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“There are 40- to 45-year-old women who don’t know anything about contraception and they have children who are adolescents already. What will they tell them? One woman asked me during counseling: ’Where have you been with your family planning methods when I was having my previous six abortions?’”
During Kyrgyzstan’s years as a Soviet republic, policies limiting the availability of contraception forced women to depend on abortion as the principal means of fertility control. Since independence in 1991, contraceptives have become more widely available and abortion rates have declined. Still, the issue remains a public health concern and abortion continues to be the predominant method of family planning in much of the country. Almost one third of Kyrgyz women of reproductive age have had an abortion; 60% of these women have had more than one. Among women who terminated their last pregnancy, 76% had not been using a contraceptive method.
As part of health sector reform in Kyrgyzstan, the PRIME II Project is using the Performance Improvement (PI) approach to assist the Ministry of Health in improving the quality and availability of postabortion family planning (PAFP) services in the oblasts of Osh and Jalalabad, home to approximately 40% of the country’s population of 4.8 million. In order to design effective interventions to increase the use of PAFP, PRIME conducted an assessment to identify obstacles that prevent women from receiving quality PAFP services. The study drew on interviews with key informants at health care facilities, focus group discussions with married women and men, observations of family planning counseling sessions and exit interviews with postabortion women.
“There are a lot of false rumors among women about contraceptive side effects,” explained one key informant when asked about barriers to PAFP services. “That’s why women still hesitate to use family planning methods, although many of them understand the danger of postabortion complications. They want to use safe family planning methods but don’t know where to get competent counseling or receive contraceptives.”
Such perceptions of low quality or unavailable services are borne out by PRIME’s assessment, which found significant performance gaps among providers of family planning counseling and services. Only 5% of the observed providers informed postabortion women that they can become pregnant as early as 11 days after an abortion; 31% incorrectly believed that clients must wait for menstruation before beginning injectable contraceptives, while 15% mistakenly maintained that women must wait for their period before taking birth control pills. Less than a third of providers counseled clients on potential side effects of their chosen family planning method. While 86% of postabortion clients selected a method, only 19% actually received one: the rest were told that their choice was unavailable or to come back later.
Key provider performance gaps identified by the assessment are being addressed through interventions implemented by PRIME II in Osh and Jalalabad during the second phase of the PAFP project. To improve the quality of PAFP services, PRIME is working with the Ministry of Health to develop protocols and prepare trainers to teach PAFP counseling. Five PAFP counseling and clinical updates will be offered to family doctors, ob/gyns and midwives in family group practices. To ensure that women receive their method of choice, contraceptive stocks are now monitored in intervention facilities, which generate reports for local facility chiefs, UNFPA, and both oblast and national Ministry of Health representatives.
PRIME and the Ministry of Health will foster increased use of services and improved knowledge about fertility and family planning through community-wide educational activities and outreach with radio messages at local markets. As a key informant summed up, “Providers must advise not only women but men as well. It’s very important to make men understand that they can play a big role in family planning. Radio, TV, literature—and special sessions for adolescents—will help to improve this situation.”
The PRIME II Project, funded by USAID and implemented by IntraHealth International and the PRIME partners, works around the world to strengthen the performance of primary providers as they strive to improve family planning and reproductive health services in their communities.
PRIME Voices #24, Kyrgyzstan: Increasing the Use of Postabortion Family Planning, 11/11/03.