 |
Efficacy Study on Family Planning Counsellors_ An Exploratory Study in Bihar |
|
|
1 Pages 1-10 |
▲back to top |
|
|
1.1 Page 1 |
▲back to top |
EfficacFyamSitlyudy on
FamCiloPyulanPnsnleailnlnogrns ing
Counsellors An Exploratory Study in Bihar
- An exploratory study in Bihar
|
|
1.2 Page 2 |
▲back to top |
|
|
1.3 Page 3 |
▲back to top |
Efficacy Study on
Family Planning
Counsellors
- An exploratory study in Bihar
This study was supported by Population Foundation of India and undertaken
by Asian Development Research Institute
|
|
1.4 Page 4 |
▲back to top |
|
|
1.5 Page 5 |
▲back to top |
Foreword
Family planning products and services make major contributions in ensuring positive
health, social and economic outcomes for individuals and families. However, this is
a realization that still remains one of the biggest challenges of the Family Planning
program. It is an unescapable fact that the family planning goals of a couple, especially the
desired results from a woman’s point of view hinge on many factors, a major one being
the availability of quality counselling services on a regular basis at health care centres. This
not only imbues women with a certain confidence in making a decision about her family
planning choices, if she is in a position to do so, but also addresses her fear of these services
being temporary. She need no longer fear that the counselling services may no longer be
available for her to follow-up on her initial session.
Bihar has been one of the pioneer states in placing counsellors at district hospitals, Primary
Health Centres and Referral Units. Their presence has significantly impacted the FP
program in the state in a positive way; the number of contraceptive users has increased,
postpartum counselling has resulted in increased PPIUCD insertion, and young married
couples are showing more of an inclination towards delaying their first pregnancy. Indeed,
family planning counselling has made it possible to exercise the fundamental right of being
able to make an informed choice in the realm of family planning and reproductive health
care by enabling clients to receive accurate information and then make their own decisions
based on it.
The main objective of this report is to build a road map, in response to the new developments
taking place. It is an effort to ensure that the FP counselling program remains at par with the
other components of the FP program in the state. It is also by way of a response to perceived
opportunities in terms of leveraging the number, skills and support to FP counsellors,
thereby making substantial contributions in improving the FP indicators in the state. In
addition, it is also a response to concerns within the FP counsellors’ fraternity that calls for
the provision of a special emphasis on their needs for capacity building; and the need for
improved infrastructure to enhance performance, paving the way for better outcomes of
counselling sessions.
I would like to thank the Population Foundation of India and the Asian Development
Research Institute in undertaking this study and highlighting important insights into the FP
counsellor program in the state.
Jitendra Srivastava, IAS
Secretary Health-cum- Executive Director,
State Health Society, Bihar
|
|
1.6 Page 6 |
▲back to top |
Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
Acknowledgements
The Family Planning program deals with a large diversity of people, ranging in the age group of 15-49 years who have
varying degrees of information, requirement, apprehensions and abilities and with it different needs in relation to it.
It can therefore be rightly said that effective family planning is largely dependent on counselling, which empowers
the couple or clients to know about family planning options at the most crucial stage of their lives, decide from the basket
of choices and above all place their confidence in the counsellor. Trained in family planning counselling, the counsellors
guide them towards using the method of contraceptive that they find most appropriate.
Studies have shown that there exists a strong link between the adoption of contraception and better child and maternal
health. Thus timely communication between the clients and the counsellor play an important part, not only in family
planning related matters, but also in ensuring a better quality of life for them.
Bihar is one of the pioneering states in terms of having family planning counsellors at 105 facilities, which include Medical
Colleges, District Hospitals, First Referral Units, Primary Health Centres, and Additional Primary Health Centres. The
State Health Society, Bihar had an ambitious plan of scaling up the program. However, prior to that, it was felt essential to
carry out a study to identify effective practices for replication, as also address any need for change to improve the strategies
and implementation of the program.
The Population Foundation of India was privileged to receive this responsibility from the SHSB. In partnership with the
Asian Development Research Institute, a prestigious research organisation, not only the state but at the national level, this
exploratory study was undertaken.
We acknowledge the excellent support of SHSB in being with us at the every stage of the study. This was provided by
way of valuable feedback on the research methodology, the research tool, orientation of the survey team and ensuring the
coordination between our surveyors and the team at the visited facilities.
We would like to express our sincere appreciation to Mr. Jitendra Srivastava, IAS, and Secretary Health-cum-Executive
Director SHSB for his dynamic leadership in the process of giving the study its final shape.
We acknowledge the important support of Dr. Kumar Purushottam Singh Nirala for his contributions in the development
of the report of the study.
We are truly grateful to the hospital superintendents and Medical Officers-in-Charge who supported us and spared their
time in giving their valuable inputs to the study.
We highly appreciate the commitment of FP counsellors who took time out for us from their busy schedules to talk to
us, presenting us with an understanding of the whole program. By sharing their insights, they provided inputs towards
not only improving the roles and responsibilities of counsellors but also ensuring better care for clients and the health care
system as a whole.
We greatly value and acknowledge the support of ADRI, especially Dr. Shaibal Gupta, Mr. P. P. Ghosh, Mr. R. K. Shahi
and their team of surveyors in undertaking this task. We thank them for not only visiting the facilities and interacting with
doctors and counsellors but also for undertaking the important task of assessing the data and information which culminated
into this report and which can provide a key reference to the state for further planning in the program. We would also like
to take this opportunity to acknowledge the fine technical support provided by Ms. Gracy Andrew. These were critical in
developing the report and articulating the information in a reader-friendly manner.
|
|
1.7 Page 7 |
▲back to top |
Contents
Executive Summary...........................................................................................................................................................1
Background....................................................................................................................................................................... 2
Context............................................................................................................................................................................... 3
Objectives of Study............................................................................................................................................................. 3
Design and Methodology.................................................................................................................................................... 3
Limitations.......................................................................................................................................................................... 4
Facilities Covered................................................................................................................................................................ 5
Study Themes...................................................................................................................................................................... 6
Findings............................................................................................................................................................................. 7
Profile of Various Stakeholders........................................................................................................................................... 7
Client Profile....................................................................................................................................................................... 7
Profile of Counsellors......................................................................................................................................................... 8
Profile of Supervisors.......................................................................................................................................................... 8
Profile of ANMs/ASHAs................................................................................................................................................... 8
Provision of Services.........................................................................................................................................................9
Role of the Counsellor........................................................................................................................................................ 9
Counselling......................................................................................................................................................................... 9
Record-Keeping & Other Duties........................................................................................................................................ 10
Supervision of Counsellors................................................................................................................................................. 10
Feedback on Counselling Services...................................................................................................................................... 10
Challenges.......................................................................................................................................................................... 12
Infrastructural Challenges................................................................................................................................................... 12
Workload............................................................................................................................................................................ 12
Operational Challenges....................................................................................................................................................... 12
Community Attitudes......................................................................................................................................................... 12
Other Challenges................................................................................................................................................................ 12
Adoption of Services by Clients......................................................................................................................................... 13
Recommendations............................................................................................................................................................. 14
Approach to FP Counselling.............................................................................................................................................. 14
Availability of Contraceptives............................................................................................................................................ 14
Privacy and Accessibility.................................................................................................................................................... 14
Other Infrastructure Needs................................................................................................................................................. 14
|
|
1.8 Page 8 |
▲back to top |
Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
Additional Personnel.......................................................................................................................................................... 14
Female Counsellors............................................................................................................................................................. 14
Capacity Building and Supervision..................................................................................................................................... 15
Conclusion.......................................................................................................................................................................... 15
APPENDIX....................................................................................................................................................................... 15
Type and Size of Study Respondents.................................................................................................................................. 15
Age-wise Composition of Clients at the Health Facilities.................................................................................................. 15
Educational Status of Clients.............................................................................................................................................. 15
Purpose of Visit by Exit Clients......................................................................................................................................... 16
Use of a Contraceptive Ever............................................................................................................................................... 16
Counsellor Profile............................................................................................................................................................... 16
Qualifications of Counsellors.............................................................................................................................................. 16
|
|
1.9 Page 9 |
▲back to top |
Executive Summary 1
Executive Summary
The decadal growth rate of the population in Bihar,
the third most populous state in India, was pegged at
25.1 per cent by the 2011 Census of India. In 2013,
Kumar, A. & Singh, A. examined the data from all three
rounds of the National Family Health Survey (NFHS), and
in their paper, Trends and Determinants of Unmet Need
for Family Planning in Bihar (India), found an unmet need
of 25 per cent for family planning services among married
women aged between 15-49 years, with only 18 per cent of
the demand for spacing services having been met.
Over the last 7-8 years, The National Health Mission has
initiated a number of schemes to provide adequate health
care to rural populations, particularly women and children,
as well as help in increasing institutional deliveries. As
a consequence, institutional deliveries have increased
considerably, providing a platform for doctors and other
health workers to inform a good number of women, couples
and family members about key issues related to maternal
health, new born and child’s health, and family planning.
Based on this information, clients are able to take their own
decisions and exercise their rights to obtain good quality
healthcare in these areas. Against this backdrop, a need was
felt to strengthen counselling on family planning, maternal
and child health issues; this was reflected in Government of
India’s commitment made at the London Family Planning
Summit in June 2012, where it undertook to enhance such
counselling services and increase the number of counsellors.
Bihar appointed 105 Family Planning (FP) counsellors in
the medical colleges and First Referral Units (FRUs) of the
state health facilities. A year later, the State Health Society of
Bihar reviewed the counselling services to identify effective
practices for replication and to address any need for change,
while formulating the state policy on scaling-up of the
existing services by appointing additional counsellors to
other health facilities.
The Population Foundation of India, Delhi, on being
assigned the task, undertook to develop guidelines for an
exploratory study which was implemented through the
Asian Development Research Institute, Bihar. The objective
of the study was to assess the quality of, and identify gaps
within the family planning counselling services of medical
colleges, hospitals, district hospitals, sub-divisional hospitals,
FRUs and Primary Health Centres (PHCs) in meeting the
needs of clients.
The study covered 24 state health facilities offering family
planning services, covering an equal number of those with
and those without the services of a trained Family Health
Counsellor. Semi-structured interviews were conducted with
12 trained family planning counsellors and their supervisors, as
well as medical officers handling counselling in the 12 facilities
without counsellors. Exit interviews were held with 96 clients
who availed of these services, and in addition, in-depth
interviews were held with 3 counsellors and 1 supervisor.
The study findings showed that all the clients interviewed
had found the information received from counsellors to
be beneficial and useful. All the supervisors of counsellors
found that they were dedicated to family counselling
and a huge support to the program. In facilities without
counsellors, the doctors expected to undertake this task were
too preoccupied with medical duties to undertake it within
or outside the facility. The lack of privacy and a shortage of
contraceptives were factors found to impact the effectiveness
of the counselling services.
The study found that promotional material with audio-visual
content could be more effective than the print form generally
used, considering the limited literacy status of a majority of
clients. It also pointed to the fact that a separate space dedicated
to counselling would ensure privacy; and that the provision
of an additionally trained person in such facilities, having had
a large number of beneficiaries/clients, could enhance family
planning promotion in communities as well as address the
need for a substitute in the counsellor’s absence.
Other recommendations include the need for regular
refresher trainings for counsellors, laying particular
emphasis on the relationship between the adoption of
contraception and better child and maternal health. It was
also suggested that the maintenance of records could be more
effective if computerised, as against the current practice of
maintaining manual registers that do not allow a correlation
of data. The supervision of counsellors could more effective
if the supervisors were trained to focus on the quality of
counselling.
The study shows that facilities without counsellors would
benefit with the appointment of counsellors; it also establishes
that in order to improve the results of the counselling
services there is a need to address the existing shortage in the
availability of contraceptives.
|
|
1.10 Page 10 |
▲back to top |
2 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
Background
The International Conference on Population and
Development (ICPD), 1994 and the Millennium
Development Goals reaffirmed the need to make
Universal Access to Reproductive Health a global priority.
This saw worldwide progress, in the form of improved
access to sexual and reproductive health services. Yet
globally, a large number of women still die of causes related
to pregnancy and childbirth, even though maternal deaths
have fallen by 45 per cent. Similarly, though contraceptive
use has increased by 10 per cent, an unmet need for it
still exists in many parts of the world, and there is a large
inequality in sexual and reproductive health outcomes
across countries.1
Globally, research and program experience show that a
first pregnancy at 18 or later, and a gap of two or more
years between births, or a six-month gap after an abortion,
contributes significantly to child survival and safe
motherhood. This helps reduce maternal and infant illness
or death, and helps couples ensure healthy fertility and
pregnancy outcomes.
In India, family planning is guided by the National Population
Policy, 2000. As a signatory to the ICPD Program of Action
(PoA) and the Millennium Declaration, India too has
committed to a target free approach to family planning.2
Services that earlier focused on the need to limit population
growth have now expanded to address the health needs of
mother and child through sexual and reproductive health
programs. In 1996, the family planning program was renamed
as the Reproductive and Child Health (RCH) program, and
in 2005, when the National Health Mission (NHM) was
launched, RCH (II) became an integral part of it.3
Under this wider ambit of family planning services,
emphasis has been laid on the spacing of births to address
maternal and child healthcare needs by adopting a suitable
family planning method. In tandem with the information
that is provided to women, efforts have been put into
strengthening institutional support and community-based
services through ANMs and ASHAs.4
The reach of these services has been extended to every part
of the country; in rural areas, through the PHCs and SCs;
and in urban areas, through the Urban Family Welfare
Centres and Postpartum Centres. These efforts have seen
the Crude Birth Rate fall to 21.6, and the Total Fertility
Rate decrease to 2.4 in 2012. The use of contraceptives have
increased nationwide among women aged between 15-49
years by 8.1 per cent between NFHS2 and NFHS3.5
At the London Family Planning Summit in June, 2012,
India made a commitment to enhance the counselling
services and increase the number of counsellors. In line with
this, the Ministry of Health and Family Welfare decided to
employ family planning counsellors dedicated to providing
counselling to couples on family planning, maternal and
child health issues.
1 Integrated and Comprehensive SRH Services: A Global View Snow
R.C, Laski L., Mutumba M, Global Public Health,
2015 Vol. 10, n02, 149-173
2 Family Planning: A Right and a Choice, UNFPA
3 Annual Report 2013-14, Department of Health and
Family Welfare, Govt. of India
4 Annual Report 2013-14, Department of Health and
Family Welfare, Govt. of India
5 Annual Report 2013-14, Department of Health and
Family Welfare, Govt. of India
|
|
2 Pages 11-20 |
▲back to top |
|
|
2.1 Page 11 |
▲back to top |
Context 3
Context
Bihar, the third most populous state in India has
a population of over 104 million (2011) which is
around 8.6 per cent of the nation’s population. Its
decadal growth rate of population has been pegged at 25.1
per cent (Census 2011).
The Total Fertility Rate of the state stands at 3.7, the Infant
Mortality Rate at 44, and the Maternal Mortality Ratio at
261 (SRS 2007 – 2009), which is higher than the national
average.
The sex ratio in the state is 916 as compared to 914 in
the country.6 Its infant and maternal mortality rates are
among the highest for the country, as is the proportion of
underweight, malnourished children aged below 3 years.7
A study by A. Kumar and A. Singh in 2013 analysed the
data from three rounds of the National Family Health
Survey to identify trends of unmet needs in the family
planning services of Bihar.
The study found 25 per cent of currently married women
in the age group of 15-49 years to have an unmet need
for family planning services. Only 18 per cent of the
total demand for spacing methods was found to be met
as compared to about 72 per cent of the total demand for
limiting methods.8
The shortfall in services becomes magnified as government
health facilities in Bihar have, in recent years, seen an
unprecedented rise in the number of beneficiary visits and
institutional deliveries.
The Department of Health, the State Health Society, and
the Government of Bihar revitalized the Family Planning
Programme (FPP) with an emphasis on post-partum family
planning services. Trained counsellors were appointed in
health facilities to create awareness among beneficiaries and
their attendants on the range of family planning methods
available, along with addressing issues related to maternal
and child health.
6http://nrhm.gov.in/nrhm-in-state/state-wise-information/bihar.html
7 http://www.unicef.org/india/overview_4289.htm
8 Kumar, A & Singh, A (2013) Trends and Determinants of Unmet Need
for Family Planning in Bihar (India): Evidence from National Family
Health Surveys
A total of 105 family planning counsellors were appointed
by the Government of Bihar in medical colleges and referral
hospitals designated as First Referral Units (FRUs), as part
of the National Health Mission (NHM).
The counsellors have been in place for over a year, and
the State Health Society of Bihar decided to undertake a
review of their services. The Population Foundation of
India, Delhi, was appointed to undertake an exploratory
study to review the counselling process for family planning
in health services.
The broad aim of the review was to inform the government
on the functioning of the services, identifying effective
practices for replication, as well as shortfalls that need to
be addressed in the scaling-up of these services to cover the
entire state.
The Population Foundation of India devised guidelines
for the study, which were implemented through its
study partner, the Asian Development Research Institute
in Bihar.
Objectives of Study
The main objectives of this exploratory study were:
(i) To assess the quality of FP counselling services at the
health facilities
(ii) To identify areas of improvement in order to
maximize benefits
(iii) To inform the policy decision on the scaling-up of FP
counselling services in the state
Design and Methodology
The list of health facilities with counsellors was obtained
from the Bihar State Health Society for a selection of
samples. These facilities were ranked as high, medium, and
low-performing, based on the number of users of family
planning services. In consultation with the State Health
Society (SHS), it was proposed that purposive sampling be
used to cover 2 facilities from each group for the study.
A similar number of facilities without counsellors was
also to be included in the study to compare the delivery of
counselling services.
|
|
2.2 Page 12 |
▲back to top |
4 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
The list of facilities included in the study was finalised in
consultation with the SHS.
The study was undertaken in 24 state health facilities
offering family planning services, covering an equal number
of those with and without the services of a trained Family
Health Counsellor (FHC).
The participants in the field study were:
(a) 12 counsellors and his/her/their supervisor, and 12
personnel in charge of family planning services where
a trained counsellor was not formally appointed.
(b) 96 beneficiaries of the services as clients exiting the
health facility after a first visit, and clients on a follow-
up visit to the counsellor or to facilities without a
trained counsellor.
(c) The Auxiliary Nurse Midwife and the ASHA who
provided extension services in the community.
The study had two parts. In the main component, semi-
structured interviews were administered to counsellors,
supervisors, ANMs and ASHAs. 96 clients who received the
services responded to exit interviews. Data was entered into
spreadsheets and analysed with reference to the objectives
of the study.
In an additional brief, a short study employing in-depth
interviews with 3 counsellors and a supervisor was
undertaken. These were audio-taped, transcribed, and
thematically analysed to come up with a reflection on
the ground reality to complement the findings of the
main study.
Findings from both parts of the study have been
incorporated in this Report.
Limitations
The original study guidelines considered ranking state
health facilities as high, medium, and low- performing
facilities among those with and without trained counsellors.
The ranking was to be used to ensure that an equal number
of each were part of the study.
The Bihar Health Society provided a list of the health
facilities in the state along with monthly reports. However,
it was not possible to rank the facilities on performance
due to inconsistencies and a lack of correlation in client
data. In the final study design, the only criterion considered
was that of having an equal number of facilities with and
without a counsellor.
|
|
2.3 Page 13 |
▲back to top |
Context 5
Facilities Covered
The 24 health facilities covered by the study were:
A. With Counsellors
Sl. No. Name of Medical Colleges /FRUs
1. Darbhanga Medical College
2. Referral Hospital, Benipur
3. Referral Hospital, Jale
4. ANMMCH, Gaya
5. Lady Elgin Zanana Hospital, Gaya
6. SDH Sherghati
7. PMCH, Patna
8. Sub-Divisional Hospital, Danapur
9. Referral Hospital, Naubatpur
10. JLNMCH, Bhagalpur
11. Referral Hospital, Sultanganj
12. Sub-Divisional Hospital, Kahalgaon
District
Darbhanga
Darbhanga
Darbhanga
Gaya
Gaya
Gaya
Patna
Patna
Patna
Bhagalpur
Bhagalpur
Bhagalpur
B. Without Counsellors
Sl. No. Name of Medical Colleges /FRUs
1. SKMCH, Muzaffarpur
2. Referral Hospital, Goraul
3. Referral Hospital, Raghopur
4. Sub-Divisional Hospital, Nirmali
5. Referral Hospital, Ghoshi
6. Referral Hospital, Nathnagar
District
Muzaffarpur
Vaishali
Vaishali
Supaul
Jehanabad
Bhagalpur
Category of Facility
Medical College
FRU
FRU
Medical College
FRU
FRU
Medical College
FRU
FRU
Medical College
FRU
FRU
Category of Facility
Medical College
FRU
FRU
FRU
FRU
FRU
|
|
2.4 Page 14 |
▲back to top |
6 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
B. Without Counsellors
Sl. No. Name of Medical Colleges /FRUs
7. Referral Hospital, Taraiya
8. Sub-Divisional Hospital, Hilsa
9. Referral Hospital, Islampur
10. Sadar Hospital Begusarai
11. Sub-Divisional Hospital, Sheohar
12. Referral Hospital, Andhrathadi
District
Saran
Nalanda
Nalanda
Begusarai
Sheohar
Madhubani
Category of Facility
SDH
SDH
FRU
Sadar
SDH
FRU
In-depth interviews were conducted in 3 of the health facilities with a trained counsellor:
1) Sub-Divisional Hospital, Danapur
2) District (Sadar) Hospital, Hajipur
3) District (Sadar) Hospital, Naubatpur
Study Themes
(I) The following themes were covered in the semi-
structured interviews:
With Counsellors
• Training
• Challenges
• Knowledge levels
• Suggestions for improvement
With Clients
• Client profile
• Kind of services and information received
• Feedback in terms of satisfaction
With Supervisors
• Role of the supervisor
• Observations on the counsellor’s performance
• Suggestions for improvement of the services
With ANMs/ ASHAs
• Views on the usefulness of the family counselling
service
• The support that they have received from the FP
counsellor in delivering the service
(II) The main themes covered by the in-depth interviews
were:
• Protocols and processes followed
• Supervisory and record-keeping mechanisms being
maintained
• Enablers and barriers to optimizing the services
|
|
2.5 Page 15 |
▲back to top |
Findings
Profile of Various Stakeholders
Client Profile
The profile of clients attending the health facilities showed
58 per cent for those in the age-bracket of 21-25 years, 23
per cent for those between 26-30 years, 14 per cent for those
between 16-20 year of age, and only 5 per cent for those
above 30 years. Their education level was seen to be as 44
per cent illiterate or just literate, 31 per cent who had not
completed their matriculation, 15 per cent matriculates
or those who have completed their intermediate, and
10 per cent graduates or post-graduates.
In facilities with counsellors, 79 per cent had come for
counselling services, and 21 per cent for a pregnancy test
or ANC. In facilities without counsellors, 58 per cent
had come for a health related check-up, 40 per cent for
a pregnancy test or ANC, and only 2 per cent had come
specifically for information on family planning.
The exit interviews showed that in facilities with counsellors,
10 per cent of the clients had used a contraceptive earlier and
90 per cent had not; and in facilities without counsellors, 8
per cent had used a contraceptive earlier and 92 per cent had
never done so. But, the follow-up interviews showed some
discrepancies as those in facilities with counsellors had 42
per cent saying they had used contraceptives, and 58 per cent
saying they had not; while the facilities without counsellors
had 6 per cent saying they had used contraceptives, and 94
per cent saying they had not.
The initial proposal considered interviewing an equal
number of male and female beneficiaries of the program
through exit interviews of clients on their first visit and
of those on follow- up visits. However, the women who
came for antenatal care and delivery services were generally
accompanied by women family members, and only 1 male
client was available from a facility without a counsellor.
Thus, a total of 95 women clients and the single male client
were covered by the exit and follow-up interviews.
Client interviews showed 98 per cent of the clients to
be housewives, with just 1 being formally employed and
another employed as an agricultural labourer.
Both the exit and follow-up interviews had women aged
between 21-25 years; 60 per cent had been married off when
Findings 7
|
|
2.6 Page 16 |
▲back to top |
8 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
they were between 10-18 years of age. More than half the
husbands of follow-up clients were aged between 14-19 years
at the time of marriage; 40 per cent were married between
the ages of 19-23 years, while a negligible proportion, i.e.
2 per cent of husbands in the counsellor attended group,
and around 4 per cent from facilities without counsellors
were aged between 23-26 years at the time of marriage.
The proportion of clients with 3 or more children was 38
per cent in facilities with counsellors, and 27 per cent in
facilities without.
Profile of Counsellors
Of the 12 counsellors, 5 were male, and 7 female. Their
ages ranged between 27 and 43 years, the mean age being
37. In terms of qualification, 10 were post-graduates and
above, and 2 were graduates and above. 2 of the 12 had
completed an additional diploma in counselling. Except for
2 counsellors, all had worked in the health sector for more
than 3 years. 10 of them were married, and 2 were not.
All 12 counsellors had joined duty in 2012 after a 4-day
training held by the State Health Society. 10 counsellors
reported their trainings to be satisfactory while 2 found it
only partially so.
4 of the counsellors attended a one-day workshop held by
JHPIEGO in Patna in November, 2014. 3 of the counsellors
attended a two-day refresher course organized by the State
Health Society in 2013, and 1 attended a day-long ANM
training for enhancement of skills.
An assessment of the knowledge levels of the counsellors
was undertaken, using a set of statements which they had
to confirm as true or false. Of the 12 counsellors, 10 fared
fairly well, indicating adequate knowledge about family
planning, while 2 scored badly, indicating the reverse.
Profile of Supervisors
All the family planning services, both with and without
a designated counsellor, were supervised either by the
Medical Officer in-Charge, or the Health Manager.
The medical officers were doctors with an MBBS degree
and/or additional degrees or diplomas in medical and
allied sciences. The qualifications of the health managers
were generally those of a Master’s degree in business
administration (MBA) or in an area of social sciences. Most
supervisors had undergone training in family planning for
a duration that ranged from 2-7 days.
Profile of ANMs/ASHAs
Of the 24 facilities, 1 ANM from each facility was
interviewed except one, where the ASHA was interviewed.
Most of the ANMs, and the one ASHA were undergraduates
(16 out of 24), while the others were graduates and above.
|
|
2.7 Page 17 |
▲back to top |
Provision of Services 9
Provision of Services
Role of the Counsellor
Counselling
The counsellors worked for 5 hours, 6 days a week at
the health facilities with timings that varied as per
the facility. Four of the 12 counsellors indicated that
they had adequate space for counselling, while the others
suggested that they did not.
The numbers counselled varied across facilities; on an average,
most reported meeting 3 to 6 clients in a day, with a few seeing
as many as 15 to 20 a day. Most clients were females.
According to the protocols, the counsellor’s role in the
health facility involved informing male and female clients
about the choice of family planning methods that helped
ensure spacing between child-births as well as limiting.
They were to make use of promotional material and
samples of devices used to explain and familiarize clients
with the method. They were also required to describe the
limitations and side-effects associated with every method,
and explain how spacing ensured child and maternal health
after birth.
After the family made a choice of the method most
appropriate for them, the counsellor was to follow-up on the
delivery of the required services. This included identifying
and addressing any related problem/s that cropped up.
The system envisaged having beneficiaries pass through
the HIV/AIDS and family planning counsellors before
consulting the doctor when coming for antenatal (ANC)
and post-natal care (PNC).
In actual practice, counselling services were provided by the
counsellors in the labour room, the wards, and the OPD.
Even in cases where there was a separate counselling room,
it was not restricted to the private setting. The monthly
follow-up of cases was done through a telephonic follow-
up, and in the community, through the ASHA/ANM.
In the interviews with counsellors, when asked to rank their
responsibilities, most of them ranked the counselling about
different methods of family planning and the side effects
of each, the importance of delaying the first child, and
spacing to be the most important of their responsibilities.
Maintaining records, providing follow-up services to clients
and sharing other information, as on nutrition and child
health, were ranked much lower.
In the in-depth interviews, the counsellors described how
they visited the labour-room to “counsel” potential women
clients about the PPIUCD (Postpartum Intrauterine
Contraceptive Device) and/or sterilisation, and visited
maternity wards to which women were admitted for
delivery or post-delivery care (especially in the case of
C-Section) as well.
They followed the same protocol for all women: if the
woman was having her first or second child, they would
advise her to accept the PPIUCD, so that she could space
her next pregnancy. After the third child, they advised
sterilisation. They often worked along with the ANMs and
ASHAs. Under the Janani Suraksha Yojana (JSY), the ASHA,
as a community-worker, is provided a cash incentive of Rs.
600 for each case, and a cash support of Rs. 1400 is provided
to the expectant mother for maternal care. The ASHA
advises the woman and her family, and she, along with
the FP counsellor, often continue the dialogue by talking
to the women about the advantages of spacing, clarifying
any doubts and myths that such women might have come
across with regard to the PPIUCD.
However, in the interviews with clients, only 27 per cent
reported to have been motivated by the ASHA to avail the
counselling services. Most said that they were self-motivated
or motivated by friends and relatives. The ANMs, in their
interviews, reported that they convinced and counselled
the clients, and then directed them to the counsellors for
detailed counselling.
According to the counsellors, not all the clients they
counselled, accepted their advice; and the reasons for
non-acceptance, as cited by the counsellors, were lack of
education and awareness. Some of them reported that
the methods did not suit some clients. In the in-depth-
interviews, however, the counsellors elaborated on these
aspects. They explained that the biggest problem were
those of the women being illiterate and not being the main
decision-makers on issues related to childbearing and/or
the use of contraceptives, easily influenced by myths that
prevailed around the use of IUDs. A common myth about
the IUDs is that it causes cancer. Some women attributed
|
|
2.8 Page 18 |
▲back to top |
10 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
any and all health problems that they faced post-insertion
of the IUD to that alone, and these myths were spread in
the village by word-of-mouth.
According to the counsellors, sometimes, the women
have had problems such as bleeding after the insertions,
especially if the IUD’s were not fixed precisely, or if bent.
The ASHA, at times, avoids advising the women about
IUD devices, and sticks to sterilisation. In their experience,
they found it easier to convince women or couples who
are literate. Often a woman who was convinced and agreed
to the process would later be pressurised by her family
to withdraw the consent. These are some reasons why
PPIUCDs are accepted less often, and sterilisations found
more acceptable after a third child, especially if there is at
least one male offspring.
However, the counsellors claim that there has been more
acceptance over time. Over the question whether they
have a strategy to create awareness among the clients, 11
counsellors replied in the affirmative, saying that they
organize fortnightly camps and display posters at these.
They said that the ASHA has played a key role in creating
awareness; and as per their experience, the acceptance of the
PPIUCD for spacing was more successful when they (the
ASHA) mobilised women and talked to them.
Sometimes, couples that agreed to the use of contraceptive
methods, requested the counsellor and the ASHA not
to inform other family members. The counsellors also
suggested that if some outreach programs were implemented
at the community level, along with counselling, then there
would be better acceptance from the families. This, in
addition, would help them follow-up on probable users
counselled at the facility.
Record-Keeping & other Duties
One of the other duties that the counsellors perform, is the
maintenance of records. They prepare monthly progress
reports and maintain 4 types of registers:
(i) Family Planning Counselling Register;
(ii) Follow-up Register;
(iii) Contraceptive Device Register; and
(iv) IUCD Register.
Since the registers are big, they generally write the
information in a smaller book or diary, and considerable
time is later spent in transferring that information into the
registers.
During the in-depth interviews, the counsellors revealed
that they also maintain records of the incentives due to
each ASHA for sterilisation or PPIUCD (the ASHA gets
Rs. 150/- if she refers a woman for IUD, and Rs. 300/- if she
brings them in for sterilisation). The FP counsellor keeps
records of the number of women each ASHA refers, and
gives these to the accountant for the payment to be made
to her.
Supervision of Counsellors
A counsellor is supervised either by the Chief Medical
Officer or the Hospital Manager. Most of their
supervision centres on their maintenance of attendance
and counselling records of clients. The supervisors
sometimes assist when the clients need to meet the
doctor after the counselling sessions. A major focus
of the supervision is on whether the target number of
sterilisations and PPIUDs performed, are met. The
counsellors have a set target to convince 10 per cent of the
women going in for deliveries to later use contraceptive
methods; and their performance is appraised based on
the numbers that accept PPIUCD or sterilisations.
Feedback on Counselling Services
During exit interviews, the clients who visited the
counsellors were asked about what they found beneficial
and what they liked and disliked about the counselling
service. Around 70 per cent of the clients found the new
information on family planning methods, useful. One-
third of the clients, specifically found the information
about spacing as well as IUCD and PPIUCD, new and
useful to them. Of all the clients interviewed, only 4 spoke
of receiving information on care during pregnancy, and
one spoke of information on child care that she found
useful. Most did not have any complaints about the
counsellors; 7 clients objected to a male presence during
counselling, 9 clients thought privacy was needed, while
one did not like the fact that she was counselled soon
after delivery.
|
|
2.9 Page 19 |
▲back to top |
Provision of Services 11
There was a suggestion that it would be best if both husband
and wife were asked to come together for counselling. It
was also proposed that the complete dosage of medicines
be given and not merely a part of what was required; that
doctors should avoid caesarean operations; and that they
should not refuse the removal of Copper-T if the insertion
was done elsewhere.
The supervisors of counsellors were asked to rate the
performance level of those working under them, and
they were all rated as good or as very good. All of them
opined that having counsellors in the facility, specially
dedicated for family counselling, was a huge support for the
program. They were all of the view that with the posting
of counsellors, the number of family planning beneficiaries
had increased, though the extent of increase reported varied
considerably. While 4 of them reported an increase of up
to a 25 per cent, 5 reported an increase ranging between
40-50 per cent, and for one, it was above 60 per cent. The
2 remaining supervisors, however, did not say anything.
|
|
2.10 Page 20 |
▲back to top |
12 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
Challenges
In their interviews, the counsellors were asked to
distinguish the challenges they faced as operational,
infrastructural, and community/ attitudinal.
Infrastructural Challenges
The key infrastructural challenge that was listed in common
by counsellors, their supervisors, and the medical officers in
facilities without a counsellor, was the non-availability of
space for counselling. Most spoke of not having a separate
room for counselling, which made the lack of privacy a
primary operational challenge. Of the 12 counsellors, only 4
spoke of adequate space being available. Counselling was often
undertaken in the labour room or in the post-partum ward.
Counsellors additionally spoke of the non-availability of
closed shelves / cupboards for storing records. There were
no chairs for themselves or their clients, and no promotional
material such as posters / pamphlets. One even mentioned
the challenge of not having a computer.
Workload
In terms of challenges under this head, they spoke of
having to handle a large number of clients single-handedly,
leaving them short of time for counselling. This was also
corroborated by the clients who said that not enough time
was being dedicated to their counselling needs. With no
trained substitute to take over their duties in their absence,
some had to rely on ANMs; and in one case, the AIDS
counsellor had to take charge in the counsellor’s absence.
The counsellors who reported attending to more than 10
clients a day, voiced the need for an additional counsellor
which could help improve their service delivery.
The counsellors also spoke of the additional duties allotted
to them, over and above assigned duties, and which affected
their work.
Operational Challenges
In the health facilities without a counsellor, and as per
a supervisor from facilities with a counsellor, the non-
availability of family planning devices was a challenge.
Counsellors also found the lack of cooperation by doctors
to be a challenge and which had an impact on their
performance.
Nine of the 12 counsellors suggested that the supervisors
could directly send the female beneficiaries to them from
the OPD for family planning counselling.
Half of those handling counselling in facilities without
counsellors felt that the doctors just did not have the
time to provide counselling services, and that trained
counsellors could make the program more effective. They
felt that without counsellors, ‘counselling is nobody’s
responsibility’.
Community Attitudes
Counsellors and their supervisors felt that the low levels
of literacy and misconceptions in the community or ill-
informed knowledge on family planning methods such
as IUCD and sterilisation, were affecting the adoption of
family planning methods. This was reported by 8 out of
the 12 supervisors, and by 11 of the 12 handling counselling
services in facilities without counsellors.
During the in-depth interviews, they spoke of the pressure
and stress that they underwent with meeting targets. The
acceptance of family planning depends on a number of
factors, but they feared that if they did not meet these, they
could lose their jobs.
The counsellors felt that they could address the lack of
community awareness through fortnightly camps, using
display posters to create awareness. However, there
was already a shortage of promotional material such as
posters, pamphlets, brochures etc. in the health facilities
where even audio-visual material could be played on
TV to create awareness. It was also reported that close
coordination between the ASHA and the counsellor had
a positive impact in the acceptance of family planning
methods by couples.
Other Challenges
In the in-depth interviews, counsellors also expressed
their dissatisfaction with the remuneration that they
received. Having had no increment in the last 3 years
seemed to have affected their morale. According to one
of them, many had left due to the low salary levels and
the uncertainty associated with the job since they were on
short-term contracts.
|
|
3 Pages 21-30 |
▲back to top |
|
|
3.1 Page 21 |
▲back to top |
The beneficiaries of the program, i.e. the women clients
interviewed, were also concerned about the lack of privacy
and confidentiality in counselling. Their next concern was
about the limited time that was devoted to this. More than
half of the exit-clients, i.e. 54 per cent mentioned the lack
of availability of contraceptives.
Adoption of Services by Clients
While 77 per cent of the clients in facilities with counsellors
were counselled on family planning methods, only 29
per cent were in facilities without counsellors. The
doctors expected to provide counselling in facilities of
the latter category, find this to be affecting their medical
responsibilities, and thus do not have the time for it. This
makes it clear that trained counsellors need to be appointed
in facilities not having counsellors.
Though 90 per cent of the exit-clients in both types of
facilities reported never having used a condom before;
42 per cent of the follow-up clients from facilities with
counsellors stated having used contraceptives; while 94
per cent from facilities without counsellors had still not
used them.
However, clients do not appear to avail of the promoted
contraceptive methods at the health facilities, as only 35
per cent of the follow-up clients indicated their source to
be the government hospital, while 48 per cent mentioned
the market. The short supply of condoms and pills becomes
relevant here. For IUCD insertions, 36 per cent mentioned
having gone to private clinics. However, no one spoke of
private clinics and only mentioned government hospitals
when speaking of sterilisation.
Almost 98 per cent of the clients said they would
recommend their friends / peers to avail of the counselling
services, mainly because the contraceptive methods were
explained better in government health facilities.
Challenges 13
|
|
3.2 Page 22 |
▲back to top |
14 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
Recommendations
The family planning counsellor plays an important
role within the family planning services of the health
sector. Their presence has had a positive impact on
the use of services and in improving the comfort levels of the
women and families in considering various contraceptive
methods.
While there is no doubt that there is a need to have a
family planning counsellor in all the facilities, there is
also a parallel need to strengthen the service and make it
more robust.
Some of the areas that need strengthening are:
Approach to FP Counselling
Most women who avail the family counselling services are
illiterate or housewives who are generally accompanied by
women family members. The client community rejects
the adoption of IUCDs promoted for child-spacing.
The promotional material for family planning needs to
therefore, address this aspect and stress on the positive
health outcomes on maternal and child health, when using
spacing methods. It is equally important to inform them
about the risks that they lay themselves open to by not
adopting these, as well as dispel the myths associated with
sterilisation. The low literacy levels indicate that the use of
audio-visual material may be more effective.
Both the community rejection of PPIUCDs for spacing
child birth, and the outright non-acceptance of sterilisation,
need to be addressed by reorienting ANMs and ASHAs
to the facts underlying the approach and providing them
support through the health facility, to address issues at the
ground level.
Availability of Contraceptives
Most exit clients had never used a contraceptive before,
and were unfamiliar with condoms, IUCDs or the Pill.
There is a need to familiarize them with these devices and
ensure the possibility of adoption, as well as the conviction
to overrule community disapproval if they opt for one.
This would be possible by ensuring greater availability
of contraceptives, as clients mentioned that they had to
get them from the market and go to private clinics for
PPIUCD insertions. Therefore, while strengthening the
demand for the services, it is equally important to address
shortages in the system.
Privacy and Accessibility
Privacy and confidentiality are very important requirements
in enabling couples to make the right choice. It is important
for the counsellors to have private space, which they can
use for counselling.
Alternate approaches need to be considered as the
envisaged system of having the client mandatorily visit
the counsellor before meeting the doctor is not working.
Other suggestions, such as the counsellor being seated near
the immunization room which every pregnant lady goes to,
could be considered.
Other Infrastructure Needs
Counsellors have expressed concerns of confidentiality as
they do not have lockable shelves to house the counselling
records maintained by them. Though all seemed familiar
with computer usage, only one spoke of the need for
computer literacy. Indeed, the computerization of
counselling records in the form of individual client data
would be useful in eliminating the maintenance of manual
registers that end up providing unrelated numerical data
which has to be recompiled as patient data for any practical
attempt at evaluation.
Additional Personnel
The counsellors’ spoke of an additional workload over and
above, and beyond their counselling duty. Those attending
to over 10 clients a day indicated the need for assistance
with counselling. As no trained substitute is available to
take over duties in their absence, viable alternatives need
to be explored.
Female Counsellors
Some clients exiting counselling sessions where male
counsellors had been appointed, expressed their preference
for female counsellors. The profile of clients indicates that
there is no community acceptance of, or communication
on contraception or family planning within it. For
enhancing community acceptance of preventing child-
|
|
3.3 Page 23 |
▲back to top |
Recommendations 15
bearing at an early age, female counsellors would be most
effective.
Capacity-Building and Supervision
The role of the counsellor has to be enhanced from a mere
giver of advice and information to one facilitating couples
to make choices. This can be ensured through training and
the right supervision which moves beyond targets, and
focuses on the quality of counselling.
Conclusion
The study highlights the fact that the counselling
services have exposed clients to contraceptives as part of
new and useful information regarding family planning.
The family counselling services are an essential asset
to the program within the state health facilities. There
is a need to ensure that the services are strengthened
through additional trainings, adequate supervision and
infrastructure, availability of contraceptives, and the
building of community acceptance through advocacy
using audio-visual material and community service
support. If the areas identified as weak in the study are
addressed, the up-scaling of counselling services in other
health facilities will definitely have a positive impact on
the programme.
Appendix
Respondents
Supervisor/in-charge of counsellor
Counsellors
ANM (FP service providers)
Exit interviews
Follow-up interviews
In-depth interviews
Counsellors
Supervisor
Total
Type and Size of Study: Respondents
Number of
Respondents per
Facility
Total Respondents
in Facilities with
Counsellors
1
12
1
12
12
4
48
4
48
Total Respondents
in Facilities without
Counsellors
12
0
12
48
48
3
0
0
1
0
0
136
120
Age-wise Composition of Clients at Health Facilities
Age Group
Numbers
Percentage
16-20 years
27
14%
21-25 years
112
58%
26-30 years
44
23%
Above 30 years
9
5%
Total
192
Educational Status of Clients
Education Level
Numbers Percentage
Illiterate
65
34%
Just literate
20
10%
Non-matric
59
31%
Matriculate/Intermediate
29
15%
Graduate /Post-graduate
19
10%
Total
192
|
|
3.4 Page 24 |
▲back to top |
16 Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
Purpose of Visit by Exit Clients
Purpose
To know about contraceptive devices
Facilities with Counsellors
Number
%
20
41.7
To know about F/P
6
12.5
To know about spacing between two children
12
25.0
For pregnancy test/ANC
10
20.8
For health related check-up
—
—
Total
48
100.0
Facilities without Counsellors
Number
%
—
—
1
2.1
—
—
19
39.6
28
58.3
48
100.0
Ph.D. /
Post-graduate
10
LL.B/MBA/IMA
2
Qualifications of Counsellors
Additional Counselling
Qualifications
2
Experience in Health Sector
Less than
3 years
3-5 years
More than
5 years
2
5
5
Response
Yes
No
Total
Sex
Male
Female
Total
Facilities with
Counsellors
5 (10.4%)
Use of a Contraceptive Ever
Exit
Facilities without
Counsellors
4 (8.3%)
Follow-up
Facilities with
Counsellors
Facilities without
Counsellors
20 (41.7%)
3 (6.2%)
43 (89.6%)
44 (91.8%)
28 (58.3%)
45 (93.7%)
48 (100%)
48 (100%)
48 (100%)
48 (100%)
Number
5
7
12
Counsellor Profile
Marital Status
Number
Unmarried
2
Married
10
Others
0
Total
12
Age Group
27-32 years
33-37 years
38-43 years
44 and above
Total
Number
4
0
7
1
12
|
|
3.5 Page 25 |
▲back to top |
Notes:
|
|
3.6 Page 26 |
▲back to top |
Notes:
|
|
3.7 Page 27 |
▲back to top |
about PFI
Population Foundation of India is a national NGO, which promotes and
advocates for the effective formulation and implementation of gender
sensitive population, health and development strategies and policies.
The organisation was founded in 1970 by a group of socially committed
industrialists under the leadership of the late JRD Tata and Dr Bharat Ram.
PFI addresses population issues within the larger discourse of empowering
women and men, so that they are able to take informed decisions related to
their fertility, health and well-being. It works with the government, both
at the national and state levels, and with NGOs, in the areas of community
action for health, urban health, scaling up of successful pilots and social and
behaviour change communication. PFI is guided by an eminent governing
board and advisory council comprising distinguished persons from civil
society, the government and the private sector.
|
|
3.8 Page 28 |
▲back to top |
Efficacy Study on Family Planning Counsellors - An exploratory study in Bihar
B-28 Qutab Institutional Area,
New Delhi- 110 016
State Health Society, Bihar
Parivar Kalyan Bhawan,
Sheikhpura, Patna, Bihar- 800014