Supporting Women in Ethiopia and Senegal to Manage Postpartum Pregnancy Risk with Behavioral Design

Summary:

It is well established that pregnancies in the postpartum period increase health risks for women and their infants, yet increasing postpartum family planning (PPFP) continues to be a challenge. With the support of in-country and global partners we applied the behavioral design process to understand the drivers of low contraceptive uptake among postpartum women and to develop and test behaviorally informed solutions in Senegal and Ethiopia. Through an iterative, co-creation process with partners and end users, we developed interventions for both countries. Both intervention sets leveraged immunization days: in Senegal by creating a referral process from immunization to FP counseling and in Ethiopia through a pregnancy risk screening tool to identify women for FP counseling. In Senegal, an IVR platform with differentiated content for providers and clients complemented the service delivery channel. In Ethiopia, other interventions included a planning prompt, counseling guide, and tracking notebook for health workers. In both countries, we ran pilots to test the feasibility and acceptability of the solutions. We found that it was feasible to hand out referral cards or screen for pregnancy risk during immunization days and both seemed to be a promising means of increasing counseling rates among postpartum women, thus suggesting the feasibility of integrating FP and immunization services using low-cost behavioral solutions. Upcoming research will shed additional light on the effectiveness of these interventions on the behavioral mechanisms identified and how these mechanisms link to increased FP uptake.

Background/Objectives:

It is well established closely spaced pregnancies increase health risks for women and their infants, yet increasing PPFP uptake continues to be a challenge. With the support of in-country and global partners we applied the behavioral design process to understand the drivers of low PPFP uptake and to develop and test behaviorally informed solutions in Senegal (unmet need among postpartum women 60% in 2017) and Ethiopia (unmet need among postpartum women 35% in 2011).

Description of Intervention and/or Methods/Design:

In both countries, we conducted behavioral diagnosis. We generated hypotheses about contextual and psychological barriers potentially inhibiting postpartum women from using family planning, then conducted in-depth interviews, focus groups, and process observations with postpartum women, health workers, husbands, and other stakeholders (Ethiopia n=107; Senegal n=95). The data were analyzed to distill the key behavioral barriers to FP uptake, which became the focus of design. Through an iterative co-creation process with partners and end users we developed interventions. Intervention sets in both countries leveraged immunization days :in Senegal by creating a referral process from immunization to FP counseling and in Ethiopia through a pregnancy risk screening tool to identify women for FP counseling. In Senegal an IVR platform with differentiated content for providers and clients complemented the service delivery channel. In Ethiopia other interventions included a planning prompt, counseling guide, and tracking notebook for community health workers.

Results/Lessons Learned:

We ran pilots to test the feasibility and acceptability of the solutions in Kaolack and Ziguinchor in Senegal and Tigray, Ethiopia. We found it feasible to hand out referral cards or screen for pregnancy risk during immunization days and both seemed to be a promising means of increasing counseling rates among postpartum women, thus suggesting the feasibility of integrating family planning and immunization services using low-cost behavioral solutions. In Ethiopia, non-use increased on busy immunization days so new strategies were created post-pilot to improve providers' buy-in and confidence to use the tools efficiently. In the case of Senegal, clients who enrolled in the IVR message system generally reported that they had learned something new about FP or MNCH through the content, and most reported speaking with someone else about the content.

Discussion/Implications for the Field:

Developing solutions which are evidence-based and innovative for large-scale health systems can be a challenge. In Ethiopia and Senegal, extensive iteration and dialogue were needed to find solutions that were both acceptable to all partners and also well-matched to the behavioral barriers identified in the formative work. Despite the challenges, behavioral solutions which integrate family planning and immunizations hold promise to support postpartum women to avoid unwanted pregnancy. An experimental evaluation is planned in Ethiopia to assess the impact of the solutions on intention to use contraceptives and usage rates, along with other intermediate outcomes.

Abstract submitted by:

Carol Cisse - ideas42
Thomas Tasche - ideas42
Finou Mendy - IntraHealth International
Kesete Berhane - Pathfinder International
Madeline Kau - ideas42
Rachel Banay - ideas42
Lydia Trupe - Breakthrough ACTION Zambia