Twelve month follow-up of a contraceptive implant outreach service in rural Papua New Guinea

A cross-sectional study of factors associated with immediate postpartum uptake of contraceptive implants in Papua New Guinea

OBJECTIVES

In 2016 the Port Moresby General Hospital in Papua New Guinea introduced a midwife led postpartum contraception service to educate patients and provide contraceptive implants. This study examines the factors that were associated with immediate postpartum uptake of the implants.

STUDY DESIGN

We conducted a cross-sectional study of patients on the hospital postnatal ward who gave birth between March 2017 and January 2018. Patients aged 16-45 who had a vaginal birth with a singleton, live baby not requiring admission to the special care nursery were eligible for inclusion and invited to complete a survey prior to discharge.

RESULTS

Of 2082 patients approached, all consented to participate in the survey. Of those completing the survey, 531 (25.5%) chose to have the contraceptive implant provided immediately postpartum. Excluding patients who chose tubal ligation (n = 330), in multivariable analysis, higher odds of implant uptake was associated with no prior contraception use compared to prior use (aOR 1.38; 95% CI 1.07 -1.77), unplanned pregnancy compared to planned (aOR 1.37, 95% CI 1.07-1.79), and having received antenatal education about the implant compared to no information (AOR 1.65, 95% CI 1.23-2.10).

CONCLUSIONS

Antenatal education about the contraceptive implant impacted on likelihood of immediate postpartum method uptake. Patients who had no prior use of contraception and those with unplanned pregnancies were also more likely to request the implants, suggesting that the midwife-led postpartum service is successfully reaching patients with a previous unmet need for contraception.

IMPLICATIONS

This study demonstrates successful delivery of a postpartum implant program in a setting where community access to contraception is limited. Antenatal information and education can support implant uptake and that the program provides the opportunity for birth spacing and limiting in patients with a previous unmet need.

Postpartum women's knowledge and planned use of contraception in Myanmar

BACKGROUND

Maternal mortality in Myanmar is one of the highest in the WHO South-East Asian region. Additionally, the country has a high unmet need for contraception and low rates of uptake of long-acting reversible contraceptive methods (LARCs) including intrauterine devices (IUDs) and implants. Engagement with health professionals around the time of a birth is an ideal opportunity for women to access contraception but immediate postpartum provision is not widely offered in Myanmar.

METHODS

We undertook a cross-sectional survey of women immediately postpartum at two hospitals in Yangon to investigate their knowledge, and past use of, contraceptive methods and their plans for postpartum contraception including perceptions of implants and IUDs. Four trained obstetrics staff collected data using electronic tablets between January 2017 and January 2018.

RESULTS

Of the 1755 participants, 55.1% had used pills and 42.2% injectables. In contrast, only 0.5% had used an IUD and 0.3% an implant. Few women (4.4%) anticipated starting contraception immediately postpartum and only a minority would consider future use of an implant (36.9%) or an IUD (13.0%). Fear of side effects was the major barrier to future implant and IUD uptake, reported by 64.5% and 62.5%, respectively.

CONCLUSIONS

Women in maternity care in Yangon have some awareness of IUDs and implants but many hold misconceptions about their side effects leading to reluctance to use. Reducing the unmet need for contraception and improving maternal outcomes in Myanmar could be achieved by improving education, policy and practice around immediate postpartum contraception provision, with a particular focus on LARC methods.

Risk factors and knowledge associated with high unintended pregnancy rates and low family planning use among pregnant women in Papua New Guinea

Unintended pregnancy is a major driver of poor maternal and child health in resource-limited settings. Data on pregnancy intention and use of family planning (FP) is scarce in Papua New Guinea (PNG), but are needed to inform public health strategies to improve FP accessibility and uptake. Data from a facility-based cross-sectional sample of 699 pregnant women assessed prevalence and predictors of unintended pregnancy and modern FP use among pregnant women in East New Britain Province, PNG. More than half (55%) the women reported their pregnancy as unintended. Few (18%) reported ever having used a modern FP method, and knowledge of different methods was low. Being single, separated or divorced (AOR 9.66; 95% CI 3.27–28.54), educated to a tertiary or vocational level (AOR 1.78 CI 1.15–2.73), and gravidity > 1 (AOR 1.43 for each additional pregnancy CI 1.29–1.59) were associated with unintended pregnancy; being accompanied by a male partner to ANC was associated with a reduced unintended pregnancy (0.46 CI 0.30–0.73). Factors associated with modern FP use included male partner involvement (AOR 2.26 CI 1.39–3.67) and gravidity > 1 (AOR 1.54 for each additional pregnancy CI 1.36–1.74). FP use also varied by the facility women attended. Findings highlight an urgent need for targeted interventions to improve FP knowledge, uptake and access, and male partner involvement, to reduce unintended pregnancies and their complications.

A systematic review on clinical effectiveness, side-effect profile and meta-analysis on continuation rate of etonogestrel contraceptive implant

BACKGROUND

Unintended pregnancies (UIP) have a significant impact on health of women and the health budget of countries. Contraception is an effective way to prevent UIPs. The study objective was to collate evidence on clinical effectiveness of etonogestrel subdermal implant (ESI), continuation rate and side effect profile among eligible women of reproductive age group, as compared to levonorgestrel intrauterine system (LNG-IUS), copper intrauterine device (Cu-IUD) and depot medroxy progesterone acetate injections; other types of contraceptive implants were excluded as comparators.

METHODS

The protocol of the systematic review was registered in Prospero (registration number: CRD42018116580). MEDLINE via PubMed, Cochrane library and web of science were the electronic databases searched. A search strategy was formulated and studies from 1998 to 2019 were included. Clinical trial registries and grey literature search was done. Critical assessment of included studies was done using appropriate tools. A qualitative synthesis of included studies was done and a meta-analysis was conducted in RevMan software for continuation rates of ESI as compared to other long acting reversible contraceptives (LARC) e.g. LNG IUS and Cu-IUD.

RESULTS

The search yielded 23,545 studies. After excluding 467 duplicates, 23,078 titles were screened and 51 studies were included for the review. Eight of the 15 studies reporting clinical effectiveness reported 100% effectiveness and overall pearl index ranged from 0 to 1.4. One-year continuation rates ranged from 57-97%; 44-95% at the end of second year and 25-78% by 3 years of use. Abnormal menstruation was the most commonly reported side effect. There was no significant difference in bone mineral density at 1 year follow-up. The meta-analyses showed that odds ratio (OR) of 1-year continuation rate was 1.55 (1.36, 1.76) for LNG-IUS vs. ESI and 1.34 (1.13, 1.58) for copper-IUD vs. ESI; showing that continuation rates at the end of one-year were higher in LNG-IUS and copper-IUD as compared to ESI.

CONCLUSION

ESI is clinically effective and safe contraceptive method to use, yet 1-year continuation rates are lower as compared to LNG-IUS and copper-IUD, mostly attributed to the disturbances in the menstruation.

Modern contraceptive utilization and associated factors among married and cohabiting women in Papua New Guinea: a population-based cross-sectional study

BACKGROUND

Universal access to family planning has been emphasized by the international development agenda, as evident in the Sustainable Development Goal 3.7. This notwithstanding, the use of modern contraceptives has been minimal in low- and middle-income countries, especially in Papua New Guinea. In view of this, we investigated the factors associated with the use of modern contraceptives and the associated factors among married and cohabiting women in Papua New Guinea.

METHODS

The study utilised the Demographic and Health Survey data of 2345 women in sexual unions in Papua New Guinea. We employed a descriptive and binary logistic regression analyses. We presented the results as crude Odds Ratios (COR) and adjusted Odds Ratios (AOR), with 95% confidence intervals (CI) signifying level of precision. Level of statistical significance was set at p < 0.05.

RESULTS

We found that 74.4% of the women were using modern contraceptives ranging from injectables (44.5%) to other modern methods (0.23%). Women aged 15-19 [AOR = 7.425, 95% CI = 2.853, 19.32], residents of the Highland region [AOR = 1.521, 95% CI =1.086, 2.131], self-employed women in the agricultural sector [AOR = 1.710, 95% CI = 1.218, 2.400], and women who listened to radio at least once a week [AOR = 1.409, 95% CI = 1.048, 1.895] had higher odds of modern contraceptive usage. However, women in the Islands region [AOR = 0.291, 95% CI = 0.224, 0.377], women whose husbands had higher education [AOR = 0.531,95%CI = 0.318,0.886], women in professional/technical/managerial work [AOR = 0.643, 95% CI = 0.420, 0.986], and those with no child [AOR = 0.213, CI = 0.0498,0.911] had lower odds of modern contraceptive use.

CONCLUSION

Out of the 2345 participants, we found that majority of them were using modern contraceptives and the commonly used modern contraceptive was injectables. Age, region of residence, partner's education, employment, partner's desire for children, and frequency of listening to radio are associated with modern contraceptive usage. Tailored reproductive healthcare should be developed for women who are disadvantaged when it comes to the usage of modern contraceptives in order to boost modern contraceptive use among them. Further investigation is needed to unravel the motivation for the high usage of injectables among married and cohabiting women in Papua New Guinea.

Improving the quality of maternal and newborn care in the Pacific region: A scoping review

Background

Quality care is essential for improving maternal and newborn health. Low- and middle-income Pacific Island nations face challenges in delivering quality maternal and newborn care. The aim of this review was to identify all published studies of interventions which sought to improve the quality of maternal and newborn care in Pacific low-and middle-income countries.

Methods

A scoping review framework was used. Databases and grey literature were searched for studies published between January 2000 and July 2019 which described actions to improve the quality of maternal and newborn care in Pacific low- and middle-income countries. Interventions were categorised using a four-level health system framework and the WHO quality of maternal and newborn care standards. An expert advisory group of Pacific Islander clinicians and researchers provided guidance throughout the review process.

Results

2010 citations were identified and 32 studies included. Most interventions focused on the clinical service or organisational level, such as healthcare worker training, audit processes and improvements to infrastructure. Few addressed patient experiences or system-wide improvements. Enablers to improving quality care included community engagement, collaborative partnerships, adequate staff education and training and alignment with local priorities.

Conclusions

There are several quality improvement initiatives in low- and middle-income Pacific Island nations, most at the point of health service delivery. To effectively strengthen quality maternal and newborn care in this region, efforts must broaden to improve health system leadership, deliver sustaining education programs and encompass learnings from women and their communities.

Community attitudes and gendered influences on decision making around contraceptive implant use in rural Papua New Guinea

Background

Despite targeted interventions to improve contraceptive implant acceptability and uptake in rural Papua New Guinea (PNG), ongoing use of this method remains limited. Previous literature has suggested community attitudes and intrinsic factors within the decision-making process may be negatively impacting on implant uptake, however these elements have not previously been studied in detail in this context. We set out to explore community attitudes towards the contraceptive implant and the pathways to decision making around implant use in a rural community on Karkar Island, PNG.

Methods

We conducted 10 focus-group (FGD) and 23 in-depth interviews (IDI) using semi-structured topic guides. Key sampling characteristics included age, exposure or non-exposure to implants, marital status, education and willingness to participate in discussion. Four FGDs were held with women, four with men and two with mixed gender. IDIs were carried out with five women (current implant users, former implant users, implant never users), five men, five religious leaders (Catholic and non-Catholic), four village leaders and four health workers. Two in-depth interviews (four participants) were analysed as dyads and the remaining participant responses were analysed individually.

Results

Men were supportive of their wives using family planning but there was a community-wide lack of familiarity about the contraceptive implant which influenced its low uptake. Men perceived family planning to be ‘women’s business’ but remained strongly influential in the decision making processes around method use. Young men were more receptive to biomedical information than older men and had a greater tendency towards wanting to use implants. Older men preferred to be guided by prominent community members for decisions concerning implants whilst young men were more likely to engage with health services directly.

Conclusions

In communities where a couple’s decision to use the contraceptive implant is strongly coloured by gendered roles and social perceptions, having a detailed understanding of the relational dynamics affecting the decision-making unit is useful in targeting future healthcare interventions. Engaging groups who are reluctant to connect with health information, as well as those who are most influential in the decision making process, will have the greatest impact on increasing implant acceptability and uptake.

Impact of the contraceptive implant on maternal and neonatal morbidity and mortality in rural Papua New Guinea: a retrospective observational cohort study

OBJECTIVES

Using routinely collected birth data, this study sought to measure changes in maternal and neonatal morbidity and mortality after introduction of the levonorgestrel contraceptive implant into a large, rural island population in Papua New Guinea (PNG).

STUDY DESIGN

We conducted a retrospective observational study of birth records from 4251 births that occurred between January 2010 and December 2016 on Karkar Island, PNG. The primary outcome was the change in crude birth rate (CBR) before (2010-2012) and after (2014-2016) introduction of the implant. Secondary outcomes were the change in rates (per year/1000 births) of severe postpartum hemorrhage, postpartum infection, hospital readmission, prematurity (<37 weeks), low birth weight (<2500 g) and maternal and neonatal mortality. We also studied changes in the number of pregnancies affected by grand multiparity (≥4) and short interpregnancy interval (<12 months) for the same time periods. Data were analyzed using interrupted time series and Poisson regression.

RESULTS

CBR was stable until 2012 and then declined from 2014 (p<.0001). Following introduction of the implant, the annual rate/1000 births of selected adverse birth outcomes decreased between 56% and 74% (p<.0001). The number of women with parity ≥4 who gave birth decreased by 59% (p<.0001), and the number with interpregnancy interval <12 months decreased by 64% (p<.0001).

CONCLUSIONS

Introduction of the contraceptive implant was associated with reductions in CBR, maternal and neonatal morbidity, and the number of women with high-risk pregnancies giving birth.

IMPLICATIONS

These results encourage efforts to increase knowledge and availability of the contraceptive implant in low- and middle-income countries such as PNG. In cases where it reduces the CBR and the number of women with high-risk pregnancies birthing, the implant may have a beneficial impact on maternal and neonatal morbidity.