Repositioning family planning through community based distribution agents in Malawi.

Introduction Despite being one of the countries that has enjoyed relative peace for a sufficiently long time, Malawi remains one of the countries in the world with the worst health indicators. The maternal mortality rate for Malawi is very high by any standard. According to the Malawi Demographic and Health Surveys (MDHS), the maternal mortality rate for Malawi almost doubled between 1992 (620 per 100,000 live births)1 and 2000 (1,120 per 100,000 live births)2 and only dropped slightly to 984 per 100,000 live births (95% CI: 822-1,142) in 20043. The lifetime risk of maternal death in Malawi is 1 in 17, which does not compare favourably with the world average of 1 in 74 and 1 in 4,085 for industrialised countries4. There are many factors that affect maternal mortality and one of them is parity, age at marriage, age of the mother and child spacing all of which determine the fertility pattern of a country. Available statistics already show that fertility in Malawi is still high with an estimated total fertility rate (TFR) of 6.0. There are regional differentials in as far as fertility is concerned in Malawi. Fertility rate was higher in the central region (TFR =6.4) and lowest in the northern region (TFR=5.6). The southern region recorded a TFR of 5.8. Use of modern methods of family planning is higher in the central region (30%), followed by the northern region (29%) and southern region (27%). Median age at first birth was consistently lower for the southern region across all age groups with an overall average of 18.7 years for the 20-49 year age group as compared to 19.4 and 19.0 years for the central and northern regions respectively. Median age at marriage for women in the 20-49 year age group was 17.6 for the southern region (17.8 and 18.4 for the northern and central region respectively). The northern region, however, recorded the highest number of months since preceding births (36.5) as compared to southern region (36.4) and central region (34.9)3. Just like most of the countries in southern Africa, Malawi is experiencing an unprecedented HIV/AIDS epidemic with an infection rate among the childbearing age group of 16.4%5. Youth aged 15-24 claim 46% of new HIV infections of which 60% occur among girls. HIV in Malawi is mainly spread through heterosexual sex hence it remains a reproductive health issues6. However, HIV/AIDS control efforts are hampered by low voluntary counselling and testing (VCT) uptake7 which indicates that significant behaviour change has not yet occurred in Malawi. Worse still, the role of condom use for dual protection has not yet been taken advantage of in Malawi.8 Special AIDS prevention programmes in Malawi focus on use of condoms, limiting the number of sexual partners and delay of initiation of sexual relationships in young persons although some social cultural factors have also been associated with HIV transmission9. In line with African Union Maputo Plan of Action on Sexual and Reproductive Health adopted in 2006 in Mozambique10, Malawi has been trying to revitalize family planning through repositioning. Family planning reposition is done through increasing family planning awareness, relevance and use of contraceptive information and services through appropriate policies and programmes11. Between 1999 and 2003, the Malawi Government, with financial support from the World Bank implemented a Learning and Innovation Population and Family Planning Project (PoP/Fp) of communitybased family planning delivery system in three districts. The objective of the project was to test the feasibility of implementing comprehensive district wide community based distribution (CBD) approach to delivery of family planning services. Three pilot districts, Chitipa in the Northern Region, Ntchisi in the Central Region and Chiradzulu in the Southern Region were selected on the basis of their poor social economic indicators in comparison to other districts in their respective regions. The control districts were Karonga in the Northern Region, Dowa in the Central Region and Mulanje in the Southern Region. Control districts were districts that were adjacent to the pilot districts and this was for evaluation purposes. The expected outcome of the project was an increase in the contraceptive prevalence rate (CPR) for modern family planning methods. The objective of this paper is to present results of a comparative analysis of the end of project expected outcome and related outputs for the pilot and control districts12. Methodology The Population and Family Planning Project The Population and Family Planning Project was a community based project designed to test the feasibility of implementing a comprehensive district wide community based distribution (CBD) approach to delivery of family planning services. The project aimed to train about 100 Community Based Distribution Agents (CBDAs) and strive to retain at least 80% of them through an incentive package. The project’s target was to have an average of 200 clients per each CBDA. CBDAs were counselling clients in their residences on family planning and supplying them with the chosen method or refer them to the nearest clinic if they chose a method which required a nurse/medical doctor/clinical officer such as injectables, norplant or tubal ligation. CBDAs were also providing counselling using and distributing leaflets, flyers and posters which were produced and tested centrally by the PoP/FP Secretariat.