PRB

(August 2011) Around the globe, family planning has been integrated with maternal and child health services for some years, even decades. In countries where integration is a key element of the health system, birth rates have fallen as more women have been able to avoid unintended pregnancies. As a result, population growth has slowed and certain countries have been able to accelerate economic progress and lift more people out of poverty. However, for women who are pregnant or have recently given birth, unmet need for family planning is still high. But a number of challenges face the integration of services, including resistance to change from government leaders and society in general.

In the case of Russia, John Snow, Inc. overcame such obstacles to implement a comprehensive family planning and maternal child health project, now managed by an autonomous nongovernmental organization, the Institute for Family Health. In a PRB Discuss Online, Natalia Vartapetova, chief of party, Institutionalizing Best Practices in Maternal and Child Health Project in the Russian Federation, JSI; and Asta-Maria Kenney, senior advisor, JSI, answered questions from participants about how JSI overcame resistance to family planning in Russia.

Aug. 25, 2011 NOON (EDT)

Transcript of Questions and Answers

Mia Foreman: The historical perspective of the JSI Russia case study is quite interesting! Thank you for sharing. It has been 4 years since the case study “Russia: Integrating Family Planning into the Health System” was published. Can you please update us on the current health status within the ten regions that are implementing or have implemented the Maternal and Child Health Initiative? What are the current abortion rates? What is the CPR? MMR and IMR? Have you seen a vast improvement in these regions since this case study was published?
Asta-Maria Kenney: Given the vast size of the Russian Federation and the urgent need to modernize FP/MCH practices across such a huge country, each new project takes us to new regions and we no longer maintain as close contact as we would wish with some of the pioneers—and do not collect data from them on a regular basis. We do, however, have some data about how five of the early oblasts (regions) are progressing at three points in time (2004, 2006, and 2009).

These data come from surveys of pregnant and postpartum women about their use of modern contraception before their pregnancy:

We also have official abortion rates (abortions/1,000 women aged 15-49) for the period 2003–2009 for 10 regions that participated in the first Maternal & Child Initiative (2003–2006). Please note, however, that these regions received minimal support from the project after 2006.

Both sets of data are encouraging and indicate that the project’s impact outlasted the project life! Data on maternal and infant mortality are considered highly sensitive in Russia, so they are hard to obtain and must be used with caution.

J Kishore: Family Planning and Maternal and Child health services are integrated for a long time in India. However, contraceptive use and use of permanent methods is not improved substantially. Male participation remains the lowest. Do you think that better strategic and innovative program are required to achieve goal for population control.
Asta-Maria Kenney: Not being familiar with the Indian context, it is hard for us to comment on your situation. In Russia, the concern is not population control but exactly the opposite: how to reverse the sharp population declines of the past couple of decades. The challenge in Russia is how to help the government—which has a strong pronatalist policy, including substantial payments for childbirth—recognize that most countries of the world support FP as an important health measure as well as because couples should be able to freely determine their family size. In fact, there is significant evidence that in developed countries where fertility is already low, improving/expanding FP encourages couples to switch from abortion to contraception, while having little or no impact on fertility.

Dramani Mahama: 1) Please how were you able to overcome resistance to family planning in Russia? 2) Who did you use to achieve the goal of overcoming resistance to family planning in Russia? 3) How much resources did you use for the integration of family planning and maternal/child health services in Russia?
Natalia Vartapetova: There were three key approaches to reduce resistance to family planning: (1) education of medical workers, primary OBGNs and midwives on the latest evidences and FP methods; (2) education of decision makers (government and community leaders) on the advantages of FP including church leaders on abortion prevention; (3) communication campaigns and information for women and men. Education activities do not cost much but unfortunately quite often neglected.

Issa Almasarweh: 1) Does a country with a negative population growth rate like Russia need to strengthen its family planning services? 2) Does Russia need a technical assistance from John Snow and funding from USAID?
Natalia Vartapetova: 1) Yes, Russia needs to strengthen FP services and programs as far as abortion rate and prevalence of STIs and HIV are still high as well as number of unwanted abandoned babies. 2) JSI and USAID-funded projects bring the latest knowledge and scientific evidence to Russian health care as well as modern training approaches and skills. Unfortunately currently Russian medical workers for various reasons have very limited opportunities to get new information and skills. USAID and JSI support is very important for improving quality of care for women and children in Russia.

Cecily Westermann: Some countries—including Russia—have attained the status of “negative population growth.” For many reasons, including conservation of resources, it would be best if other countries also achieved this status. How does one present “negative population growth” as an asset? Thank you.
Natalia Vartapetova: In Russia authorities are very concerned about a small size of the population taking into account Russia geographic territory. We cannot promote “negative population growth” as “an asset” but can explain this fact as a logical consequence of a new technological era that changing people’s lives, opportunities and priorities.

Laurentiu Stan: A reality of former Eastern Europe health system of Semashko type is that services are provided through parallel networks of providers. In your case, what were the MCH service delivery places were FP was most successfully integrated? Which were the key messages and approaches facilitating such integration?
Asta-Maria Kenney: Over the more than decade-long lifespan of the Russia projects, FP has been most successfully integrated into maternity hospitals and women’s consultations (outpatient clinics serving women), largely because most project interventions have been focused on these facilities. Other sites include pediatric polyclinics, HIV centers and STI dispensaries. Some partner oblasts (regions) have also had considerable success in integrating FP into rural health care: family doctors and general practitioners’ offices and FAPs (nurse practitioner/midwife points.) Family planning information has also been integrated on a small scale into pharmacies and into social services in a few oblasts. Given the sensitivities of FP in Russia, our core approach has been what we call “horizontal integration,” which refers to including FP into other health services, most significantly, maternal and child health care: antenatal care, breastfeeding and postpartum care (both in the hospital and at the later postpartum visit.) The most successful messages were: (1) For health workers: FP is an integral part of maternal and child health services, contributing to reduced maternal and infant mortality; (2) For health workers and the public: contraception is a better alternative to abortion; this addressed the widespread use of abortion as the main means of fertility control, despite most women’s profound dislike of obtaining repeat abortions; (3) For health workers and the public: modern contraception is safe and effective; this message addressed the deeply-held views, dating back to Soviet times, that contraception is dangerous to health and not very effective in preventing pregnancy.

Terry Hull: Integration of family planning with MCH would seem to be part of the issue, but what about the broader integration of reproductive and sexual health issues across the lifespan. Is Russia doing anything on these?
Natalia Vartapetova: We are working a lot now on integrating and incorporating reproductive and sexual health in healthy life context. Health promotion programs are very popular in Russia and get a significant attention and support from the Federal and regional governments. We use all available evidence to present and promote importance of reproductive and sexual health programs to decrease morbidity and mortality and improve quality of life.

Richard Cincotta: Among the U.S. public health community, many were surprised by the poor quality of health care and particularly MCH/FP services in Russia. Some argue that services declined in quality with the fall of communism. Others argue that these services improved very little since the early 1980s. How far back can one trace Russia’s MCH/FP problems? And how has this legacy affected your project?
Natalia Vartapetova: One can get trends of abortion, maternal and infant mortality rates back to 1970s. The most significant decrease has happened after 2000. You can check WHO Global Health Observatory to see the trends. In the project regions improvements have been more visible even initially they had higher rates than the Russia average.

Soumya: Social issues surrounding abortion, as well as penalties for abortion providers and women who undergo abortions, restrict access to PAC services even when legal. Whether such incidence are also common in Russia? If so, is Russia doing anything on these?
Asta-Maria Kenney: Abortion has been legal in Russia for many years. Along with IUDs, it was the the major method of fertility control. So abortion rates have traditionally been high and there is no stigma associated with abortion. Thus the obstacles you cite really haven’t been a big issue. Rather, the challenge is to integrate counseling and modern contraceptive care with abortion services, to help women avoid another unintended pregnancy.

Mia Foreman: After reading the JSI case study and learning more about this project, it is apparent to me that this is a well designed and excellent example of FP/MCH integration. We know it is difficult to replicate this exact model in other countries that work within different health systems and under different circumstances. At the same time, since we have a wide audience from across the globe participating in this forum, could you share with us key elements of the project that were needed to design and implement such a successful program that perhaps others can adapt?
Asta-Maria Kenney: Thank you for your kind comments! There were very many elements, but probably the most crucial ones were: (1) starting in pilot sites to fine-tune interventions and demonstrate results and, later, scaling up; (2) using Evidence-Based Medicine to convince health workers of the safety and efficacy of FP; (3) a highly participatory process that allowed counterparts to discuss evidence, ask questions, share concerns and adapt material to the Russian context; (4) working on policy at the same time as working to improve service delivery, since it is risky in Russia to practice in ways inconsistent with policy; (5) building cadres of leaders and advocates in each oblast (region) who expanded the reach of the project’s work; (6) educating and empowering the public at the same time as strengthening health services.

Karin Ringheim: Hello Asta-Maria and Natalia, thank you for providing your expertise on this topic. Knowing that integration of family planning and maternal and child health services was extensively researched in the late 1960s and early 1970s, and found to be successful in averting unwanted pregnancies, I’m interested in your views on why integrated services did not become the norm in the Soviet Union and much of the developing world? What factors stood in the way of what appears to be common sense? Thank you.
Natalia Vartapetova: The Soviet health care system was built on the approach that any health problem could be successfully solved only by a high specialized service. That is why it consisted of a number vertical medical professional services and experienced a significant lack of modern public health approach.

Cynthia Buckley: In March of this year, meetings were held with various religious leaders in the Russian Federation on population issues across the former Soviet Union and the problem of abortion. Led by officials of the Orthodox Church, the meetings generated a list of four recommendations to curb reliance upon abortion: 1) Public policies supporting motherhood and children, 2) Using traditional religions to raise public perceptions of the value of family, 3) Use of mass media to encourage marital fidelity and discourage abortions, and 4) Propaganda for healthy lifestyles, and creating a positive image for large families among youth. At no point in the records from the meeting (or in my research—dozens of other similar meetings) was the importance of family planning or reproductive health education mentioned for sustaining healthy families, or as a potentially effective means to decrease the demand for abortion. How has the religious community within the Russian Federation been integrated into the development and roll out of your comprehensive family planning and maternal child health program? What strategies proved most effective for engaging the religious community for either John Snow International or the Institute for Family Health? www.mospat.ru/en/2011/03/05/news37284/
Natalia Vartapetova: Russian Orthodox Church is often politically visible in Russia but is far from the real life in many regions. In some regions the Church was a good partner in developing reproductive health programs in the frame of the regional community committees. Russian is a multicultural and multiconfessional country and Muslim leaders have been quite supportive in promoting modern reproductive health in some regions as well.

Laurentiu Stan: Have you considered integrating FP into abortion departments? If yes, may you describe the process and which messages, materials, strategies, and methods you used? May you share any specific lessons learned that can be applied in other EE countries with similar health systems; e.g. Ukraine.
Natalia Vartapetova: The project actively worked with gynecological/abortion departments. The main strategies and lessons learned are: provide FP counseling after (not before) the abortion procedure; ensure good quality of the counseling; integrate FP into broader comprehensive post-abortion care messages; give women information materials to take home. Our data shows that repeated abortions rate in the project regions has fallen 1.7 times.

Cletus Tindana: For some countries, family planning and maternal/child health services have always been together and the advantages cannot be over emphasized as compared to running a parallel system. Why has it taken Russia all these years to start integrating these services? What are some of the advantages derived in the parallel system?
Asta-Maria Kenney: The Soviet health system was always very vertical and specialized. Consequently, when FP was introduced, a separate, but very tiny FP system was established. Probably partly because it wasn’t very well integrated with MCH (or other) services, and for a variety of political reasons, it didn’t “take off.” What our projects did was “mainstream” FP into MCH care—and to some extent into AIDS services and pediatric care—which put them into an appropriate context. The results are encouraging—if not yet everything we might have hoped for!

Lena Kolyada: Have you engaged private sector (private doctors, pharma, etc.) in the integration process. If yes, could you please share how?
Natalia Vartapetova: There are still quite a few private health care providers in Russia. People mostly use public services. We involved pharmaceutical producers in promotion of family planning. There were three directions where this collaboration was especially successful: training of health providers, printing and dissemination of education materials for providers and printing and dissemination information materials for clients.

Yuba Raj Tripathi: What kind of population policy is applied in Russia at present for the better MCH? How?
Natalia Vartapetova: The government tries to stimulate fertility through various incentives like a 3-year maternal leave and so called maternal capital for child education or housing. The government also put significant amount of resources into development of modern perinatal services across Russia to make maternal care safer and more attractive for clients.

Laurentiu Stan: Is very well known that Russia and other countries in Eastern Europe displays a relatively high rate of abortions. Do you have any results showing how and why the integration of FP with MCH services contributed to reduction of unwanted pregnancies and abortions?
Natalia Vartapetova: In the project regions percent of antenatal clients who reported that pregnancy was not planned decreased from 33 percent in 2004 to 22 percent in 2009.

Asta-Maria Kenney: Please see our response to Mia Foreman’s question concerning CPR and abortion rates. We have data from other project sites, but they cover short time periods, while the data above look at trends beyond the life of the project, so they are particularly compelling. Unfortunately, we did not collect data on unwanted pregnancies.

Priyanka Dixit: 1) In developing countries, is the relation between utilization of antenatal care and institutional delivery and further institutional delivery and child immunization services causal? 2) Do women who receive maternal care services have improved adoption of contraceptive use, in terms of duration and type of method?
Asta-Maria Kenney: Use of antenatal care and hospital deliveries are virtually universal in the Russian Federation. Childhood immunization and the schedule for infant care is well integrated into the woman’s postpartum visits as well as into home visits afterwards. As for the second question, there is very limited data available about contraceptive use in Russia as a whole. However, at the sites where the project has worked, postpartum contraceptive use has improved and women get better counseling about their contraceptive options.

Linda Ippolito: Congratulations Asta and Natalia for very informative session, and all the best with the continuation of these important initiatives.