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Situational Analyses of Key Reproductive Health Services in Angola

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Situational Analyses of Key Reproductive Health Services in Angola 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
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