), quantitative findings are outlined in detail. Here are a selected few:

• At baseline, counselling on postpartum care and contraception, besides other topics, was reported by less than 6% of the couples. At the 9-month postpartum follow-up interview, a significant increase was found in counselling on all topics in the experimental areas compared to the control areas.
• Eighty-eight percent of the women from the experimental area received the booklet on HTSP and reported reading it. Of those who received the booklet, 89% showed it to their husbands, and 49% of that group shared it with their mothers-in-law. According to researchers, sharing the booklet with the husband also created an opportunity to discuss planning for the next child and using a contraceptive.
• Knowledge of spacing methods increased significantly in the experimental areas compared to the control areas. For instance, knowledge that an IUD could protect against pregnancy for up to 10 years increased from less than 1% at baseline to 46% at the 9-month postpartum follow-up. This knowledge remained at less than 5% in the control area. Eighty-four percent of women in the experimental area could state that an IUD is placed in the uterus and discuss the correct use of oral contraceptive pills (OCPs). Similarly, increases in knowledge about contraceptive methods were observed among men in the experimental area compared to the control area.
• At the 9-month postpartum follow-up, 62% of the women in experimental sites used modern contraceptives, and 22% used LAM at 4 months postpartum, compared to 31% and 0%, respectively, in the control group. The condom was the main method used (44% in the experimental area and 23% in the control area). Of the 22% of women who used LAM as a contraceptive, 68% transitioned to a modern contraceptive.

Researchers claim that the study showed the following:

• "The BCC model developed to promote HTSP was effective in promoting LAM and postpartum contraception and could be rolled out easily.
• Misconceptions about the return of fertility and its links to the biological marker of the menstrual cycle are the main barriers in a timely beginning of postpartum contraception.
• Acceptance of CWs in a family increases if counseling focuses on HTSP and its benefits to mother, child, and family.
• The complementing effort by CWs of two Ministries to achieve similar objectives is feasible and provides a synergistic effect.
• The BCC materials, counseling aids, and messages developed for the projects are ready to use in scaling up the program."

Central points to emerge for those considering replicating this model:

1. Qualitative research had revealed that not all messages are equally attractive to all the key audiences: the woman, her husband, and her mother-in-law. While all support delay of next child, the reasons and importance of the reason varied by intended audiences. In response to this finding, when organisers talked with different audiences, they shared the information which they would like to hear most.
2. Supportive supervision of the work was an important component of the intervention; organisers oriented the supervisors of the CW as to how they could be more useful to the CW and how their performance could be improved. The goal was to assist the supervisors in changing the style and procedure of supervision to make it more effective, rather than to simply increase the number of visits and intensify supervision input - strategies that organisers have found to be generally not sustainable.
3. Inter-sectoral coordination can be fostered by working with district-level authorities and showing them how an integrated approach at the field level could contribute to the objectives of both departments. It is useful to linking the project activities with their programme objectives and achievements. In addition, offering a regular briefing to both departments on the progress of work and involving them to improve the work was found to help in sustaining their support and interest in the interventions. In the process, organisers build their capacity to see how these interventions could help their own programme. A component of technical assistance (TA) is critical to help district authorities create conditions for scale-up.

The key message to emerge from this study is that young couples indeed want to delay their next pregnancy. But figuring out how to develop and deliver messages tailored to particular families and/or communities is a challenge. Here is where an effective and well-planned communication strategy becomes crucial.