Expansion of Postpartum/Postabortion Contraceptive Services in Honduras

This 31-page study was motivated by the observation that, in Honduras, only 54% of deliveries are assisted by medical staff and 39% of deliveries take place at Ministry of Health of Honduras (MOH) health centres or hospitals. Further, studies indicate that by eliminating unwanted pregnancies, up to 25% of maternal deaths could be avoided in Honduras, and by spacing children, up to 25% of children's deaths could be avoided. A baseline diagnosis for this study showed that a great demand existed for contraceptive methods before discharge from the hospital (more than 30% of the women seen for a delivery or a complication due to abortion were interested in adopting a contraceptive method prior to discharge); further, only 35% of the women who had given birth had planned the pregnancy, and close to one-half said they would have preferred to wait longer or not become pregnant. However, "although the unmet need for family planning services is relatively high (11% of women) and family planning helps protect mothers' and children's health, hospitals in Honduras rarely offer postpartum/postabortion contraceptive services." It is in this context that the MOH, Population Council/FRONTIERS, and the Hospital Escuela collaborated, beginning in 1999, to train providers to offer family planning counselling and methods to postpartum and postabortion women in Honduras.

The intervention tested the strategy of using interpersonal communication and information, education, and communication (IEC) materials to increase knowledge and motivation for use of family planning methods following childbirth or treatment for incomplete abortion. Physicians, nurses, nurse auxiliaries, social workers, and educators in the Ob/Gyn wards attended a 30-hour workshop on service promotion and counselling in family planning. Then, 7 workshops were given (one in each of three hospitals and two in each of two hospitals) between December 1999 and April 2000. The following topics were reviewed in the workshops: 1) effective communication; 2) characteristics of good communication; 3) promotion, information, and counseling concepts; 4) a counsellor's qualities and characteristics; 5) informed consent and informed choice; 6) orientation and counselling techniques; 7) counselling needs of special populations. The workshop included the use of informed consent forms for intrauterine device (IUD) insertion and for voluntary surgical contraception (VSC), as well as the use of pamphlets, videos, and flipcharts to promote and provide family planning counselling. On average, the participants improved their knowledge scores by 21% between the training's pre- and post-tests. In a second phase, five 5-day courses on contraceptive methodology were given (one in each hospital) between April and July 2000.

Selected Findings:

• Among postpartum women, the proportion who received information about contraceptive methods during their hospital stay increased from 43% to 87%; the proportion who were offered a contraceptive method increased from 42% to 82%; the proportion who received a contraceptive method during their stay increased from 10% to 33%; and the proportion of women who had delivered and wanted a method before leaving the hospital but did not receive it decreased from 41% to 7%.
• Among the women who had been treated for an abortion (close to 10% of those who had delivered), the results were even better: information increased from 17% to 85%; offering of methods increased in the same proportion; acceptance of methods increased from 13% to 54%; and unmet need decreased from 48% to 21%. In both cases (postpartum as well as postabortion women), the main cause for unmet need was the impossibility of going through all the surgical sterilisation procedures asked for prior to discharge from the hospital.
• The mix of methods chosen became more diverse during the intervention. Postpartum
  women shifted from almost exclusive reliance on the IUD and voluntary sterilisation to greater use of temporary methods such as condoms and lactational amenorrhoea. Postabortion women shifted from voluntary sterilisation to a mix of sterilisation, injectables, or oral contraceptives.

"The main reasons for this success are attributed to the involvement of MOH managers in planning the activities and to the quarterly discussions of the monitoring surveys, which helped the providers focus their attention on the introduction and strengthening of services during an entire year. Finally, we recommend also training nurse auxiliaries in IUD insertion, since some hospitals care for an important proportion of deliveries." In short, the authors urge that regularly scheduled collection and presentation of data be included in the project design, so that opportunities are presented to recognise progress and seek solutions to problems. Participation on the part of both management and providers is key. Based on the success of this model at the five hospitals, the U.S. Agency for International Development (USAID) provided support to EngenderHealth for the continued expansion of the model to five additional hospitals in Honduras.

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