Empowering the women of Delhi with an IUD

Day 10. PSI.

Our first full day in Delhi was spent with Populations Services International, otherwise known to most of the world as PSI. PSI is 3rd largest NGO in the world. That is huge! Leading programs include targeting malaria, child survival, HIV, reproductive health and non-communicable disease. In India particularly, PSI has been working there for almost 30 years - working effortlessly on HIV/AIDS, reproductive health, malaria prevention and child survival. Our day was focused on learning about the reproductive health programs. We began our day in the PSI office of Delhi learning about the Freedom 5 project, or the promotion of IUDs in women of reproductive age (WRA) amongst vulnerable and poor women. Our two hours at PSI was very similar to sitting in class at GW - learning about the objectives, goals, and impact of this project. The goal of this initiative is to increase the use of IUDs by 1.1% by 2012. Now, that at first seems small but let's talk about the number of women that live in Delhi - 1.1% will make an impact!

After gaining an understanding of the mission of this initiative, we were guided to a specific neighborhood the Freedom 5 program is implemented. We first went to a clinic that is often visited by poorer families. Here we spoke with the physician on call to learn more about the women that come in asking for an IUD. According to the physician, most women come in after their fourth or fifth child at which time they are ready to stop having children (at least for awhile)!

We then went to a specific locality where health promoters were conducting their work - going door-to-door obtaining information on who lived there, the number of children, what languages they speak, etc --essentially a census, a very detailed census. This allowed the health promoters to be more strategic in talking to women and families about PSI, family planning and IUDs. It was incredible to watch. These health promoters had so much information one each household in the entire neighborhood. They knew their health issues (more than just the reproductive health concerns). As these women gained credibility in the neighborhoods, they gained relationships with the families living there and were able to have honest conversations around family planning and also help women understand the process and implementation of an IUD. There were a number of things I found to be quite interesting today.

1. In many instances women asked to wait for their husbands to come home from work so they could have the conversation of family planning together AND the mother-in-law was the one in most households who remained the barrier to obtaining proper family planning tools. It made sense but wasn't my first thought. I initially just assumed husbands would be the largest barrier in implementing this program.

2. How is this being sustainable. Yes, wonderful health promoters are going into the field and teaching women the notion of family planning and empowering them through education and birth control essentially, but what happens after that? Once women have IUDs inserted - are they teaching others the power of education and smaller families particularly in lower income neighborhoods?

3. How is this being evaluated? There seems to be a lack of data when it comes comparing women who discuss and implement family planning vs. not.

Our day spent in these neighborhoods was extremely educational. Learning from PSI, an internationally known integral NGO it was calming to see how a program is conceived in a conference room and then fully implemented in the field. Our other days in India, we focused on smaller firms that had more narrowed mission spaces. Seeing that even larger NGOs can continue on a focal point was refreshing. I think at times, I get caught up thinking that larger firms fall into the corporate traditional enterprise and the smaller firms though they are doing amazing work get caught in the struggle of limited funds and low resources. Today affirmed that it really does not matter where you work -- the programs get initiated the same way and the work gets implemented with determined, honest, and passionate individuals.

Reproductive health is everyone's health

Wednesday, 08.10.11

Today we met an organization that focused on the population and issues that get me fired up. I mean REALLY get me fired up.

I spent two years in undergrad marching down Peachtree Street in Atlanta, Georgia towards the State Capitol with one hand holding a Planned Parenthood poster and the other hand raised high and clinched tightly like the Che Guavara spirit I was channeling. I was a revolutionary for family planning – or really for reproductive choice. I was loud, I demanded to be heard, and I wasn’t going to listen to any prolife stance. Damnit, I was right!

circa 2008

Over the next 3 years I have been earnestly trying to find a way to channel that energy and passion into a tangible impact. Activism is great and definitely serves its purpose of letting an issue ring in everyone’s ears. For me, however, I knew the real change I wanted to make would be individualized; helping men and women at the grassroots level one person at a time. I focused my senior thesis around reproductive health in Latin America, organically leading the topic of my thesis to be centered on family planning initiatives by President Alberto Fujimori in Peru in the 1990s – showing that investing in family planning and women’s health can lead to significant economic, social, and political impacts. There were some issues with Fujimori’s approach to nationalized family planning programs, so invite me over for some tea and I can tell you all about it. For now, though, we’ll stay on topic.

My senior thesis is what helped mature my desire to be in public health, particularly women’s health and family planning. I was finally able to see a very powerful link between investing in women and developing a nation; my background in political science was finally paying off! After graduation, I worked at the American Cancer Society to get my foot in the door of the public health arena and be sure this was the path I wanted to pursue. It was and still is. After having worked in a very conservative, professional environment, having many conservative friends, and having had my foot shoved into my mouth a few times, I am learning how to explore family planning from all perspectives. My goal has been and continues to be focused on having a respectful and calm dialogue regarding family planning that promotes dignity, respect, empowerment, and development for all parties involved. Graduate school has aided in this much needed perspective, directing me towards facts and figures to back up my side of the argument. No longer am I just some fiery twenty-something belting prochoice mantras into a megaphone, attempting to lead my reproductive revolution. It’s befitting to say that I can now carry a calm conversation (well, sometimes) that is centered on helping women help themselves through reproductive health. You’ve definitely come a long way, baby!

All of this brings me to my reflection on my time with PSI (Population Service International) and what information I want to share with you. I appreciate the work that PSI is doing and the vast communities that they serve. They are really making a difference even if it is still too soon to measure statistical significance (all you biostat people). Their service in Delhi is focused on family planning through IUDs (intra-uterine device) and medical abortion (MA) kits. Given the very conservative community that PSI is serving, there are definitely many barriers that this organization faces by introducing these forms of family planning methods. One of the female doctors from the local hospital shared with us how many women have to seek out the IUD secretly because they cannot get their husbands approval. Most of the women asking about the IUD are married women who have already had three or more children. The community that we visited in Delhi was predominantly Muslim and contraceptives are not allowed by the conservative sect of this religion. So what’s a woman to do? She lives in a developing nation where there are high maternal and infant mortality rates, mediocre health care, and lack of access (and rights) to pregnancy-preventing contraceptives. Well, in this case study, women go to their local physician and have an IUD inserted.

Here’s a commercial produced by PSI India that plays on local TV stations addressing the importance of family planning and IUDs for married couples: Lock and Key

Here is my stance, one that has taken some time to mature and understand completely -

Overall understanding of the importance of family planning:

*When a woman has control over her fertility (through contraceptives, family planning, sterilization, or abstinence), she has the ability to finish her education (versus adolescent marriage and/or adolescent motherhood) and pursue a career all her own and become a contributing member of society. The developing world is not investing in half of their population and the well-being of those nations is definitely suffering from this investment slack.

[Quickly let me add that stay-at-home moms are great, especially if they choose to stay at home. However, a mother/woman being tied to the house because she keeps getting pregnant and has no choice in the pregnancy and/or is forced to quit school because of pregnancy/marriage without her choosing is not okay by me]

• Women have the RIGHT to have full authority over their body and decisions regarding their body
• Women have the right to choose what family planning measure works for them
• Women should be allowed to access all contraceptive measures available
• Women have a right to an equal education
• Women have a right to equal job opportunities
• Women should be allowed to have control over their fertility and the amount of children they have
• Women have a right to quality and affordable health care
• Women are amazing J

Given my stance, let me say that access to IUDs and medial abortion kits are crucial in my book. I uphold that your political/social/religious opinions are moot when it comes to contraceptives access. You do not have to use the contraceptives, you do not have to condone the contraceptives, but they should ALWAYS be readily available and the right of women (and men) to access them should ALWAYS be there.

There should always be quality and affordable healthcare available to all people and contraceptives should be in ample supply and nearly free of cost to all communities. When a nation invests in their family planning programs and services they are investing in the well-being and future success of their nation. Take Peru for example, via my senior thesis escapade. When Peru invested in nationwide family planning programs and services, they experienced monumental economic and social growth – finally they were investing in the other half of the population! (Read “Half the Sky” to get the full picture of my point).

Family planning = growth, prosperity, and an end to the cycle of poverty (poor people making more poor people making more poor people). Brilliant!

Now, I know the whole idea of the medical abortion kits might turn many readers’ stomachs. Unfortunately, family planning’s red-headed step child is definitely abortion. However, abortion is not a preferred family planning measure, so rest assured that MA kits will rarely be chosen over continuous, effective birth control methods. Abortion is used mostly in dire situations, where other measures have failed. (I have oodles of statistics on abortions in the US that I can share sometime…)

When a community invest in family planning and respects the female and her decisions with her body, abortion rates significantly decrease. Abortion would rarely, if ever, be needed if reproductive health was given the same focus and investment as cosmological surgery and consumer product purchasing in the US. However, in some settings, in some situations, another child is too much. Especially in developing countries, in impoverished communities, another mouth to feed is damn near unfathomable when a family is subsisting off of less than $2 USD per day. That’s when the PSI medical abortion kits come into play. Whether a pregnancy is intended or unintended, safe medical services are vitally needed. Too many maternal deaths and morbidity occur from illegal, unsafe abortions. What PSI is doing is providing a safer means for a very discrete and difficult decision to end the possibility of a pregnancy. Whether we agree with abortions or not is beyond the point right now – what is so incredibly important is that there are services out there for women and families and that the option of a safe, affordable (nearly free) emergency measure is readily available. According to the pharmacist we interviewed in the Muslim community in Delhi, 4 to 5 medical abortion kits are sold daily. Let me repeat that: daily. Obviously, there is a need for serious family planning services in this community. Until that investment can be made by the government, the community, and the individuals themselves, emergency contraception is going to have to remain part of the equation.

What I am hoping is that a community like the one I visited in Delhi will begin to embrace the use of contraceptives and family planning services, such as IUDs, so that medical abortion kits will not be needed as much. But things happen, life happens, accidents happen, mistakes happen, terrible things can happen so medial abortion kits should always remain readily available.

I was so impressed by the services and information provided by PSI. Bravo for them for tackling a VERY testy subject that manages to impassion just about everyone (in one direction or the other). There is definitely room for growth, development, and data evaluation in their services to know what sorts of differences are being made within the specific communities. However, their services are just the start – just the beginning of the conversation surrounding family planning in this community. As I mentioned, your opinion on contraceptives and abortion is moot in the grander cry for access to all forms of family planning methods. When a woman/family/couple has a choice over fertility and family size, so begins the conversation on gender equality, respect, and overall well-being of the community as a whole.

Family planning is the answer. Access, quality, and affordability are nonnegotiable terms to a healthy future for any community.

Affirmation at PSI

Our first meeting in Delhi was with Population Services International (PSI). PSI is the third largest NGO in the world and is the undisputed leader (in my mind anyway!) in global health program marketing and communications, as well as program efficacy. Their interventions bring aid to millions of people around the world and their programmatic efforts span a variety of topics including malaria, reproductive health, safe water, and others.

Our meeting with PSI inspired me on many different levels. The most basic, yet perhaps the most important, is that it reaffirmed the lessons that we are learning in the classroom through the MPH program at GWU. This was truly an opportunity to see classroom knowledge being applied in the field, with success. As we listened to the very sophisticated reproductive health program presentation, it was so affirming to see simple things like health and behavior objectives incorporated into the presentation. I find myself sometimes actually being in awe of people who are successful in their careers, in areas where I would want to work and this was truly a moment where I thought “hey! I can definitely do that” and this feeling is directly attributed to my classroom experience at GWU. It’s funny, isn’t it, how sometimes you have to travel halfway around the world to have an affirming experience for what you are completing back home.

The PSI program for reproductive health is extremely well thought out, and has many components. My friend and classmate Kelly Healy has done simply an unbeatable job outlining the program in her blog today so I will spare another identical recap and will instead blog about what I found to be the best aspect of the program: the use of contraceptives through empowerment.

It was stressed numerous times during our discussion that empowerment was the major objective of the program, a sentiment that I truly appreciate. Giving women a contraceptive without information or skills is akin to giving them nothing at all. The PSI program uses a variety of techniques to truly empower women. Their outreach program identifies leaders in the community and trains them as Interpersonal Communicators (IPC). These IPC’s then go out into their own community, where they are already known, to educate and provide tools to empower women to talk to their husbands about contraception and understand where and how they can get it. PSI uses the Freedom5 intrauterine device (IUD) to do this. The IUD is a cost effective, long lasting (5 years), proven effective and reversible form of birth control that is sustainable for these communities.

From my perspective, there is so much that PSI is doing right in the area of reproductive health. Their programming combines grassroots community efforts on the ground with high-level social media campaigns that reach masses of people with just one television advertisement. They truly are a world-class organization and are worthy of every cent of funding.

The meeting with PSI also provided a type of full-circle experience for me as I reflect on this course as a whole. In addition to affirming classroom lessons from the MPH program as a whole, meeting with PSI provided great contrast and similarity to some of the smaller, more community-based NGO’s we met with in Mumbai and Delhi. Comparing a PSI program to an Acorn India (the NGO we met with in the Dharavi slum in Mumbai) provides a case study in its own right on the full spectrum of social entrepreneurship as well as NGO’s who are truly making a difference in communities, from the top to the bottom. PSI may have more money and resources to put together a power point, speak at a conference or provide marketing materials --- but is what they are doing so different from Acorn or Impact India? I don’t think so.

I appreciate so much about what PSI is doing in India, and around the world. Their funding allows for true market research to be conducted – resulting in more efficient, effective and targeted program. Now, if only every NGO could have such funding! It can be easy to become blinded by the celebrity and sophistication of programs from PSI; however, it is so important to remember that their mission is the same as any of the other smaller NGO’s we’ve seen in India. PSI wants to help people, they have identified target areas in which to do so, and they create programs for communities that provide education, resources and support.

Day 7 – Social Marketing in Action

After a lovely dinner in Delhi with Nandita Chopra, the NIH Representative to India, we headed off Wednesday a.m. for a busy day with Population Services International (PSI), looking specifically at its Women's Health Project. I knew going into this day that I was going to love it because a) I love women’s health and b) PSI is pretty much THE organization when it comes to health communication and social marketing. From the very beginning of the meeting when they flipped on the projector and started talking about objectives (SMART objectives like we learn about in class!), we could see the difference between a small, local NGO and a multi-national one like PSI. The team we met with walked us through the integrated program they have in place to reach women, healthcare providers, pharmacists, and opinion leaders. The scope of the project is too large to recap in one blog, so I’m going to focus on the interpersonal communicators (IPCs), which I was later able to watch in action.

The IPCs are primarily charged with increasing awareness about and use of intrauterine devices (IUDs), which are a safe and effective long-term (but not permanent) method of birth control. Most women choose an IUD after having several children, when they want to limit their family sizes, but have not completely ruled out more children. The IUD PSI promotes is called Freedom5, because it lasts for 5 years.

To raise awareness of IUDs, PSI has trained a team of IPCs to go into urban areas throughout several districts in northern India. The IPCs gather household information and, after determining that there is a women of reproductive age (WRA) who could benefit from an IUD, provides information and referrals. There are two good things I saw about this approach that no doubt reflect PSI’s experience and knowledge. First, the IPCs do not just provide information on IUDs, they educate the women about the “contraception basket,” including condoms, oral contraceptive pills, injections i.e. Depo-Provera, and IUDs. Secondly, the IPCs are not incentivized based on the number of IUDs inserted, which might lead to more forceful interactions with women. Instead, they are encouraged to meet certain targets for the number of women they speak with each day. If a woman is interested in IUDs, the IPC gives her a referral card and information for a nearby clinic. If the women goes to the clinic, the referral card serves as a tracking device to see how many women visit a doctor and how many actually get an IUD inserted.

When we went into the field, we met up with four of the IPCs and an IPC coordinator. Jenn M. and I had a chance to observe a one-on-one session with an IPC and a woman in her home. She invited us without reservations into her home where she shooed away two men, who looked to be maybe her son and father or father-in-law and had us sit on a bed in a small room. The IPC began speaking with her in Hindi and gathering the household data including her age and information about her children. We learned that she had four children and used condoms, but was hesitant about an IUD because she thought her husband would disapprove. Her reaction when we asked if she wanted more children was clear, she grasped her stomach and said no. It was clear that this family was struggling with the small means it had, so one could easily understand why the woman wanted to limit her family size. So the IPC gave her some additional information to keep in case she decided to pursue an IUD in the future. In public health classes we are always talking about community outreach workers and it was very neat to see one in action.

In addition to outreach via IPCs, PSI runs a call center that does follow up calls to women who have IUDs inserted (and give consent to follow up) to counsel them on any side effects or concerns one-month after the procedure. The outreach program is also integrated with a mass media campaign that promotes the idea of an IUD being a lock with a key. When we visited a clinic in the partner network we saw this advertisement posted on the wall. PSI said the campaign has already been very successful, with a 60% reach. Of the women reached, 50% reported that they talked with their husband about an IUD, 10% went to a provider, and 5% got an IUD. While these numbers may seem small, they are actually quite significant for a health promotion campaign. The mass media campaign augments the personal outreach because it can also help influence a woman’s husband and mother-in-law, who in this culture have a strong influence on decisions about contraception.

One of my favorite parts about the day with PSI was when PSI’s maternal and child health lead Sanjeev Dham flipped the conversation around and asked us for our criticism of the Women's Health Project. He really valued our insights, which included thoughts on expanding the program and strengthening evaluation.

Reality Check

After meeting with Acumen on Monday and hearing about their projects, challenges and successes, it gave a great frame of reference for our following two meetings with international, American-based organizations. On Tuesday, we flew from Mumbai to Delhi and, during dinner that night, met with Nandita Chopra, a representative of the National Institutes of Health (NIH), living and working in Delhi on the NIH's India portfolio. It was really interesting to speak with her about her role and what the NIH is doing to promote health in India. She has an extensive history in HIV/AIDS research and it was amazing to hear about the work the NIH is doing, particularly for me, in the way of HIV/AIDS prevention in India.

The following day, we met with PSI – a HUGE international NGO with thousands of projects across the globe – I was definitely interested in PSI prior to the meeting, and was pleasantly surprised at the level of depth we were afforded to experience. I figured we would meet with them in a similar fashion as with Acumen or UnLtd - they would discuss their projects, provide some interesting examples and allow us to ask questions. They did that, and so much more. The PSI staff really engaged us. After a presentation of their current local women's health projects – working to increase access to low-cost intrauterine devices (IUDs) and medical abortion – they requested that each of us provide criticism of the project.

Obviously each of us would come away with thoughts about the program – the model, the implementation, the evaluation methods - but it was so refreshing to be asked, point-blank, about a real, functioning program (and then have the opportunity to go out and see it; to meet the people who take the theory and models about which we learn in class and turn them into something tangible). Amidst the craziness and uncertainty which India can breed within you, our time with PSI was the professional reality check I needed and really solidified much of my India experience thus far. Though our meetings and interactions with other organizations have been enlightening and engaging on a number of levels, I am still figuring out what social entrepreneurship means to me, and what role I can play within that sphere. Regardless of how India or social entrepreneurship strikes me, today reminded me that soon, I will be done with my degree, and will be doing work like this; work which will have the potential to make a real impact on people's lives.

Halfway there!

Greetings all from Paris!

It was a quick and easy flight from Minneapolis and now I, like Kelly below, am ruminating on social entrepreneurship, my upcoming experience in India and my thoughts on the blogs we were assigned to look at.

Each of the four organizations has their own perspective on social entrepreneurship and seeks to fulfill its’ mission in different ways. Samhita and Global India Fund provide a veritable database of worthy organizations that have been exhaustively vetted, such that potential donors can feel confident in where there money is going. I try to make several small donations to causes I feel strongly about throughout the year and as my interests take on a more global perspective, the value of a service like this becomes more and more apparent. Global India Fund and Samhita truly take the guess work out of making a charitable donation abroad and, by way of the vast database, provide different ways to do so. Having the choice of making a donation directly to an individual, or to a bank that will distribute the funds as a loan or any other option really gives the donor a feeling of control over their donation.

Kiva is one of the more compelling sites of those we were tasked with visiting. Of course, all of the organizations provide wonderful services and convincing reasons to be charitable; however, I think that the actual aesthetic of the Kiva site provides the best user experience. There are so many different options available to donors now; I feel that having a unique and gripping user experience can really set an organization apart from the others. I really love the ability to scroll over the different individual boxes on Kiva’s home page, see their personal story and really understand how Kiva has helped them. For me, this added a very personal element that I feel is slightly lacking on the other organization web sites. In class we heard from Kate Roberts, the powerhouse PR and Marketing genius from PSI. Not only was her presentation exciting and informative, it also helped us understand the value of making the social entrepreneurship truly personable and relational. I honestly feel that, when soliciting funds for any organization, it really is all about two things: 1) who you know and 2) how you engage them. Although Kiva is quite different than PSI, I like to make the connection between an individual who has the keen ability to connect with others and an organizations website that really does go the extra little bit to make the experience of the user better – and thus create a more likely environment for donation.

GlobalGiving also provides this type of personalized user experience. I appreciate how they separate the available projects by both geography as well as topic so if I were interested in donating money to say a maternal and child health program in sub-saharan Africa, I would be able to make one click of a mouse and see the project options available which fit those specific parameters.

All of these organizations provide ways to truly make a difference, no matter the size or scope of the donation. Each has its’ own personality which caters to, potentially, a certain type of philanthropist. Social entrepreneurship, as we have studied in the classroom and through our own personal experiences, doesn’t fit into one category. The term can really be experienced and encompassed in a variety of different ways, whether it is a charitable organization, a profitable company, or simply a grass-roots way to provide support for a cause an individual deems worthy. What ties all of this together; however, is the need for financial backing. The organizations mentioned above all provide this service, but in different ways.

I still have 10+ hours of travel until I get to India, and I truly cannot wait to arrive and see some of the tenets of social entrepreneurship at work. Undoubtedly this will be a challenging experience – emotionally, mentally and otherwise. I am thrilled to be joining such an esteemed, smart and adventurous group of people on this journey and look forward to seeing everyone tomorrow morning.

Brooke