Scaling-up Access to Long-term Family Planning Methods in Northern Ethiopia

September 20, 2011 marks the one-year anniversary of Every Woman, Every Child, a global effort to achieve country-led commitments to bring life-saving health care to millions of women and children in the developing world by 2015. This series looks at maternal health in several countries with the highest number of maternal deaths every year. UNFPA, UNICEF, WHO, the World Bank and UNAIDS – known as the Health 4+ -- are supporting these countries to achieve their Global Strategy commitments.

ATAYE, Amhara Region, Ethiopia — On eve of Ethiopia's New Year (celebrated in mid-September), things are slow at the Ataye Health Centre. But Hanna Kelemework, clad in her white nurse's gown, is expecting clients to show up for family planning services on their way home after making some purchases for the holiday.

The just-ended Ethiopian year has seen a major increase in the utilization of long-acting family planning methods at the Ataye Health Centre, and Nurse Hanna is one of medical professionals providing services. The intra-uterine contraceptive device (IUCD), which can prevent pregnancy for 10-12 years, has now become the second most widely used long-acting family planning method at the health centre, after Implanon, a hormonal-based contraceptive that is implanted under the skin and works for about three years.

When IUCDs were offered at the clinic five years ago, only about 16 were requested for the whole year. But as word has spread about this method, which is cheap, reversible, safe and effective for most women, demand has increased. Now an average of 75 women are getting IUCDs every month.

Scaling up, and offering new contraceptive options

The surge in the provision and utilization of long-acting family planning methods at the Ataye Health Centre is part of the scale-up initiative the Ethiopian Government has been undertaking in recent years on these methods which UNFPA has been supporting through funds secured from the Global Programme to Enhance Reproductive Health Commodity Security.

Over the course of 2009, the Federal Ministry of Health implemented the Implanon scale-up initiative. Taking into account the early success in this initiative and the huge demand for long-acting family planning methods in Ethiopia, the Ministry then launched an IUCD scale-up initiative. Together, these initiatives are addressing the country's large unmet needs: According to the latest DHS data (2005), one in three married Ethiopian women would like to avoid or delay pregnancy, but is not using a modern contraceptive.

The Ataye Health Centre is applying a two-pronged approach in scaling up long-acting contraceptives. About 7,500 women in its catchment area come to the Health Center seeking services. Through an outreach programme, Nurse Hanna and her colleagues travel periodically to the four sub-centres and Health Posts to insert IUCDs. The outreach is coordinated with woreda (district) health officials, Community-Based Reproductive Health agents and Health Extension Workers working at the grassroots level.

Just 35, with six children, Haregnesh welcomes a break from childbearing

Most of the clients who are benefiting from IUCD are 35 years of age and older. Woizero Haregnesh Jafer is typical. She began childbearing early, giving birth to the first of her six children while she was just 17. Because she experienced side effects with shorter term, she opted for IUCD after counselling with Nurse Hanna. "I witnessed the difference in a within one month of getting the service; I now could eat very well and I see my menstruation regularly," says Woizero Haregnesh who has been on IUCD for one year now.

The income that Haregnesh's husband earns as a cobbler was barely enough to support their large family. Now, freed up from frequent clinic visits and the possibility of another mouth to feed, she has volunteered to speak to other women at local gatherings about her experience. "This is working for us very well as clients like Haregnesh are sending women to the Health Centre to benefit from the long-acting family planning methods," says Nurse Hanna.

Overcoming barriers to adoption of IUCDs

Still, IUCD use remains very low in Ethiopia — at about 2.1 per cent of all women. Lack of equipment and supplies, and trained service providers at public and private or NGO-run health facilities is one persistent barrier to the adoption of long-acting methods in this mostly rural country. Misconceptions about it are another.

The current initiative aims to address both issues. Nurse Hanna says most of her clients first came seeking short-term family planning methods. But offered different choices and sensitive counseling, they often switch to longer acting alternatives.

The scale-up initiative seeks to ensure that by 2015 all hospitals and health centres will be providing IUCD insertion and removal services as part of the comprehensive family planning services. Moreover, the initiative is looking at increasing the users of IUCD to a total of around 1.5 million women of reproductive age by the year 2015. Ultimately the IUCD initiative is going to be integrated into the ongoing family planning programming.

The effort Nurse Hanna and her colleagues are putting into the initiative is already heralding an early success for the long-term family planning method scale-up initiative. Not a single woman has come back to her Health Centre so far seeking removal.

-- Abraham Gelaw, UNFPA Ethiopia