Family Planning in a Rural Setting in Uganda: The USHAPE Initiative

Dr. Emily Clark

Royal College of General Practitioners | UK First-5 General Practitioner; Beyond Europe Lead, Junior International Committee

Dr. Clare Goodhart

Cambridge University | Senior Clinical Tutor (hon), General Practitioner, Trainer, Training Programme Director

Family planning and the Millennium Development Goals

Family planning and the Millennium Development Goals2

Background

Family planning can save lives. The total fertility rate in Uganda is 5.9 children per woman, higher than in neighbouring countries.1. Ugandan women are having, on average, 1.7 more children than they plan. At least one woman in the world dies every minute due to pregnancy and childbirth; the risk is 100 times greater in developing countries. Family planning prevents maternal deaths for a number of reasons:

  1. By delaying motherhood, because adolescents are twice as likely to die in childbirth; national statistics show that by 18-19 years, 77% of Ugandan girls are sexually active, and the teenage pregnancy rate in Uganda is 24%, the highest in Africa.3
  2. By helping women limit their family size and thereby avoid riskier pregnancies as they get older.
  3. By avoiding unwanted pregnancies, which lead women to undergo illegal and dangerous abortions. Up to 25% of maternal deaths are thought to be due to unsafe terminations of pregnancy.

Family planning also reduces infant mortality, because it is known that children born less than two years after their sibling are twice as likely to die.

USHAPE (Ugandan Sexual Health and Pastoral Education) is an initiative, run in conjunction with the Royal College of General Practitioners, delivering family planning and sexual health training and education in Uganda. Our work began at Bwindi Community Hospital in 2013, and we have since been awarded funding and support from the Tropical Health & Education Trust (THET), which has been a huge help in advancing our programs. We hope to offer lessons learned from our experiences in Uganda to inform the further development of USAID and WHO resources for family planning training. Bwindi Community Hospital was featured as a success story on the WHO Family Planning Training Resource Package website. Following the cascade model of training, in May 2015 the USHAPE initiative was taken to Kisiizi Hospital in rural southwest Uganda, where co-author Dr. Emily Clark volunteered with the Maternal and Newborn hub (Liverpool-Mulago Partnership) from January to July 2015. While at Kisiizi Hospital, Dr. Clark conducted the following study and interventions.

USHAPE training cascade model

The USHAPE cascade model involves training Ugandan trainers with the aim of future scale-up and long-term development.

Aims

  • Determine the rate of unmet need for family planning among women of reproductive age in the population local to Kisiizi Hospital.
  • Disseminate positive messages about modern contraception in an attempt to dispel fears and misconceptions and address the high rate of unmet need for family planning.
  • Use the successful USHAPE model.4 to train all health workers in family planning to a basic Level 1 and key staff to a higher Level 2, which is equivalent to the UK Diploma in Sexual and Reproductive Health.
  • Tackle some of the barriers to family planning, including the costs to women, at Kisiizi Hospital.
  • Work towards reducing the number of teenage pregnancies and the subsequent morbidity and mortality among these young mothers. In a predominantly Christian environment, abstinence is emphasised, but contrary to intuition, more comprehensive sexual health education delays the onset of sexual activity among youth.

 

implant practice

Dr. Emily Clark helps a student practice inserting an implant. 

Methods

  • Screening: 100 patients were screened in the outpatient department by being asked the following questions: “Are you on family planning? Do you want a child in the next two years?” If patients answered no to both of these, they were classed as having an unmet need for family planning.
  • Empowering staff: In April 2015, the authors and Sister Damari Kagaza, an enrolled nurse, went to Bwindi Community Hospital for basic Level 1 and higher Level 2 training. Damari was enthused and inspired by this training and helped to run the training at Kisiizi Hospital.
  • Level 1 training: The aim is to enhance every hospital staff member’s knowledge, so that the responsibility for family planning is not just left to the family planning nurse; the whole institution makes it part of their day to day work to screen for unmet need and offer brief intervention.
  • Level 2 training: This higher level of training up-skills clinicians to become family planning providers, with the necessary communication, educational, and practical skills.

implant insertion

Students learned the practical skills necessary for intrauterine coil and implant insertion, and had a chance to practice on real patients.

Results

  • The screening for unmet need for contraception revealed that 51% of clients at the Kisiizi Hospital outpatient clinic have an unmet need, which is higher than the national average of 38%.
  • In an average month, over 500 patients attend the antenatal clinic, yet only 15 patients visit the family planning clinic.
  • Barriers to uptake of family planning at Kisiizi include religious beliefs, fear of side effects, concern that family planning can cause HIV and cancer, fear of subsequent subfertility, and the high cost of services (for example, it costs 20,000 shillings for an implant, around £5).
  • 68 staff members at Kisiizi were trained to a basic level by attending four hours of training. This included medical, midwifery, surgical, and nursing staff as well as support staff. Even more staff attended the first session, an overview of why family planning matters to us all—including managers, religious leaders, the dentist, and even the tailor!
  • A further 32 staff members have been trained to Level 2. These were nurses from maternity unit, antenatal clinic, surgical ward, medical ward, and diploma student nurses. In their own unpaid time, they attended 30 hours of training over five days, including sessions on anatomy and physiology, counselling, sensitive scenarios, talking to teenagers and men, cervical cancer, and in-depth knowledge of family planning methods. They learned the practical skills necessary for intrauterine coil and implant insertion, and had a chance to practice on real patients. They all had to give a community education talk, and all managed to pass a rigorous written exam.
  • In addition, the management at Kisiizi have agreed to support family planning by making many methods free to members of the health insurance scheme and significantly reducing the costs of coils/implants.
  • Level 2 candidates helped put together a patient education film in the local language, Rukiga, for use in outpatient and HIV clinics.
  • Feedback was gained from Level 1 and 2 candidates as to their post-course confidence as well as the content and delivery of the course, which will shape future trainings.

 

Level 2 candidates

Successful Level 2 candidates.

Discussion

This “whole institution” approach to training has led to service improvement developments at Kisiizi Hospital. There have already been notable improvements, with 92 patients attending the family planning clinic during August 2015 compared to only 15 in March 2015. Our cascade model of training involves training Ugandan USHAPE trainers with the aim of future scale-up and long-term development. The aim is to reduce the unmet need for family planning at Kisiizi Hospital from 51% to 25% in three years.

The Level 2 candidates demonstrated that they now have the skills and confidence to teach in the community. More work is needed to create demand for services in the community, as well as for provision of family planning. There are further areas that can be developed, including youth-friendly services and engaging with male community members.

The authors have followed up the Level 2 candidates with semi-structured interviews and are supporting them in further development of practical skills, as well as advertising and sensitisation of the community.

Feedback from the Training

Level 1 feedback from a 19-year-old female student nurse: “The course of family planning has been interesting and encouraging to everyone, whether married or unmarried, so as to encourage everyone who has heard to teach all the people in the nation in order to prevent maternal and infant mortality.”

Level 2 feedback from a 28-year-old male surgical nurse: “The course was so wonderful and interesting. Above all it was educating. Thank you very much you people and may the Lord God bless you. This is just the beginning.”


1. The World Bank, databank, 2013

2. Cates Jr W. Family planning: the essential link to achieving all eight Millennium Development Goals. Contraception. 2010;81(6):460-61.

3. Stella Neema, Nakanyike Musisi and Richard Kibombo; Adolescent Sexual and Reproductive Health in Uganda: A Synthesis of Research Evidence, Occasional Report No. 14, 2004

4. Graffy J, Capewell SJ, Goodhart C, Rwamatware BM. Creating a whole institution approach to in-service training in sexual and reproductive health in Uganda. Journal of Family Planning and Reproductive Health Care 2015. http://jfprhc.bmj.com/content/early/2015/09/10/jfprhc-2014-100977.abstract

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