While availability of contraceptive methods and integration of family planning services into maternal health programs are keys to promoting women’s health, the barriers to contraceptive use are also worth examining. The success of integrated services depends on how well programs identify and address these barriers in the delivery of the care they provide.
Even when family planning services are available, many women do not utilize them for various reasons. They may have difficulty traveling to a clinic or they may not have the financial means to pay for services. Preconceived notions about health services also impact a woman’s decision to seek care. When making decisions related to contraception, women are influenced by their own past experiences or the experiences of others in their social circles. In Haiti, for example, women consider the side effects associated with contraception (including permanent infertility), the safety of their infants while breastfeeding, and their husbands’ permission. This last point is also true in rural Ghana, where a woman’s partner’s approval of contraception determines whether she will adopt it.
In countries where many languages are spoken and literacy rates are low, cultural and communication barriers often affect uptake of reproductive health services. In Guatemala, for example, women belonging to indigenous groups are less likely to deliver in healthcare institutions and less likely to use family planning methods. Where geographical access to care is not a barrier, inability to speak a country’s main language (in this case, Spanish) often prevents women from seeking care.
In addition to considering the cultural factors that influence care-seeking, identifying barriers to care through monitoring, evaluation and quality improvement strategies is crucial prior to and during the process of integrating family planning into maternal health services. In Afghanistan, for example, quality improvement teams in private and public hospitals addressed reasons for low contraceptive use in an effort to understand the decisions of the population they were serving. At the same time, they expanded their services by integrating family planning into their maternal health programs. Barriers to integrating family planning into postpartum services included the following:
- Weak family planning counseling skills among postpartum staff
- Lack of job aids among staff to increase patient awareness
- Lack of private spaces for family planning counseling; and
- Lack of husband and mother-in-law involvement in the counseling process.
Interventions to eliminate these barriers were introduced in the hospitals and included training on family planning counseling to the postpartum staff, providing job aids to the staff, creating a private area for counseling, and involving family members in the counseling session (either in person or via an electronic medium).These initiatives resulted in an increase in the percentage of postpartum women who received family planning counseling before discharge and an increase in the number of women who received counseling along with their husbands. Women were more likely to adopt a contraceptive method of their choice and less likely to become pregnant at the 12- and 18-month period post-discharge as a result of these quality improvement strategies being weaved into FP-MH integration efforts.
Religious values and structural violence may also deter women from accessing family planning services. Even with sufficient supplies and staff to counsel women, these barriers can significantly impede the impact of well-developed and well-integrated programs. Overcoming these barriers means providing accessible care that is culturally-sensitive and patient-centered. To address them, family planning-maternal health (FP-MH) programs should:
- Engage women and their partners/family members in the care they provide through a welcoming environment. This can be done by encouraging women to bring those who are influential in their health decisions to their maternal health visits.
- Create educational tools and programs for women and men in order to break down cultural and social myths related to family planning.
- Develop communication tools with the help of the people for whom they are being created. Using human-centered design is a way to involve the target population in program development and improvement and break down barriers to women getting the care they need from FP-MH programs.
In order to deliver family planning information and services to women who want and need it, programs must tailor their services to match the cultural values, unmet needs, and literacy levels of their target audience. These factors vary between and within countries, which means each program needs to be sensitive to the unique characteristics of its target population. With this in mind and in light of the barriers that play a role in the use of family planning methods, programs should consider the following:
- Who is the target population?
- Does the target population extend beyond the women who will directly receive services from the program?
- Who plays an influential role in the lives of the people we are trying to help through our program?
- How can we address the barriers that we have identified in a culturally sensitive manner?
- How can we successfully integrate family planning services into our maternal health program and simultaneously promote an environment that respects the target population’s values?
Evaluating these points is imperative to creating and implementing quality integrated FP-MH services. A program’s ability to be effective in the community depends upon its capacity to address the needs of the women it is designed to serve and promote an environment of respectful and patient-centered care.