Improving Family Planning Counseling Through Task Shifting and Use of Mobile Technology

The Problem

There is a large unmet need for postpartum family planning in Kenya. As in other parts of the world, most Kenyan women who give birth do not want to have another baby in the two years following delivery, yet 90 percent of those who are 0 to 3 months postpartum and 68 percent of those who are 12 months postpartum have unmet needs for contraception. Meeting these needs could substantially increase contraceptive prevalence, and reduce unintended pregnancies and short birth intervals, which pose substantial health risks to mothers and babies. Key barriers to postpartum contraceptive use include lack of awareness about pregnancy risk after delivery, as well as myths and misconceptions about contraception. Family planning counseling could address these information needs, but is often not provided in the antenatal and postpartum period—and postpartum counseling, when offered, can vary in quality. Information shared about contraceptives is often too detailed, which makes it difficult for women to retain key messages and make informed decisions.

The Solution

Jacaranda is modifying its service delivery model and leveraging mobile technology to increase uptake and continuation of postpartum family planning. Jacaranda wants to ensure that all pregnant and postpartum women visiting its health facilities receive high quality counseling on postpartum family planning. To accomplish this, it has incorporated family planning education throughout its antenatal care, delivery, postnatal care, and child wellness services. It has also engaged in “task shifting”—that is, it has transitioned certain family planning counseling functions from overburdened nurses to patient care assistants (PCAs), who are trained and provided with job aids to ensure they provide high quality care. To support continuation of postpartum contraceptive use, Jacaranda also developed and launched a mobile text-messaging-based outreach system, which sends additional family planning information to clients, and features a call-back mechanism clients can use to ask nurses to contact them by phone to answer follow-up questions.

The Strategy

Task Shifting of family planning counseling:

• Incorporating family planning into maternal health service delivery. Jacaranda has started to provide family planning counseling and services during antenatal care visits, upon discharge after delivery, and during postnatal care visits and child wellness visits.
• Shifting family planning responsibilities from nurses to other health workers. Jacaranda sought to transition as many components of family planning counseling as possible to PCAs, so nurses would be responsible only for more complex guidance and provision of contraceptives. Jacaranda trained PCAs on an adapted version of the Balanced Counseling Strategy (BCS), a counseling protocol that uses standardized job aids and an algorithm to guide family planning decision-making during provider-client interactions. Jacaranda also trained PCA “champions” to provide group-level counseling at community- and facility-based outreach events.
• Text messaging to encourage continuous use of contraceptives. During their postnatal care visit, clients who choose to start a contraceptive method can sign up for a six-week mobile outreach service. Those who enroll are sent customized text messages that provide (1) information on method-specific side effects, and (2) reminders for follow-up appointments. Text messages also have a built-in call-back function—women can reply to the text message and request a phone counseling session with a nurse.
• Research and dissemination. Jacaranda has collected preliminary data to track the effects of the family planning integration and text messaging interventions. Women Deliver and Jacaranda identified key implementation results and lessons learned and developed targeted advocacy messages, disseminated through Women Deliver’s “Celebrate Solutions” platform and partners, to encourage replication of project efforts.

I like how personal the messages are and how you feel welcomed to the program.
The messages were also so helpful in reminding me how to use injectables the right way so that I don’t become pregnant.

—Jacaranda client

Achievements

Integrating family planning into maternal health care delivery and shifting family planning counseling to PCAs have increased client receipt of counseling and uptake of postpartum contraception. Postpartum family planning counseling has been integrated into postpartum care services and transitioned to PCAs. As a result, more than 70 percent of Jacaranda delivery clients report receiving postpartum family planning counseling, compared with 30 percent of women delivering at nearby facilities. Survey data collected by Jacaranda also show increased use of modern contraceptives, particularly long-acting reversible contraception, at nine weeks postpartum following the introduction of postpartum family planning counseling by PCAs.

Preliminary findings from the text messaging pilot show an increase in perceived quality of family planning services. Clients who received text messages were more likely to have heard all key family planning counseling messages (such as how to use the method, what to do if problems arise, and the availability of alternative methods) than those who only received in-person family planning counseling. They were also more likely to rate facilities highly on six measures of quality of care (including privacy of care and availability of opportunities to ask questions), and were less likely to report having unaddressed concerns about family planning.

Shifting family planning counseling from nurses to PCAs has generated interest from public-sector partners. The public sector became interested in Jacaranda’s task-shifting effort because nurses at government clinics are similarly overburdened with tasks that can be easily transitioned to lower-level providers. Jacaranda is drawing on the trainings and lessons from this project to design a quality improvement toolkit for its public-sector partners.

Challenges

Space constraints at facilities limited opportunities for task shifting. Jacaranda had originally planned to use both PCAs and community health workers (CHWs) to provide individual family planning counseling in the continuum of maternal health care. However, bringing additional non-nursing staff, such as CHWs, into facilities with limited space was not feasible. Eventually, Jacaranda focused its task shifting efforts only on PCAs, who were trained to provide individual counseling to delivery and postpartum care clients, and group counseling to antenatal care clients to supplement individual counseling nurses provided.

Clients were confused by some elements of the text messaging platform. A number of clients who participated in the pilot wanted to respond to the text messages they received from Jacaranda, but they were unclear about how to use the platform, in particular how to respond to short codes and how much time they had to respond. Jacaranda plans to explain how to use the system in greater detail during its next round of client recruitment, and also provide a practical demonstration.

Key Learnings

Providing more information on side effects can lead to greater reporting of symptoms. Preliminary findings suggest that women who received text messages, which focused on method-specific side effects, were more likely to report experiencing these symptoms. Although these women did not reduce use of contraceptives, there is some evidence that they switched contraceptive methods more often. It is important to consider the potential unintended consequences of providing information on side effects, such as discontinuation, if alternative methods are not readily available.

Skilled providers are needed for follow-up counseling requests. Jacaranda had originally considered training CHWs to respond to call-back requests from clients who received text messages and had questions about their selected contraceptive method. If CHWs were unable to provide the necessary information, nurses would respond. However, Jacaranda found that follow-up calls were typically from clients experiencing severe side effects, and their concerns were best addressed by nurses.

Next Steps

Jacaranda will continue to pursue task shifting of care processes to PCAs, expanding the role of PCAs to other components of maternal health care service delivery. It is also conducting a randomized controlled trial (RCT) to evaluate the effectiveness of the text messaging platform, in partnership with the University of California, San Francisco and the Harvard School of Public Health. Jacaranda will work with Women Deliver to disseminate findings from the RCT, as well as other evidence and learnings generated under the project.