Population Services International

Day 7

Fresh off our plane into Delhi we walk into the building of PSI, or Population Services International. This NGO is the third largest worldwide and not surprisingly so…

As a student focusing in maternal and child heath, the Women’s Health Project presented by the PSI representative, Sanjeev Dham and colleague, was of special interest. The goal of the Women’s Health Pahel (Project) is to reduce maternal mortality and morbidity through increase in use of Intrauterine Devices (IUDs), from 3-4.1% in targeted areas, and an increase in medical abortion (MA) kits. This project exists only in urban areas in three states; 1 in Delhi, 9 in Rajasthan, and 10 in Utter Pradesh.

The overarching goal is to support the empowerment of women. The target population used to achieve this goal includes women of reproductive age, medical providers, pharmacists, and communicators. Interpersonal communicators (IPC) have a background in social work and are trained by PSI staff to go into the community and speak with the women at their homes about IUDs and MA kits. Their objective is to dispel myths associated with IUDs and MA and also provide support and education. The IPCs provide counsel and if the women are interested in IUD insertion will then give a referral coupon. The woman may then present this at the nearest designated clinic to receive the IUD at a discounted price, usually what translates to $6 U.S. dollars. The IPC will make a note at headquarters of who was given a referral coupon and the medical provider will submit the name of who actually came in for the procedure. From this data, the impact of the IPCs may be evaluated. Also, the women are tracked and given follow up phone calls. Approximately, 800-1,000 outbound calls are made every two weeks to offer support and answer questions post IUD insertion.

Several media sources have been used to support this “lock and key” idea of the IUD. For example, a television commercial run in prime time shows a women behind locked bars holding the key while her husband cannot get to her. The commercial ends with the couple sitting with a physician discussing how they can control the “lock” or IUD, with a “key” by choosing when it is inserted and removed.

Women are offered a variety of support; in addition to follow up calls they are given the number to a “helpline” in which they may call at any time with any question. The Helpline is confidential and non-judging. The Helpline receives about 600 calls per week. It is important to note that the majority of women do not have mobile phones and will receive follow up calls within their home where their husbands have full ear shot of their conversations. If a woman has not told her husband, or is afraid to do so, this method of contact fails. In fact, 20% of IUDs are removed within the first month. Some removal is due to unwanted side effects of heavy bleeding and abdominal cramps, but the bulk of this percentage is because husbands force their wives to have the device removed.

Husbands must be considered in all campaigns for contraception. The fact that few women have complete say over their choice of contraception, or even to use it in the first place has proven to be a cultural barrier that has no easy answer.

Medical abortion kits are also addressed by the IPCs as they walk the neighborhoods of Delhi. These kits require a prescription at 9 weeks of gestation. Local chemists sell 80% of the MA kits, many of these pharmacists set up shop on the corner of the street. The chemist we spoke to as we went on site relayed that he sells, 4-5 MAs per day.

PSI currently has two and a half years of data, which is undergoing analysis to measure the effectiveness of the advocacy campagin.

Visiting the site of a clinic that offers the insertion service to the women was an interesting insight into a culture that permeates into the clinical care of the women of Delhi. The clinic was full of women, the only men to be seen were those who were awaiting the birth of a child. Reproductive heath outside of childbirth is often an unsupported decision. We had the opportunity to speak with the doctor in between patients, and she informed us the majority of women for whom she inserted the IUD had already given birth to four or five children. In addition to this information, the majority of women had not discussed this decision with their husbands. Many gave the impression their husbands would not be supportive.

The doctor also told us many of the teenage girls who come into the clinic with their mothers appear to be pregnant, yet due to cultural barriers these young women cannot be administered pregnancy tests. Outside the context of marriage, sex is not discussed.

Women need to be empowered not only to choose their own means of contraception, but to feel they can discuss their choices with their husbands. IPCs must be given more training to speak with the husbands as well as the wives. Many times the wives will invite the IPC inside her home to also speak with her husband; this idea and practice should be brought up to scale. Along these lines, IPCs should also receive training to address teenage reproductive health education. It would be inappropriate to tell a woman how to raise and educate her daughter, but speaking of the importance of this education and how it could benefit the health of her daughter is matter of fact.

Health education takes time and results can be slow, but with the aid of the PSI Interpersonal Communicators, the team of health providers, and the staff manning the helpline, the women of Delhi are being reached one block, one street, and household at a time. In this there is much promise.