In Season 2 of Inside the FP Story, Knowledge SUCCESS collaborates with the World Health Organization (WHO) / IBP Network to explore issues around implementing family planning programs. In this episode, we will hear about two programs on opposite sides of the globe—one in Guatemala and the other in Vietnam. Both programs used innovative approaches to engage with communities in remote areas and meet their family planning needs.
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Sarah Harlan From Knowledge SUCCESS and the World Health Organization’s IBP Network, this is Season 2 of Inside the FP Story—a podcast with family planning professionals, for family planning professionals.
The international family planning field has generated a lot of data, a lot of reports, and a lot of lessons learned. But we don’t often have the opportunity to get behind that information, to hear directly from the people who implemented a program, or who did the analysis, and so we reinvent the wheel or miss the mark because we don’t know what could be really critical in a particular context. Inside the FP Story is that opportunity.
Each season, we hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, the Partnerships Team Lead for the Knowledge SUCCESS project. I’m pleased to welcome our narrator, Sakshi Sharma.
Narrator Last season on “Inside the FP Story,” Knowledge SUCCESS collaborated with FP2030 to explore the elements of successful family planning programs. Hearing directly from those who work in family planning in Afghanistan, Kenya, Mozambique, and Senegal—we learned what makes their programs successful, heard about common pitfalls over the last ten years, and examined what’s ahead for family planning in this new decade.
So we know what we need to do, but how do we get there? This season, we’re happy to partner with the World Health Organization’s IBP Network to explore the ins and outs of implementing family planning programs. During this six-episode season, you will hear from the authors of a series of implementation stories—published by the IBP Network and Knowledge SUCCESS. These stories offer practical examples—and specific guidance for others—on implementing high-impact practices in family planning and using the latest tools and guidance from the World Health Organization, or WHO.
Have you ever wondered how to engage a community in your family planning work, how to address the diverse needs of youth, or how to ensure that there is a supportive environment for your program? These questions—and more—will be answered on this season of “Inside the FP Story.” From a “Craft Academy” in Benin that teaches girls about contraception as they create beaded jewelry, to a mobile service delivery program serving women in rural Guatemala, to a program working to remove taxes on contraceptives in Madagascar—we will talk to guests from 15 countries around the world on not only what they did, but how they did it. As you listen to their stories, you can apply their recommendations in your own programs.
Our first two episodes this season will explore the importance of community engagement to meet family planning needs. Involving communities in activities and decisions that shape their reproductive health can help address these barriers—improving women’s knowledge and decision-making power related to family planning, and even leading to higher levels of contraceptive use.
In this episode, we will focus on two programs that have engaged communities in rural areas to meet their family planning needs. Women living in remote areas—including those belonging to ethnic, linguistic, or other minority groups—face increased difficulty in accessing family planning. Poverty rates are often much higher among these groups, and they can face increased cultural, interpersonal, and communication barriers to healthcare.
In this episode, we will hear about two programs on opposite sides of the globe—one in Guatemala and the other in Vietnam. Both programs used innovative approaches to engage with communities in remote areas and meet their family planning needs.
Let’s get started.
Narrator In Guatemala, Wuqu’ Kawoq—also known as the Maya Health Alliance—works in partnership with a microfinance organization called Friendship Bridge. Together, they implement mobile outreach services—in which trained nurses offer family planning and other preventive health care services to rural indigenous women. These communities are geographically isolated—with little access to public transport, paved roads, or health facilities.
We spoke with Dr. Andrea Garcia, The Medical Manager for the Health for Life Program, and Dr. Kirsten Austad, the Director of Women’s Health, about this program.
Dr. Andrea Garcia My name is Andrea Garcia. I am a medical doctor in Guatemala, working with Maya Health Alliance, Wuqu’ Kawoq, in the Health for Life program.
Dr. Kirsten Austad My name is Kirsten Austad. I'm a family medicine physician from Boston and I worked for six years as Director of Women's Health for Maya Health Alliance, Wuqu’ Kawoq, including working with Dr. Andrea in the Health for Life Program.
Dr. Andrea Garcia We are working with Friendship Bridge and they are providing an existing network of underserved women in the rural area of the communities we work in. And we are able to actively promote preventative healthcare services to these women, which include an array of services in preventative health, and one of these services is family planning—not only counseling, but also the provision of family planning methods.
Narrator In Guatemala, as in many countries around the world, the rate of poverty is the highest in rural areas—and indigenous women in particular are underserved by traditional healthcare services. We asked Dr. Andrea and Dr. Kirsten to describe some of the barriers these women face when seeking family planning services, as well as the strategies that they use to overcome these challenges.
Dr. Kirsten Austad Guatemala is a challenging place to work in, in women's health. We work primarily in areas of the country that have a large rural populations, and a large population that we work with are of indigenous Maya descent, and many of them still speak indigenous languages. And so there's a lot of barriers that they face to getting health care in the public system, where services are not readily available in indigenous languages. So one of the two big barriers that we have to overcome are: first, reaching a rural population of women; and two, providing services that are both culturally and linguistically accessible to women.
And we found that in family planning, that's especially important that women feel comfortable, that they feel that the nurse who's taking care of them understands where they're coming from culturally, and that they, if they do speak one of the Maya languages, that they can receive the family planning counseling in their native language. And we found that going to women and providing services in their homes makes them a lot more comfortable and has resulted in us having a much higher uptake and continuation rate of our family planning methods as compared to the public system.
Dr. Andrea Garcia Yeah. So the nurses that we have on our team, they are of indigenous descent as well. The main focus of our mobile service is to be able to do the clinics and be able to talk to the women in their own language. So the nurses that are hired, we try to hire nurses that live around the area where they will be serving their other patients.
Dr. Kirsten Austad Guatemala has 23 different indigenous languages. And so a lot of people just say, “Well, it's not possible to deliver services to, you know, women in their native languages.” But we found that it definitely is. And alongside that, a really important part of it that Dr. Andrea alluded to is that the nurses are all trained in a form of family planning counseling known as shared decision-making. And so typically women feel very judged when they go to a public health center to get family planning services. They're often scolded for how many children they have, and they're told, “You have to use the family planning, you have to pick a family planning method.” And that really leads to a lot of women, understandably, not wanting to even bring up the topic of family planning, because they're basically afraid they're going to get forced into having to use some method of family planning. And this was a huge barrier, we found, to long-acting reversible methods. So, implants are something that we found that when women feel comfortable with their provider, when they are not feeling judged, and when they know that if they don't like the method, that we will remove it without forcing them to continue using it. That really, that has been key in increasing our uptake of LARCs. And implants are really popular among our patients and I don't think they would be if we didn't have that shared decision-making approach to family planning counseling, and, and it's definitely not easy because a lot of our nurses come to us sort of with these ideas of, “Women should be family planning. If they don't like their implant, they need to keep trying it because otherwise they're going to get pregnant.” And so a lot of it is working with our nurses to help change their mind, their frame of mind about how family planning services really should work.
Narrator So far, we’ve learned that providing services in a community’s native language is very important, as is shared decision-making and addressing provider bias.
But how do the indigenous Maya women find and use these services? And once they find them, what do these services look like?
Dr. Andrea explained that each nurse working with this program has an assigned group of women around the communities that they visit. Prior to the COVID-19 pandemic, women had group meetings with their Friendship Bridge loan officers. Nurses would join these meetings as well, to discuss the health program. Now, with COVID-10 precautions, nurses call women individually to offer and arrange the health services, in lieu of attending group meetings.
So, what does the actual visit entail once the nurse arrives at the woman’s home?
Dr. Andrea Garcia So this would be, we weigh the women, we take their blood pressure, their glucose levels. We also talk about breast cancer and how to do a self-exam. We also provide pap smears to detect cervical cancer and family planning methods and counseling.
These are basically the services that we provide. And all of these become also an opportunity for the nurses to talk about chronic disease and everything that can happen if we don’t prevent and find these diseases on time. So this is how it goes, and the patient will say, “Hey, I’m interested in all the services. I only want to have my blood pressure taken.” So this is all voluntary. So the patient will only accept the services that she needs at the present moment. And then we do this with each woman yearly. Every year, they receive a visit from our nurses to do like the whole package, if we can put it that way. Now if a woman decides to accept, for example, a family planning method, or she has an abnormal pap smear and things like this, then we do provide follow-up visits before the yearly visit.
Narration During the COVID-19 pandemic, when other services shut down, this program prioritized preventive healthcare. And despite the pandemic, they were able to maintain around a 35% contraceptive prevalence rate among the rural communities they serve—compared to 36% nationally that includes urban and rural areas.
Further, the program has led to significantly higher use of long-acting reversible contraception—often referred to as LARCs—in rural communities, when compared with national rates. A key aspect of this LARC uptake has been high-quality counseling.
Dr. Andrea Garcia Our LARCs, like the implant for example, has been one of the methods that are preferred by the patients. But the counseling has been really important to gaining trust in our patients. So the acceptance of long-acting methods has been really, really high. For example, last year we had 50% compared to 4%, which is what national surveys report. So this is a number that showed that if we are able to provide services that women feel comfortable with, they will make choices that are better suited for their needs.
Dr. Kirsten Austad And I think the other part that we found about our acceptance of LARCs is that we do follow-up phone calls with women at six weeks, six months, and then yearly. And that those are really important to dispel myths that, during the initial counseling we address, but we find that the nurse leaves and then sort of the woman is thinking about things. Maybe her family members are commenting that maybe her implant is causing her to have headaches or gain weight. And that ongoing support from the nurse has been really important to address myths about the method and make a woman feel comfortable.
Narrator Despite the successes, staff turnover has been a persistent challenge for the program. Retention is a big issue in any program—but when you are recruiting nurses with such a specific skill set, it can be really difficult for the program when staff leaves. Maya Health Alliance is addressing this challenge by providing high-quality training for their nurses.
Dr. Kirsten Austad You know, we've often been told that the solutions for family planning and global health need to be completely scalable and that you can’t invest too much in training. You need things that are automated, that are, and you know, what we've really found is that really investing in our nurses and making them really well-trained and making them feel ready to go to the field and do these more advanced counseling techniques, it is possible. And when you do that, when you really invest in your health care team, I think that the retention issue gets a lot better because people feel like when they're growing professionally in their role as a nurse, that they're far more likely to stay. And that the leadership of people like Dr. Andrea is really important, to have a supportive leadership team that responds to the needs of the nurses and really listens to what's working in the field, what's not working, and using a data-driven approach to understanding and tailoring your services.
Narrator We also asked about the high-impact practice brief and WHO guidelines that they used in their program. Dr. Kirsten explained what specifically appealed to them about these materials, and how they used them in their program.
Dr. Kirsten Austad We definitely use the WHO guidelines and the handbook in order to guide our training of nurses. And I think one aspect of it that we found extremely helpful is that in the public system, often women are required to come to start a new method while menstruating—we see a lot of women who get pregnant sort of while they're waiting for a period so that they can go to a health center while they're menstruating to get a method started. And so the algorithms, the quick start algorithms that exist in the, in the handbook we use those in are extremely helpful for being able to provide initiation of contraceptive methods based on the clinical circumstance and on a urine pregnancy test. So I think that is one example of how we found the handbook to be really useful compared to sort of local standards of care.
And then in terms of how we used the mobile outreach service delivery high-impact practice, we really thought through a lot of the issues that the brief brought up in terms of who is the best sort of level of provider to be doing field visits. Was it the typical, the classic method of a doctor going out and doing these things? And we’ve definitely found that using our nurses is a more effective way of doing community outreach—one, because it allows us to make our reach even further, and it also, as we’ve been talking about congruence of language, that there are very few doctors that speak these indigenous languages, and so it works a lot better for us to have our nurses out in the field. And when they do have clinical questions that are not address by aspects that they’ve been trained on, or some part of one of our clinical algorithms, that they are able to reach out to Dr. Andrea.
Narrator Overall, their story shows us a very practical example of how this mobile outreach brief can be put into practice. By using WHO guidelines for starting contraception, engaging with both public and private partners, and task sharing family planning service delivery (that is, working with nurses)—this program has been successful in reaching women in remote areas and meeting their family planning needs.
To end the conversation, we asked both Dr. Andrea and Dr. Kirsten what their biggest message would be to others looking to do a similar program, and reach underserved communities.
Dr. Andrea Garcia I think that the biggest message is that in rural multicultural contexts you can provide quality health care services to underserved populations—in this case, indigenous women. It can be done, with a little bit extra effort, for example making sure that the health care providers speak the language of the patient. Making sure that there aren't any biases involved during counseling. Shared decision-making, for example, here in Guatemala isn't something that is provided even in private healthcare services or in urban settings.
Dr. Kirsten Austad We find it's really important that all women in Guatemala, regardless of where they live, what language they speak, have access to high-quality family planning services. One thing that we found is that you really don't know what women's preferences are for family planning until they have access to high-quality counseling and services that are conveniently delivered to them. Our experience shows something that I refer to as revealed preference, which is that women's preferences aren't revealed until they have access to high-quality services.
Narrator Now we are going to turn our attention to Vietnam, where women in rural and ethnic minority communities—particularly in the mountainous remote regions of the country—experience higher rates of unmet family planning needs than the general population. To address this, MSI Reproductive Choices uses a creative community engagement approach—one that combines family planning access with entrepreneurship. Trained midwives—known as Marie Stopes Ladies, or MS Ladies—provide advice and affordable family planning products among ethnic minorities in rural communities, while also earning money to support their own families.
We spoke with Giang Thi Huong Phan, Program Development Manager at MSI Reproductive Choices in Vietnam, about the program.
(A note for our listeners that MSI Reproductive Choices was formerly known as Marie Stopes International.)
Giang Thi Huong Phan My name is Giang Thi Huong Phan and I'm working at Marie Stopes Vietnam as Program Development Manager. Marie Stopes Vietnam has an innovative model where we work with the provincial department of health and utilize the midwives service providers who are working at public community health stations. First, we trained them to be able to provide quality family planning services. And then, monitoring, following up with them to make sure that they will be able to provide quality services.
They also visit the clients’ house in the community to sell the short-term products for short-term family planning and other reproductive health service products, like, you know, multivitamin for prenatal care iron supplement for pregnant women, and sanitary feminine wash for women. Family planning services used to be provided free of charge at every community health station, because the government got funding and donation from UNFPA and KFW. But now we cut out the subsidize the free of charge family planning. So, in many community health stations you know, the government encouraged social marketing, where people in the community pay for family planning services.
Narrator She explained that family planning products and services used to be provided free of charge at local community health stations. However, these were cut due to reductions in locally allocated health funding. These cuts have disproportionately impacted ethnic minorities and women in rural areas. The MS Ladies Program is a way to sustain provision of family planning services to these communities.
MS Ladies visit women’s homes to provide basic education on sexual and reproductive health, and to distribute contraceptive products. They ensure that a wide range of high-quality and low-cost family planning products and services are available and easily accessible. MS Ladies provided over 38,000 family planning products over a two-year period—including 4,000 long-acting products.
Giang Thi Huong Phan We call them Marie Stopes Ladies, but they actually are midwife service providers who work at the community health station. And their daily work is at community health station to provide family planning and reproductive health services for the people who are living in the community. They also provide educational reproductive health adaptation or talk to groups of people. So now in some of the days, they will organize people from the community, the woman who live in the community come to the community health station, and they educate the woman about sexual reproductive health and family planning. And in some community health stations, they have more than one midwife. So those midwives can share their time and they can visit the people house. They can visit the household to meet with the women. Sometimes they organize group discussion right at the woman’s house, and can meet individually. Outside of the working hours, the midwives service providers also visit the women to offer short-term family planning and other reproductive health products.
Narrator There are normally one or two MS Ladies per community. The program collaborates with provincial departments of health to access the network of community health stations and to provide services.
Giang Thi Huong Phan And the department of health is also providing regularly support, like in term of, support on their work, their training, their time management because most of the time they work for the government, the community health stations.
And, during the time they visit the household, visit the woman in the household, they only provide short term family planning and reproductive health services. But if they find a woman having a need on long-term family planning, for example, IUD, they would refer the woman to the community health station to receive services.
Narrator Giang explained that all Marie Stopes programs in the country work in rural areas—and that community engagement is a key strategy for reaching families with family planning information and services.
This project also works with the H’mong community—an ethnic minority that resides mostly in the mountainous northern area of Vietnam. Giang explained to us that there are specific gender dynamics the MS Ladies must take into account.
Giang Thi Huong Phan For H’mong people, the husband would be the one who decides whether the woman use any family planning methods. So over the time, our MS Lady know how it worked with them. So, for every time they visit the H’mong household, they would try to talk, invite the husband and the wife, and they educate husband and wife together, to provide counseling to them. Then, you know, the husband will say, “Okay. You know, I agree with my wife will use this method.” The husband and the wife will discuss, and later on the wife would be able to access to our family planning services.
Narrator In addition to serving women and their families in remote areas of Vietnam, this program has had a positive impact on the Marie Stopes Ladies themselves. Because they charge a small fee for the products they sell in this project, they improve their own income and that of their families. They also gain capacity, and can keep serving their communities for many years. They receive intensive training in contraceptive counseling and service provision—including IUD insertions, implant insertion and removal, and more.
The feedback they receive from the Marie Stopes Ladies reflects these positive aspects of the program.
Giang Thi Huong Phan We got very good, very positive feedback from MS Ladies, who said that they’ve been, you know, have good training and they've learned a lot. Because MS Lady has been trained on, apart from service provision skill, they also being trained on communication skill, you know, talking with the clients. So they say they've learned new skills and updated knowledge. And they have a chance to exchange experience within MS Lady Network. Not only within the province where they’re implementing the project, but we also had them to have a field visit and exchange experience with the other province because the project is implemented in two provinces.
Narrator There are now over 200 Marie Stopes Ladies in total. And of course, any project of this size encounters challenges along the way. We asked Giang to describe some of the barriers they faced, and how the project worked to overcome them.
Giang Thi Huong Phan We have a field challenge during operating the model. We’re using tablets for MS Ladies to import data. So every day from the central office, we can easily access the network and see how many products have been sold and how many clients have been visited, et cetera. However, there's a difficulty with MS Ladies using high technology that take some time to train them again and again in terms of, you know, technologies like that.
Narrator In addition to technology, working with the H’mong communities in the mountain areas came with its own set of challenges. Due to natural disasters—like floods and landslides—the roads are often blocked, and service providers cannot access the communities for long periods of time, even through public transportation.
Giang Thi Huong Phan MS Lady visit, the people’s house by motorbike. But some of the area that motorbike also cannot access and, midwife had to leave their motorbike in some of the people’s houses and go by foot to visit the ethnic minority who live in, you know, up to the top of the mountain.
Narrator In addition to facing geographic challenges, Giang explained challenges finding reliable suppliers for the family planning and reproductive health products for the MS Ladies to bring to the communities. They overcame this challenge through public-private partnerships.
Working with local pharmaceutical companies helps the program maintain a regular supply of products for MS Ladies.
Overall, the MS Ladies program has been successful in reaching women in remote areas. MS Ladies help ensure that a wide range of family planning methods are consistently available and accessible—such as condoms, contraceptive pills, injectables, IUDs, and implants.
We asked Giang to sum up the importance of community engagement for her program.
Giang Thi Huong Phan Marie Stopes Lady has to work, collaborate with the woman union, family union and other, you know, organizations within their community to be able to access to their network, educating many people at the same time. So that involves a lot of people in the community, in different areas of the community.
Narrator Whether traveling through the mountains on motorbike or even foot—communicating with individuals or community groups—MS Ladies engage with a range of community organizations to successfully provide family planning in remote areas of Vietnam. In short, the program succeeds by meeting these communities where they are.
Narrator In hearing these two stories, we can see how community engagement strategies can be tailored to meet the diverse needs of underserved communities living in rural and remote areas. We hope you have learned from these stories and can apply similar strategies in your own family planning programs.
These stories are part of a series of 15 stories selected from a global competition hosted by IBP and Knowledge SUCCESS to highlight experiences implementing High Impact Practices and WHO guidelines. If this episode left you hungry for more, we encourage you to read the stories on the IBP Network website and join us for episode 2 where we'll continue talking about community engagement—but through the lens of integrating family planning and other health areas.
Inside the FP Story is a podcast produced by the Knowledge SUCCESS project and the World Health Organization’s IBP Network. This episode was written by Sarah Harlan and Anne Ballard Sara, and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Nandita Thatte, Ados May, and Carolin Ekman.
Special thanks to our guests Andrea Garcia, Kirsten Austad, and Giang Thi Huong Phan.
To download episodes and to find additional links and materials, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher. You can also find Spanish and French transcripts at KnowledgeSuccess.org.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org