Improving Access to Long-Acting Improving Access to Long-Acting Contraceptives in JordanContraceptives in Jordan

Situation, Issues, and RecommendedSituation, Issues, and Recommended

ActionsActions

Dr Ruwaida RashidMOH / WCHD Director

2011

Topics

1. Situation of family planning methods use in Jordan.

2. Interventions to improve access to long acting contraceptives in Jordan.

Jordan Contraceptives Logistic System. Improving Access to IUDs at MCH Centers. Introducing Long Acting Hormonal Methods (Implants)

in the Jordan Contraceptives Logistic System. Family Planning Sentinel Surveillance at MCH Centers.

3. Recommended Actions.

1 . Situation of family planning methods use in Jordan.

Current Use of Family Planning Methods and Method Mix / 2009

Trends in the Use of Modern Family Planning Methods(%)

Trends in Current Use of Family Planning Methods

Percentage of currently married women 15-49 using any method

59

6

Contraceptive Discontinuation 2009

Main Reason for Discontinuation

35

17

13

12

9

4

2

2

Wanted to become pregnant

Became pregnant while using

Wanted more effective method

Side effects

Health concerns

Infrequent sex/husband away

Husband disapproved

Inconvenient to use

Impact of Changing Method Mix Impact of Changing Method Mix on Jordan’s TFRon Jordan’s TFR

Indicator

Scenario ACurrent Method Mix remains constant at

2009 level

Scenario B50% of Traditional

Method users shifts to Modern Methods)%(

Average Method Effectiveness 0.83 0.89

Modern CPR)%( 40.50 49.15

CYP 345,000 417,000

Unintended Pregnancies 82,000 50,000

Births 171,000 156,000

TFR 3.80 3.45

Method Mix Issues in Jordan

• Fear of side effects• Provider bias• Provider availability (female provider)• User preferences• Availability of financial resources• Quality of counseling services (practices &

space)

22 . .Interventions to improve access to Interventions to improve access to long-acting contraceptiveslong-acting contraceptives

in Jordan in Jordan

Jordan Contraceptive Logistic Jordan Contraceptive Logistic System (JCLS)System (JCLS)

No Products………… No programs►Established in 1997 at MoH. All contraceptives

were provided by USAID.

►In 2005, USAID started to phase out and completed in 2009. MoH started to purchase all contraceptives.

►A budget item in MoH budget is specified for contraceptives procurement in 2011.

FP Methods Available in Jordan FP Methods Available in Jordan Contraceptive Logistic SystemContraceptive Logistic System

• Pills (combined and estrogen only pills).• IUDs (copper T).• Injectables (3 months ).• Implant (one rod).• Male condoms.

Programs Under Jordan Programs Under Jordan Contraceptive Logistic SystemContraceptive Logistic System

• Ministry of Health (health centers and hospitals) • Royal Medical Services.• UNRWA Clinics.• Jordan Association for Family Planning and

Protection.• Governmental universities hospitals.• Private sector clinics through PSP project .• Other NGOs

Total of 662 clinics provided with contraceptives for free.

Method Mix at at MoH-2010

Method Mix for the whole Method Mix for the whole System-2010System-2010

60%14.60%

21.40%

2.60% 1.40%

IUDs

Condoms

Pills

DMPA

Implanon

Contribution of Partners under Contribution of Partners under the System to CYP - 2010the System to CYP - 2010

Important Issues Related to Important Issues Related to JCLS JCLS

New choices of contraceptives methods should be added to the system. some of the barriers are:

• Concerns regarding stock out ,over stock, when adding different brands of combined oral pills to the system.

• Limited brands of oral pills (COCs ,POPs) and types of contraceptives registered at JFDA.

Limited market for family planning methods in Jordan.

Long and complicated procurement procedures.

Improving Access to Intra Uterine Devices (IUDs) at MCH Clinics

► IUD is a long term, effective, and well accepted family planning method in Jordan. However, access to this method is limited due to shortage of female providers.

MoH Pilot Project on IUDs Insertion by Midwives

► Objective : Improve Access to IUD Services at MoH Primary Health Care Level.

► Started in 2003 and continued successfully until 2009.

► 182 midwives at MCH centers were trained to offer IUD insertion service and permitted to provide the services.

► Results :• No significant complications were reported.

NUMBER OF HEALTH CENTERS PROVIDING IUD SERVICES 2003-2009

100119

142

167 175 182 193

0

50

100

150

200

2003 2004 2005 2006 2007 2008 2009

.n

175

PERCENTAGE OF IUDs INSERTED BY MIDWIVES 2004-2010

19.824.8

29

3742.8

46.5

39

0

10

20

30

40

50

2004 2005 2006 2007 2008 2009 2010

.n

► ►Policy Change Policy Change Recently, the Minister of Health approved adding Recently, the Minister of Health approved adding

the “task of IUD insertion under physician’s the “task of IUD insertion under physician’s supervision” in job description for midwivessupervision” in job description for midwives..

Introducing Long Acting Hormonal Methods-Implants- in Jordan

Contraceptives Logistics System

► Why Implants ??• Effective and long acting.• Acceptable from male physician providers.• Expand choices of contraceptives.

►Implants was introduced in Jordan Contraceptive Logistic system in 2006 in cooperation with Organon in a limited scale (two training courses).

►►In cooperation with HSSIn cooperation with HSS2,2, a core of 13 trainers a core of 13 trainers were trained in 2010, then several training courses were trained in 2010, then several training courses were conducted.were conducted.

►►Currently, Currently, - - Total number of trained physicians: 94 Total number of trained physicians: 94 (from MOH, JAFPP, RMS) (from MOH, JAFPP, RMS) - - Number of health facilities providing implants: 48 Number of health facilities providing implants: 48 (at MOH, RMS) (at MOH, RMS)

►►IssuesIssues• High over turn of trained health providers.

• Limited promotional activities towards Implants.

• The need for assessment of acceptance, side effects, and discontinuation of implants.

Family Planning Sentinel Surveillance

at MCH Clinics

Established in cooperation with HSS project for discontinuation of combined pills and IUDs using prospective study design.

Contraceptive Discontinuation Rate (%) by Reason and Method-(2009-2010)

Reason

Discontinuation Rate

Pills IUDs

Method failure 1.5 1.1

Desire to become pregnant 10.2 2.2

Switched to another method 18.6 6.6

Other reasons 12.2 4.1

Total 42 14

Reason IUD Pills Total

% % %

Method failure 6.2 4.5 5

Husband’s absence 3.5 4.5 4.3

Desire to become pregnant 19.5 26.2 24.3

Health reasons 8 9.8 9.3

Husband or others disapproval 4.4 3.5 3.8

Separation 0.9 1.7 1.5

Side effects 51.3 44.4 46.4

Other 6.2 5.2 5.5

Total 28.3 71.7 100

Percent Distribution of Contraceptive Discontinuation by

Reason

► ►Issues based on the resultsIssues based on the results

• High discontinuation rate especially among COCs users (although less than national rate).

• Most of discontinuers (42%) switch to another method mainly condom which is less effective.

• High % of IUD users (39%) switch to COCs which is short term, while 27% of COCs users switch to IUD which is long term.

• Side effects play a major role in discontinuation and switching.

3 .Recommended Actions

Recommended Actions

►Conduct an assessment of the feasibility and effectiveness of introducing new brands and varieties of pills to Jordan FP logistic system.

►Introduce new family planning methods to the Jordan FP logistic system.

►Simplify the procurement procedure of FP methods.

Recommended Actions

►Operationalize the Minister’s decision which approved adding IUDs insertion to midwife job description.

►Collect and analyze information on Implanon discontinuation rate, side effects, and acceptance, to be used as a tool for evidence based promotion for service providers.

►Strengthen FP communication activities on increasing demand for long-acting hormonal contraceptives, decreasing demand for traditional methods, and on birth spacing and limiting to promote appropriate method selection.

Recommended Actions

► Conduct an assessment of the family planning counseling services.

►Strengthen counseling services with focus on provision of special counseling and follow up for COCs users, and sufficient information and counseling on side effects and on most suitable methods for limiting and spacing.

Thank YouThank You