key: cord-0974038-2uvxsyqo authors: Antillon, Camilo; Webbe, Victoria; Husken, Saskia title: Supporting young women in Francophone West and Central Africa with their reproductive health decisions: what can we learn from the Lydia Conseil Call Centre? date: 2022-04-04 journal: Sexual and reproductive health matters DOI: 10.1080/26410397.2022.2054225 sha: 65fbd3b82bc56925e694f4da88f9066b1a5efaec doc_id: 974038 cord_uid: 2uvxsyqo nan High rates of unintended pregnancy, unsafe abortion and unmet need for contraception are persistent sexual and reproductive health (SRH) challenges in Francophone West and Central Africa (FWACA). These challenges are linked to existing barriers, particularly for young women, to access the SRH information and services they need. Correct information, and quality products and services that preserve young women's privacy and social safety, are of crucial importance for their health and well-being. National governments have an obligation to respect, protect and fulfil rights related to women's SRH, including the right to SRH education. Violations of these rights have far-reaching socio-economic consequences as well as health implications for women. Besides monitoring government policies and actions, civil society can fill gaps left by national institutions. In this article, we share the experience of the Lydia Conseil Call Centre initiated by DKT International * (henceforward DKT), and we argue that call centres help women circumvent the stigma and silence that limit their access to quality information and care, thereby helping to fulfil their SRH rights. Between 2015 and 2019, the annual unintended pregnancy rate in FWACA was estimated to be 91 per 1000 women aged 15-44 years. The FWACA region includes countries with some of the world's highest teenage pregnancy rates, including Niger at 204 births per 100,000 teenage women, Mali 125, Guinea 142 and Côte d'Ivoire 125. 1 Out of all unintended pregnancies, 42% in West Africa and 30% in Central Africa ended in an abortion. 2 FWACA also has by far the highest abortion-related case fatality rate in the world, with approximately 450 deaths per 100,000 abortions. 3 The modern contraceptive prevalence rate (mCPR) is low across the two sub-regions, ranging from 13% in Guinea to 27% in Burkina Faso, among all women of reproductive age. Conversely, there is a high unmet need for modern contraception, reaching as high as 36% in Benin and an average of 27% for the region. Unmet need is even higher among unmarried women. 4 The most-cited reasons for unmet need in FWACA include lack of awareness of methods (over 5%), high costs (6%), lack of access (10%) and (among single women) not being married. This could be linked to a perception of infrequent sexual activity due to their marital status, but it could also be an indication of young unmarried women's fear that, if they were to access contraceptive services, they could be stigmatised for having pre-marital sex. 4 On the other hand, married adolescents aged 15-19 in FWACA have a notably low mCPR, which may be * DKT International is a charitable non-profit organisation that promotes family planning and HIV prevention through social marketing. attributable to social and cultural pressure to have a child before starting a family planning method. 5 The negative effects in the region of social stigma on young women's sexual and reproductive autonomy have been documented. For example, in her ethnographic research among young people in Dakar, Senegal, Van Eerdewijk 6 describes how Dakarois society sees sex as restricted to the institution of marriage only and condemns sex outside of it. These dominant patriarchal notions of female sexuality constitute important barriers for them to access the information they need to make their SRH decisions. With these challenges in mind, DKT launched the Lydia Conseil Call Centre in 2018. Based in Dakar and building on the notoriety of the DKT regional family planning brand "Lydia", Lydia Conseil is one of the largest regional SRH call centres in FWACA. Via this service, users from anywhere in the FWACA region can anonymously connect via telephone or social media channels to a trained DKT Midwife Operator who answers questions and provides advice on contraceptives, pregnancy and other SRH related topics. The Call Centre partners with "She Makes Her Safe Choice", a programme led by Rutgers and DKT, with support from the Dutch Postcode Lottery. This programme aims to reduce unsafe abortions worldwide by using a multi-component approach: improving supply of contraceptives and safe abortion methods through trained providers, creating awareness about existing family planning and legal abortion services, and facilitating a supportive environment for the prevention of unintended pregnancies and unsafe abortion. Other resources in the region include Marie Stopes International's phone-based helpline called Adama Call, which serves as a source of information for MSI clinics and services in Senegal, and UNFPA Benin partnered with tech companies to create an application called Ma Vie Mon Choix to increase youth access to SRH information. Websites such as https://findmymethod.org/ and https://www.howtouseabortionpill.org/ include FWACA-specific information on access to quality RH products, including safe abortion methods. Complementing these initiatives, Lydia Conseil combines the tailored medical counselling of a hotline with the geographic scale of a web platform. In cases where further medical intervention is needed, the Call Centre midwives are able to refer users to healthcare providers and products through DKT FWACA in-country networks. Between February 2018 and April 2020, the Lydia Conseil Call Centre responded to almost 40,000 calls and messages specifically on contraception, unintended pregnancies and abortion. The Call Centre is currently able to respond to 4500 calls and online communications every month. Users ask questions on a variety of topics ranging from specific contraceptive methods and possible side effects, to STIs and HIV, to gynaecological health concerns. Users can connect via phone at the cost of a local call, or SMS, except in Senegal and Cote d'Ivoire where it is toll-free, or they can choose to reach the Call Centre via WhatsApp and social media messaging through Facebook or Instagram. With 37,943 counselling sessions logged, family planning represented the most common topic addressed by the Call Centre, followed by sexually transmitted infections (STIs) (13,755) and pregnancy (11,210). The age distribution of users was similar for all major topics, with the majority of queries coming from 19 to 25-year-olds, followed by 26-35-year-olds (see supplementary table). In terms of the proportion of calls contributed by users under 19 years old, this age group contributed the highest proportion in the categories of STIs (8% of all queries) and sexuality (10% of all queries). This 'top three' order, i.e. family planning, STIs and pregnancy, is the trend in all countries in the region, except in Senegal and Cameroon, where pregnancy-related counselling outpaced STIs (see supplementary table) . Senegal has some of the most restrictive abortion laws in the region, which may explain why the majority of pregnancyrelated contacts (both phone calls and all other communications to Lydia Conseil) from Senegal focused on ways to become pregnant, while Cameroon's pregnancy-related contacts focused more on abortion. Due to the current legal restrictions on abortion in Senegal, the Call Centre operators do not offer counselling on abortion. Nevertheless, each month women reach out in need of information on managing unintended pregnancies and safe abortion services, and these inquiries have increased since the start of the Covid-19 crisis. The Call Centre midwives are determined to provide assistance and to protect and advance each caller's right to the highest attainable standard of health in their respective countries, hence women seeking to terminate their unintended pregnancy are currently advised to see a quality gynaecologist for further assistance. During its first nine months of operations, the Call Centre responded to about one hundred calls on all topics each month, but after November 2018 the number increased 20-fold. This steep increase coincided with the introduction of a Facebook Ads campaign promoting the Call Centre service across the region. The contribution of this campaign to the increased visibility and use of the Call Centre is confirmed by the fact that almost all users (97%) claimed to have heard about the Call Centre via Facebook. The highest number of calls and messages to the Call Centre came from Senegal and Benin, both in absolute terms and in relation to their populations, followed by Guinea, Cameroon, Burkina Faso and Mali. The Lydia Conseil platform has been promoted through partnerships with local initiatives in both countries, including targeted Facebook advertising, which explains the increased numbers of calls and messages. For example, in Senegal, Lydia Conseil partnered with the popular series C'est la Vie!, which has mentioned the platform on their web series and on their social media. When comparing the only two countries that had a toll-free line to the Call Centre, the number of communications received from Côte d'Ivoire was half the number received from Senegal, despite its much larger population, although this is likely in part due to technical difficulties faced with the Côte d'Ivoire phone number. A closer look at the channels chosen by users to reach the Call Centre (see supplementary table) and the marketing strategies used to promote it, offer some insights into user preferences. While 95% of users across the FWACA region reached the Call Centre via online messaging services, namely WhatsApp and Facebook and Instagram Messenger, a mere 4% reached out via a phone call. The vast majority of phone calls to the Call Centre originated from Senegal, with almost one in five Senegalese reaching the Call Centre by phone. This could be explained by the fact that besides a toll-free line, Senegal has had TV and radio campaigns promoting the Call Centre. In the FWACA region, where high illiteracy rates and limited internet connectivity create barriers for large segments of the population, in particular women, to access online platforms, the combined use of TV and radio advertisement and a toll-free phone line remain important promotional channels. The Call Centre is currently looking into options for future campaigns, including integrating the Lydia Conseil contact information into awareness raising activities via DKT FWACA. However, some fundamental limitations of the Call Centre make intensive promotion of the phone line a challenge. First, there is a capacity issue. Direct phone calls demand immediate answer and require more time to respond than WhatsApp or Facebook messages. This means that increasing numbers of phone calls would put a significant strain on the service. Language also poses a significant challenge. The Lydia Conseil operators speak five languages between them, but with hundreds of local languages throughout the FWACA region, the majority of counselling sessions are conducted in French, which callers from rural areas are less likely and/or less comfortable to speak, with the attendant risk of causing gaps in information and hindering trust and/or rapport-building between caller and operator. When examining the proportion of users who contacted Lydia Conseil through different online channels, an interesting contrast emerges based on the topic they intended to address. Among those who had questions on contraception, 75% used Facebook/Instagram Messenger and 25% used WhatsApp. However, the proportion is almost reversed for those who had inquiries on unintended pregnancies and abortion, with two thirds favouring WhatsApp, and one third Facebook/Instagram Messenger. The preference of WhatsApp over Facebook/Instagram to communicate on more sensitive matters may indicate a perception among users that the former offers greater privacy and anonymity than the latter. More than 9 in 10 Lydia Conseil users were women, and the majority of them were young: 12% were aged 15-19, and 48% were aged 20-24. When we compare this to the age structure of married and sexually active unmarried women in the region, 4 we can see that young women are over-represented among the users of Lydia Conseil. It is also interesting to observe that three quarters of the 15-24-year-old women who reached Lydia Conseil had no children. This is in stark contrast with regional statistics that show the majority of women in that age range having already had at least one child: for example, 71% of women aged 15-24 in Burking Faso have already given birth. 4 The over-representation of young women with no children among the Lydia Conseil users is in line with the fact that, as stated above, unmet need for contraception in the region is higher among young unmarried women, and most of the unmet need in that group is in order to prevent a first pregnancy, rather than to space or limit pregnancies. This could be seen as an indication that Lydia Conseil is successfully reaching a group of women that have greater limitations in accessing family planning information and services through other sources. The over-representation of young women may also indicate that services like Lydia Conseil are not adapted to the needs of other groups. Online channels such as Facebook, Instagram and What-sApp have played a key role in making Lydia Conseil visible and accessible to an important number of women in the region. The fact that the number of users who live in major urban centres is disproportionately high in all countries (see supplementary table) is illustrative of this point. However, the use of online channels could be limiting the access based on a range of factors. Limited internet access, particularly for women who live in rural or marginalised settings, access to a smartphone, and the technical literacy to use it, can all pose significant barriers, particularly for older women. This might explain why more young women contact Lydia Conseil. Furthermore, Lydia Conseil's heavy use of online platforms could also make it more vulnerable to censorship, particularly in settings with a strong online and offline presence of conservative groups. Lydia Conseil Facebook ads have been blocked in the past after false user reports that the service was selling medications, which goes against Facebook's community standards. Although ultimately resolved, these issues can cause significant delays to campaigns, and result in noticeable drops in contact rates, delaying correct information and referrals to reach users, and consequently putting their health and lives in danger. The experience of Lydia Conseil shows that call centres can be a viable solution to the needs of women in FWACA for SRH information, particularly among young unmarried women, who face greater information barriers due to the stigma associated with female pre-marital sex. Through this experience we have learned about comparative advantages of using offline and online channels to reach various underserved groups, and we note that the Call Centre is a valuable addition to existing structures and sources of information. Social media advertising has been an effective strategy to increase the visibility of the Call Centre and online communication platforms have been the channels most favoured by its users so far. End-to-end mobile messaging apps, in particular, seem to provide a greater sense of security to discuss more sensitive SRH matters. At the same time, persistent limitations in digital access and literacy, especially among marginalised women, make over-reliance on such platforms problematic. While involving significant time and resource investments, we note that offline communication channels, such as telephone, TV and radio, continue to play a key role in reaching women and girls with the SRH information they need. The experience of the Lydia Conseil Call Centre provides valuable learnings for future interventions, particularly those able to adapt to local populations' literacy and language needs. No potential conflict of interest was reported by the author(s). Supplemental data for this article can be accessed at http://dx.doi.org/10.1080/26410397.2022. 2054225. 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