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Thapa K, Amatya S, Thapa A, Greeley M. Post-pregnancy family planning in Southeast Asia with a focus on novel training techniques. Best Pract Res Clin Obstet Gynaecol 2024; 94:102479. [PMID: 38412641 DOI: 10.1016/j.bpobgyn.2024.102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/05/2024] [Accepted: 02/05/2024] [Indexed: 02/29/2024]
Abstract
Postpartum Family Planning is a critical strategy in the first 12 months post-childbirth. It aims to prevent unintended, closely spaced pregnancies and thereby help reducing maternal, neonatal as well as child morbidity and mortality. Despite its significance, many women remain without contraception despite a desire to avoid pregnancy. The World Health Organization suggests a 24-month inter-pregnancy interval after delivery, emphasizing the importance of contraceptive counselling from the antenatal to the immediate postpartum period. In South Asia, utilization of PPFP is minimal, even though the inclination towards birth spacing is high. Addressing these needs requires strengthening the capacity of service providers and promoting evidence-based practices. Novel training approaches in South Asia are Competency-Based On-the-Job Training, Group Based Training, Simulation Training, E-Learning, Mentorship Programs, and Continuing Professional Development. Among these, On-the-Job Training and Group Based Training were notably implemented. Emphasizing PPFP and ensuring proper training in this domain is essential for women's health and well-being post-delivery.
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Affiliation(s)
- Kusum Thapa
- Jhpiego, 1776 Massachusetts Avenue, Washington DC, 20036, USA.
| | - Sapana Amatya
- Paropakar Maternity and Women's Hospital, Kathmandu, Nepal
| | - Anil Thapa
- Jhpiego/Nepal, Oasis Building, Patan Dhoka, Lalitpur, Nepal
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Dangal G, Dhital R, Dwa YP, Poudel S, Pariyar J, Subedi K. Implementation of cervical cancer prevention and screening across five tertiary hospitals in Nepal and its policy implications: A mixed-methods study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002832. [PMID: 38236836 PMCID: PMC10796028 DOI: 10.1371/journal.pgph.0002832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024]
Abstract
In Nepal, cervical cancer is the most common cancer among women despite the existing policies. This study intends to assess the implementation of cervical cancer prevention and screening through service utilization by women, knowledge and attitude among health professionals, and the perceptions of stakeholders in Nepal. This mixed-methods study was conducted in 2022 across five tertiary hospitals in Kathmandu, Nepal. The quantitative study comprised the health professionals and women attending gynecology outpatient clinics from the selected hospitals. The qualitative study comprised stakeholders including service providers and experts on cervical cancer from selected hospitals, civil societies, and the Ministry of Health and Population. The utilization of screening through pap smear among 657 women across five hospitals was 22.2% and HPV vaccination was 1.5%. The utilization of cervical cancer screening was associated with older age [adjusted odds ratio (AOR) = 1.09, CI: 1.07, 8.19], married (AOR = 3.024, CI: 1.12, 8.19), higher education (AOR = 3.024, CI:1.12, 8.42), oral contraceptives use (AOR = 2.49, CI: 1.36, 4.39), and ever heard of cervical cancer screening (AOR = 13.28, CI: 6.85, 25.73). Among 254 health professionals, the knowledge score was positively associated with them ever having a training [Standardized Beta (β) = 0.20, CI: 0.44, 2.43)] and having outreach activities in their hospital (β = 0.19 CI: 0.89, 9.53) regarding cervical cancer screening. The female as compared to male health professionals (β = 0.16, CI: 0.41, 8.16, P = 0.03) and having a cervical cancer screening guideline as compared to none (β = 0.19 CI: 0.89, 9.53, P = 0.026) were more likely to have a better attitude for screening. The qualitative findings among 23 stakeholders reflected implementation challenges in policy, supply, service delivery, providers, and community. This study showed low utilization of prevention and services by women and implementation gaps on cervical cancer prevention and screening services across five tertiary hospitals in Kathmandu, Nepal. The findings could help designing more focused interventions.
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Affiliation(s)
- Ganesh Dangal
- Nepal Society of Obstetricians and Gynaecologists, Kathmandu, Nepal
- Kathmandu Model Hospital, Kathmandu, Nepal
| | | | - Yam Prasad Dwa
- Nepal Society of Obstetricians and Gynaecologists, Kathmandu, Nepal
- KIST Medical College and Teaching Hospital, Lalitpur, Nepal
| | - Sandesh Poudel
- Nepal Society of Obstetricians and Gynaecologists, Kathmandu, Nepal
- Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
| | - Jitendra Pariyar
- Nepal Society of Obstetricians and Gynaecologists, Kathmandu, Nepal
- Civil Service Hospital of Nepal, Kathmandu, Nepal
| | - Kirtipal Subedi
- Nepal Society of Obstetricians and Gynaecologists, Kathmandu, Nepal
- Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
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Anderson R, Zaman SB, Jimmy AN, Read JM, Limmer M. Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review. BMC Pregnancy Childbirth 2023; 23:712. [PMID: 37798690 PMCID: PMC10552246 DOI: 10.1186/s12884-023-06027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND There is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems. METHODS An integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis. RESULTS Fifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers. CONCLUSIONS Effectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization. TRIAL REGISTRATION The protocol is registered in PROSPERO (CRD42022367657).
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Affiliation(s)
- Rondi Anderson
- The Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Sojib Bin Zaman
- Department of Health Sciences, James Madison University, Harrisonburg, Virginia, USA
| | - Abdun Naqib Jimmy
- Environmental Science Department, Jahangirnagar University, Dhaka, Bangladesh
| | - Jonathan M Read
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Mark Limmer
- The Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Kassa BG, Ayele AD, Belay HG, Tefera AG, Tiruneh GA, Ayenew NT, Mihiretie GN, Tenaw LA, Semahegn AM, Worku MD. Postpartum intrauterine contraceptive device use and its associated factors in Ethiopia: systematic review and meta-analysis. Reprod Health 2021; 18:225. [PMID: 34774058 PMCID: PMC8590214 DOI: 10.1186/s12978-021-01273-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The intrauterine contraceptive device, a type of long-acting reversible contraception, is one of the most effective and safe contraceptive methods. In Ethiopia, intrauterine contraceptive device is little known and practised to delay pregnancy. Therefore, this study aimed to assess post-partum intrauterine contraceptive device utilisation and its associated factors among women in Ethiopia. METHOD In the current meta-analysis, variables were searched from different electronic database systems, including PubMed, Google Scholar, EMBASE, HINAR, Scopus, Web of Sciences, and Grey literature. Data were extracted using a standardised data collection measurement tool. The data were also analysed by using STATA 16 statistical software. I2 tests assessed heterogeneity between the studies. A random-effect model was used to forecast the pooled utilisation of postpartum intrauterine contraceptive device. RESULTS Twelve full-article studies were included. The pooled prevalence of post-partum intrauterine contraceptive device among women in Ethiopia was 21.63%. Occupation (OR = 4.44, 95% CI, 2.24-8.81), educational level of college and above (OR = 5.93, 95% CI, 2.55-13.8), antenatal care (OR = 2.09, 95% CI, 1.4-3.12), age (OR = 4.8, 95% CI, 2.3-10.04), good knowledge (OR = 4.16, 95% CI, 1.65-10.49), counseling (OR = 3.05, 95%CI, 1.41-6.63), husband support (OR = 11.48, 95% CI, 6.05-21.79) and awareness about IUCD (OR = 3.86, 95% CI, 1.46-10.2) were positively associated with utilization of postpartum intrauterine contraception device. CONCLUSIONS Utilisation of post-partum intrauterine contraceptive device was significantly low. Scaling up women's educational status and ANC use has paramount importance in increasing post-partum IUD use, which further improves maternal and child health in general. This finding may be useful in both reproductive health promotion at an individual level and policy-making regarding this issue.
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Affiliation(s)
- Bekalu Getnet Kassa
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Alemu Degu Ayele
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Habtamu Gebrehana Belay
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Adanech Getie Tefera
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Netsanet Temesgen Ayenew
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Lebeza Alemu Tenaw
- School of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Abenezer Melkie Semahegn
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mulugeta Dilie Worku
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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Dhital R, Silwal RC, Pokhrel KN, Pokhrel S, Tuladhar H, Bright S, Tunnacliffe EA, Thapa K, Makins A. Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention. PLoS One 2021; 16:e0258834. [PMID: 34669735 PMCID: PMC8528303 DOI: 10.1371/journal.pone.0258834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. Methods This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. Results In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV’s involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. Conclusion The FCHVs’ knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.
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Affiliation(s)
- Rolina Dhital
- Green Tara Nepal, Kathmandu, Nepal
- Health Action and Research, Kathmandu, Nepal
- * E-mail:
| | | | - Khem Narayan Pokhrel
- Green Tara Nepal, Kathmandu, Nepal
- Tropical Health and Education Trust, Kathmandu, Nepal
| | | | - Heera Tuladhar
- Nepal Society of Obstetricians and Gynecologists, Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
| | - Suzanna Bright
- International Federation of Gynecology and Obstetrics, London, United Kingdom
| | | | - Kusum Thapa
- Nepal Society of Obstetricians and Gynecologists, Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
| | - Anita Makins
- International Federation of Gynecology and Obstetrics, London, United Kingdom
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de Silva R, Huber-Krum S, Samarasekera A, Karra M, Pearson E, Senanayake H, Canning D, Shah I. Provider perspectives in implementing the Postpartum Intrauterine Device Initiative in Sri Lanka: a qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:193-199. [PMID: 33214196 DOI: 10.1136/bmjsrh-2020-200876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Integration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery. METHODS We applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS Findings indicated that providers were willing to adopt the intervention and reiterated the importance of postpartum family planning. However, the intervention was not consistently implemented as intended, including provider bias in counselling and lack of attention to women's preferences. Organisational barriers to implementation included time constraints and inadequate training. Providers suggested that a range of paramedical staff be trained in counselling and PPIUD insertion to mitigate barriers and to facilitate scaling up the intervention. CONCLUSIONS To improve and scale up the PPIUD Initiative, training efforts should be expanded to primary and secondary care facilities and implementation strategies better utilised (eg, on-the-job training). The training can be strengthened by improving providers' knowledge of all types of methods and interpersonal communication skills, and emphasising the importance of unbiased, evidence-based contraceptive counselling techniques.
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Affiliation(s)
- Ranjith de Silva
- Sri Lanka College of Obstetricians and Gynaecologists, Colombo, Sri Lanka
| | - Sarah Huber-Krum
- Harvard T H Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
| | | | - Mahesh Karra
- Frederick S Pardee School of Global Studies, Boston University, Boston, Massachusetts, USA
| | | | | | - David Canning
- Harvard T H Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
| | - Iqbal Shah
- Harvard T H Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
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Eva G, Gold J, Makins A, Bright S, Dean K, Tunnacliffe EA, Fatima P, Yesmin A, Muganyizi P, Kimario GF, Dalziel K. Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:107-122. [PMID: 33795364 PMCID: PMC8087427 DOI: 10.9745/ghsp-d-20-00447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/10/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors. METHODS A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted. RESULTS Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.
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Affiliation(s)
- Gillian Eva
- Independent consultant, Washington, DC, USA.
| | - Judy Gold
- Independent consultant, Melbourne, Australia
| | - Anita Makins
- International Federation of Gynecology and Obstetrics, London, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department Women's and Reproductive Health, Oxford University, Oxford, UK
| | - Suzanna Bright
- International Federation of Gynecology and Obstetrics, London, UK
| | - Katherine Dean
- International Federation of Gynecology and Obstetrics, London, UK
| | | | - Parveen Fatima
- Obstetrical and Gynaecological Society of Bangladesh, Dhaka, Bangladesh
| | - Afroja Yesmin
- Obstetrical and Gynaecological Society of Bangladesh, Dhaka, Bangladesh
| | | | | | - Kim Dalziel
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Stone L, Puri MC, Guo M, Shah IH. Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up. Reprod Health 2021; 18:43. [PMID: 33596937 PMCID: PMC7891136 DOI: 10.1186/s12978-021-01099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background Health service providers play a key role in addressing women’s need for postpartum pregnancy prevention. Yet, in Nepal, little is known about providers’ knowledge, attitudes, and practice (KAP) on providing postpartum family planning (PPFP), particularly the immediate postpartum intrauterine device (PPIUD). This paper assesses providers KAP towards the provision of PPIUDs in Nepal prior to a PPIUD intervention to gain a baseline insight and analyzes whether their KAP changes both 6 and 24 months after the start of the intervention. Methods Data come from a randomized trial assessing the impact of a PPIUD intervention in Nepal between 2015 and 2017. We interviewed 96 providers working in six study hospitals who completed a baseline interview and follow-up interviews at 6 and 24 months. We used descriptive analysis, McNemar’s test and the Wilcoxon signed-rank test to assess KAP of providers over 2 years. Results The PPIUD KAP scores improved significantly between the baseline and 6-month follow-up. Knowledge scores increased from 2.9 out of 4 to 3.5, attitude scores increased from 4 out of 7 to 5.3, and practice scores increased from 0.9 out of 3 to 2.8. There was a significant increase in positive attitude and practice between 6 and 24 months. Knowledge on a women’s chance of getting pregnant while using an IUD was poor. Attitudes on recommending a PPIUD to different women significantly improved, however, attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Practice of PPIUD counseling and insertion improved significantly from baseline to 24 months, from 10.4 and 9.4% to 99% respectively. Conclusions Although KAP improved significantly among providers during the PPIUD intervention, providers’ knowledge on a women’s chance of getting pregnant while using an IUD and attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Provider KAP could be improved further through ongoing and more in-depth training to maintain providers’ knowledge, reduce provider bias and misconceptions about PPIUD eligibility, and to ensure providers understand the importance of birth spacing.
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Affiliation(s)
- Lucy Stone
- Independent Consultant, Kathmandu, Nepal.
| | - Mahesh C Puri
- Center for Research On Environment, Health and Population Activities (CREHPA), Kusunti, Lalitpur, P.O. Box 9626, Kathmandu, Nepal
| | - Muqi Guo
- Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Iqbal H Shah
- Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
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Thapa K, Dhital R, Rajbhandari S, Mishra S, Subedi S, Dotel BR, Vaidya S, Pande S, Tunnacliffe EA, Makins A, Arulkumaran S. Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study. BMC Health Serv Res 2020; 20:123. [PMID: 32066440 PMCID: PMC7027278 DOI: 10.1186/s12913-020-4969-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 02/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV’s knowledge through orientation on PPFP. Methods We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data. Results In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling. Conclusion The orientation improved the FCHV’s knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV’s role in improving community-based PPFP services.
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Affiliation(s)
- Kusum Thapa
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.
| | - Rolina Dhital
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Sameena Rajbhandari
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Sangeeta Mishra
- Koshi Zonal Hospital, Biratnagar, Morang District, Province One, Nepal
| | - Shanti Subedi
- Nobel Medical College Teaching Hospital, Biratnagar, Morang District, Province One, Nepal
| | | | - Sapana Vaidya
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Saroja Pande
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | | | - Anita Makins
- International Federation of Obstetrics and Gynecology, London, UK
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Kweku M, Amu H, Awolu A, Adjuik M, Ayanore MA, Manu E, Tarkang EE, Komesuor J, Asalu GA, Aku FY, Kugbey N, Anumu F, Boateng LA, Alornyo JS, Glover R, Letsa T, Bawah AA, Kanlisi NS, Awoonor-Williams JK, Phillips JF, Gyapong JO. Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care. PLoS One 2020; 15:e0226808. [PMID: 31914122 PMCID: PMC6948830 DOI: 10.1371/journal.pone.0226808] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 12/05/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017. METHODS This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed. RESULTS Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns. CONCLUSION Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.
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Affiliation(s)
- Margaret Kweku
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Hubert Amu
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Adam Awolu
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Martin Adjuik
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | | | - Emmanuel Manu
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | | | - Joyce Komesuor
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | | | - Fortress Yayra Aku
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Nuworza Kugbey
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Fidelis Anumu
- Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
| | | | | | - Roland Glover
- Volta Regional Health Directorate, Ghana Health Service, Ho, Ghana
| | - Timothy Letsa
- Volta Regional Health Directorate, Ghana Health Service, Ho, Ghana
| | - Ayaga A. Bawah
- Regional Institute of Population Studies, University of Ghana, Legon, Accra, Ghana
| | - Nicholas S. Kanlisi
- Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - James F. Phillips
- Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - John Owusu Gyapong
- Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
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11
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Cooper M, McGeechan K, Glasier A, Coutts S, McGuire F, Harden J, Boydell N, Cameron ST. Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation. Acta Obstet Gynecol Scand 2019; 99:598-607. [PMID: 31837002 PMCID: PMC7217220 DOI: 10.1111/aogs.13787] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/05/2019] [Accepted: 12/10/2019] [Indexed: 11/26/2022]
Abstract
Introduction Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter‐pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model. Material and methods Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow‐up was conducted in‐person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion‐related variables. Results Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re‐insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%. Conclusions Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re‐insertion and therefore longer‐term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.
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Affiliation(s)
- Michelle Cooper
- MRC Center for Reproductive Health, University of Edinburgh, Edinburgh, UK.,Department of Obstetrics and Gynecology, NHS Lothian, Edinburgh, UK
| | - Kevin McGeechan
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Anna Glasier
- MRC Center for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Shiona Coutts
- Department of Obstetrics and Gynecology, NHS Lothian, Edinburgh, UK
| | - Frances McGuire
- Department of Obstetrics and Gynecology, NHS Lothian, Edinburgh, UK
| | - Jeni Harden
- Usher Institute of Population Health Science, University of Edinburgh, Edinburgh, UK
| | - Nicola Boydell
- Usher Institute of Population Health Science, University of Edinburgh, Edinburgh, UK
| | - Sharon T Cameron
- MRC Center for Reproductive Health, University of Edinburgh, Edinburgh, UK.,Department of Obstetrics and Gynecology, NHS Lothian, Edinburgh, UK
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12
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Thapa K, Dhital R, Rajbhandari S, Acharya S, Mishra S, Pokhrel SM, Pande S, Tunnacliffe EA, Makins A. Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study. BMC Pregnancy Childbirth 2019; 19:148. [PMID: 31046715 PMCID: PMC6498647 DOI: 10.1186/s12884-019-2310-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/23/2019] [Indexed: 11/25/2022] Open
Abstract
Background The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. Methods This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. Results The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women’s intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband’s preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. Conclusion As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD. Electronic supplementary material The online version of this article (10.1186/s12884-019-2310-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kusum Thapa
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.
| | - Rolina Dhital
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Sameena Rajbhandari
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | - Shreedhar Acharya
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.,Department of Obstetrics and Gynecology, Lumbini Zonal Hospital, Butwal, Nepal
| | - Sangeeta Mishra
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.,Department of Obstetrics and Gynecology, Koshi Zonal Hospital, Biratnagar, Nepal
| | - Sunil Mani Pokhrel
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal.,Department of Obstetrics and Gynecology, Bharatpur Hospital, Bharatpur, Nepal
| | - Saroja Pande
- Nepal Society of Obstetricians and Gynaecologists, Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, GPO: 23700, Nepal
| | | | - Anita Makins
- International Federation of Obstetrics and Gynaecology, London, UK
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13
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Makins A, Arulkumaran S. Institutionalization of postpartum intrauterine devices. Int J Gynaecol Obstet 2018; 143 Suppl 1:1-3. [PMID: 30225872 DOI: 10.1002/ijgo.12597] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anita Makins
- International Federation of Gynecology and Obstetrics, London, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sabaratnam Arulkumaran
- International Federation of Gynecology and Obstetrics, London, UK.,St George's, University of London, London, UK
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