All Options are on the Table: How Training Health Care Workers is Improving the Uptake of LARCs in Kenya
Contraceptive uptake among women in Kenya has steadily risen over the last ten years, and injectables and implants have emerged as the most popular modern methods.
But who is meeting this growing demand for family planning information and services?
In Kenya, the shortage of health care workers affects the availability and quality of counseling on the latest contraceptive technologies. Over the last four years, IntraHealth International, through the USAID-funded FUNZOKenya project, has worked with the Ministry of Health (MOH) to support training of health care workers in the delivery of long-acting reversible contraceptives (LARCs). Since 2012, 3,019 health workers in 8 counties have been trained to counsel clients on available family planning methods and on insertion of intrauterine contraceptive devices (IUCD).
Why LARC training?
Several factors necessitated additional training of health care workers—the goal was to train 10,000—on provision of LARCs. One was the growing popularity and demand for LARCs. Another was the introduction a new type of implant that is easier to insert and use, Implanon NXT.
To improve availability of LARCs in the rural areas, the MOH identified eight counties, based on total fertility rate (TFR) and number of trained health care providers, where FUNZOKenya would focus the LARC training efforts. While Kenya’s national TFR is 3.9 births, some of the selected counties are much higher, like West Pokot (7.2), Turkana (6.9) and Tana River (5.8).
Harnessing the regional training hubs strategy
FUNZOKenya works with eight medical training institutions that provide regional on HIV and AIDS; maternal, neonatal, and child health; and family planning. These “training hubs,” spread across the country to improve coverage, are linked to county hospitals that serve as sites for clinical practice and use both faculty- and county-based practitioners as trainers. The use of “training hubs” ensures that faculty keeps updated on latest contraceptive technologies and trends and facilitates ongoing mentorship opportunities. The “training hubs” have also reported using the newly gained knowledge in family planning to influence revision and/or development of pre-service curricula.
The impact on end users
One benefit of this training is improved access to family planning services for clients. The growing availability of LARC-trained healthcare workers has motivated the county governments to open additional sites to bring services closer to clients and to offer LARCs at more sites. One of the most heartening successes is in West Pokot, a rural county with among the poorest family planning and contraceptive uptake indicators in the country. The West Pokot county chief officer of health reported that availability of LARC-trained health care workers had prompted the county to open four additional service delivery points.
In Mombasa County, a nurse at a local health center reported that before the LARC training offered by FUNZOKenya, women who opted for the LARC methods were often referred to Coast County Referral hospital, which was inconvenient. She remarked,
“In 2012 before I attended the training, there was a woman who came to me and wanted an IUCD. I referred her to Coast General Hospital because we were not offering the services here. Then one month later she came and wanted an injection because she had not made the trip to Mombasa. Unfortunately, when I ran the mandatory pregnancy test she was already three weeks pregnant.”
A second benefit for the end users is empowerment, especially in cases where the male partners insist on controlling the use of contraception. For example, in Kwale County, which had poor family planning uptake and a TFR of 4.7, there is a reported a practice referred to locally as the “Mwenye syndrome,” where a woman has to get approval from her husband before taking up any family planning services or she risks divorce.
A third benefit for the end users is increased contraceptive options for women. During one of the training workshops conducted in Kitui County, where women have an average of four children, a young woman who arrived at the Kitui County Referral Hospital, where the LARC practical sessions were taking place, reported that she had come for her regular dose of injectable contraception. Upon learning about the Implanon NXT and its benefits, she changed her mind and opted for that instead. The Kitui County Reproductive Health coordinator reported that, in addition to high poverty, illiteracy and retrogressive cultural beliefs, the insufficient number of health care providers with the skills to administer LARCs was a major hindrance to uptake.
Supporting health workers
LARC training benefits the health care providers as much as their clients. The curriculum emphasizes extensive practice for skills building and imparts competencies in contraceptive counseling and insertion and removal of IUCD and implants. The training also requires participants to insert and remove at least five IUCDs and contraceptive implants before certification by the Ministry of Health. Additionally, the course requires post-training supportive supervision. The counseling training is aimed at empowering providers to help clients overcome barriers, such as negative cultural beliefs, to LARC uptake. Participants have reported that these trainings have changed the way they deliver services:
“A lot of things are changing in family planning, and it’s important that health workers are well updated on the new technologies. After the training I am now confident to counsel clients on these methods because I am able to provide them personally.”
A health care worker in Kitui County Hospital indicated that providers often lack the confidence to offer LARCs and shy away from insertion of an IUCD or implant. This means that women seeking family planning services are not offered these options, and their choices are limited to injectables and pills.
Increased training on provision of LARCs benefits everyone. Harnessing regional hubs will ensure training spreads beyond the counties initially involved. The next Demographic and Health Survey for Kenya will likely be in 2019—I look forward to seeing the increase in uptake of LARCs and the resulting decrease in fertility rates.