Kali (name changed), a resident of rural India in Ajmer district, Rajasthan was two months pregnant. One day Kali suddenly started experiencing unusual cramps and bleeding, and went to a Community Health Centre (CHC) for a checkup. However, Kali was unable to receive a proper diagnosis as most of the healthcare resources been diverted for COVID response due to huge surge in cases. Distressed, she approached the ASHA worker, who reached out to our Project Coordinator. After due deliberation, the client and her husband decided to travel to our Ajmer clinic for a checkup. Our Project Coordinator was constantly in touch with the client, as stricter lockdown had restricted traveling to far-off destination.
At the clinic, the client was counselled and a pelvic examination was conducted to diagnose the problem, where it was found that she had a miscarriage. To avoid further complications, a surgery had to be conducted at the earliest. The client was counselled about the procedure and multiple contraceptive options she had for avoiding future unintended pregnancies. Client shared, “At first my husband and I were extremely scared and worried as my bleeding was not stopping and I was not able to get any treatment. I am thankful to the ASHA worker and FRHSI team for helping me during this difficult time. I am really satisfied with the service and happy to see that all the COVID protocols were followed by the team.”
The number of COVID positive cases has increased alarmingly in April 2021 in Bihar, eastern state of India. Keeping in view the strong second wave of the coronavirus, Govt of Bihar has converted most of the Primary Health Centres/Community Health Centres into COVID isolation centres. FRHS India’s Bihar team, following all protocols and guidelines has taken an initiative for increased availability and access to the LARC options of FP and counselling at Health Sub centres. Health sub-centres are at the most farthest areas and serves the most vulnerable clients. As COT services remain suspended due to COVID; MCOT services have resumed in April to provide IUCD, OCPs, ECPs, counselling services.
Providing FP and SA services in the current situation is extremely challenging as these are not priority services for the govt due to COVID onslaught; but the team mates are advancing the mission of the organisation and providing crucial FP and SA services to clients wherever possible.
The IUCD and counselling services provided via MCOTs, are reaching to adolescents, young adults and also FRHS India’s media age group of 28 years.
Mobilisation efforts have been amped up to generate awareness on temporary ,methods of contraception.
Client speak: Dulari Devi, 28 is a resident of rural India in Champaran district; she is a mother of two, and her husband works as a daily wage labourer. The family earns less than USD 1.5/day, and is below the poverty line, Due to covid, her husband lost his job, as things have come to a standstill in India; she was all set to opt for a permanent method of FP (MSL) in April, but since all PHCs and CHCs have been converted into COVID centres, FRHS India team could not provide her with the services. But understanding her situation, and her intent to avoid an unintended pregnancy; FRHS India team counselled her to opt for IUCD. Alongwith frontline workers; FRHS India team managed to arrange an appointment for her at a Health Sub Centre; where she was offered IUCD. “I can not afford any more children, and was looking
forward to a permanent method; but that is not possible in the current situation. I thank FRHS India team who are still serving in rural India and at Health Sub Centres, and providing us crucial FP services. Most providers are unable to provide services, but FRHS india is the only organisation, who is still providing FP services in such far flung areas,” She shared. There are many like Dulari devi across the country who are unable to access FP and SA services, and this pandemic would have a devastating effect on unintended pregnancies and unsafe abortions.
Pooja Devi, another resident echoed the same sentiments, “I also had an appointment for sterilisation, but could not get service; but I also availed IUCD services at HSC.”
Myths and stigma is further adding to our challenges in providing services. Tanuja Kumari, Counsellor with FRHS India shares, “Many come for sterilisation, which have to be converted to IUCD; but most aren’t very happy with the suggestion, they insist on permanent methods. We counsel them and convince that in current situations; IUCD is the best option to avoid unintended pregnancies. DMPA too is difficult to administer, as following up for next doses is challenging with teams, resources and even clients contracting COVID. “
“Most women break down, and are scared of repeated abortions and pregnancies, and fear that unavailability of permanent method would be challenging. We counsel each one of them, and are converting permanent methods to IUCD. One such client came with her Mother-in-law; and her MIL was terrified that she would contract Covid 19 from the IUCD! The team took a much longer time to convince the family to opt for IUCD.”
Such myths associated with IUCD is further adding to the problems of the teams on ground.
FRHS India teams across the board are facing enormous challenges to provide services; but each one is advancing the mission and upholding the values.
On March 2020 because of the Covid-19 pandemic and the subsequent lockdown, all services were gravely affected, including the reproductive services that are provided by our clinical outreach teams. During the lockdown in Uttar Pradesh’s Hathras district, Rajni Devi (name changed) wanted to avail sterilisation services but was not sure where to avail it from any other place and she contacted FRHS India. We counselled her and informed her about different choices/methods available and she chose to avail female sterilisation. Since our services were temporarily affected, we advised her to use condoms and contraceptive pills in the meanwhile. Rajni shared, “With 6 kids and limited financial resources, we were sure that our family was complete. I wanted to avail sterilisation services at the soonest and was in touch with FRHS India’s nurse who guided me to take temporary methods during the lockdown.” As soon as the services resumed, Rajni reached our fixed day service and she received the method of her choice. Family planning is an essential and crucial service, and unavailability of it affects women disproportionately. Rani’s situation was similar to Rajni’s, she was eager to avail FP services, but the lockdown posed a huge barrier. Already a mother of three kids, Rani wanted to avail female sterilisation. Her fourth pregnancy was terminated as per her choice, and she did not want to risk getting pregnant again.
“ASHA didis had informed me about condoms during the lockdown, but I wasn’t very happy with the choices given, I felt scared that I might get pregnant again,” shared Rani. After much counselling, she started taking OCPs. As soon as our fixed day services started in UP following all COVID-19 protocols, Rani was amongst the first few to avail the services.
“One does not realise how important family planning is, till one is forced with reduced choices. During the lockdown every day I risked getting pregnant,” she added.
FRHS India has developed a clinical service guideline, following MSI Reproductive Choices protocols and MOHFW’s protocols.
Client-centeredness is one of our core values, and it is non-negotiable when it comes to service delivery. We have often seen women come with their daughters-in-laws (DIL) to avail family planning services. But in Ajmer during Unlock 1, we witnessed a comforting change, when a 28-year-old DIL got her 41 year old Mother-in-Law (MIL) Saroj to FRHS India’s fixed day service to avail sterilisation services. Lakshmi had earlier availed tubal ligation in FRHS India’s Ajmer clinic and was very satisfied with the services and quality of care. The change in tide left the service delivery team with much cheer. “Women at various reproductive ages need family planning, and when bahus mange to empower the older women in the families to take autonomous decisions on their reproductive choices, then things improve for the entire family, “shared Saroj. In the same fixed day service, we met Sarita who got her DIL Lata to avail FRHS India’s services. “I want the best and safest for her, and no other place like FRHS India. The teams here are very engaging, the counselling is very detailed, and the care is clearly visible,” expressed Sarita.
A client named Reena (name changed) who availed abortion services from the Bareilly clinic traveled 45 kms to the clinic to seek the service. She was informed about FRHS India by her sister who had earlier received services from this clinic and was very satisfied. Reena already had three children and due to poor socio-economic conditions, felt, she would not be able to raise another one. Both Reena and her husband decided to make the arduous journey on a two wheeler and were stopped every few kilometers by policemen who were monitoring the lockdown on ground.
Describing her condition to them, she was eventually able to reach the clinic and received comprehensive care. “When we learnt that I am pregnant, we were terrified. We did not want to have another child, we already have 3 kids and my husband works as a painter, hence it is not easy to meet ends. We decided to get a safe abortion, we tried to get the service nearby but owing to the lockdown nothing was available, private clinics were also closed. As soon as we were informed of FRHS India clinic, we decided to reach Bareilly. My husband took out his two wheeler and we started off, at every naka (checkpost) we were stopped, but an ASHA didi and a staff from the FRHSI clinic were in touch with us over the phone and would also talk to the police if needed. When we were stopped, we did not mention that we are going for an abortion, instead said that I am pregnant and needed immediate help. We were not sure how would the police react if they heard that we were travelling amidst a lockdown for an abortion,” shared Reena while describing her ardous journey.
Upon reaching the clinic and getting proper counselling, she availed SA and PAFP. FRHS India colleagues were in touch with her throughout her journey back and also did follow-ups as per MSI guidelines.
Family Planning service delivery has always been a challenging task. Despite challenges, FRHS India works towards the empowerment of women by providing them with affordable and accessible sexual and reproductive health services. Thus, enabling them to make informed decisions about their fertility and future.
Amidst a global pandemic which has affected India significantly, our COT team in Etah has been working hard to ensure women are not deprived of critical reproductive health services.
On 24th February 2020, a client, Krishna, expressed doubts about the success of her sterilization procedure, as she had missed her periods for the past 45 days. The Etah COT team had a scheduled FDS, and had delivered female sterilization and IUCD services to Krishna. As soon as Nisha (Counsellor, Etah Team) was apprised of Krishna’s doubts, she instantly advised Krishna to take a pregnancy test, which came out to be positive. Nisha stated the circumstances to the clinical team, which suggested an ultrasound, followed by medical termination of the pregnancy, subject to Krishna’s consent and guidelines of the Indian Medical Termination of Pregnancy Act.
In efforts to grapple the pandemic, ‘Janta Curfew’ was announced on 22nd March, followed by a complete nation-wide lockdown on 25th March. On 23rd March, our Etah COT team members- Ashwani (FC), Nisha (Nurse) & Jitendra (Driver) went to Krishna’s place to facilitate an ultrasound, in order to establish Krishna’s condition and gestation period. Unfortunately, there were no ultrasound services available in Etah district, which then led the team to travel 70 kms with the client, to get the ultrasound service in Mainpuri district.
The ultrasound revealed that Krishna was pregnant for 9 weeks and 4 days. The client gave her consent for medical termination of pregnancy, and requested to avail temporary contraception method in the future. However, the procedure had to be postponed due to a personal emergency the client was facing.
The FRHS team remained in constant touch with Krishna during this time. Unfortunately, by the time Krishna decided to avail the termination procedure, the stringent nation-wide lockdown was well in place, and the availability of services in Etah or nearby districts became impossible, due to crunch of doctors and heavy burden on medical facilities. The nearest services available were 250 km away, in Bareilly.
During this difficult time, the FRHS India team had been in touch with government officials, to re-start abortion services at FRHSI Clinics with proper measure against COVID-19 infection. Fortunately, services at FRHS clinics were re-started with government approvals, as the termination of pregnancy is an emergency service.
The Etah COT team bridged the 250 km distance, and travelled with the client and her husband to Bareilly. Upon reaching the clinic in Bareilly, Dr. Manju Gupta along with the clinical team carried out an abortion and post abortion IUCD services were also offered. The procedure went well, and the clinical team remained in touch with Krishna afterwards. The client has expressed gratitude towards the FRHS India team, and is perfectly healthy.
Congratulations to our Sitamarhi Clinical Outreach Team, who have been recognized by the Government of Bihar for their outstanding work in health and family welfare.
As part of Bihar’s Republic Day celebrations, the team was presented with an award for their contribution to the delivery of high quality family planning services.
Alongside the team award, Mr. Prince, Program Coordinator and Ms Juhi, Counsellor were also recognized for their contribution in this area.
The team serves two districts- Sitamarhi and Seohar in the state of Bihar. In 2017, they provided services to a total of 5,494 clients (4,260 female sterilizations, 57 male sterilization and 1,177 (IUCD) in the two districts.
FRHS India is honored to have received such recognition and would like to thank donors, partners and well-wishers for their continued support and encouragement.
One of the things that FRHS India is known for is our dedication to getting services through to the last mile. So when communities in the state of Bihar were cut off by record-breaking floodwaters, our teams knew what they had to do.
In 2016, the monsoon floods of India’s Ganges river broke all the previous records, in places reaching more than 50m (166ft). Bihar state was particularly badly affected, with more than 150 deaths and nearly half a million people evacuated.
A small outreach team comprising Nurse Rani Kumari, Counsellor Chandan Bharti and Programme Coordinator Chandra Bhushan organised for a narrow wooden raft to carry them across the flooded areas towards the Araria district, where local women had been unable to access contraception services for more than a month.
That wasn’t the end of their journey. Once they had crossed the flooded area, the team walked for more than an hour to reach the health centre at Mirzapur. In places, they were forced to wade through knee-deep slush, physically carrying all the required equipment for the day’s procedures. In total, the team travelled a distance of 25km over three hours – an extraordinary effort.
As soon as the local women learnt of the team’s arrival, they quickly lined up for services. The team provided 14 women with IUDs that day, giving them long-acting protection against unplanned pregnancy, come rain or shine.
Pinky joined the partnership in 2010, aged just 22, when she was assigned the role of counselling women on their contraceptive options in the remote Rajasthan townships of Sanganer and Bassi. At first, the work was tough – many of the women Pinky visited had received little education and were unused to making decisions, deferring instead to their husbands and community elders – but she persisted.
It took time to gain the women’s trust, but gradually and with some determination, Pinky encouraged them to share their concerns about family planning more openly. She realised that most of the women she met understood the value of being able to manage the size of their family, but were constrained by factors like the distance to their nearest health clinic, or family commitments taking priority.
By adopting the client-centred approach that FRHS India, formerly Marie Stopes India is known for, Pinky was able to not only understand the challenges her clients faced in accessing contraception but offer them solutions. As a result, uptake of contraception in the townships began to rise.
In 2013, FRHS India began a focused drive to increase the number of men coming forward for vasectomy. Having already won the confidence of the women in the community, Pinky was well-placed to promote the procedure among their husbands and male family members. However, her initial efforts were met with resistance, sometimes even with gossip and mockery.
Once again Pinky persisted, continuing to face the communities she visited with courage, addressing the myths surrounding the procedure, and explaining the method to the men with as much ease as she had to the women.
Gradually, the men of Sanganer and Bassi realised that what she was telling them not only made sense, but was to their benefit. Increasing numbers started coming forward for vasectomy. Pinky’s biggest achievement came in November 2014, when she encouraged 32 men to undergo a vasectomy on a single day.
Pinky has been so successful in her work that she now plays an important role in generating demand for vasectomy in almost every district in Rajasthan, India’s largest state. In her new role as Block Coordinator, she heads a team of 14 peer motivators, who she trains to motivate men across the state to take up vasectomy. In addition to training others, she continues to meet clients of her own and looks forward to breaking her own record soon!
Bairgania is one of the blocks in Sitamarhi district which borders Nepal. The road to Bairgania is not much of a road and last year’s flood has further worsened the conditions of the navigable road. While political parties have been promising reconstruction of the roads, residents there might have to wait for a little longer. However, this does not deter FHRSI’s Clinical Outreach Team (COT) to continue with the Fixed day Services.
The arrival of the FRHSI ambulance at the Community Health Centre (CHC) at Bairgania brings smiles and raises hope across families. The team quickly sets up the canopy, registration desks, sanitises the OT, counselling and pre-operative rooms and starts attending to clients from the word go
“FRHSI has been delivering services in our area for several years now, the team is extremely efficient and respects our needs,” shared Geeta Devi, a mother of 5, who had come for Tubal Ligation as she is certain that her family is complete.
FRHSI is committed to providing family planning services to each and all and always puts clients’ needs at its centre of all operations. Quality of Care is a non-compromising issue and teams across regions ensure that utmost care is taken while addressing clients’ needs.
The Fixed Day Services are a life saver for many families in Bairgania block, as families are keen to access family planning services, especially long term measures, so that they can attend to their children efficiently.
“I always wanted a smaller family, but I wasn’t aware of family planning services. We have 7 children and my husband works as a labourer in Delhi; now due to our large family we face a lot of financial constraints. Had I known of these services earlier, we could have managed the pregnancies better,” said Kamla, a client who had come for Tubal Ligation. Kamla is not alone, the unmet FP needs, especially in far flung areas such as Bairgania is enormous, and bridging the gap is what FRHSI is striving for with every passing day.
There are very many misconceptions and stigma attached to Non-Scalpel Vasectomy (NSV) and FRHSI addresses all such misconceptions and taboo through sensitisation, advocacy and relentless conversations with various stakeholders, especially the MEN.
Family planning in India has always been plugged in as a woman’s job; men had habitually been out of any such discussion or dialogues. India’s patriarchal mindset has further stemmed the habit. However, things are changing, and men are increasingly getting involved in discussions around FP services and Sexual and Reproductive Health and Rights. But when it comes to availing long term methods, women have been sharing the load…nonetheless there are men like Ahmad who have not only availed NSV, but also has been actively advocating for it among his peers and community.
Ahmad got to know about FRHSI’s NSV COT during a mobilisation activity, “I waited for everyone to disperse, after that I mustered courage to talk to the team,” he shares smilingly, “This is so because, men availing NSV is looked down upon and there is a general perception that it would affect a man’s physical strength, which would have an impact on his earning/employment.” Ahmad is a rickshaw puller by profession.
But that was then, he was fully assured by the team and the doctor, post which he went for the services. “The day I got NSV done, was quite dramatic, I came riding my rickshaw, much to the worry of the NSV COT team, as they did not want me to ply the rickshaw on my return after the services. However, after the procedure, I did not feel a thing; in fact I was ready to sit on my rick after the stipulated post- operative time and after the team had given me a clearance for discharge. Not only did I ply my vehicle, I got two more of my friends within the next 30 minutes to the CHC,” he shares enthusiastically. He further shares that his intention was not to pull a stunt, but wanted to grab eyeballs and address naysayers. Ahmad single handedly, has managed to influence at least 10 of his friends for the same. Not all heroes wear capes!
Raghu, another NSV client shared that “In our community NSV is not common, but I wanted to share the burden.” Raghu, however was not as happy as Ahmad after his services, he was suffering from dilemma. As a security guard, he is expected to man a telecom tower all through night and had caught a cold, “On my first night of duty after NSV, I felt chills, and I thought, people were right, NSV does reduce your stamina! But then when I started having runny nose, I realised that I caught a cold..and was unnecessarily feeding onto a myth.” He shares a hearty laugh narrating his experience.
While sharing the nuances of NSV, CB Shrivastav, Programme Co-ordinator, Sitamarhi, FRHSI shares, “Getting clients for NSV is very difficult, and it is not only because of the stigma, but many women also suffer from misconception that NSV affects the physical health of a client. We reach out to all men and women across all communities and bust myths surrounding NSV.”
While the number of men participating in family planning is still abysmally low, things surely and certainly are changing..and FRHSI in each step is guiding and addressing apprehensions and myths to break the taboo.
Reaching out with crucial family planning services and sensitising on SRH is at the heart of FRHS India’s service delivery models. FRHSI is committed to reaching out to the poorest of poor and the most vulnerable. Giving non-discriminatory quality services is one of the key deliverables for FRHSI.
Family planning is a huge challenge for the specially-abled, as many a times; they are not able to access the Community Health Centres (CHC) or the Primary Health Centers (PHC) due the lack of infrastructure. Their needs are often neglected and brushed aside, leaving them with little choice to exercise their reproductive rights.
In order to ensure that all men and women have access to FP services in FRHSI service delivery areas, and are able to achieve their reproductive goals, teams ensure confidentiality, quality and work with great enthusiasm.
“There has been many instances where specially-abled persons, persons with hearing impairment, visual deficiency and affected by polio had reached out to ASHAs (Accredited Social and Health Activist), with whom FRHSI works very closely for FP services. We took utmost care for all our specially-abled clients, and ensured that they receive services in a dignified manner,” explained the Sitamarhi COT members.
Family planning needs of people living with disabilities are often overlooked and seldom prioritised. Across the world, people living with disabilities have poorer health outcomes, among other issues than people without disabilities. This is partly because people living with disabilities experience barriers in accessing services, information etc. At FRHSI, the aim is to reach out to the most vulnerable and teams across regions ensure that dignified services are offered to each and all. FRHSI has pioneered the ‘9 steps to quality service delivery’ and it encompasses all.
In the month of December, 2018, the Accredited Social and Health Activists (ASHA) had gone on a total strike across the state of Bihar. The ASHAs demanded fair pay and infrastructure, often the last mile champions like ASHAs and ANMs (Auxiliary Nurse and Midwife) have to face various constraints to support and fulfill ambitious government schemes. The ASHAs in Bihar stirred to demand fair pay and had stopped their activities in December 2018. Our work depends quite a lot on ASHA’s mobilisation at grass roots especially for our Fixed Day Services. The ASHA didis working with FRHSI has been associated with the programmes for many years and are motivated to help us liaise with clients. “Being an ASHA, we had to show solidarity with all the ASHA workers, but we knew that if there is a total shutdown, many deserving and vulnerable clients will be denied of crucial family planning services,” shared an ASHA worker.
Her sentiments were echoed by a fellow didi who said, “CHCs and PHCs can not function with ASHA, but the strike was necessary as our demands were falling to deaf ears. In order to ensure that clients are not at the receiving end of the stir, we would co-ordinate with FRHSI COT members in a clandestine manner and offer services, very early in the morning. Together with FRHSI , we would mobilise clients and ensure all services are delivered to each and all….much before the larger group of ASHAs could come and stall operations.”
The commitment and the passion to deliver quality services to ensure that families could have ‘Children by choice, not Chance’ is absolutely commendable.
The ASHA stir did have some impact on FRHSI’s service delivery, but overall due the on-ground resilience and dedication clients at the majority of districts and blocks in Bihar were served.
All services of Foundation for Reproductive Health Services India (FRHSI) in Rajasthan had been put on a halt for the first few days of April 2020 after the announcement of a lockdown by the Government of India to fight the COVID outbreak. The organisation, however was constantly receiving emergency calls from motivators and clients to provide abortion services.
To ensure clients received the necessary time sensitive care, FRHS India resumed services at its clinics. The organisation recognized that in times of crisis, there could be a possible denial of abortion services and therefore decided to slash its abortion fee by 50% so that the most vulnerable who are badly hit by the lockdown could afford quality care.
With this goal, FRHSI reached out to the motivators via various platforms including whatsapp to inform them of the availability of services.
Consequently, a client who was unable to avail abortion services due to lockdown reached out to FRHS India for help. She was pre-screened for abortion services by the FRHS India clinical staff over call. Post the screening, the client was provided with an appointment to get the required services at the Jaipur clinic. On 8th April 2020, the client visited FRHS India along with her motivator to seek the desired services. Following all clinical protocols, FRHS India offered the abortion services in line with its values of client centredness, quality of care and accountability.
FRHS India’s clinics in Jaipur, Ajmer and Bareilly continue to remain open during the lockdown to offer crucial sexual and reproductive health services to its clients.