On September 17, the Method Choice Community of Practice, led by the Evidence to Action (E2A) Project, hosted a webinar on the intersection of two important voluntary family planning areas—method choice and self-care. Missed this webinar? Read on for a recap, and follow the links below to watch the recording.
Particularly in the era of the COVID-19 pandemic, self-care has become more prominent in all areas of health care. For voluntary family planning, self-care means emphasizing contraceptive methods that are controlled and self-administered by women themselves. At the same time, not all methods are adaptable to self-care, and it is equally important that the voluntary family planning and reproductive health (FP/RH) community ensure women and couples have a diverse choice of methods. Method choice ensures that they can make decisions about family planning that are voluntary, client-centered, informed, and supported.
The “Reimagining Method Choice in the Era of Self-Care” webinar examined the many ways in which self-care and method choice relate. Presenters shared country-level implementation examples and discussed recent innovations in products and practices that allow women and girls to have more active participation in their health.
Patricia MacDonald, RN, MPH, Senior Family Planning/Reproductive Health Technical Advisor at the Office of Population and Reproductive Health, USAID
Overall, women and couples have a broad choice of methods, many of which are women-controlled and self-administered—for example, the Caya Diaphragm, vaginal rings, condoms, pills, and fertility awareness methods. In addition, technology has evolved for other existing methods—for example, the DMPA-SC subcutaneous injection, also known as Sayana Press, which women in many countries can now self-inject. Not only can these methods be self-administered, but women can also obtain them through multiple delivery channels (for example, drug shops) that do not require a visit to a health facility. For some methods, multiple units/packets can be supplied at one time, reducing the need for multiple contacts with health facilities or drug shops.
If we shift the context to method choice and show how self-care fits within that, we have a different perspective—one in which all contraceptive methods have elements of self-care, even if they are not self-administered, but are provider dependent (for example, implants, IUDs, vasectomy, and tubal ligation). To understand this further, we can examine the Circle of Care Model.
This model illustrates the connections between social and behavior change and service delivery—and can help us find ways in which we can support self-care before, during, and after a healthcare visit. Self-care provides support “before” as clients seek information about contraception and take action to seek care. In the “during” phase of self-care—this can mean clients having the confidence during a healthcare visit to ask questions and ensure they are presented with the choice of methods that best fits with their own needs. Self-care “after” care can include things like wound care, checking IUD strings, and seeking care from a provider when needed. Self-care also challenges the health system and health providers to help empower clients to choose a contraceptive method that meets their needs.
Martha Brady, MS, Director of Sexual and Reproductive Health at PATH, who will leverage her work leading a global team of researchers and implementers to share the latest on self-care products and practices.
“Self care is the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a health-care provider.” The scope of self-care is broad—it includes health promotion, disease prevention and control, self-medication, providing care to others, seeking specialist care when needed, and rehabilitation/palliative care. WHO published guidelines on self-care in the context of reproductive health in 2019.
While self-care is not a new concept, we are seeing growth in products and platforms that make self-care more feasible, well as healthier and safer. Self care has become more sophisticated and data-driven, which has led to more specialized, individualized medicine. There are now more digital solutions that help people access knowledge and resources and determine how to engage with self-care products and practices. When people are active participants in their own healthcare, with the use of digital self-management tools, their outcomes improve.
FP/RH products and practices include: self-administration of injectable contraception (DMPA-SC), HPV self-sampling for cervical cancer screening, over-the-counter provision of oral contraceptive pills, home ovulation prediction kits for fertility management, self-collection of samples for testing for sexually transmitted infections (STIs), HIV self-testing, emergency contraception, barrier methods of contraception (diaphragms, condoms), the contraceptive vaginal ring, fertility awareness mobile apps, pregnancy tests, and menstrual supplies.
Self care is appealing to many women—particularly young women. We are also learning that self-care requires the knowledge and ability to access resources. Self care can be empowering and can increase autonomy and agency among women. In addition, self-care is linked to task-shifting: As individuals become more involved in their own care, the burden on the health system is reduced. Finally, we are learning of potential ways to link self-care to primary health care.
The Self-Care Trailblazer Group has identified some themes needing more research and evidence—from individual agency to provider behavior, health systems, and cost effectiveness and quality. There are also many questions related to method choice and self-care that are important to learn more about. Some of these questions are:
We are seeing an elevated interest in self-care, especially in the context of the COVID-19 pandemic. Many people are using telemedicine or digital health applications to find their way into health care, including contraception. Self care can help transform access to contraception, and is also a key component of achieving universal health coverage (UHC) more broadly. However, we need to make sure that self-care is working in harder-to-reach areas. We also need to ensure that self-care is person-centered and values autonomy, while still connecting people with the health system when needed.
“Self-care is more than products, technologies, and interventions. It is an approach, a practice, and a growing movement. The self-care movement is building, and this provides a great opportunity for the self-care and the method choice communities to work together.”
— Martha Brady
Dorine Irankunda, MD, Clinical Advisor, PSI
The Caya Diaphragm program is guided by a quality of care approach to self-care. As self-care has become more prevalent and accessible—and as the COVID-19 pandemic has acted as a catalyst for self managing health—we must work to ensure quality of care in all self-care interventions. To help with this, the Self-Care Trailblazer Group developed a quality of care framework for self-care to help health systems and clients accessing healthcare on their own. This framework can help programs recognize an individual’s engagement in their own care, while ensuring quality, equity, and accountability.
The Caya Diaphragm is a discreet, woman-initiated, reusable (for up to two years), one-size-fits-most device. It is a non-hormonal method that fits over the cervix to prevent pregnancy. With support from USAID, PATH and its partners developed the Caya Diaphragm through an interactive human-centered design process, which led to several design features that made Caya Diaphragm easy to use, especially for new users.
In Niger, the Caya Diaphragm was presented with Caya gel. In Benin, it is being presented in tandem with cycle beads in some settings—counseling will include the information that women could use cycle beads as a primary method, and Caya during fertile days. This is just being introduced now, but they will share learnings from this approach when available.
To introduce this new contraceptive method, the Expanding Effective Contraceptive Options (EECO) Project goes through 5 stages: regulatory assessment; consumer and market research; procurement and quality assurance; marketing, distribution, and service delivery, and monitoring and learning. Niger is at the last stage (monitoring and learning); in Benin, they are at the early stages (will start training soon). The device is being distributed in Niger via the public, private, and community health channels. The Caya Diaphragm program is working to ensure quality of care throughout the client journey—and during all channels—in obtaining the method.
The Caya Diaphragm team completed a mystery study in October 2019 to evaluate the introduction program in Niger. One finding was that some clients were not able to practice insertion with a pelvic model. Also, some providers were not able to offer Caya (not all were trained).
The team has learned that the Caya Diaphragm is highly acceptable in the context of Niger—and seems to fill a gap in the method mix by appealing to women who prefer non-hormonal methods or want a user-controlled method, and/or have infrequent sex. They have also learned that users have an ongoing need for support as they use this method. Using a new self-care method can be confusing for some women. Ensuring a support system (especially via community health workers) is important to ensure proper use and continuation. Finally, the team has learned that buy-in from key opinion leaders is important for the success of Caya Diaphragm introduction.
Natacha Mugeni, MSc, Health Coordinator, Kasha Global, Rwanda
Kasha Global is a direct-to-consumer platform built for users in low- and middle- income countries. They deliver personal health and self-care products.to urban and rural areas—including hard-to-reach areas. Kasha started in 2016 in Rwanda, and expanded to Kenya in 2018.
People can order and access information about Kasha in a number of ways—via feature phones (internet not required), the Kasha website, a mobile app, or a call center (using call, text, or WhatsApp). Kasha provides a range of products—from pharmaceutical products to personal care products. Related to reproductive health, their products include ovulation tests, pregnancy tests, family planning methods, and menstrual products. They offer free delivery via direct delivery (in urban areas), via pick-up points (in urban and rural points), and via Kasha agents (in urban and rural areas), most of whom are community health workers. Products in discreet packaging, and they offer affordable prices for low- and middle-income communities. Soon, they will be introducing DMPA-SC in Kenya, and are working on a home delivery pilot for ARVs in Rwanda.
Kasha ensures confidentiality and minimizes contact with providers. At the same time, they link clients with providers for remote interactions and counseling sessions when needed. They also provide online live interaction sessions.
During the last part of the webinar, panelists answered questions from participants. This session was moderated by Eric Ramirez-Ferrero, PhD, MPH, Technical Director of the Evidence to Action Project. Below is a summary of questions and answers (note that these are not actual transcriptions).
Martha Brady: While self-care is not a new concept, programming for self-care is new. We have a few things underway, and a body of work around advocacy, working with a number of countries’ Ministries of Health. This work aims to work with governments to determine how they are defining self-care in their context, and what specific policy advocacy asks there are within that. For example, task shifting to women self-injecting contraception is a clearer ask. There is increasing work on translating clients’ self-care interests with policy makers. There are a number of civil society groups engaged in these self-care consultations at the country level. And regarding monitoring around self-care choices, this is a bold new world, and there are bright opportunities for understanding this as we go forward. It is a work in progress.
Natacha Mugeni: We have pick-up locations at places where youth gather—for example, youth centers or schools. Young people can choose any place for receiving packages, including in their homes or their friends’ homes. We haven’t had many complaints about delivery options. When we started, our users were mostly women. For RH products, at first, older people were most of the clients, as the prices were higher than young people could afford. Since then, we have partnered with the Packard Foundation to subsidize products in Rwanda—young people have a coupon code. The coupon code is shared through youth ambassadors and youth centers—so young people now only pay 10-20% of the cost. In general, subsidization has been key in driving young people to our platforms for RH products.
Martha Brady: Men can be users of self-care—it’s not an exclusive domain of women. For example, many men are using HIV self testing. Is there something different about self-care that men will or won’t approve of? We don’t know, but this is an area that needs to be explored more, so we can understand how partners of a female self-care partner would feel about self-care.
Natacha Mugeni: We do have a number of male users. Most purchase condoms. Male condoms are the most popular in Kenya, and men often purchase them. Men also purchase lubricants through our company.
Dorine Irankunda: The Caya Diaphragm is a barrier method. There is no hormone in the device, so there are really no contraindications or side effects. It can be used safely by everyone. But we always highlight the fact that it doesn’t protect against HIV, so women should use additional protection (condom) if there is a risk for HIV.
Martha Brady: There are discussions around self-care packages in some countries. Contraception would be in this package. But some of this depends on how countries articulate self-care in their context—what do they mean by “self-care,” and what do they want to include in that? This is driven by context, and the trailblazers group is working on this.
Natasha Mugeni: Being a Kasha agent is not a full-time job, and is on commission basis. They don’t leave their CHW jobs, but this is something that gives them an advantage and opportunity to reach more people in the community. They show people how to communicate and use the Kasha platform, but it isn’t their full-time job.
Martha: In order to monitor and evaluate clients on self-care, we need to have an active program on this topic. We’re still new to this, but we do need to have M&E built into country work as they go forward with self-care so we can learn more about these self-care interventions.
Natacha Mugeni: We have a nurse in-house now, as well as a digital tool. We also have a forum where women can go and discuss side effects, learn about contraceptive choices, and share experiences. This is now live in Kenya, and will expand into Rwanda. And we want to expand referrals to others—beyond doctors and clinics, we often get requests for lawyers and other professionals—so we want to make sure our platform is as useful as possible.
Did you miss this session? You can watch the webinar recording here.
What does it take to operationalize an environment where all individuals can freely choose a contraceptive method that best meets their reproductive desires and lifestyles? Join the Method Choice Community of Practice, led by E2A, to explore new contraceptive data, trends, and country experiences.