Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

Getting to FP2020: Harnessing the private sector to increase modern contraceptive access and choice in Ethiopia, Nigeria, and DRC

Background

An estimated 214 million women have unmet need for family planning in developing regions. Improved utilization of the private sector is key to achieving universal access to a range of safe and effective modern contraceptive methods stipulated by FP2020 and SDG commitments. Until now, a lack of market data has limited understanding of the private sector’s role in increasing contraceptive coverage and choice.

Methods

In 2015, the FPwatch Project conducted representative outlet surveys in Ethiopia, Nigeria, and DRC using a full census approach in selected administrative areas. Every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, availability, and price.

Findings

Excluding general retailers, 96% of potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods available. In Ethiopia, 41% of modern contraceptive stocking outlets were in the private sector compared with approximately 80% in Nigeria and DRC where drug shops were dominant. Ninety-five percent of private sector outlets in Ethiopia had modern contraceptive methods available; 37% had three or more methods. In Nigeria and DRC, only 54% and 42% of private sector outlets stocked modern contraceptives with 5% and 4% stocking three or more methods, respectively. High prices in Nigeria and DRC create barriers to consumer access and choice.

Discussion

There is a missed opportunity to provide modern contraception through the private sector, particularly drug shops. Subsidies and interventions, like social marketing and social franchising, could leverage the private sector’s role in increasing access to a range of contraceptives. Achieving global FP2020 commitments depends on the expansion of national contraceptive policies that promote greater partnership and cooperation with the private sector and improvement of decisions around funding streams of countries with large populations and high unmet need like Ethiopia, Nigeria, and DRC.

A systematic review of contraceptive continuation among women living with HIV

BACKGROUND

Women living with HIV (WLHIV) experience high rates of unmet contraceptive need and unintended pregnancy. Contraceptive method-specific continuation rates and associated factors are critical for guiding providers tasked with both reproductive health (RH) and HIV care. We conducted this systematic review to determine whether contraceptive continuation rates differ between WLHIV and uninfected women and, for WLHIV, whether differences are impacted by method type, antiretroviral therapy use or other factors.

METHODS

We searched Ovid MEDLINE, POPLINE and PubMed.gov for studies published between January 1, 2000, and August 31, 2016. Inclusion criteria comprised prospective data of WLHIV, nonbarrier method continuation as an outcome measure, and recorded method switching and/or discontinuation.

RESULTS

Of 939 citations screened, 22 articles from 18 studies were eligible. For studies with comparator groups, data quality was moderate overall based on Grading of Recommendations, Assessment, Development and Evaluations and Newcastle-Ottawa Quality Assessment scales. Of four studies comparing women by HIV serostatus, two showed higher rates of contraceptive continuation among WLHIV versus uninfected women, while two others detected lower continuation rates for the same comparison. Generally, baseline method continuation exceeded 60% for studies with >12months of follow-up. Studies providing contraception had higher continuation rates than studies not providing contraception, while women allocated to contraceptive methods in trials had similar continuation rates to those choosing contraceptive methods. Across all studies, continuation rates differed by method and context, with the copper intrauterine device showing greatest variability between sites (51%-91% continuation rates at ≥12months). Implant continuation rates were ≥86%, though use was low relative to other methods and limited to few studes.

CONCLUSIONS

Contraceptive continuation among WLHIV differs by method and context. More longitudinal studies with contraceptive continuation as a measured outcome following ≥12months are needed to strengthen integration of RH and HIV care.

Determinant of Implanon Discontinuation among Women Who Ever Used Implanon in Diguna Fango District, Wolayita Zone, Southern Ethiopia: A Community Based Case Control Study

Background

A significant number of women make Implanon their first choice of contraception. However, they discontinue their Implanon before its expiry date was high, but factors that contribute to discontinuing their Implanon were poorly described in Ethiopia.

Methods

A community based unmatched case control study was conducted. Then simple random sampling technique was used to select 340 women. Data was collected by nurses using face to face interview. Epi-Info version 7 and SPSS 20 software were used. Bivariate and multiple logistic regressions were performed with COR and AOR with 95% CI.

Findings

Having preinsertion counseling (AOR: 0.36, 95% CI: 0.20–0.64), having follow-up appointment (AOR: 0.35, 95% CI: 0.2–0.62), age at insertion <20 years (AOR: 3, 95% CI: 1.16–7.8), women who had no formal education (AOR: 2.8, 95% CI: 1.31–6.11), women who had ≤4 children (AOR: 1.8, 95% CI: 1.01–3.21), and women who had previous abortion history (AOR: 2.3, 95% CI: 1.10–4.63) were determinants of Implanon discontinuation.

Conclusions

Policy makers and concerned bodies should take into account future intervention and also great emphasis should be given to follow-up appointment and counseling services, especially counseling on side effects, and informed choice for clients after Implanon insertion.

Poor Knowledge and Nonuse of Long-Acting/Permanent Methods of Contraceptives in Six Districts in Indonesia

This analysis aimed at examining the association between the level of knowledge about long-acting/permanent methods of contraceptives (LAPM) and nonuse of LAPM among currently married, nonpregnant, and fecund women aged 15 to 49 years intending to limit childbearing. Data were derived from a cross-sectional study in Tuban, Kediri, and Lumajang District (East Java Province) and Lombok Barat, Lombok Timur, and Sumbawa District (Nusa Tenggara Barat Province) in June 2012. Information was obtained from 4323 respondents. Using multivariate logistic regression, we found that women with moderate levels of LAPM knowledge were less likely to use LAPM than women with high levels of knowledge (adjusted odds ratio [aOR] = 2.01, 95% CI = 1.51-2.68). Women with low level of LAPM knowledge were less likely to use LAPM than women with high levels of knowledge (aOR = 4.25, 95% CI = 3.37-5.36). Efforts to strengthen counseling services and increased provider knowledge and counselling skills are important to improve women's knowledge about and use of LAPM.

Perceptions of and barriers to family planning services in the poorest regions of Chiapas, Mexico: a qualitative study of men, women, and adolescents

Background

In the poorest regions of Chiapas, Mexico, 50.2% of women in need of contraceptives do not use any modern method. A qualitative study was needed to design effective and culturally appropriate interventions.

Methods

We used purposive maximum-variation sampling to select eight municipalities with a high proportion of residents in the poorest wealth quintile, including urban, rural, indigenous, and non-indigenous communities. We conducted 44 focus group discussions with 292 women, adolescent women, and men using semi-structured topic guides. We analyzed the data through recursive abstraction.

Results

There were intergenerational and cultural gaps in the acceptability of family planning, and in some communities family planning use was greatly limited by gender roles and religious objections to contraception. Men strongly influenced family planning choices in many households, but were largely unreached by outreach and education programs due to their work hours. Respondents were aware of many modern methods but often lacked deeper knowledge and held misconceptions about long-term fertility risks posed by some hormonal methods. Acute physical side effects also dissuaded use. The implant was a new and highly acceptable method due to ease of use, low upkeep, and minimal side effects; however, it was perceived as subject to stock-outs. Adolescent women reported being refused services at health facilities and requested more reproductive health information from their parents and schools. Mass and social media are growing sources of reproductive health information.

Conclusions

Our study identifies a number of barriers to family planning that have yet to be adequately addressed by existing programs in Chiapas’ poorest regions, and calls for reinvigorated efforts to provide effective, acceptable, and culturally appropriate interventions for these communities.

Electronic supplementary material

The online version of this article (10.1186/s12978-017-0392-4) contains supplementary material, which is available to authorized users.

Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda

Between 2011 and 2014, the program provided more than 330,000 family planning services, mostly to rural women in the informal sector with little or no education. 70% of the voucher clients chose an implant and 25% an intrauterine device.

From 2001 to 2011, modern contraceptive prevalence in Uganda increased from 18% to 26%. However, modern method use, in particular use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs), remained low. In the 2011 Uganda Demographic and Health Survey, only 1 of 5 married women used a LARC or PM even though 34% indicated an unmet need for contraception. Between 2011 and 2014, a social franchise and family planning voucher program, supporting 400 private facilities to provide family planning counseling and broaden contraceptive choice by adding LARCs and PMs to the service mix, offered a voucher to enable poor women to access family planning services at franchised facilities. This study analyzes service trends and voucher client demographics and estimates the contribution of the program to increasing contraceptive prevalence in Uganda, using the Impact 2 model developed by Marie Stopes International. Between March 2011 and December 2014, 330,826 women received a family planning service using the voucher, of which 70% of voucher clients chose an implant and 25% chose an intrauterine device. The median age of voucher users was 28 years; 79% had no education or only a primary education; and 48% reported they were unemployed or a housewife. We estimated that by 2014, 280,000 of the approximately 8,600,000 women of reproductive age in Uganda were using a contraceptive method provided by the program and that 120,000 of the clients were “additional users” of contraception, contributing 1.4 percentage points to the national modern contraceptive prevalence rate. The combination of family planning vouchers and a franchise-based quality improvement initiative can leverage existing private health infrastructure to substantially expand family planning access and choice for disadvantaged populations and potentially improve contraceptive prevalence when scaled nationally.

Efavirenz decreases etonogestrel exposure: a pharmacokinetic evaluation of implantable contraception with antiretroviral therapy

OBJECTIVES

The primary objective of this study was to characterize the pharmacokinetics of etonogestrel (ENG) released from a contraceptive implant in Ugandan women living with HIV who were receiving efavirenz (EFV) or nevirapine (NVP)-based antiretroviral therapy (ART), compared with ART-naive women over 24 weeks.

DESIGN

Nonrandomized, parallel-group study with three arms: ART-naive, NVP, or EFV-based ART (N = 20/group).

METHODS

Sparse pharmacokinetic sampling of ENG, NVP, or EFV were performed at screening, entry, and then 1, 4, 12, and 24-week postimplant insertion. The primary endpoint was ENG concentrations at week 24, compared between the ART-naive group and each ART group, using geometric mean ratio (GMR) with 90% confidence intervals.

RESULTS

Sixty participants competed the 24-week study and data from 58 participants are included; one participant each was excluded from the NVP group and EFV group because of a sample processing error and ART nonadherence, respectively. At week 24, geometric mean ENG was 362, 341, and 66 pg/ml in the ART-naive, NVP, and EFV groups, respectively [GMR: NVP : ART-naive 0.94 (0.90-1.01); EFV : ART-naive 0.18 (0.17-0.20)]. NVP and EFV concentrations were lower at week 24 compared to preimplant [NVP: geometric mean 5.7 versus 6.8 mg/l, respectively, GMR 0.84 (0.83-0.85); EFV: geometric mean 3.6 versus 4.9 mg/l, respectively, GMR 0.73 (0.69-0.80)].

CONCLUSION

After 24 weeks of combined use, ENG exposure was 82% lower in women using EFV-based ART compared with ART-naive women. In contrast, NVP did not significantly impact ENG exposure. These results raise concerns about reduced effectiveness of implantable contraception for women taking EFV-based ART.

The promotion of intrauterine contraception in low- and middle-income countries: a narrative review

CONTEXT

The contribution of copper-bearing intrauterine devices (IUDs) to overall contraceptive protection has declined in many countries, despite their well-known advantages. In response, initiatives to promote this method have been undertaken.

OBJECTIVE

To review and interpret the experience of interventions to promote use of IUDs in low- and middle-income countries in order to provide strategic guidance for policies and programs.

METHODS

We conducted a systematic search of Medline, Popline, Embase and Global Health electronic databases for relevant journal papers, reports and gray literature since 2010. Telephone interviews were held with two donors and six international family planning organizations.

RESULTS

We identified a total of 31 publications. Four reported the results of randomized control trials and three were derived from quasi-experiments. The majority were based on service statistics. Eight publications concerned interventions for HIV-positive women or couples, nine for postpartum or postabortion cases and 14 for general populations. Intervention approaches included vouchers, franchising of private practitioners, mobile outreach services, placement of dedicated staff in high-volume facilities and demand creation. Most publications adduced evidence of a positive impact and some reported impressively large numbers of IUD insertions. Results to date on the uptake of IUDs in postpartum interventions are modest. There is also almost no evidence of effects on IUD use at national levels. Implant uptake generally exceeded IUD uptake when both were offered.

CONCLUSION

The evidence base is weak and offers few lessons on what strategies are most effective. The overall impression is that IUD use can be increased in a variety of ways but that progress is hampered by persistent adverse perceptions by both providers and potential clients. Provider enthusiasm is a key to success. The lack of a population impact stems in part from the fact that nearly all interventions are initiated by international organizations, with limited national reach except in small countries, rather than by government agencies.

Vasectomy: A Long, Slow Haul to Successful Takeoff

Vasectomy use is plagued by low demand among men. Nevertheless, its compelling advantages make substantial investment worthwhile. On the supply side, a priority is to actively link vasectomy with service delivery approaches for the other highly effective long-acting and permanent clinical methods. Robust demand generation should include messaging specific to vasectomy, but should also draw on broader social and behavior change communication efforts increasingly aimed at engaging men in family planning.

Accessible Contraceptive Implant Removal Services: An Essential Element of Quality Service Delivery and Scale-Up

Use of contraceptive implants has surged in recent years, yet emerging data show a deficit of service delivery capacity and coverage for implant removals. The number of projected removals needed in the 69 FP2020 focus countries in 2018 (4.9–5.8 million) is more than twice that estimated for 2015 (2.2 million). We must proactively plan and execute high-quality implant removal services in order to fulfill the exceptional promise of implants in meeting client needs and advancing toward FP2020 goals.

Rapid Contraceptive Uptake and Changing Method Mix With High Use of Long-Acting Reversible Contraceptives in Crisis-Affected Populations in Chad and the Democratic Republic of the Congo

The global health community has recognized that expanding the contraceptive method mix is a programmatic imperative since (1) one-third of unintended pregnancies are due to method failure or discontinuation, and (2) the addition of a new method to the existing mix tends to increase total contraceptive use. Since July 2011, CARE has been implementing the Supporting Access to Family Planning and Post-Abortion Care (SAFPAC) initiative to increase the availability, quality, and use of contraception, with a particular focus on highly effective and long-acting reversible methods-intrauterine devices (IUDs) and implants-in crisis-affected settings in Chad and the Democratic Republic of the Congo (DRC). This initiative supports government health systems at primary and referral levels to provide a wide range of contraceptive services to people affected by conflict and/or displacement. Before the initiative, long-acting reversible methods were either unknown or unavailable in the intervention areas. However, as soon as trained providers were in place, we noted a dramatic and sustained increase in new users of all contraceptive methods, especially implants, with total new clients reaching 82,855, or 32% of the estimated number of women of reproductive age in the respective catchment areas in both countries, at the end of the fourth year. Demand for implants was very strong in the first 6 months after provider training. During this time, implants consistently accounted for more than 50% of the method mix, reaching as high as 89% in Chad and 74% in DRC. To ensure that all clients were getting the contraceptive method of their choice, we conducted a series of discussions and sought feedback from different stakeholders in order to modify program strategies. Key program modifications included more focused communication in mass media, community, and interpersonal channels about the benefits of IUDs while reinforcing the wide range of methods available and refresher training for providers on how to insert IUDs to strengthen their competence and confidence. Over time, we noted a gradual redistribution of the method mix in parallel with vigorous continued family planning uptake. This experience suggests that analyzing method mix can be helpful for designing program strategies and that expanding method choice can accelerate satisfying demand, especially in environments with high unmet need for contraception.

Is Household Wealth Associated With Use of Long-Acting Reversible and Permanent Methods of Contraception? A Multi-Country Analysis

In general, across the developing world, wealthier women are more likely than poorer women to use long-acting and permanent methods of contraception instead of short-acting methods. Exceptions are Bangladesh, India, and possibly Haiti.

As programs continue to expand access to family planning information, services, and products, it is critical that these efforts be undertaken with an equity lens, ensuring that regardless of socioeconomic status, all women and couples can use the method that meets their needs. This study explores the relationship between household wealth and the use of long-acting and permanent methods (LAPMs) versus short-acting methods of contraception among modern method users, using multivariate analyses based on Demographic Health Survey data from 30 developing countries conducted between 2006 and 2013. Overall, and controlling for relevant individual and household characteristics including age, number of living children, education, and urban/rural residence, we found that wealthier women were more likely than poorer women to use LAPMs instead of short-acting methods: 20 of the 30 countries showed a positive and statistically significant association between wealth and LAPM use. For 10 of those countries, however, LAPM use was significantly higher only for the top (1 or 2) wealthiest quintiles. Eight countries showed no broad pattern of association, while in 2 countries—Bangladesh and India—poorer women were more likely to use LAPMs than wealthier women. The positive association between wealth and LAPM use was found most consistently in the Latin American and the Caribbean countries in our sample. These findings can help program implementers respond better to women’s needs for modern contraception, especially in reaching women from lower- and middle-income households.

Expanding Access to the Intrauterine Device in Public Health Facilities in Ethiopia: A Mixed-Methods Study

Following the introduction of IUDs into the Ethiopian public health sector, use of the method increased from <1% in 2011 to 6% in 2014 in a sample of 40 health facilities. This shift occurred in the context of wide method choice, following provider training, provision of post-training supplies, and community-based awareness creation. The IUD was acceptable to a diverse range of clients, including new contraceptive users, those with little to no education, those from rural areas, and younger women, thus suggesting a strong latent demand for IUDs in Ethiopia.

In Ethiopia, modern contraceptive prevalence among currently married women nearly tripled over the last decade, but the method mix remains skewed toward short-acting methods. Since 2011, the Integrated Family Health Program (IFHP+), jointly implemented by Pathfinder International and John Snow Inc., has supported the Federal Ministry of Health to introduce intrauterine devices (IUDs) in more than 800 health centers across 4 regions to improve access to a wider range of methods. Between March and August 2014, Pathfinder conducted a mixed-methods study in 40 purposively selected health centers to assess shifts in the contraceptive method mix following introduction of IUDs using data from family planning registers; determine the characteristics of IUD users through a cross-sectional survey of 2,943 family planning clients who accepted the IUD; explore reasons for method discontinuation among 165 clients seeking IUD removal services; and identify facilitators and barriers to IUD use through focus group discussions (N = 115 clients) and key informant interviews (N = 36 providers, facility heads, and health office heads). Introduction of IUDs into the 40 health centers participating in the study was correlated with a statistically significant increase in the contribution of all long-acting reversible contraceptives (LARCs)—both IUDs and implants—to the method mix, from 6.9% in 2011 to 20.5% in 2014 (P<.001). Our study found that latent demand for the IUD was more prevalent than anticipated and that the method was acceptable to a broad cross-section of women. Of the 2,943 women who sought IUDs during the 6-month study period, 18.0% were new contraceptive users (i.e., those using a contraceptive method for the first time ever), 44.7% reported no educational attainment, 62.5% were from rural areas, and 59.3% were younger than 30 years old, with almost 3 in 10 (27.7%) under the age of 25. The most commonly cited reason for seeking IUD removal services was a desire to become pregnant (43% of women). Qualitative data indicated that while acceptability of the method is growing, limited community awareness, myths and misconceptions about the IUD, and infrastructure deficits at health centers must be addressed to further expand access to a broad range of contraceptive methods.

Task Sharing Implant Insertion by Community Health Workers: Not Just Can It Work, but How Might It Work Practically and With Impact in the Real World

Demonstrating that a health service, such as providing contraceptive implants, can be safely task shared to less highly trained workers is crucial but is only one step toward effective implementation at scale. Providers need dedicated time, enough clients, supplies, supervision, and other system support, allowing them to maintain their competency, confidence, and productivity.

Improved Reproductive Health Equity Between the Poor and the Rich: An Analysis of Trends in 46 Low- and Middle-Income Countries

In light of advocacy efforts to reach the poorest with better health services, an examination of recent history reveals that overall the poor-rich gap in contraceptive use is already narrowing substantially, and more so where family planning programs are stronger. For most of 18 other reproductive health indicators, the gap is also narrowing. However, contraceptive use gaps in many sub-Saharan African countries have not diminished, calling for strong family planning program efforts to improve equity.

While several indicators for reproductive health have improved for entire populations, few analyses are available for trends over time in the gaps between the poor and the rich. This paper tracks improvements in the equitable distribution of reproductive health indicators according to wealth quintiles, especially for contraceptive use, in 46 low- and middle-income countries based on national population-based surveys conducted between 1990 and 2013. It focuses on the gaps between the poorest and richest quintiles in the earliest and latest survey rounds across a number of reproductive health indicators related to family planning, fertility desires, antenatal care, and infant and child mortality, as well as on improvements in the absolute levels of contraceptive use by the poorest quintile. Gap changes were decomposed to show how the gaps can either diminish or grow due to either the bottom or top quintile, or both. In addition, bivariate correlation analysis was conducted to examine the relationship of the gaps, and of contraceptive use by the poor, to national family planning program efforts. Overall, the gaps between the poorest and richest have narrowed, due primarily to faster improvements among the poor than the rich. For example, the gap between the richest and poorest in the modern contraceptive prevalence rate has declined by 25%, from a 20.4 percentage point difference to a 15.4 point difference. And the gap has decreased more where family planning programs have been stronger. Across most of 18 other reproductive health indicators, the gaps have also been narrowing. For instance, the poor-rich gap for antenatal care decreased by over a third, from a difference of 30.7 percentage points to 19.6 percentage points. Gaps in infant and child mortality also have declined by about one-third. The pattern for contraceptive use in sub-Saharan Africa, however, has been mixed, with the gap actually increasing in some countries with strong programs. This disparity may largely reflect that family planning in the region is generally at an earlier stage in its history, and so programs may initially be reaching better-off clients, especially in urban areas. To promote additional equity, programs should emphasize efforts to increase access to voluntary family planning services to the least well-off, including those in rural and peri-urban areas.

WHO Tiered-Effectiveness Counseling Is Rights-Based Family Planning

Contraceptive effectiveness is the leading characteristic for most women when choosing a method, but they often are not well informed about effectiveness of methods. Because of the serious consequences of “misinformed choice,” counseling should proactively discuss the most effective methods—long-acting reversible contraceptives and permanent methods—using the WHO tiered-effectiveness model.

The influence of partnership on contraceptive use among HIV-infected women accessing antiretroviral therapy in rural Uganda

OBJECTIVE

The objective was to determine individual and dyadic factors associated with effective contraceptive use among human immunodeficiency virus (HIV)-infected women accessing antiretroviral therapy (ART) in rural Uganda.

STUDY DESIGN

HIV-infected women enrolled in the Uganda AIDS Rural Treatment Outcomes cohort completed questionnaires (detailing sociobehavioral characteristics, sexual and reproductive history, contraceptive use, fertility desires) and phlebotomy (October 2011-March 2013). We describe prevalence of effective contraceptive use (i.e., consistent condom use and/or oral contraceptives, injectable hormonal contraception, intrauterine device, female sterilization) in the previous 6 months among sexually active, nonpregnant women (18-40 years). We assessed covariates of contraceptive use using multivariable logistic regression.

RESULTS

A total of 362 women (median values: age 30 years, CD4 count 397 cells/mm(3), 4.0 years since ART initiation) were included. Among 284 sexually active women, 50% did not desire a(nother) child, and 51% had a seroconcordant partner. Forty-five percent (n=127) reported effective contraceptive use, of whom 57% (n=72) used condoms, 42% (n=53) injectables, 12% (n=15) oral contraceptives and 11% (n=14) other effective methods. Dual contraception was reported by 6% (n=8). Only "partnership fertility desire" was independently associated with contraceptive use; women who reported that neither partner desired a child had significantly increased odds of contraceptive use (adjusted odds ratio: 2.40, 95% confidence interval: 1.07-5.35) compared with women in partnerships where at least one partner desired a child.

CONCLUSIONS

Less than half of sexually active HIV-infected women accessing ART used effective contraception, of which 44% (n=56) relied exclusively on male condoms, highlighting a continued need to expand access to a wider range of longer-acting female-controlled contraceptive methods. Association with partnership fertility desire underscores the need to include men in reproductive health programming.

IMPLICATIONS STATEMENT

Less than half of sexually active HIV-infected women accessing ART in rural Uganda reported using effective contraception, of whom 44% relied exclusively on the male condom. These findings highlight the need to expand access to a wider range of longer-acting, female-controlled contraceptive methods for women seeking to limit or space pregnancies. Use of contraception was more likely when both the male and female partner expressed concordant desires to limit future fertility, emphasizing the importance of engaging men in reproductive health programming.

Evaluation of service quality in family planning clinics in Lusaka, Zambia

OBJECTIVE

To determine the quality of contraceptive services in family planning clinics in Lusaka, Zambia, using a standardized approach.

STUDY DESIGN

We utilized the Quick Investigation of Quality, a cross-sectional survey tool consisting of a facility assessment, client-provider observation and client exit interview, in public-sector family planning clinics. Data were collected on availability of seven contraceptive methods, information given to clients, interpersonal relations between providers and clients, providers' technical competence and mechanisms for continuity and follow-up.

RESULTS

Data were collected from five client-provider observations and client exit interviews in each of six public-sector family planning clinics. All clinics had at least two contraceptive methods continuously available for the preceding 6 months. Most providers asked clients about concerns with their contraceptive method (80%) and told clients when to return to the clinic (87%). Most clients reported that the provider advised what to do if a problem develops (93%), described possible side effects (89%), explained how to use the method effectively (85%) and told them when to come for follow-up (83%). Clients were satisfied with services received (93%).

CONCLUSION(S)

This application of the Quick Investigation of Quality showed that the participating family planning clinics in Lusaka, Zambia, were prepared to offer high-quality services with the available commodities and that clients were satisfied with the received services. Despite the subjective client satisfaction, quality improvement efforts are needed to increase contraceptive availability.

IMPLICATIONS

Although clients perceived the quality of care received to be high, family planning service quality could be improved to continuously offer the full spectrum of contraceptive options. The Quick Investigation of Quality was easily implemented in Lusaka, Zambia, and this simple approach could be utilized in a variety of settings as a modality for quality improvement.

Social Franchising: A Blockbuster to Address Unmet Need for Family Planning and to Advance Toward the FP2020 Goal

Social franchising has scaled-up provision of voluntary family planning, especially long-acting reversible contraceptives, across Africa and Asia at a rapid and remarkable pace. The approach should be pursued vigorously, especially in countries with a significant private-sector presence, to advance the FP2020 goal of providing access to modern contraception to 120 million additional clients by 2020.

Stunning popularity of LARCs with good access and quality: a major opportunity to meet family planning needs

Given true choice, a very high proportion of women, perhaps most, would select one of the long-acting reversible contraceptives (LARCs)—implants or IUDs—for contraception. If implemented on a wide scale, it would not only drastically alter the current method mix but also serve client needs much better and prevent unintended pregnancy more successfully.

Trends in the contraceptive method mix in low- and middle-income countries: analysis using a new "average deviation" measure

Applying a standard measure of the method mix evenness suggests 4 patterns among 15 countries moving toward a more balanced mix: (1) rise of one previously underrepresented or new method, (2) replacement of traditional with modern methods, (3) continued but declining domination by a single method, and (4) general movement toward a balanced mix. Improving availability of underutilized or new methods can improve the method mix, although better implementation of more popular methods might increase contraceptive use more expeditiously.

The method mix of contraceptive use is severely unbalanced in many countries, with over half of all use provided by just 1 or 2 methods. That tends to limit the range of user options and constrains the total prevalence of use, leading to unplanned pregnancies and births or abortions. Previous analyses of method mix distortions focused on countries where a single method accounted for more than half of all use (the 50% rule). We introduce a new measure that uses the average deviation (AD) of method shares around their own mean and apply that to a secondary analysis of method mix data for 8 contraceptive methods from 666 national surveys in 123 countries. A high AD value indicates a skewed method mix while a low AD value indicates a more uniform pattern across methods; the values can range from 0 to 21.9. Most AD values ranged from 6 to 19, with an interquartile range of 8.6 to 12.2. Using the AD measure, we identified 15 countries where the method mix has evolved from a distorted one to a better balanced one, with AD values declining, on average, by 35% over time. Countries show disparate paths in method gains and losses toward a balanced mix, but 4 patterns are suggested: (1) rise of one method partially offset by changes in other methods, (2) replacement of traditional with modern methods, (3) continued but declining domination by a single method, and (4) declines in dominant methods with increases in other methods toward a balanced mix. Regions differ markedly in their method mix profiles and preferences, raising the question of whether programmatic resources are best devoted to better provision of the well-accepted methods or to deploying neglected or new ones, or to a combination of both approaches.

Using behavior change communication to lead a comprehensive family planning program: the Nigerian Urban Reproductive Health Initiative

Greater exposure to a comprehensive family planning program in urban Nigeria that emphasized demand generation and communication theory was associated with improved ideation among women (their beliefs, ideas, and feelings about family planning), and more positive ideation was associated with greater contraceptive use, especially among the poor. Improving providers' knowledge, attitudes, and skills was also key. By the end of the observation period, outreach through mobile service delivery contributed nearly one-half of the project clinics' family planning services.

Background:

The Nigerian Urban Reproductive Health Initiative (NURHI), a 6-year comprehensive family planning program (2009–2015) in 4 cities, intentionally applies communication theories to all program elements, not just the demand generation ones, relying mainly on a theory called ideation—the concept that contraceptive use is influenced by people's beliefs, ideas, and feelings and that changing these ideational factors can change people's behavior.

Program Description:

The project used multiple communication channels to foster dialogue about family planning, increase social approval for it, and improve accurate knowledge about contraceptives. Mobile service delivery was started in the third year to improve access to clinical methods in slums.

Methods:

Data from representative baseline (2010–11) and midterm (2012) surveys of women of reproductive age in the project cities were analyzed. We also used propensity score matching to create a statistically equivalent control group of women not exposed to project activities, and we examined service delivery data from NURHI-supported clinics (January 2011–May 2013) to determine the contribution of mobile services to total family planning services.

Results:

Three years into the initiative, analysis of longitudinal data shows that use of modern contraceptives has increased in each city, varying from 2.3 to 15.5 percentage points, and that the observed increases were predicted by exposure to NURHI activities. Of note is that modern method use increased substantially among the poorest wealth quintiles in project cities, on average, by 8.4 percentage points. The more project activities women were exposed to, the greater their contraceptive use. For example, among women not using a modern method at baseline, contraceptive prevalence among those with no exposure by midterm was 19.1% vs. 43.4% among those with high exposure. Project exposure had a positive dose-response relationship with ideation, as did ideation and contraceptive use. By the end of the observation period, mobile services were contributing nearly 50% of total family planning services provided through NURHI-supported clinics. Propensity score matching found that the increase in contraceptive use in the 4 cities attributable to project exposure was 9.9 percentage points. Intention to use family planning in the next 12 months also increased by 7.5 to 10.2 percentage points across the 4 cities.

Conclusion:

Demand-led family planning programs, in which demand generation is the driving force behind the design rather than the conventional, service delivery-oriented approach, may be more suitable in places where expressed demand for contraceptives is low.

A better future for injectable contraception?

Provision of injectables though drug shops appears practicable and can contribute a marked share of family planning services.

A potential longer-acting injectable providing at least 6 months of protection appeals to programmatic professionals.

Subcutaneous administration of DMPA offers major injectable improvements over the current intramuscular approach.

Ironically, while injectable use will inevitably grow, better choice and wider availability of other methods—especially of long-acting and permanent methods—will reduce injectables′ overall share.

A bright future for IUD use in Africa?

High uptake of IUDs under the mobile outreach service delivery model in Kenya bodes well for IUDs in sub-Saharan Africa, if delivered with good access and quality.

Evidence-based public health: not only whether it works, but how it can be made to work practicably at scale

Because public health must operate at scale in widely diverse, complex situations, randomized controlled trials (RCTs) have limited utility for public health. Other methodologies are needed. A key conceptual backbone is a detailed “theory of change” to apply appropriate evidence for each operational component. Synthesizing patterns of findings across multiple methodologies provides key insights. Programs operating successfully across a variety of settings can provide some of the best evidence. Challenges include judging the quality of such evidence and assisting programs to apply it. WHO and others should shift emphasis from RCTs to more relevant evidence when assessing public health issues.

Progestin-only contraception: injectables and implants

Progestin-only contraceptive injectables and implants are highly effective, longer-acting contraceptive methods that can be used by most women in most circumstances. Globally, 6% of women using modern contraception use injectables and 1% use implants. Injectables are the predominant contraceptive method used in sub-Saharan Africa, and account for 43% of modern contraceptive methods used. A lower-dose, subcutaneous formulation of the most widely used injectable, depot-medroxyprogesterone acetate, has been developed. Implants have the highest effectiveness of any contraceptive method. Commodity cost, which historically limited implant availability in low-resource countries, was markedly lowered between 2012 and 2013. Changes in menstrual bleeding patterns are extremely common with both methods, and a main cause of discontinuation. Advice from normative bodies differs on progestin-only contraceptive use by breastfeeding women 0-6 weeks postpartum. Whether these methods are associated with HIV acquisition is a controversial issue, with important implications for sub-Saharan Africa, which has a disproportionate burden of both human immunodeficiency virus (HIV) and maternal mortality.