Mrs Gertrude Edom, the founder and chief executive officer of St Gertrude Maternity Centre located in Topland, a suburb in Enugu city, had just seen her last set of patients and was settling down to attend to her administrative tasks. Her clinical duties include maternal and child health, immunisation and family planning. She is one of the 62 family planning providers trained by the Society for Family Health (SFH) in three states to deliver intrauterine hormonal devices (IUDs), a modern contraceptive method.
According to a new FP2030 report released at the 2022 International Conference on Family Planning (ICFP2022), global uptake and use of family planning services among women is increasing. The data revealed that an estimated 371 million women of reproductive age now use a modern method of family planning. This means that in about a decade, between 2012 and 2022, the number of women using a modern contraceptive method increased by 87 million. As the push for a demographic transition continues to gain momentum, the number of women using modern contraceptive methods in Nigeria has increased from around 4 million women in 2012 to over 6 million in 2021. The modern contraceptive prevalence rate for all women increased from 10.6 to 14.8 during the same time period in Nigeria.
Despite these gains, there is still a 48% unmet need for family planning among sexually active unmarried women and a 19% need among currently married women in Nigeria, according to Dr Anthony A. Nwala, Assistant Chief Programme Quality Officer at SFH. A range of factors contribute to this gap including a “lack of trained health care workers to provide services in the different family planning methods,” according to him. In addition, as a result of Nigeria’s underperforming primary healthcare system, access to modern contraceptive methods is limited in areas where these services are most needed.
Rethinking capacity building
Through the Research for Scalable Solutions (R4S)/Learning About Expanded Access and Potential of LNG IUS Initiative (LEAP) project, SFH developed a digital learning curriculum for improving the knowledge, skills and attitude of service providers in Enugu, Kano, and Oyo State.
In 2021, with funding support from the Bill & Melinda Gates Foundation and Research for Scalable Solutions, the project set out to increase access and uptake of modern contraceptives, in accordance with the Federal Ministry of Health’s Hormonal IUD introduction and scaling-up strategy. It aimed to generate timely, actionable evidence to help determine if and how the Levonorgestrel Intrauterine System (LNG-IUS) can play a catalytic role in increasing contraceptive use and continuation rates in sub-Saharan Africa.
The project used two strategies: remote training of providers like Edom and a research component that evaluated the knowledge, competency, acceptability and cost of a digital training course on hormonal IUDs for private and public sector family planning providers in Nigeria. Many people use hormonal IUDs to help with period problems because they are 99% effective as a contraceptive method for preventing pregnancy. They can cut down on cramps and make periods lighter. The method is also long-lasting (up to ten years), which means that anyone who uses it will not have to worry about conception once it is properly inserted.
The digital training curriculum provided an alternative option to the traditional in-person training of family planning providers across Nigeria. To assess its acceptability, 90 providers from public and private facilities across the three states provided insights. The ICA foundation provided unbranded LNS-IUS training materials.
The way to go?
The project contributed to the development of a digital training course on Hormonal IUDs which is now available on Kaya, a global learning platform with self-directed and self-paced online courses for humanitarian workers. According to Mrs Maureen Nwankwo, the Enugu State Family Planning Coordinator, they also trained 14 master trainers in the three project states who helped provide further mentorship and support to the 62 trained family planning providers. “The service providers come in for two days of physical training and mentoring after going through the online training module,” she added.
For Edom, the digital platform offered an opportunity for her to train the next generation of providers because “she is phasing out”. As a result, she gave one of her nurses permission to provide family planning services when Edom was unavailable. Despite her years of practice, she finds the content useful.
According to findings from the project’s research component, the hybrid training approach cost N139, 040 (USD 316) per provider trained across all states, while in-person training cost N187, 400 (USD 426), saving N48,400 (USD 110). As a result, the Federal Ministry of Health (FMOH) has accepted the digital training tool as a pre-training requirement for all Hormonal IUD training in-country.
The study also found that 82% of trained providers thought that digital training was more convenient than in-person training, and the content aligned with the FMOH standards and priorities for hormonal IUDs.
Edom stated that her favourite aspect of the digital hybrid training was the ability to continue building her skills without leaving her clinic, as she had done in previous training.
Key lessons for scale-up
One of the factors that led to the project’s success was engaging the FMOH and the State Ministry of Health (SMOH). Nwala revealed that the FMOH formed part of the planning, review, and validation of training and this facilitated the project’s implementation. “The federal and state ministries of health are the drivers of health care in Nigeria. As part of our strategy in our project implementation, stakeholder engagement has always enabled us to achieve our goals and objectives. In the R4S/LEAP project, we started with advocacy visits to the FMOH and SMOH/PHCDA to introduce the project and seek their support and collaboration,” he said.
The SMOH assisted in the selection of public health facility providers for training, master trainers and clinical practical, as well as supervision of the providers. To make the list, Nwankpo, the State Family Planning Coordinator stated that a health worker needed a working android phone and knowledge of inserting long-acting reversible contraceptives (LARC).
As motivation to complete the training modules, the trainees received technical assistance through WhatsApp, and this also contributed to the success of the project. Some of them however found it challenging to navigate the Kaya platform and the lesson for the SFH team is that they should ensure they provide pre-training digital orientation to help those who may not be very familiar with e-learning platforms.
Edom said she often required the assistance of her children to navigate the digital training platform. However, she wasn’t the only one who encountered challenges with the platform. About 95% reported facing at least one technical challenge, said the SFH team. The project team received most of these reports from providers in Enugu state, older providers, and providers participating in digital training for the first time.
The lessons learned and difficulties encountered are influencing the project’s next steps, which include translation into French for use by training providers in francophone African countries. Other projects with family planning components implemented by SFH or other development partners will now use the training tools for their training rather than reinventing the wheel.
As the project has shown, closing the capacity gaps that prevent access to family planning services in Nigeria requires making informed decisions about how service providers are trained. As the FMOH leverages the funds allocated to Family Planning in the 2023 budget recently signed by the President to improve family planning uptake across the country, low-cost tools like the digital hybrid training tool can help providers like Edom in upskilling without having to leave their place of work.