Opportunities and Pitfalls in Integration of Family Planning and HIV Prevention Efforts in Developing Countries

Impact of integrating a postpartum family planning program into a community-based maternal and newborn health program on birth spacing and preterm birth in rural Bangladesh

Background

Short birth intervals are associated with an increased risk of adverse perinatal outcomes. However, reduction of rates of short birth intervals is challenging in low-resource settings where majority of the women deliver at home with limited access to family planning services immediately after delivery. This study examines the feasibility of integrating a post-partum family planning intervention package within a community-based maternal and newborn health intervention package, and evaluates the impact of integration on reduction of rates of short birth intervals and preterm births.

Methods

In a quasi-experimental trial design, unions with an average population of about 25 000 and a first level health facility were allocated to an intervention arm (n = 4) to receive integrated post-partum family planning and maternal and newborn health (PPFP-MNH) interventions, or to a control arm (n = 4) to receive the MNH interventions only. Trained community health workers were the primary outreach service providers in both study arms. The primary outcomes of interest were birth spacing and preterm births. We also examined if there were any unintended consequences of integration.

Results

At baseline, short birth intervals of less than 24 months and preterm birth rates were similar among women in the intervention and control arms. Integrating PPFP into the MNH intervention package did not negatively influence maternal and neonatal outcomes; during the intervention period, there was no difference in community health workers’ home visit coverage or neonatal care practices between the two study arms. Compared to the control arm, women in the intervention arm had a 19% lower risk of short birth interval (adjusted relative risk (RR) = 0.81, 95% confidence interval (CI) = 0.69-0.95) and 21% lower risk of preterm birth (adjusted RR = 0.79; 95% CI = 0.63-0.99).

Conclusions

Study findings demonstrate the feasibility and effectiveness of integrating PPFP interventions into a community based MNH intervention package. Thus, MNH programs should consider systematically integrating PPFP as a service component to improve pregnancy spacing and reduce the risk of preterm birth.

Randomized evaluation and cost-effectiveness of HIV and sexual and reproductive health service referral and linkage models in Zambia

BACKGROUND

Provision of HIV prevention and sexual and reproductive health services in Zambia is largely characterized by discrete service provision with weak client referral and linkage. The literature reveals gaps in the continuity of care for HIV and sexual and reproductive health. This study assessed whether improved service delivery models increased the uptake and cost-effectiveness of HIV and sexual and reproductive health services.

METHODS

Adult clients 18+ years of age accessing family planning (females), HIV testing and counseling (females and males), and male circumcision services (males) were recruited, enrolled and individually randomized to one of three study arms: 1) the standard model of service provision at the entry point (N = 1319); 2) an enhanced counseling and referral to add-on service with follow-up (N = 1323); and 3) the components of study arm two, with the additional offer of an escort (N = 1321). Interviews were conducted with the same clients at baseline, six weeks and six months. Uptake of services for HIV, family planning, male circumcision, and cervical cancer screening at six weeks and six months were the primary endpoints. Pairwise chi-square and multivariable logistic regression statistical tests assessed differences across study arms, which were also assessed for incremental cost-efficiency and cost-effectiveness.

RESULTS

A total of 3963 clients, 1920 males and 2043 females, were enrolled; 82 % of participants at six weeks were tracked and 81 % at six months; follow-up rates did not vary significantly by study arm. The odds of clients accessing HIV testing and counseling, cervical cancer screening services among females, and circumcision services among males varied significantly by study arm at six weeks and six months; less consistent findings were observed for HIV care and treatment. Client uptake of family planning services did not vary significantly by study arm. Integrated services were found to be more efficiently provided than vertical service provision; the cost-effectiveness for HIV/AIDS and cervical cancer was high in the enhanced service models.

CONCLUSIONS

Study results provide evidence for increasing the linkages and integration of a selection of HIV and sexual and reproductive health services. The study provided cost-effective service delivery models that enhanced the likelihood of clients accessing some additional needed health services.

TRIAL REGISTRATION

ISRCTN84228514 Retrospectively registered. The study was retrospectively registered in the ISRCTN clinical trials registry on 06 October 2015. The first recruitment of participants occurred on 17 December 2013.

Integration opportunities for HIV and family planning services in Addis Ababa, Ethiopia: an organizational network analysis

Background

Public health resources are often deployed in developing countries by foreign governments, national governments, civil society and the private health clinics, but seldom in ways that are coordinated within a particular community or population. The lack of coordination results in inefficiencies and suboptimal results. Organizational network analysis can reveal how organizations interact with each other and provide insights into means of realizing better public health results from the resources already deployed. Our objective in this study was to identify the missed opportunities for the integration of HIV care and family planning services and to inform future network strengthening.

Methods

In two sub-cities of Addis Ababa, we identified each organization providing either HIV care or family planning services. We interviewed representatives of each of them about exchanges of clients with each of the others. With network analysis, we identified network characteristics in each sub-city network, such as referral density and centrality; and gaps in the referral patterns. The results were shared with representatives from the organizations.

Results

The two networks were of similar size (25 and 26 organizations) and had referral densities of 0.115 and 0.155 out of a possible range from 0 (none) to 1.0 (all possible connections). Two organizations in one sub-city did not refer HIV clients to a family planning organization. One organization in one sub-city and seven in the other offered few HIV services and did not refer clients to any other HIV service provider. Representatives from the networks confirmed the results reflected their experience and expressed an interest in establishing more links between organizations.

Conclusions

Because of organizations not working together, women in the two sub-cities were at risk of not receiving needed family planning or HIV care services. Facilitating referrals among a few organizations that are most often working in isolation could remediate the problem, but the overall referral densities suggests that improved connections throughout might benefit conditions in addition to HIV and family planning that need service integration.

Reproductive behaviour and HIV status of antenatal clients in northern Tanzania: opportunities for family planning and preventing mother-to-child transmission integration

OBJECTIVES

To examine reproductive and contraceptive history and intentions by HIV status among women at antenatal clinics to help inform initiatives to integrate family planning into antenatal/preventing mother-to-child transmission services in Mwanza region, Tanzania.

DESIGN

A questionnaire survey was carried out in antenatal clinics in Mwanza region, Tanzania in 2007-2008.

METHODS

: We interviewed 5284 pregnant women attending 15 antenatal clinics offering HIV testing in Mwanza City and Magu district, northern Tanzania. The questionnaires asked about reproductive and contraceptive history and intentions, and sexual behaviour. Subject to participants' consent, we collected blood to determine HIV status and linked these results to the questionnaire data through individual numbers.

RESULTS

HIV prevalence was 8.9% overall, and family planning ever use was 26%. HIV-positive and HIV-negative women differed with respect to age, parity, length of last birth interval, child survival, childbearing intentions and intention to breastfeed. HIV-positive women were more likely to have used family planning, particularly hormonal methods. Patterns of family planning use and unmet need for contraception yielded useful information for the design of family planning counselling services at antenatal clinics.

CONCLUSION

Our survey findings point to numerous potential benefits of offering family planning counselling as a part of antenatal services, particularly in clinics offering HIV testing. The differences in reproductive history and intentions between HIV-positive and HIV-negative women highlight the necessity of tailoring family planning counselling to their specific needs.

Barriers to high-quality primary reproductive health services in an urban area of Iran: views of public health providers

OBJECTIVE

to explore public primary reproductive health providers' views on their own roles and tasks in their present organisation, and the perceived barriers to providing high-quality services.

DESIGN

a qualitative approach using semi-structured, audio-taped focus group discussions (FGDs). The discussions were held in Farsi or Turkish, transcribed verbatim, translated into English and analysed using content analysis.

SETTING

family health units of public health facilities, Tabriz, Iran.

PARTICIPANTS

two FGDs with 12 midwives and two FGDs with eight other family health providers working at the facilities.

FINDINGS

the providers identified the most satisfying part of their duties as working with clients. A dominant theme in all FGDs was the providers' frustration about a number of factors, most of which were beyond their control. The identified system and organisational barriers were grouped into five categories: multiplicity of tasks and incompatibility with the providers' own basic training; suboptimal supervision and management; too little time for clients; lack of privacy and appropriate materials for education and counselling; and inadequate opportunities for continuing education.

KEY CONCLUSIONS

this study highlighted the providers' satisfaction in working with clients, and their dissatisfaction with not being used to the best of their capabilities due to a number of systemic and organisational barriers.

IMPLICATIONS FOR PRACTICE

based on these findings, multifaceted interventions seem to be necessary to improve staff productivity and service quality. The interventions should include needs-based pre-service education, supportive supervision and management, provision of educational materials, simplifying record management, and appointing more staff in socio-economically deprived areas. Research is needed to identify the best way to integrate the services, as well as basic and continuing educational needs of staff.