Too often, it seems as though we talk about contraception strictly in terms of access. More than 222 million women want to prevent pregnancy, but can’t access to modern contraception. If these women could simply get to a health provider where family planning methods are in stock, then all of their problems would be solved, right?
If only it were that easy.
Talking only about access leaves quality in family planning provision out of the conversation, and that’s a mistake. We need to consider all of the challenges that go into meeting the family planning needs of an individual woman. When I hear the word quality, the first thing that comes to mind is counseling, and just how difficult it can be for service providers to provide quality counseling.
I learned this firsthand while serving as a health volunteer in northern Cameroon. I had never received training in health care provision or counseling, and my knowledge of reproductive health stemmed from college biology and the two years I spent working on family planning programming and policy at USAID. However, when my close friend Djanabo wanted to talk about family planning methods after giving birth to her sixth child, I wanted to help. I also knew that realistically, I was still better positioned to discuss her options than anyone else in her village. Djanabo spoke brilliant French and loved to read, both of which made her an outlier in the small, rural village where she lived. In this area of Cameroon, girls were just starting to stay in school long enough to make it to high school and most older women could not read or write.
Still, I struggled with translating what I knew about family planning service delivery at the program level into what would make sense to Djanabo in real life. How could I help this one person make the right decision for her? It’s a challenge family planning providers face on a daily basis. But health providers in many countries are also trying to balance a given individual counseling session with the line of women waiting outside their door for a range of services. These providers face difficult working conditions, long hours with little or no pay, often limited training and shortfalls in necessary supplies. When exploring the issue of quality, we should never forget these challenges. Instead, we need to focus on supporting providers to provide the best counseling possible.
Djanabo agreed to let me share our counseling experience as one example of how to make the technical relatable:
Think: What are the client’s reproductive intentions?
Say: Did Djanabo want to space her next pregnancy or was she ready to stop having children?
This conversation occurred a few weeks after Djanabo had given birth to her sixth child. She explained that her and her husband felt six was the perfect number. They had 3 girls and 3 boys and hoped to provide the children with as many opportunities as possible. In other words, Djanabo wanted to limit future childbearing.
Think: Has the client ever used and then stopped using a family planning method? If yes, why did they stop using that method?
Say: Had Djanabo had a positive (or negative) experience with a family planning method?
All of Djanabo’s children had been spaced about two years apart, which implied to me she had some knowledge of how to avoid a pregnancy. I asked if she had used family planning methods in the past—keeping in mind the local health center only offered condoms, pills and injectables. Djanabo explained that for a period after each pregnancy she relied on breastfeeding (aka Lactational Amenorrhea). She had tried injectables, but did not like the irregular bleeding she experienced. We talked about how some of these side effects can dissipate as your body acclimates to the hormones in injectables. However, given that Djanabo was ready to limit future pregnancies, she was more interested in long-acting methods.
Think: Ask what the client knows about family planning methods, in particular LARCs.
Say: What did Djanabo know about implants and IUDs (aka long-acting reversible methods)?
I asked if Djanabo knew about contraceptive implants or IUDs. She had heard of them but did not fully understand how they worked or the difference between them. Through discussion and my drawing some rudimentary pictures (I was not prepared enough to have a counseling flip chart handy), I explained the basics of these two methods, as well as some potential side effects. We also discussed the fact that to obtain these methods, she would have to find a trained provider in the regional capital city (3-4 hours away by bus on dirt road). I offered to help her find a skilled provider. Djanabo appreciated the long-acting nature of these methods, and was motivated enough that she would have invested in the travel costs. But in the end she was uncomfortable with the idea of having a foreign object inside her body at all, let alone for several years. To keep things in perspective, I have heard this concern expressed by young women in America as well.
Think: Is the client familiar with tubal ligation?
Say: Was Djanabo interested in female sterilization?
Yes! Djanabo knew about and was interested in sterilization. We discussed the benefits (permanent and effective) as well as potential side effects. Djanabo wanted to obtain a tubal ligation. She would have to have the procedure in a hospital in the regional capital city. We strategized about how to find a well-trained provider at one of the private hospitals and how to find out the cost. Djanabo’s husband was a small shopkeeper and farmer, and Djanabo earned some money as a tailor. They would have to save to pay for the procedure, as well as the transportation and recovery period.
By the end of this exchange, we had spent 2 hours talking openly and honestly about benefits and side effects. I couldn’t think of a better way to spend my day, because at the end of it Djanabo had freely decided on the method of her choice based on full, evidence-based information.
This conversation happened about two weeks before I was ending my service as a Peace Corps volunteer. Since I wouldn’t be there to help Djanabo realize her decision, I left her with more information on family planning methods. If I couldn’t be there, I wanted to make sure she was armed with accurate information when she did seek out a provider. I would like to think this was a quality—albeit informal—counseling experience. If nothing else, it demonstrates how much time, effort and knowledge goes into helping one woman find her ideal method.
Update: I called Djanabo a week ago to find out how her family is doing now, 2 years later. Her oldest son just passed the BEPC, an exam in the French school system need to continue on to high school. Her two middle daughters—who used to complain about classes—are flourishing and excited to be continuing in school. Djanabo has not had any more children since I left Cameroon.