Reducing maternal mortality through informed family planning

In June 2021, we founded Lafiya Nigeria, a non-profit organisation that works toward ending maternal mortality in Nigeria by widening the access and information about family planning. 

TL; DR Introduction to our organisation in a 3-min video

This post describes (I) the challenge we aim to solve, (II) our approach, (III), our traction, (IV) our value-add, (V) our plans, (VI) how you can get involved in our initative.

(I) The challenge

In low and middle-income countries, women are dying from giving life. Nearly 300,000 women and girls are dying from pregnancy-related complications each year, according to the Guttmacher Institute. Other health complications such as obstetric fistula, postpartum anemia, and postnatal depression are also key health burdens borne by pregnant women.

Reducing the number of unintended pregnancies is an effective means of reducing health burdens for mothers and newborns. Despite a significant number of women in these countries wanting to avoid pregnancy, many are not using modern contraceptives, resulting in 85 million unintended pregnancies per year. If all women with unmet need were provided access to and used modern contraceptives, the Lancet estimated that maternal deaths globally would drop 44%. An estimated 70,000 maternal deaths could be prevented each year, with 441,000 new-born deaths also averted. Additionally, the Guttmacher Institute estimates that every dollar spent on contraceptive services beyond the current level would reduce the cost of pregnancy-related and newborn care by three dollars. The Copenhagen Consensus also found that every dollar spent on access to modern contraception leads to 120 dollars of social, economic, and environmental benefits.

Access to family planning is beyond a health issue: its dividends are seen also   in positive effects on education, income generation, and children's welfare. A study in Indonesia found that providing access to family planning was three times more effective than improving school quality in keeping girls in school an extra year. Research in Colombia found that girls with access to family planning clinics were 7% more likely to participate in the formal workforce as adults. Long-term studies have also shown that providing access to family planning programs can lead to improved college completion rates of children and higher family incomes decades later. These spillover effects are difficult to measure and are often neglected in traditional cost-effectiveness analyses.

In recent years, there has been an increase in the use of modern contraceptives in countries like Nigeria but there has also been an increase in the unmet need. From 2012 to 2019, the portion of women using contraceptives in Nigeria rose from 11.2% to 14.2%, while the unmet need also rose from 22.4% to 23.7%. These figures are greatly exaggerated 

Focus: Nigeria

Lafiya Nigeria focuses on rural and underserved regions of northern Nigeria

Nigeria has >45M women of child-bearing age, and 65%  have unmet contraceptive needs (IHME), resulting in around 40,000 maternal deaths a year. 

In Nigeria, over 83% of women had not used any contraceptive methods for family prevention in 2018. This rate reached 96% among women without any education. This staggering gap in health provision results in maternal and infant deaths. In Nigeria, over 40,000 women die each year from pregnancy-related issues. The loss of life does end with mother, either. Over one million children under the age of five also die as a result of losing their mothers to pregnancy delivery complications.

In our pilot region, Jigawa, more than 98% of women have no prior contraceptive use due to stockouts (38% nationally for injectables) and a shortage of trained medical personnel (1 doctor per 39,000 people in Jigawa).

(II) Our approach

Lafiya Nigeria’s intervention is increasing access to self-injectable contraceptives (DMPA-SC, “Sayana Press”)  in the northern states and closing the information gap on family planning. The contraceptive is successful in removing obstacles to consistent usage: it is cost-effective, and self-administration ensures that the end user does not have to travel long distances to a health clinic repeatedly. One injection protects from pregnancy for 13 weeks, is easily transported without needing a cold chain, and is thus a good solution for the urgent unmet need for family planning in Nigeria.

We recruit "Lafiya Sisters" from existing local networks of nurses and midwives who were chosen by their communities to receive a 2-year healthcare education.  Then we upskill them in FP counselling and administration, and equip them with Sayana-Press contraceptives, which they routinely distribute to rural women while working in health clinics and informal community settings. 

Working with Lafiya Sisters is the key to our model. It not only allows us to provide a cost-effective solution, but also creates a long-term effect on behavioural change of the beneficiaries. Lafiya Sisters are based in local communities and work as nurses and midwives in hospitals and clinics, which means that they are trusted by our end users. The topic of family planning is still challenging to discuss in a public setting in northern Nigeria due to cultural and religious norms. Working solely with female health professionals who have already proven themselves to end users through their work is crucial in those settings. 

(III) Our traction

Since winning the D-Prize last year, Lafiya Nigeria has already successfully demonstrated that its innovative distribution model led by community champions reaches beneficiaries in places where other organisations fail. 

We have reached 2400 women, with each intervention costing only $3 per contraceptive delivered, with $12.4 per DALY averted and $30 per pregnancy averted. The program is estimated to have reduced one maternal death already. The model emphasises the agency of our users, opting for a DMPA-SC, a contraceptive that allows women to not only decide when and how they want to use contraception but is also self-administered. 

After 6 months of our operations, we met 342% of the scale of the government’s distribution in the same time scale. We know we fill the gap in an area where government inefficiencies and neglect from other NGOs leave a massive unmet need. We are targeting women who are at substantially higher risk of maternal death (>60% of our users), first-time contraceptive users (35% of our users), and without education (>40% of our users).

If you want to learn more about the results of our pilot program, please find the detailed pilot report here.

(IV) Our value-add

Focus on rural and hard-to-reach regions

We saw that the existing programs by other NGOs and the government tend to address unmet needs in urban areas and among an educated population with good access to the internet. Although this approach generates high-impact numbers, it misses an important and populous part of society. Lafiya Nigeria targets underserved communities that live in rural and hard-to-reach regions. 

Community-based and female-led

Generating trust between CHWs and end-users helps alleviate concerns and eliminate misconceptions surrounding family planning, promoting continual usage for a lasting impact. Unlike other interventions targeting rural ideas, we are not doing outreach to local communities; we are rooted within.

Leveraging existing community programs  

Lafiya’s strategic partnership with Women4Health ensures that the team of Lafiya Sisters is trained to a high standard of healthcare literacy and can be easily upskilled with additional family planning training organised by Lafiya Nigeria. This can only be achieved through leveraging existing community skill-building programs and a trained workforce.

A fully digitalised monitoring system

Our solution allows our Lafiya Sisters to safely store user data even in locations without good internet connections. Using SurveyCTO, Lafiya Sisters can fill up the user questionnaire at the point of delivery and upload it later when they get back to their clinics. The questionnaire keeps track of geolocation and creates a time stamp, which allows us to prevent fraud and falsification of user records. Moreover, the questionnaire also has a voice recording option that saves the record of a user's consent, which protects users from being pressured to use contraception and confirms their identity. 

Hyper-focus on the Sayana Press 

Sayana Press is an innovative, cost-effective, and safe contraceptive approved in more than 40 countries, including the EU. It has a lower dosage than its intramuscular counterpart, Depo-Provera, leading to fewer side effects reported among users. Additionally, it does not need to be stored or transported in cold chains, making it the perfect choice for our intervention in Nigeria.

We believe that family planning and, more specifically, Sayana Press, could be an underexplored and neglected cause area in the EA community. GiveWell has indicated that the program is promising and requires further investigation. We aim to do rigorous evaluations of all our programming and therefore contribute to the literature on the effectiveness of Sayana Press interventions.

(V) Our plans

We are currently starting our scale-up across Jigawa and Kebbi state. We want to replicate the success of the model in Jigawa in another state, as well as increase our impact. Within the next two weeks, we will train ~30 more health workers, which will increase our total number to 42. 

We also want to have a closer partnership with local and state governments. We believe that having a former Sexual and Reproductive Health System Strengthening, Government Policy Development Director, Dr. Kayode Afolabi as a chair of our adivsory board will facilitate this process and lead to close collaboration between Lafiya Nigeria and the Federal Ministry of Health.

Finally, we want to use best practices and rigourous evidence to further improve our model. We have founded a Lafiya Innovation Hub, a research group that aims at conducting short- and medium-term studies to provide insights into program design. Our first project is introduction of online training for our health workers to further decrease the costs, while maintaining high quality of services provided by our health workers. 

(VI) How you can get involved

There are three ways in which you can get involved in our operations:

Volunteering: We are looking for volunteers to collect further evidence for the intervention and conduct an impact evaluation, including a comparative cost-effectiveness analysis. As an evidence-based organisation, we always strive for the highest quality of data to inform our decisions.

Funding: We have a $50,000 funding gap for 2023 to close to be able to reach our targets and scale-up our operations. Individual donors may donate on our website (US-based donors please contact us to sort out . If you know about any relevant funding sources, please get in touch with us.

Technical advice: We seek expert academics and practitioners on family planning and mHealth interventions to discuss our ideas and get feedback.
 

We are proud of the work that Lafiya Nigeria has done so far and we are optimistic about the impact it can continue to bring in the future. As an EA-aligned organisation, we want to prioritise becoming a core part of the EA Global Health & Development community to be able to share our learnings with others and strive together to make a substantial difference in the world. 
 

Klau Chmielowska and Jefferson Chen are the co-founders of Lafiya Nigeria. 

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10 comments, sorted by Click to highlight new comments since: Today at 11:23 AM

I love this thanks so much!  I love orgs like yours which are doing super important work in super difficult places. My intuition is that anything which gets more contraception int the hands of women who need it is likely to be highly cost effective. I'd love for our org to get better at providing contraception through our health centers as well, and will think about this going into this year.

A couple of questions

  1. Could you share with me how you calculated your DALYs (maybe in private message). This is purely selfish as I'm keen to calculate for my org as well!
  2. You state the cost is 3$ per woman reached, which means the total cost of your program was only $7200? What about training costs, management costs and other overheads, are those included in the cost-effectiveness analysis?
  3. Why is the state you are working in getting such bad stockouts given that so few people use family planning there? This is very interestng and doesn't make instinctive sense.

Nice work again and lots of love

Nick.

Hi Nick,

Thank you so much for your kind words! It truly is - family planning is a very important area within global health but sadly still not receiving as much attention or donor funding as other causes. I'd love to hear more about your work at OneDay Health, I'm sure there are many lessons learned to be shared.

1. Of course, here is our DALY calculation - we based some of key health assumptions on the model provided by  Marie Stopes International and their methodology. This is the first iteration of our model so I'd be keen to see how this model's assumption compare to others in the field - let's talk more!

2. Yes, as you'll be able to see in the model, out total cost of the pilot was $6256.8 USD to deliver the first 2400 doses. We are currently scaling up our program so hoping to bring this number even lower. The key point here is that both Jefferson and myself have been working on it without compensation. I decided to go full time in October after seeing the results of the pilot and we also just employed our Program Officer, so we will be adding those costs as we incur them.

3. Family planning is still a difficult issue to discuss - both with end users and state officials. Jigawa started work on family planning only in 2002 and for the first 15 years, it was more of an afterthought it seems. Then the Federal Ministry of Health prioritised family planning and released national guidelines to increase the use of modern contraception. So, the states are now building the groundwork for advocacy and distribution, struggling with budgeting for such high needs. 

On the user side, the fertility rate is 8 children per family in Jigawa state, which means that this a fast-growing problem. Few people use any contraception in the state but many health facilities receive no contraceptives products at all. Our pilot number of contraception delivered may seem small but FP state coordinator told us that last year they received only 1400 doses of any injectables across 400 health facilities in the state.

This is definitely a fascinating question. It seems like there are numerous push and pull factors for both state provision and user demand for family planning. Many of our users report fear of side effects, fear of infertility, and lack of any education of family planning as the reasons of their previous lack of FP usage. Our model addresses both demand generation as well as providing the products to meet this demand in an accessible and affordable way.

Lots of love from Nigeria,
Klau

Thanks so much for the in-depth reply

I'm about to post a cost-effectiveness analysis here for OneDay Health, and I might just use your calculator for the family planning aspect if that's OK. It's a small part of what we do (average 2-3 injections per month per OneDay Health center) but it would still add something to our analysis. I'll definitely discount though as I'm sure every dose of family planning that  you supply under those difficult conditions in Nigeria has more impact even than in remote rural Uganda due to the higher birthrate there and immense barriers to accessing family planning even more than Uganda.

I LOVE that you are working with real local salaries and with volunteer managers, keeping your costs very low. It almost seems like you have started with a kind of minimum viable product  which is absolutely the best way to start. Many top-down projects start with horrendously inflated costs and this causes funders to not believe that organisations such as yours can operate so cheaply.

 Unfortunately at OneDay Health  we have found our management costs to increase substantially as we scaled (accounting costs, more higher level management and transport needed etc.) while unfortunately we find very few economies of scale - I hope you'll do better than us there. Still though even if your management costs massively increase I'm sure you will remain super cost effective. I find this very stressful as I always hoped if anything our costs would reduce as we grew where in reality the opposite happens. My only advice here would be to try not to worry if costs increase. You are doing more good even if it is more expensive per dose administered!

I'm surprised though you don't get at least a lot your contraceptives for free through partners. In Uganda we connect with Marie Stopes and Reproductive Health International to get most family planning supplies at no cost to us. Obviously the cost is still there in reality, but it makes programming easier from our end.

Thanks, Nick.

Hi Nick,

Thank you for your patience with my reply. I'm currently in Nigeria and organising two trainings for 40+ health workers so it's really busy now.

Of course, feel free to use our calculations, I am happy that it can be useful for your organisation. Also, I'd love to see your own cost-effectiveness analysis for OneDay Health, I'll be waiting for your post soon. I'll also post soon forecasted calculations for this year. 

My strong belief is you do not need a lot to make a lot of positive impact and it is better to do things on a shoestring budget to avoid unnecessary spending. It is yet another exercise in responsibility for the founder - not only for the effects but also for inputs. One thing we are conscious about are the scaling up costs. The costs may increase temporarily but ultimately we are scaling up our health worker network 3.5 times this month and initial calculations look quite promising! Thank you for your kind words - it is important to remember that some of the new costs are investments for future impact.

It is so interesting to hear about your connection with MSI and RHI -I'd love to hear more about it and just dropped you a message on LinkedIn, let's chat soon!

Sending lots of love still from Nigeria,
Klau

This is great. Would you be willing to put a (speculative, ballpark) number on what your $/DALY will be moving forward?

Hi Joshua, great question! I've been waiting to finish this phase of the training to have a better estimate of the future $/DALY. Once I'm back to the UK, I'll spend some time to prepare a forecast for the upcoming cost-effectiveness and share a speculative number then! I'm personally quite conservative with future numbers and will make sure to conduct an in-depth analysis before sharing it on the Forum. I'll remember to reply to this comment once it's ready :)

Best wishes with your work!

Thank you so much!

This is exciting! Thanks for writing this up. I'll share the post and calls to action with my networks :)

Thank you so much, Grace!