"This technical brief describes the E2A Project [Evidence to Action for Strengthened Family Planning (FP) and Reproductive Health Services for Women and Girls Project]’s interventions for first-time mothers in Shinyanga District (of Shinyanga Region), Tanzania, from July 2015 to September 2016. The interventions, implemented as part of Pathfinder International’s ongoing community-based family planning program in Shinyanga, drew on lessons learned from Pathfinder’s previous interventions for first-time parents in India, Uganda, and Burkina Faso. The interventions were designed to intervene at all levels of the socio-ecological model: individual, community, and structural."
As part of E2A’s work focused on building experience and evidence on the practical 'how to' of implementing first-time parents (FTP) programmes, this documentation of a Pathfinder International project with young women and mothers in Tanzania focuses on strategies building on previous Pathfinder programmes. "These programs have shown that targeted FTP interventions can reduce young first-time mothers’ social isolation and increase their knowledge of and access to sexual and reproductive health services..." to increase contraceptive use and promote healthy timing and spacing of pregnancies (HTSP).
With 33.1% of unmarried adolescents and young women using contraceptives and a decline to 13.3% among married 15-19 year-olds, Tanzania, specifically the rural and largely Catholic community of Shingana, presented "inadequate health infrastructure, significant challenges to FP service delivery, and sociocultural issues that impede women’s access to FP services."
The three-pronged E2A approach for the individual and structural levels with objectives that included:
- "Improve facility-based providers’ insertion and removal skills for long-acting reversible contraception (LARC)...
- Improve the capacity of community health workers (CHWs) to create demand for and increase access to a comprehensive package of quality services, information, and counseling on HTSP among first-time mothers.
- Create an enabling environment and sustainable conditions for provision of FP services..." for young mothers through the Village Development Committee, community engagement of key leaders, and strengthening referral linkages between facilities and CHWs.
- "Strengthen coordination of systematic mobile outreach services by district and regional health authorities to enhance coverage and optimize utilization of resources, including integrating FP/SRH services with immunization days.
- Support documentation and dissemination of FTP intervention strategies and contribute to scale-up within the district, region, and beyond."
The individual level strategies used small groups monthly meetings and peer leadership selected by CHWs for meeting with the community "to develop knowledge and skills related to HTSP, FP, SRH (sexual and reproductive health), positive parenting skills, gender-equitable relationships, and human rights." Peer leaders sought out young mothers and invited them to meetings where peer groups could connect with nutrition counseling, prevention of mother-to-child HIV transmission, HIV counseling and testing, and gender-based violence services. Capacity building of CHWs for home visits included sharing information with couples and key influencers in the household about contraception, HTSP, and encouraging couples communication on FP.
At the community level, strategies were implemented to increase demand, including: advocacy meetings with community leaders and immunisation outreach.
At the structural level, E2A built capacity of facility-based providers to offer a broad contraceptive method mix, including LARC, training 40 health providers at 39 facilities. It also trained "the 40 providers on the mobile phone-based balanced counseling strategy employed by E2A/Pathfinder’s community-based FP project in Shinyanga so that they could supervise the CHWs and follow up." And the project also coordinated mobile outreach at district and regional levels.
Evidence was gathered using questions from ExpandNet's "Beginning with the end in mind (BWEIM) framework." From focus groups discussions (FGDs) and key information interviews (KIIs) with various key project implementers at three points in time, the process documentation team assessed 12 recommendations outlined in the BWEIM framework in order to: correct information of the peer leaders; support CHWs to engage young mothers, parents, family, partners, and in-laws; correct stock outs, and address provider perceptions. "Eighteen FGDs were conducted with frontline implementers, including health service providers, CHWs, and peer leaders, and eight KIIs were conducted with Pathfinder staff, and regional and district Ministry of Health (MOH) representatives..." which provided time for reflection, critical thinking, and joint problem-solving.
Results showed an increase in demand for service provision and appreciation for training received by CHWs and service providers. Lessons and recommendations from project results include the following:
- "Test the inclusion of peer groups for young men in intervention strategies.
- Ensure peer leaders have sufficient support to lead small peer groups.
- Consider incorporation of income generating activities into small peer groups.
- Address inhibitive social norms through engagement of family members.
- Tailor messages for young married and unmarried women and girls.
- Ensure FP services meet the needs of first-time mothers, with a focus on confidentiality of services and inclusion of young female providers.”
The document concludes that,though quantitative data indicate several trends, they were not sufficient to generate solid evidence related to awareness and use of FP services. The scalablilty assessment suggested that interventions are scalable, could potentially address FP as a public health challenge and are aligned with sociocultural and institutional settings. "Additionally, the qualitative monitoring methodology allowed E2A to be flexible and to routinely reflect about the design of the project with frontline implementers and make adaptations.... Tanzania’s Ministry of Health will need support to address systemic constraints related to the delivery of youth-friendly SRH services. The male-engagement interventions proposed in this brief should also be piloted."
Evidence to Action (E2A) is a USAID-funded cooperative agreement led by Pathfinder International in partnership with ExpandNet, IntraHealth International, Management Sciences for Health (MSH), and PATH.
Evidence to Acition Project (E2A) website, January 11 2018.