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Emergency Contraception : Global Activity

An evaluation of EC introduction activities in Indonesia
– Dr Peter Fajans, WHO, Geneva

It is important to learn from the experience of different countries, so that India does not repeat the mistakes that others made.

The Consortium Core Team in Indonesia included:

• Pathfinder International

• Program for Appropriate Technology (PATH)

• World Health Organization (WHO) and

• International Council on Management of Population Programmes (ICOMP) on behalf of WHO

WHO was specifically invited for conducting baseline survey and evaluation. The first step in evaluation was baseline survey of providers’ and clients’ attitudes, knowledge and practice, so that it could guide the local adoption of strategies for IEC developed by the Consortium and help designing the model services. The survey was conducted from February to June 1997 in four provinces. The findings indicated (i) knowledge of FP was almost universal, still there was frequent inappropriate use of contraception; (ii) knowledge about EC was very limited, only 25% providers and 4% clients knew about it; (iii) most respondents considered EC as an abortifacient (because it is taken after sex); since abortion is illegal, this was a major barrier; (iv) most respondents were aware of both modern and traditional methods to induce menstruation, if late, and various practices were widely used. Evaluation revealed that when designing intervention, the base- line survey findings were forgotten.

The first stage project was launched in 12 IPPA clinics in six provinces. The clinics selected were primarily used by women seeking menstrual regulation and long-term contraceptive methods such as sterilization and IUD. Many women presented themselves to the clinic either too late or were not suitable for EC. In the first nine months of project implementation, only 186 units of Postinor-2 were provided to the clients.

Subsequently, expansion of service delivery sites was done in 1998. Ten NGO clinics in Jakarta and Bali and the University of Indonesia and Obstetrics & Gynaecology teaching clinics participated in the project. In 1999, Indonesian Midwives Association in Jakarta, Bali, and Central Java were incorporated, as many Indonesian women access reproductive health services through midwives. This distribution route was thought to have a potential to make EC more widely available. Following this, the number of clients increased significantly.

Over 180 midwives, doctors and counsellors were trained as service-providers of Postinor-2. They, in turn, informally trained other personnel. Orientation sessions were conducted for over 1300 midwives, physicians, obstetricians and gynaecologists, senior policy-makers, officials and reporters. Formal training was initially for 2 days, but was later reduced to one and half days. Informal training period was variable without any curriculum.

5500 units of Postinor-2 were sent to Indonesia. Of these, 4575 were distributed to providers and 1819 issued to the clients. The price ranged from free to 50,000 Rupia (approximately US $ 7).

Evaluation of introductory activities

Evaluation was conducted from June 1999 to March 2000 to assess the impact of the activities on the availability and use of Postinor-2, the operational problems, and the lessons learnt in implementation. Data collection utilized in-depth interviews, focus-group discussions and use of mystery clients. Interviews with clinic managers, service-providers and stock-holders were conducted. They were all enthusiastic and supported future introduction of Postinor-2. The interviews revealed that clinic managers and service-providers both had insufficient knowledge, a number of misconceptions, and many queries related to Postinor-2. The providers reported difficulties in identifying clients who met the indications for use of Postinor-2. Many providers suggested that there should be future efforts to inform the general public through mass media and hotline services. Training sessions needed to include real life scenarios. Single training was not sufficient. Refresher training with service delivery guidelines in regional language was required.

Evaluation of profile of users and user behaviour revealed that most women sought EC after a missed period. The clients were predominantly married, between 25-36 years, with one to three living children. The reasons for taking Postinor-2 were as follows:

• late for contraceptive injection (20%)

• late for menstrual period (20%)

• had sex without contraception (11%)

• forgot to take oral contraceptive pill (9%)

• husband returned unexpectedly (8%)

It was felt that EC was mostly used when it was not required e.g. taken as a menstrual inducer or given to women presenting late for DMPA re-injection even when within one week of the safe window.

It was concluded from these interviews that a need for Emergency Contraception clearly exists in Indonesia. Registration would be required before the scope of Postinor-2 could be further expanded. If registration was not obtained, Indonesia might consider promotion of combined oral contraceptives or the copper IUD. Clear strategies were needed to be developed if the method was to be introduced widely and with appropriate quality of care.

Approval process was expected to take less than one year. Although the Consortium met with a National Family Planning Coordinating Board throughout the introductory trial, the Board continued to have concerns. It was felt that the key religious groups must give their approval before the Ministry of Health could take any action.

The Consortium was able to promote discussion on Emergency Contraception among a broad range of stakeholders and mobilize the participation of many of these groups. These efforts led to a high profile for Emergency Contraception in the national media. Of particular importance was the involvement of the Indonesian Midwives’ Association and the Muhammadiyah Health Council.

Lessons Learnt / recommendations

• A need exists for a more systematic and strategic approach to introduction.

• The involvement of key stakeholders is essential to ensure broad delivery coverage, as well as product registration.

• Advocacy and promotion of Postinor-2, including adequate technical information, to be targeted at programme managers.

• Selection of appropriate channels for provision is essential in the introduction process.

• A single brief training session was insufficient. Technical back-up, supervision and refresher training is required.

• The training sessions need to include not only theoretical content, but also cover practical, real life scenarios.

• Service delivery protocols and medical guidelines should be translated and supplied to service-providers to be referred to in future.

• A strong IEC component is an essential part of introductory activities.

• Ensuring sustainability of supply will help to alleviate concerns of providers.

• Package inserts for Postinor-2 should be written in local language and include answers to common questions.

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