A window of hope
Head of Research at BBC Media Action in India
A community health worker uses BBC Media Action’s job aid Mobile Kunji while on a visit to a pregnant woman and her mother-in-law in Bihar, India
Yesterday I presented two research papers on family planning at the International Conference on Population and Development (ICPD) in Paris, France.
These papers are based on data from baseline research from BBC Media Action’s Shaping Demand And Practices project in Bihar, India. The programme is part of the Bill and Melinda Gates Foundation funded Ananya initiative which aims to reduce maternal and infant mortality in the northern Indian state by up to 40% by December 2015.
One of my papers focuses on family planning use during the year after a woman gives birth (the 'extended postpartum period'). The other paper examines why, at the beginning of our project, many couples don’t use modern contraceptive methods to space births. The research talks about a potential window in a woman’s life where she could avoid unintended pregnancies if she has access at the right time to the information and services she needs.
But before I explain more, I want to tell you a story about two women – two fictional characters whose stories are, however, true to life for many women in rural Bihar, a state with some of the highest maternal and infant mortality rates in the world.
'Savita' is a poor woman in her second trimester of pregnancy. She already has six children - all girls - and she doesn’t want to become pregnant again as it’s seriously affecting her health and that of her youngest daughter, Muniya, who is just one year old and severely malnourished.
Savita's husband Ramlal is a migrant worker who lives in Mumbai, very far from their village. They don’t use any modern contraceptive method and whenever Ramlal visits their village, he leaves Savita with another pregnancy which she has to manage on her own. She's unable to convey her feelings to her husband, and the family elders want Savita and Ramlal to have a male child.
Savita's younger neighbour, 'Rani', is pregnant for the first time – and is scared that she might end up like Savita. Her husband is also a migrant worker who lives in New Delhi and visits her only two or three times in a year. Rani doesn't want another child for at least another two years but like Savita, she hasn’t got anyone to talk to about what she could do.
So what are the options available for Savita and Rani? What could Savita do to avoid getting pregnant again and again? And how could Rani work out how to space the births of her children?
Our research findings point a way forward to helping women like Savita and Rani. Two of the most important findings are the very low use of contraceptive methods in the year after giving birth and the very high 'unmet need' for family planning services and supplies during this time.
In Bihar, we found that seven out of eight women (88%) in the extended postpartum period do not use any modern contraceptive method (like the oral contraceptive pill, IUD, injections, or sterilisation) and heavily depend on natural methods (like periodic abstinence, withdrawal, or lactational amenorrhea – natural postnatal infertility associated with exclusive breastfeeding before a woman’s periods return). And nine out of 10 women do not use any modern contraceptive method within the first six months after delivery. The most common methods used are condoms, periodic abstinence and female sterilization. The extended postpartum period is a time when there's a very high chance of a woman becoming pregnant: exclusive breastfeeding drops, fertility returns and sexual activity resumes.
'Unmet need' for family planning services and supplies, meanwhile, is an indicator of progress towards Millennium Development Goal #5, to improve maternal health. Unmet need is defined as the percentage of women who aren’t using contraception even though they want to avoid becoming pregnant.
In Bihar, we found two out of every three women in their extended postpartum period expressed such an unmet need for family planning. There is also a very high level of unmet need for limiting family size (40%) – as in Savita's case – and a very high need for spacing births (27%) – as in Rani's. This unmet need decreases but remains very high throughout the first year after birth: even by the end of the year, almost two thirds of women in Bihar still desired to space or limit subsequent births. Unmet need is particularly high amongst women with three or more children.
These findings suggest that if a programme like SDP could identify the women with unmet need and reach them with the necessary information and access to services at the right time, it could help women like Savita and Rani.
Armed with the knowledge gained from this baseline research, we can also point other useful ways forward.
For example, our research findings based on SDP baseline data and analysis of India’s National Family Health Survey 3 data are in line with other studies across the world in that they show that women who receive antenatal care are more likely to use family planning in that crucial one year after delivery. Projects could integrate family planning advice during antenatal visits to recognise this and use the antenatal period as a gateway for communication.
The research also highlighted the importance of the role of frontline health workers. Projects which build capacity among health workers to screen and identify women with unmet need and provide them with the correct information might also see greater success in improving women and babies’ health. Considering contraceptive methods based on postpartum timings and breastfeeding status wouldalsobe a useful focus.
Other important issues that projects could actively tackle include the importance of discussing both the high pregnancy risk in the year after delivery, the healthy timing of a woman's next pregnancy and also a couple's return to sexual activity. There may be a stigma attached to the discussion of sex, which makes women reluctant to ask for family planning services. Supporting immediate, exclusive and continued breastfeeding are also important practices for ensuring child survival during the first year.
These are only a very few of the practical approaches that arise from the wealth of interesting findings in our research. And the findings also support and inform BBC Media Action's approach in Bihar as well as our other work on family health in Madhya Pradesh and Odisha, funded by the UK’s Department of International Development. We are empowering community health workers through mobile phone tools and training), providing community activities such as street theatre and listeners clubs, and TV adverts and programmes.
A window of hope can be opened in the lives of Savita and Rani.