Coordinated FP Service Delivery
There is a high level of coordinated FP service delivery in Rwanda. This coordination is demonstrated through the complementary roles played by different provider types, nurses and CHWs, as well as the awareness of these roles by community members.
First Point of Contact: CHW
Experienced contraceptive users in both Musanze and Nyamasheke agreed that the presence of CHWs has been a tremendous asset to their communities, since the presence of a CHW brings close access to a trained FP service provider and contraceptive methods. Data showed that women appreciate the improved access CHWs bring, as nearly 100% of respondents specifically raised this topic.
It is so easy to get the product that I need….It’s so easy, there are family planning providers close to home.
Female, injectables for 10 years, 50 years old, 5 children, Musanze
…I live near the community health workers so I have access to services in the way that I want and in the time that I want.
Female, injectables for 8 years, 31 years old, 3 children, Musanze
…the availability of contraceptives is everywhere…
Female, condoms, 41 years old, 5 children, Musanze
Women noted that CHWs also do home visits, sometimes even to deliver a desired contraceptive method.
Community health workers make things easier. Like, when I need a condom they bring it to my home.
Female, condom user for 2 years, 35 years old, 4 children, Nyamasheke
CHWs were not only easy to access in terms of proximity to the women’s neighborhoods, they were also accessible as friends and confidants.
The community health workers care about us. Anytime we go they give us the services we need.
Female, injectable user for 6 years, 38 years old, 6 children, Musanze
The thing that the community health workers do to make things easier is making me feel comfortable. The community health worker is the person that you already know in the village, and there isn’t anything you can be afraid of asking her because you already know each other. You can discuss anything.
Female, injectable user, 41 years, 5 children, Musanze
CHWs were noted as the first point of contact for community members interested in using family planning for information, resupply of methods, or to discuss issues they might have with method use. CHWs were the primary contacts for women due to proximity but also rapport.
Now it is easy to get contraceptives because you can find it everywhere in your village. Before the CHWs began, you had to go all the way to the health center, but now it is easier because there is someone who can give it to you in the village.
CHW, female, 50 years old, 6 children, Musanze
We’re neighbors with the community health workers, so if I have a problem I’ll go to the community health workers…
Female, condoms, 41 years old, 5 children, Musanze
The community health workers are valuable people. They are the ones who are closest with the clients. Because any problem that a client meets, they directly go to see the community health workers.
Nurse, female, 50 years old, 3 children, Nyamasheke
CHW Refers Client to Health Center
Women and CHWs often discussed how the CHWs would connect clients with health centers and professional providers. At the clinic, every health provider has been trained in family planning service delivery.
The other thing I can say the country helped us in is that at the health center every nurse is capable to give family planning methods. This means that they trained us about family planning. Every hospital staff knows how to give family planning methods.
Nurse, female, 35 years old, 4 children, Nyamasheke
The CHW will attend to the woman, and if the issues extend beyond the capacity of the CHW, then the CHW refers the woman to the nearest health center for assistance.
If they (CHWs) are met with a problem that is higher than their level of knowledge, they send the women to the health center.
Female, pill user for 3 years, 45 years old, 2 children, Nyamasheke
Sometimes CHWs even accompany the client to their health center appointment to increase the client’s comfort in finding the right location and to help with communication.
If I have a problem I go to the community health worker first, and if she can’t resolve my problem she can accompany me to the health center because I may be shy or don’t know where to go.
Female, condoms, 41 years old, 5 children, Musanze
Problems women faced could include the need to test for pregnancy before resupply of contraceptive methods.
…the contraceptive pills lasts between two and three months, and every three months we have to go to the provider to get more. Before they give you the pills they talk with you and ask if you are good at taking them on time, and you explain your experience. And if there is a time where you may have forgotten to take the pill, she will tell you that she can’t give you more pills yet because you may be pregnant. She will tell you to go to the health center first to make sure you aren’t pregnant and that things are okay, and then you can come back and get the pills from the nurse.
Female, pill user for 10 years, 38 years old, 3 children, Musanze
CHWs would transfer women to the health center for testing prior to initiation of contraceptive use or if the needed assistance in allevation of unmanageable side effects.
Medical Tests at the Health Center
A theme present in nearly all focus groups and some interviews was the requirement for new clients to undergo medical testing at health centers prior to initiating contraceptive method use. The test results may indicate contraindication of some methods for the client. CHWs do not conduct these tests themselves, as they are only done at health centers. Rather, CHWs counsel new clients on methods, but do not initiate method use until medical tests are complete.
Even though as CHWs we teach her about different methods, we do not have the approval to give her those contraceptives. At that time we will give her a transfer to the health center. At the health center they will take some test in order to get a suitable method for her.
CHW, male, 49 years old, 4 children, Nyamasheke
The tests that providers implement may include pregnancy tests to rule out pregnancy prior to contraceptive use initiation. Providers might also test for pre-existing health conditions, such as high blood pressure, which may indicate that an individual is not eligible for certain contraceptive methods.
First, you have to go to the health centers where you get all the tests before they give you the method you want. Tests to check that you are not pregnant or that you don’t have high blood pressure and other problems.
Female, former implant user, 38 years, 5 children, Nyamasheke
Nurses at health centers also use tests to check on the health of sustained users at periodic intervals.
At health centers sometimes they test our weight to see whether after getting that method our weight is increasing or decreasing, and also our blood pressure to see whether the pressure is high so if they see that they can advise you to switch to another method. You can see that they are caring for us.
Female, pills for 4 years, 32 years old, 3 children, Musanze
Nurses Transfer Client Back to CHW
Once “cleared” by the nurses to begin using contraception, women are transferred back to the CHWs for method resupply if they elected to use condoms, pills, or injectables.
…I have first to go to the health center. After getting tests and my method they give me ordinance and I give that ordinance to the community health workers as proof that I have already gone to seek out family planning so that they can continue to look after me.
Female, injectable user for 6 years, 32 years old, 2 children, Nyamasheke
CHWs also reconnect with clients after visits to the health centers to make sure they received the services they needed, discern how satisfied they are with their selected contraceptive method, and to remind the client to visit them if any issues arise.
You have to see her again after she gets back from the health center to discuss with her. I would tell her that if she has some changes in her body she should come back to see me, because this may happen.
CHW, female, 47 years old, 4 children, Musanze
Most importantly, participants were aware of what cadre of provider could help them obtain the method they desired. Participants, regardless of method used, knew that they needed to go to a health center for long term or permanent methods, while they could access short-term methods from the CHWs, only for resupply. Study participants noted the increased efficiency of the coordinated service delivery model.
Due to a lot of women that want services of family planning, there is a program that has started, some have been oriented to health centers, and others to community health workers, in order to reduce the lines of women that were waiting for the services. And also as a way to increase the services going fast for each woman that needs the services.
Female, pills for 4 years, 32 years old, 3 children, Musanze
Coordinated Integration Of Fp During Antenatal And Postnatal Care
Within the system of coordinated FP service delivery, integrating FP into prenatal and postnatal care is a natural extension of the current system. CHWs and nurses teach women seeking prenatal care about FP so the women are informed about their options and have time to process the information with their husbands and others prior to birth. In some cases, women decide to initiate method use immediately after birth, and the health center is prepared to fulfill that desire. For others, women wait to initiate FP use until later in the postpartum period.
When someone is pregnant, in her 15th week of pregnancy, she has to go to the hospital to check if her baby is growing so at that time they get information…the doctor discusses with her about different contraceptive methods.
Nurse, female, 36 years old, 1 child, Nyamasheke
After they give her the information she needs, the CHW will send her to the doctor and the doctor before sending her into labor will find a method for her to use because she asked for it. He will find a method before sending her home, because she can get pregnant in those six months after birth.
CHW, female, 44 years old, 5 children, Musanze
CHWs also check on postpartum women who have not yet begun using contraceptives. This helps ensure that FP needs do not go unmet.
After giving birth, the CHW will continue to take care of her and further explain why using contraception is important…
CHW, female, 48 years old, 6 children, Nyamasheke
I first learned about family planning from nurses when I was going to get tests at the hospital during my first pregnancy. And then, I also learned about it when I had my first birth because here, when a woman gives birth, the community health workers visit her and give advice on how to use family planning.
Female, former injectable user, 32 years, 3 children, Musanze
At health centers when a woman is going to seek other services, they remind her that the family program is there, also after having her first child, the community health workers and nurses remind her that she has to choose methods in order to put space between her first child and her next children.
Female, pills for 4 years, 32 years old, 3 children, Musanze
…here in Rwanda women who are pregnant always have a CHW who checks in on how she is doing. So, in the discussion I have when I come to see how her pregnancy is, I would advise her about how to use family planning after giving birth and help her to choose the method that she wants to use.
CHW, female, 43 years old, 3 children, Musanze
Timing of Integration
A sequence of FP integration arose often: women were informed about FP methods during pregnancy and initiated contraception during child health visits – particularly child vaccinations and weight checks. Spacing was commonly cited as the reason for FP use.
…I first understood about family planning when I was going to get a pregnancy test when I was pregnant my first time. After getting those tests, they teach us about how a woman can use family planning programs in order to help children so they aren’t close in age in order to have a healthy life and to raise children well. They try to tell us about all methods and at that time when I go back home I discussed it with my husband. After agreeing with my husband is when we decided to use family planning after having our first kid. After giving birth, like one month, I go to the kid’s vaccination and they give me that method of family planning.
Female, former implant user, 36 years, 3 children, Nyamasheke
…at that time that I came to get vaccination for my children I learned that contraception was a good thing and it helps a family in general in Rwanda, and that’s what caused me to start using contraceptives.
Female, sterilized, 40 years, 9 children, Nyamasheke
The Community Health Worker will continue the vaccines with those children and will also continue telling her about family planning.
Nurse, female, 34 years old, 2 children, Musanze
…I was going to the health center getting some tests for my first child when the nurses reminded us that the family planning program was also there...
Female, injectable user for 6 years, 32 years old, 2 children, Nyamasheke