Situational Analyses of Key Reproductive Health Services in Angola

43 Pages·2017·0.62 MB·English

Situational Analyses
of
Key Reproductive Health Services
in Angola

Muiji wa Disanze II / Healthy Families II
USAID Associate Award: CA#AID-654-A-13-00001

Prepared by Pathfinder International
Submitted to USAID
Luanda, Angola

October 31, 2014
Table of Contents

Acronyms ...................................................................................................................................................... 2
Introduction .................................................................................................................................................. 4
Situational Analysis: Preliminary Concept Framework for a National Family Planning Strategy in Angola . 5
Situational Analysis: Contraceptive Commodity Security in Angola ........................................................... 13
Situational Analysis: Adolescent and Youth Sexual and Reproductive Health in Angola ........................... 19
Situational Analysis: Long-Acting and Permanent Methods of Family Planning in Angola ........................ 25
Situational Analysis: Improving the Quality of Family Planning Services in Angola ................................... 36

Pathfinder International: October 31, 2014 – page 1
Acronyms

ANC Antenatal care
AYSRH Adolescent and youth sexual and reproductive health
BCC Behavior change communication
CBD Community-based distribution
CECOMA Central de Compras de Medicamentos de Angola
COCs Combined oral contraceptive pills
CPR Contraceptive prevalence rate
CYP Couple-year protection
EC Emergency contraception
ENSSR Estratégia Nacional de Saúde Sexual e Reprodutiva/National Sexual and Reproductive
Health Strategy
FP Family planning
HIP High Impact Practice
HIV Human immunodeficiency virus
HPV Human papilloma virus
HTSP Healthy Timing and Spacing of Pregnancy
ISS Integrated Systems Strengthening approach
IUD Intrauterine device
LAPM Long-acting and permanent methods
LARC Long-acting, reversible contraceptive methods
LMIS Logistics management information system
MCH Maternal and child health
MDGs Millennium Development Goals
MIS Management information system
MOH Ministry of Health
MSH Management Sciences for Health
M&E Monitoring and evaluation
NGO Non-governmental organization
PMTCT Prevention of mother-to-child transmission
PNDS Plano Nacional de Desenvolvimento Sanitário/National Health Development Plan
Pathfinder International: October 31, 2014 – page 2
POP Progestin-only pills
RH Reproductive health
RH/FP Reproductive health/family planning
SASH Strengthening Angola Systems for Health
SDP Service delivery point
SOP Standard operating procedure
SRH Sexual and Reproductive Health
STI Sexually-transmitted infection
TA Technical assistance
TWG Technical working group
UNFPA United Nations Population Fund
USAID United States Agency for International Development
WHO World Health Organization

Pathfinder International: October 31, 2014 – page 3
Introduction

Pathfinder is pleased to share this compilation of situational analyses that address a selection of key
issues affecting the delivery of quality family planning (FP) services in Angola. These assessments were
prepared by Pathfinder International during the period of 2012-2014 as part of an USAID funded
advocacy and technical assistance project to reposition FP as a strategic priority in Angola.

Many of the ideas discussed in these assessments have been shared with, and supported by, key
stakeholders in Angola, who are working along with Pathfinder International to address barriers and to
advance the quality of reproductive health services in Angola.
Pathfinder International: October 31, 2014 – page 4
Situational Analysis: Preliminary Concept Framework for a National
Family Planning Strategy in Angola

Prepared by:
Marcos Arevalo, MD, MPA, MA - Chief of Party
Graciela Davila-Salvador, MD, MS, MPH - Sr. Technical Advisor for Maternal Health & Family Planning
Susan White, MPIA, MPH - Program Director

Submitted to USAID: 31 July 20121

Introduction
As the Government of Angola moves forward on its commitment to provide quality family planning (FP)
services to all Angolans, it is critically important that investments made for this purpose be utilized
strategically and in ways that maximize effectiveness, equity, cost-effectiveness, and sustainability. This
situational analysis proposes a broad framework for a national strategy that would guide the planning of
work in FP in Angola. It addresses issues related to supply of FP services, such as coverage and quality of
the services, and issues related to demand for said services.

Multiple studies have shown that maternal mortality is highest in very young women who are poor,
malnourished, anemic, and not fully mature. For youth between the ages of 15 and 19 in these
circumstances who become pregnant, the risk of death is double that of older women; and for girls
under age 15, the risk is five times as high. For a woman who becomes pregnant less than six months
after giving birth, the risk of death is doubled and the risk of (spontaneous) abortion triples. The risk also
increases for women over 40 years of age, and for those who have had four or more pregnancies.
Reducing the number of these high-risk pregnancies can potentially reduce the maternal mortality ratio
by as much as 450 points during the transition to high levels of contraceptive use2 (thus, the ratio in
Angola could move from the current rate of 610 per 100,000 live-births3 to less than 400). Reducing the
number of unsafe abortions, which account for 13% of maternal mortality in developing countries,4 also
would bring further improvements in maternal health.

Healthy Timing and Spacing of Pregnancy (HTSP) reduces the likelihood of pre-term, low-birth weight,
and small-for-gestational-age babies, thus lowering neonatal mortality in general and allowing for
extended breastfeeding. It also improves child survival indirectly by reducing the probability of maternal
death from complications of pregnancy and birth such as pre-eclampsia. HTSP is an approach that:

• Supports women and families to delay or space their pregnancies;
• Helps achieve the healthiest outcomes for women, newborns, infants, and children;
• Works within the context of free and informed contraceptive choice; and
• Takes into account fertility intentions and desired family size.

1 Additional Contributions from Susan White, MPIA, MPH, Program Director
2 Stover J, Ross J. 2010. How Increased Contraceptive Use has Reduced Maternal Mortality. Maternal and Child
Health Journal, Vol 14 No.15, 687-695.
3 UNICEF. Angola Statistics, 2010.
4 Okonofua F. 2006. Abortion and Maternal Mortality in the Developing World. Journal of Obstetrics and
Gynaecology, 28(11);974-979.
Over the past few years, the United States Agency for International Development (USAID) has sponsored
a series of studies on pregnancy spacing and health outcomes, which produced landmark publications
on the effects of pregnancy spacing on maternal,5 newborn,6 and child health outcomes. This best
evidence was summarized by the World Health Organization (WHO) in 2005 in a technical review of
studies on HTSP,7 in which it generated the following recommendations:

1. Individuals and couples should consider health risks and benefits along with other circumstances
such as their age, fecundity, fertility aspirations, access to health services, child-rearing support,
social and economic circumstances, and personal preferences in making choices for the timing
of the next pregnancy.

2. After a live birth, the recommended interval before attempting the next pregnancy is at least
two years to reduce the risk of adverse maternal, perinatal, and infant outcomes.

3. After a miscarriage or induced abortion, the recommended minimum interval to the next
pregnancy is at least six months in order to reduce risks of adverse maternal and perinatal
outcomes.

This information is most effective when incorporated into health education, counseling, and service
delivery for women and couples who would like to delay or space their pregnancies and who are
adequately informed about the available choices in contraceptive methods, taking into account their
fertility intentions and desired family size, as well as the social and cultural environment.

Angolan Context
The reproductive health/family planning (RH/FP) situation in Angola could greatly improve with
implementation of an FP strategy framed within the HTSP approach and that follows a health systems
strengthening model such as Pathfinder International’s Integrated Systems Strengthening (ISS)8
approach. The limitations of the Angolan health care system, low levels of contraceptive prevalence, and
low education levels of the wider populace are factors that need to be taken into consideration when
designing and implementing an FP strategy.

Angolan Healthcare: Healthcare in Angola in 2012 is limited, as the country only recently emerged in
2002 from 27 years of civil war. With both infrastructure and the social order disrupted, millions were
left with very limited access to healthcare. The government continues to focus on re-building damaged
facilities and expanding availability to services.
Contraceptive Use: The maternal mortality rate of 6109 per 100,000 live-births and under-five mortality
rate of 6110 per 1,000 live-births are direct results of limited access to healthcare, exacerbated by a

5 Conde-Agudelo et al. (2000) Maternal Morbidity and Mortality Associated with Interpregnancy Interval: Cross
Sectional Study. BMJ 321:1255
6 Conde-Agudelo et al. (2006) Birth Spacing and Risk of Adverse Perinatal Outcomes. JAMA 295(15): 1809-1823
7 World Health Organization,2006. Report of a WHO Technical Consultation on Birth Spacing.
8 Pathfinder International. Integrated Systems Strengthening
9 UNICEF. Angola Statistics, 2010.
10 World Health Organization: Trends in Maternal Mortality 1990 to 2008: Estimates developed by WHO, UNICEF,
UNFPA, and The World Bank, 2010. (www.unicef.org/infoby.country/angola.statistics.html).
Pathfinder International: October 31, 2014 – page 6
contraceptive prevalence rate among married women of 6%11 and total fertility rate of 5.54.12 According
to a 2011 study,13 only 9.4% of urban women and 3.0% of rural women used contraceptives. Low levels
of contraceptive use were strongly associated with youth, poverty, and cultural beliefs, as well as rural
isolation. Many rural communities have no healthcare facilities; fewer than 15% of service delivery
points (SDPs) offer FP services,14 and they offer a limited choice of methods. Adolescent fertility rates
reached 165/1,000 in 2011.15 One-third of Angolan teens have had a child by the age of 18.16 Some girls
try to get pregnant to “get a man,”17 and some sell sex to meet basic needs. There are no youth-friendly
services; however, there is increasing interest at the Ministry of Health (MOH) level in this area as
critical to a comprehensive family planning approach.
Customary beliefs in large families deter the use of FP, and many men continue to believe that children
represent wealth. However, most women interviewed for the 2011 Decker study18 expressed objections
to having many children in hard times; unmet need is a growing challenge. Most had heard of
contraception, though few had ever used it. The unavailability of contraceptives and their cost are major
limiting factors, particularly for rural women.
Today, 44% of females are under the age of 15, which means some 4.5 million additional women will
potentially need FP services within the next decade and a half.19
HTSP Approach to Promote Contraceptive Use
To maximize adoption of contraceptive use and HTSP among vulnerable women, we propose the
following:

1. Implement comprehensive community-wide education
In line with the government’s commitment to bring health information to communities, effective,
compelling, and informative messages must be crafted to communicate the health, safety, and personal
benefits of HTSP to all community members, from youth, women, and men to community and
healthcare decision-makers, senior citizens, and especially healthcare providers. Common sense
arguments for preserving the mother’s health for the sake of each child can attract the support of all
members of a community. All messages should be in accordance with an Angolan national RH
communications strategy, to be developed by the government.

Popular, harmful misconceptions about contraception abound, highlighting the need for informed
counseling and community information. In many traditionally conservative countries like Angola, large
families are signs of wealth and success, and standard rationales for contraceptive use are not
persuasive to many decision makers, including men and senior family members. However, research data
has demonstrated that new and compelling messages can be developed around child health and
survival. Providers need to be trained to provide correct information during community group talks

11 Population Reference Bureau. Datafinder: Contraceptive use among married women, all methods (age 15-49),
2011.
12 World Fact Book, CIA, Angola (April 26, 2012).
13 Decker, Martha, Constantine, Norman A., “Factors Associated with Contraceptive Use in Angola,” African Journal
of Reproductive Health, December 2011; 15(4).
14 Ministry of Health data.
15 WHO: Reproductive Health at a Glance, Angola April 2011.
16 Op sit, Decker, et al.
17 Ibid. p. 74.
18 Op sit, Decker et al.
19 Population Reference Bureau 2011. The World’s Women and Girls Data Sheet.
Pathfinder International: October 31, 2014 – page 7
(“palestras”) and address the concerns of youth, women, men, influencers, mothers-in-law, healthcare
providers, and others. Training can help resolve frequent provider concerns on contraceptives such as
weight gain or libido loss. Health workers can provide compelling health evidence that appeals to all
community members. In addition, HTSP messages can be incorporated into non-health programs such as
agriculture extension worker programs, literacy and religious groups, and progressive women’s groups.
By doing so, we will support an increase in contraception uptake and contribute to narrowing the
knowledge gap on HTSP information.

Suggested Action Step: Community knowledge-building and message acceptance could be significantly
accelerated if the Angolan MOH, with the support of international and local development agencies,
were to standardize FP information based on updated sources such as the new Manual de Formacao de
Formadores em Planeamiento Familiar.20

2. Continue to strengthen the knowledge and skills of healthcare providers in HTSP counseling as well
as method provision at all levels.
Good counseling is key to adoption of HTSP that leads to contraception uptake and correct use of the
method, which in turn is closely linked to method efficacy. If clients choose a method appropriate to
their needs, satisfaction will contribute to higher continuation rates and increase positive word-of-
mouth communication. Providers must see all client contacts as opportunities to offer and provide FP
services.

For effective and speedy program integration, Angola would benefit from model integration service sites
within each level of health service provision. Physicians, nurses, technical personnel, and community
health workers should be trained at these sites, both in counseling and method provision, and they
would then provide training and model service provision for providers from additional sites.

Suggested Action Step: A successful model for this effort was developed by Pathfinder International in
four Luanda Municipalities,21 where service providers are gaining both understanding of the benefits of
HTSP and the communication skills to share them with clients. This can be scaled up and expanded to
other parts of the country.

3. Provide HTSP messages at every point of contact with women and adolescents, including:
Focus on Youth: The burgeoning number of youth in Angola includes a vast number of adolescent girls
with low status and education. Limited information is available to them on contraception and the
benefits of delaying or spacing pregnancies. Evidence shows that girls in Angola commonly initiate
sexual activity in their early teens. However, this not socially approved. As a result of this cultural
resistance and the limited health system infrastructure, there are no youth-friendly reproductive
healthcare services. This limitation is further compounded by providers who have not been trained to
work in the area of adolescent youth sexual and reproductive health (AYSRH) services, so provider
attitudes are often judgmental toward adolescent clients. In some instances, adolescents give birth
without trained assistance. Religious and community leaders also need to be engaged to provide
comprehensive, accessible, and supportive quality care to young people. Youth-friendly RH services,
including counseling and HTSP information, must be recognized as a national healthcare priority and

20 MOH Angola, Direccao Nacional de Saude Publica. Manual de Formacao de Formadores em Planeamiento
Familiar
21 Funded by USAID 2009 to 2011
Pathfinder International: October 31, 2014 – page 8
established as a fundamental component of a national family planning strategy. Rural women should
also be a target for HTSP messages.

Suggested Action Step: The national government has declared that services for youth, including RH/FP
services, must be a priority. Initial effort must be invested in researching channels for reaching youth
(male and female, in- and out-of-school, married and unmarried) with HTSP information.

4. Apply an integrated service delivery model relevant to the Angolan health system context.
Antenatal, Postpartum, and Post-Abortion Care Visits: Maternal health services are utilized by sexually
active and fertile women. In countries with low resources, antenatal care, delivery, and postnatal care
are the most common – and often the only – points of healthcare contact for women. While women in
the immediate postpartum or post-abortion period are not fertile, their fertility will return soon, and
they will be at high risk if they become pregnant again. Women who are offered FP information and
services during antenatal or postpartum care have the added benefit of time to select a method and
discuss it with their partners.

An estimated 40% of women who have an unsafe abortion in Angola die due to complications.22 Any
adolescent or adult woman seeking an abortion or post-abortion care should be given supportive
counseling on HTSP benefits and the use of contraception. Every effort should be made to provide her
with a method before she leaves the clinic. There is evidence that when FP is routinely offered to
women who seek post-abortion care, the majority accept a method (primarily one that is a long-acting
or permanent).23

Child Immunization and Well-Baby Clinics: Children should be brought to a clinic for immunization at
two, four, six, and nine months of age. In the majority of cases, it is the mother who brings them. These
visits are ideal opportunities to offer and provide FP services to the mother, who is already past the
postpartum period. The child is already a few months old, so she can begin using almost any method at
this time without interfering with breastfeeding. Given that fertility returns within a few months after
childbirth (even strictly exclusive breastfeeding does not offer enough protection beyond six months),
it’s important that she starts using FP as soon as possible after childbirth. General child health services
and well-baby clinics are also good opportunities to offer and provide FP and to emphasize HTSP.

Community-Based Family Planning Services: A majority of Angolans still live in rural areas, and many
more live in peri-urban environments with physical and cultural characteristics similar to rural areas.
Many health services are already being provided or facilitated by community health agents in these
areas. Community-based distribution (CBD) of FP can be more effective and cost-effective in these
settings. Demand generation activities can also be carried out more effectively by community agents.

Suggested Action Step: The National Directorate of Public Health has stated its intention to increase
availability of all FP methods. To achieve coverage most efficiently, FP services should be integrated into
maternal and child health programs and strengthen community-based FP services. Small scale activities
can be started at the outset to demonstrate the feasibility and desirability of integration and of
community-based FP services.

22 Wikipedia, Maternal Health in Angola:
http://en.wikipedia.org/wiki/Maternal_health_in_Angola#Unsafe_Abortion.
23 www. mariestopes.org
Pathfinder International: October 31, 2014 – page 9