Helping Egyptian Women Achieve Optimal Birth Spacing Intervals through Fostering Linkages between Family Planning and Maternal/Child Health Services

This report explores a research intervention designed to support Egyptian women in achieving healthier birth intervals, i.e. a birth-to-conception interval of at least two years. The Population Council's United States Agency for International Development (USAID)-funded Frontiers in Reproductive Health (FRONTIERS) programme, in collaboration with the Egyptian Ministry of Health and Population (MOHP) and the non-governmental organisation (NGO) Social Planning, Analysis and Administration Consultants (SPAAC), conducted an operations research study to measure the acceptability and effectiveness of two birth spacing message models.

The two strategies being evaluated here are:

For Model I (health services model), birth spacing messages were communicated through services by health workers to women during prenatal and postpartum periods.

• Birth spacing messages were provided low parity pregnant women during prenatal care visits in the third trimester. Messages included duration of healthy birth intervals, advantages of birth spacing, effective use of lactational amenorrhoea method (LAM), and importance of the 40th day postpartum visit. Joint home visits to postpartum women by the maternal and child health (MCH) nurse and the Raedat Rifiyat (RRs - FP outreach workers) on day 2, day 4, day 7, day 21, and day 30-35. (Existing MOHP protocols require five postpartum home visits by the MCH nurse and one visit by the RRs before the 40th day postpartum). During those visits the nurse and RR gave health education and birth spacing messages. On day 40, a woman received comprehensive MCH and family planning (FP) care and counselling. Quarterly home visits by the RR to women in the extended postpartum period (12 months after delivery) were designed to educate the mother about infant nutrition and health, support the mother's use of contraception, and answer any questions related to FP.
• Existing Information, education, and communication (IEC) materials were used to enhance messages on birth spacing and postpartum use of contraception. These included a birth spacing poster, a flipchart for RRs to use during home visits, a flier on breastfeeding, and a flier on postpartum use of contraception after the first child. Two additional IEC materials were developed specifically for this project: a wall chart showing services to be offered to the mother and newborn at the day 40 postpartum visit, and a birth spacing flier encouraging 3-5 year birth spacing, providing criteria for effective use of LAM, and listing postpartum methods of contraception.

Model II (community awareness model) provided this service plus an awareness-raising component that reached out to men through training community influentials to communicate messages.

• A two-day orientation workshop was offered to community leaders in villages where community awareness activities for men were to be undertaken. Community influentials included religious leaders, school teachers, village Omdas (chiefs), agriculture extension workers (AEWs), and clinic auxiliary staff who are known to play an active role in their communities. Workshop participants were introduced to concepts of birth spacing and male responsibility for the health of their wives and children, and learned about postpartum FP methods and the importance of antenatal and postpartum visits and communication skills. Community leaders then conducted seminars, one-on-one meetings, and informal gatherings for husbands to enhance their knowledge of birth spacing and to solicit their support for postpartum use of contraception. Additionally, MOHP communication officers organised periodic seminars for men where different MCH issues, including birth spacing, were discussed. The unit doctor and local religious leaders (Moslem and Christian) were also expected to attend those meetings, where relevant brochures and fliers were to be handed out to participants.

The study used an experimental design in 6 health districts, 3 from each governorate of Assiut and Sohag in Upper Egypt. One district in each governorate was randomly assigned to implement Model I, Model II, or to serve as a control site by providing standard care only. Sources of data for this study included: exit and home interviews with low parity pregnant women at 4 months and 10-11 months postpartum (a total of 1,416 women); structured interviews with physicians, nurses, and FP outreach workers; (3) in-depth interviews with local MOHP managers and supervisors; (4) focus group discussions (FGDs) with community influentials; (5) FGDs with husbands of low parity women; and (6) service statistics on utilisation of MCH and family planning services.

Providing birth spacing messages to low parity women during antenatal and postpartum care, and also to husbands through community awareness activities, was found to be feasible and acceptable. Both models proved effective in changing women's knowledge and attitudes towards birth spacing and in enhancing use of contraception at 10-11 months postpartum, by 48% among Model I mothers and 43% among Model II mothers, compared with 31% among control group mothers. Furthermore, over the postpartum period, women in the two intervention groups used contraception more consistently than women in the control group - median duration of protection against pregnancy was 6.8 months for Model I mothers, 4.5 months for Model II mothers, and 2.9 months for control group mothers. Finally, both intervention models were associated with an increased utilisation of services, especially FP services, by women who only had one child (36% increase in Model I clinics, 47% increase in Model II clinics, and 3.2% in control clinics).

However, a fear of contraceptive side effects continues to be a major concern among women and men in all groups and is an obstacle in achieving healthy birth intervals. "Programs promoting birth spacing should include services to help women cope with side-effects and to allay concerns about effects of family planning methods on women's health and subsequent fertility."

"It is interesting to note that although contraceptive use reported among women in group II was not higher than in group I, service statistics showed a substantial increase in the proportion of FP clients with one child in Model II clinics. This could be attributed to a gradual gain in momentum of Model II interventions and awareness-raising activities, reaching a larger audience over time and impacting contraceptive use among other (and more) low parity women in the community."

Selected policy recommendations included in the report:

• Messages on birth spacing and postpartum contraception should be an integral component of antenatal care services for low parity women. Women who come for antenatal care in the third trimester should, at a minimum, receive the following information: advantages of delaying the next pregnancy for 2-3 years, postpartum FP methods, criteria for effective use of LAM, and importance of the 40th day visit.
• The postpartum home visits protocol should be revised to include fewer and more effective visits by the MCH nurse and RR. The roles of MCH and RR and messages to be given by each should be clearly defined to avoid duplication and/or redundancy of messages.
• Services provided on the mother's day 40 postpartum visit should be combined with health services for the newborn. This would enhance utilisation of both services and save time. It may also be worthwhile to move up the first postpartum family planning visit to the 30th day, and combine it with the first well-baby visit.
• Health providers should receive adequate training on the management of contraceptive side effects. Also, clients who receive FP methods should be given information that clearly mentions expected side effects and addresses misconceptions related to their chosen method. This information can also be shared with concerned members of their families.
• A mechanism for providing support to contraceptive users should be developed in order to help them cope with contraceptive side effects, and possible pressure from husband and mothers-in-law. Quarterly home visits by RRs in the extended postpartum period could serve that purpose.
• The effectiveness of community seminars could be enhanced by selecting good role models as speakers for the seminars and also, embedding birth spacing messages within the broader context of family health. Local businessmen or NGOs could assist in making the seminars more attractive to men by providing refreshments or snacks for participants or offering prizes to those who answer questions correctly.
• Awareness-raising seminars for husbands should be supported by far-reaching channels of communication such as mass media and print materials, to recruit optimum number of participants. Seminar messages for men should specifically highlight: the importance of birth spacing for 2-3 years, the religious perspective on birth spacing, the value of the girl child, and the safety of FP methods.
  

The study results have been widely disseminated in the two study governorates and have been shared with senior MOHP officials, cooperating agencies (CAs), donors, and researchers. Birth spacing messages have been integrated into service delivery guidelines for antenatal and postpartum care. Discussions are underway with MOHP officials to enhance the effectiveness of the day 40 postpartum visit, by providing more MCH services along with FP services on that visit.