Perceptions of access to long-acting reversible contraception removal among women in Burkina Faso

OBJECTIVES

Long-acting reversible contraception (LARC) initiation has been well-studied and intervened upon. Because LARC requires provider intervention for initiation and removal, it is critical to measure informed choice at the time of desired discontinuation as well. We examined perceptions of access to LARC discontinuation among women at two sites in Burkina Faso, where LARC is the dominant method in the contraceptive mix.

STUDY DESIGN

We analyzed data from a 2017-2018 population-based, cross-sectional survey of 281 implant users and 55 intrauterine device users at two sites in Burkina Faso. We measured perceptions of access to LARC discontinuation through survey items assessing whether participants (1) were informed on how to discontinue the method, (2) believed they could have LARC removed without a lot of difficulty, (3) believed cost would be a barrier to discontinuation, (4) had ever attempted to have a provider remove LARC, and (5) successfully had LARC removed. The distribution of these measures was examined in the population and for differences by gravida, parity, domestic partnership, fertility desires, and recency of last childbirth.

RESULTS

Thirty-eight (11%) of current LARC users reported that they were not informed on how to discontinue, 56 (17%) believed having their device removed would be difficult, and 54 (16%) believed cost would be a barrier to removal. Of women who attempted removal, providers did not immediately remove LARC on request for 10 (28%).

CONCLUSIONS

Findings indicate that LARC uptake is an insufficient measure of reproductive access or choice. Future studies should include patient-centered measures that span the full duration of contraceptive use.

IMPLICATIONS

This paper finds that a sizable proportion of LARC users lack information about method discontinuation and perceive or experience barriers to method removal. These findings call for a reconsideration of free and informed contraceptive choice to include the entire duration of contraceptive use, not only the time of method provision.

Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review

Background

Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.

Methods

We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.

Results

Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.

Conclusion

The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study

OBJECTIVES

Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal.

METHODS

We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred.

FINDINGS

The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day.

CONCLUSION

Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Training of healthcare providers and use of long-acting reversible contraception in low- and middle-income countries: A systematic review

INTRODUCTION

Unintended pregnancy, a major global health issue resulting in unsafe terminations of pregnancy and maternal deaths in low- and middle-income countries, could be significantly reduced through increased use of modern contraception, including long-acting reversible contraceptives (LARC). Training of healthcare providers to administer such contraceptives may improve uptake. We conducted a systematic review to collate the end-user uptake data following training of healthcare providers in low- and middle-income countries.

MATERIAL AND METHODS

We searched PubMed, Embase, the Global Health Library and the Cochrane Library up to 23 May 2020. The review was restricted to low- and middle-income countries and focused on healthcare providers who had received training in LARC. Studies that reported contraceptive uptake among women, preference of LARC among healthcare workers and/or women, and unplanned pregnancies within 12 months of LARC initiation were included. All included studies underwent quality assessment using either the Cochrane Risk of Bias Tool or the Newcastle-Ottawa Scale. PROSPERO registration number CRD42020185291.

RESULTS

A total of 28 studies (end-users n = 6 112 544) were included (27 cohort studies and one randomized trial). Nineteen studies were set in Africa, five in Asia, one in Central America and four were multi-country studies. Twenty-eight studies reported LARC use among women, and 25 studies found an increase in uptake of LARC by women using short-acting methods switching to longer-acting methods or by recruiting new users of LARC. The randomized controlled trial was assessed as high quality and reported positive findings; however, there was great heterogeneity in the type of intervention and of how outcomes were measured among the other included studies. Further, the quality of these studies varied, although it should be noted that the poor-quality studies reflected the trends of those of higher quality.

CONCLUSIONS

Despite heterogeneity, current evidence indicates that training of healthcare providers in LARC may increase the uptake among women in low- and middle-income countries. More robust studies are warranted to inform policy.