Expanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa

Family Planning Counseling for Women Living with HIV in Low- and Middle-Income Countries: A Systematic Review of the Impact on Contraceptive Uptake, Intention to Use Contraception and Pregnancy Incidence, 2011 to 2022

Women's ability to control their fertility and have the number of children they want when they want them is an internationally recognized human right. This right has been the driving force behind family planning programs in low- and middle-income countries for more than five decades. The HIV epidemic added greater urgency to those efforts once the risk of vertical transmission of the virus from mothers to their infants was recognized. In 2013, we published a systematic review of the evidence of effectiveness of family planning counseling for women living with HIV, emphasizing HIV related behaviors. In this updated review, we examined 23 studies, primarily from sub-Saharan Africa. The evidence we uncovered reflected efforts to integrate services provided to women. These showed that providing contraceptive services, including intensified counseling and support, in the HIV clinics where women living with HIV received their care increased the likelihood of subsequent use of modern contraception by as much as fourfold. These studies reflected a greater focus on women's family planning decisions and behaviors and less focus on HIV-related behaviors. Among the possible causes of this noted difference we include the widespread coverage of antiretroviral treatment for HIV. This advance has apparently changed the rationale and the approach to integrating family planning and HIV services in ways that may not have been fully appreciated. The results, however, are beneficial: greater coverage of family planning for women who wish to control their fertility and a more equal partnership between family planning services and HIV services in pursuit of the mutual goal of providing integrated services to meet women's needs.

Health facility-based interventions and the uptake of contraception among people living with HIV: A systematic review & meta-analysis

BACKGROUND OBJECTIVES

The prong 2 of 4 prong strategy introduced by the World Health Organization aims at averting unintended pregnancies among people living with HIV (PLHIV). This systematic review aimed to generate evidence on the effectuality of facility-based interventions in improving uptake of modern and dual contraception, for reducing unmet family planning (FP) needs and unintended pregnancies among PLHIV.

METHODS

Articles evaluating facility-based interventions to integrate human immunodeficiency virus (HIV) and FP published in English language were included. Eligible studies were identified from electronic and lateral search from three databases (PubMed, Cochrane Library and Web of Science) and grey literature. HIV care with no/minimal focus on FP was considered a comparator. Quality was assessed using design-appropriate tools. Descriptive analysis was presented in tables. Uptake of dual methods, unmet FP needs and unintended pregnancies were included in the meta-analysis to estimate pooled odds ratio (OR) with random effect model, P and I2 values.

RESULTS

The search yielded 2112 results. After excluding duplicates and unfit articles, 17 were found eligible for review and nine for meta-analysis. The pooled OR for uptake of dual contraception was 1.69 (1.14, 2.5) ( P =0.008; I2 =90%), for unmet FP needs was 0.58 (0487, 0.69) ( P <0.00001; I2 =0%) and for unintended pregnancies was 0.6 (0.32, 1.1) ( P =0.1, I2 =38%).

INTERPRETATION CONCLUSIONS

The results of this meta-analysis suggest that health facility-based interventions to integrate HIV and FP services do result in improved uptake of dual methods and reduce unmet need for contraception along with a protective trend on incidence of unintended pregnancies. Such facility-based integration would ensure universal access to effective contraception and facilitate in achieving Sustainable Development Goals that aim at ending epidemics like HIV.

Access to postpartum tubal ligation services in Cape Town, South Africa - an observational study

BACKGROUND

Many women receiving antenatal care in public health services in Cape Town choose bilateral tubal ligation as their preferred method of postpartum contraception during their antenatal course. If the sterilisation does not occur immediately, these women are discharged on an alternative form of contraception and, ideally, an interval date for bilateral tubal ligation is arranged.

OBJECTIVES

To assess the access to tubal ligation services in the Metro West area of Cape Town, South Africa, in women who request permanent contraception following delivery, looking specifically at the number of women requesting bilateral tubal ligation who receive the procedure intrapartum, immediately postpartum or as an interval procedure. Other objectives included determining the reproductive outcomes if bilateral tubal ligation was not performed, investigating the alternative forms of contraception provided and to study the demographics of the population requesting bilateral tubal ligation as a form of contraception.

METHODS

The study was conducted as a cross-sectional observational study collecting data over a period of 3 months, from June 2019 to August 2019. Maternity case records for deliveries between June 2019 and August 2019 from four facilities were reviewed. The facilities, representing all levels of care, were Vanguard Midwife Obstetric Unit, Wesfleur Hospital (district hospital), New Somerset Hospital (regional hospital), Groote Schuur Hospital (tertiary hospital).

RESULTS

There were 260 women who requested tubal ligation as their choice of contraception. Only 50% of these received a tubal ligation. Of the 131 tubal ligations performed, 2 were interval sterilisations. Ninety-one percent (120/131) of the tubal ligations were done at the time of caesarean section. Of the 129 women who received alternative forms of contraception, 13 women had a recurrent pregnancy.

CONCLUSION

The study suggests that only 50% of women requesting tubal ligation as form of contraception actually end up receiving the procedure. Alternative forms of contraception are widely used and relied upon, but not without risks of recurrent pregnancy. Interval tubal ligation was not easily accessed by those women who were referred for the procedure.

A one-stop shop model for improved efficiency of pre-exposure prophylaxis delivery in public clinics in western Kenya: a mixed methods implementation science study

INTRODUCTION

In public clinics in Kenya, separate, sequential delivery of the component services of pre-exposure prophylaxis (PrEP) (e.g. HIV testing, counselling, and dispensing) creates long wait times that hinder clients' ability and desire to access and continue PrEP. We conducted a mixed methods study in four public clinics in western Kenya to identify strategies for operationalizing a one-stop shop (OSS) model and evaluate whether this model could improve client wait time and care acceptability among clients and providers without negatively impacting uptake or continuation.

METHODS

From January 2020 through November 2020, we collected and analysed 47 time-and-motion observations using Mann-Whitney U tests, 29 provider and client interviews, 68 technical assistance reports, and clinic flow maps from intervention clinics. We used controlled interrupted time series (cITS) to compare trends in PrEP initiation and on-time returns from a 12-month pre-intervention period (January-December 2019) to an 8-month post-period (January-November 2020, excluding a 3-month COVID-19 wash-out period) at intervention and control clinics.

RESULTS

From the pre- to post-period, median client wait time at intervention clinics dropped significantly from 31 to 6 minutes (p = 0.02), while median provider contact time remained around 23 minutes (p = 0.4). Intervention clinics achieved efficiency gains by moving PrEP delivery to lower volume departments, moving steps closer together (e.g. relocating supplies; cross-training and task-shifting), and differentiating clients based on the subset of services needed. Clients and providers found the OSS model highly acceptable and additionally identified increased privacy, reduced stigma, and higher quality client-provider interactions as benefits of the model. From the pre- to post-period, average monthly initiations at intervention and control clinics increased by 6 and 2.3, respectively, and percent of expected follow-up visits occurring on time decreased by 18% and 26%, respectively; cITS analysis of PrEP initiations (n = 1227) and follow-up visits (n = 2696) revealed no significant difference between intervention and control clinics in terms of trends in PrEP initiation and on-time returns (all p>0.05).

CONCLUSIONS

An OSS model significantly improved client wait time and care acceptability without negatively impacting initiations or continuations, thus highlighting opportunities to improve the efficiency of PrEP delivery efficiency and client-centredness.

Integration of family planning services into health care for HIV-positive women in Botswana

OBJECTIVE

To create and assess a clinic model to address the unmet need for effective contraception among women living with HIV in Botswana, where half of all pregnancies are unintended and 30% of women of reproductive age are living with HIV.

METHODS

We introduced family planning services into an HIV clinic in Gaborone, Botswana. Our intervention gave HIV providers brief training on contraceptive counseling plus the option of immediate referral of interested patients to an on-site contraception provider. We administered a survey to patients and providers before and after intervention. Patients were female, aged 18-45 years and using antiretrovirals.

RESULTS

At baseline, 6% of 141 patients discussed contraception with their HIV-care provider, compared with 61% of 107 post intervention (P < 0.001). At baseline, 6% of patients reported wanting to use long-acting reversible contraception (LARC). Post intervention, 45% of patients chose to meet with the contraception provider, and 29% wanted to use LARC (P < 0.001 versus baseline). All providers strongly agreed that they were better informed about contraception post intervention and were satisfied with their ability to counsel and refer women for contraception.

CONCLUSIONS

Provision of on-site contraceptive services in this HIV clinic encouraged family planning discussions and increased interest in LARC.

Contraceptive needs and fertility intentions of women with breast cancer in Cape Town, South Africa: a qualitative study

Background

No known studies have been undertaken in South Africa exploring the contraceptive and fertility needs and preferences of women of reproductive age (18–49) diagnosed with breast cancer. This study set out to understand the contraceptive needs and fertility intentions of women with breast cancer in Cape Town, South Africa.

Methods

Qualitative in-depth interviews were conducted with 24 women diagnosed with breast cancer and 4 health care providers at a tertiary hospital in Cape Town, South Africa. We explored contraceptive use prior to diagnosis; the impact of breast cancer on future fertility intentions and contraceptive use; understanding of suitable contraceptive methods during and after treatment and women’s fertility related counseling needs during their continuum of care. Data were analysed using a thematic analysis approach.

Results

Since being diagnosed with breast cancer, of those women using a contraceptive method, the non-hormonal intrauterine device (IUD) was the most commonly used method. However, women reported receiving limited information from health care providers about contraceptive use and future fertility planning post treatment when fertility desires might change. Many women reported limited information received from healthcare providers about the impact of cancer treatment on their future fertility. Most women did not receive information around fertility preservation options, and few were familiar with the concept. Providers focus was more on preventing pregnancy during treatment and ensuring a patient was on a non-hormonal contraceptive method. Providers supported a more holistic, multidisciplinary approach to breast cancer patient’s contraceptive and future fertility needs.

Conclusions

Limited contraceptive and future fertility counseling were reported by women despite many women being provided with the IUD. There is a need for improved information and counseling regarding the impact of treatment on contraceptive and fertility options. It is important that cancer care providers provide timely information regarding fertility options and communicate with patients about their fertility concerns prior to treatment and throughout the course of survivorship. The development of evidence-based information tools to enhance patient-provider communication and counseling could address knowledge gaps.

Safety and continued use of the levonorgestrel intrauterine system as compared with the copper intrauterine device among women living with HIV in South Africa: A randomized controlled trial

BACKGROUND

Women living with HIV (WLHIV) have lower rates of contraceptive use than noninfected peers, yet concerns regarding contraceptive efficacy and interaction with antiretroviral therapy (ART) complicate counseling. Hormonal contraceptives may increase genital tract HIV viral load (gVL) and sexual transmission risk to male partners. We compared gVL, plasma VL (pVL), and intrauterine contraceptive (IUC) continuation between the levonorgestrel intrauterine system (LNG-IUS) and copper intrauterine device (C-IUD) in Cape Town, South Africa.

METHODS AND FINDINGS

In this double-masked, randomized controlled noninferiority trial, eligible WLHIV were ages 18-40, not pregnant or desiring pregnancy within 30 months, screened and treated (as indicated) for reproductive tract infections (RTIs) within 1 month of enrollment, and virologically suppressed using ART or above treatment threshold at enrollment (non-ART). Between October 2013, and December 2016, we randomized consenting women within ART groups, using 1:1 permuted block randomization stratified by ART use, age (18-23, 24-31, 32-40), and recent injectable progestin contraceptive (IPC) exposure, and provided the allocated IUC. At all visits, participants provided specimens for gVL (primary outcome), pVL, RTI, and pregnancy testing. We assessed gVL and pVL across 6 and 24 months controlling for enrollment measures, ART group, age, and RTI using generalized estimating equation and generalized linear models (non-ART group pVL and hemoglobin) in as-treated analyses. We measured IUC discontinuation rates with Kaplan-Meier estimates and Cox proportional hazards models. We enrolled 71 non-ART (36 LNG-IUS, 31 C-IUD; 2 declined and 2 were ineligible) and 134 ART-using (65 LNG-IUS, 67 C-IUD; 1 declined and 1 could not complete IUC insertion) women. Participant median age was 31 years, and 95% had 1 or more prior pregnancies. Proportions of women with detectable gVL were not significantly different comparing LNG-IUS to C-IUD across 6 (adjusted odds ratio [AOR]: 0.78, 95% confidence interval [CI] 0.44-1.38, p = 0.39) and 24 months (AOR: 1.03, 95% CI: 0.68-1.57, p = 0.88). Among ART users, proportions with detectable pVL were not significantly different at 6 (AOR = 0.83, 95% CI 0.37-1.86, p = 0.65) and 24 months (AOR = 0.94, 95% CI 0.49-1.81, p = 0.85), whereas among non-ART women, mean pVL was not significantly different at 6 months (-0.10 log10 copies/mL, 95% CI -0.29 to 0.10, p = 0.50) between LNG-IUS and C-IUD users. IUC continuation was 78% overall; C-IUD users experienced significantly higher expulsion (8% versus 1%, p = 0.02) and elective discontinuation (adjusted hazard ratio: 8.75, 95% CI 3.08-24.8, p < 0.001) rates. Sensitivity analysis adjusted for differential IUC discontinuation found similar gVL results. There were 39 serious adverse events (SAEs); SAEs believed to be directly related to IUC use (n = 7) comprised 3 pelvic inflammatory disease (PID) cases and 4 pregnancies with IUC in place with no discernible trend by IUC arm. Mean hemoglobin change was significantly higher among LNG-IUS users across 6 (0.57 g/dL, 95% CI 0.24-0.90; p < 0.001) and 24 months (0.71 g/dL, 95% CI 0.47-0.95; p < 0.001). Limitations included not achieving non-ART group sample size following change in ART treatment guidelines and truncated 24 months' outcome data, as 17 women were not yet eligible for their 24-month visit at study closure. Also, a change in VL assay during the study may have caused some discrepancy in VL values because of different limits of detection.

CONCLUSIONS

In this study, we found that the LNG-IUS did not increase gVL or pVL and had low levels of contraceptive failure and associated PID compared with the C-IUD among WLHIV. LNG-IUS users were significantly more likely to continue IUC use and had higher hemoglobin levels over time. The LNG-IUS appears to be a safe contraceptive with regard to HIV disease and may be a highly acceptable option for WLHIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01721798.

Maternity waiting homes as part of a comprehensive approach to maternal and newborn care: a cross-sectional survey

Background

Increased encounters with the healthcare system at multiple levels have the potential to improve maternal and newborn outcomes. The literature is replete with evidence on the impact of antenatal care and postnatal care to improve outcomes. Additionally, maternity waiting homes (MWHs) have been identified as a critical link in the continuum of care for maternal and newborn health yet there is scant data on the associations among MWH use and antenatal/postnatal attendance, family planning and immunization rates of newborns.

Methods

A cross-sectional household survey was conducted to collect data from women who delivered a child in the past 13 months from catchment areas associated with 40 healthcare facilities in seven rural Saving Mothers Giving Life districts in Zambia. Multi-stage random sampling procedures were employed with a final sample of n = 2381. Logistic regression models with adjusted odds ratios and 95% confidence intervals were used to analyze the data.

Results

The use of a MWH was associated with increased odds of attending four or more antenatal care visits (OR = 1.45, 95% CI = 1.26, 1.68), attending all postnatal care check-ups (OR = 2.00, 95% CI = 1.29, 3.12) and taking measures to avoid pregnancy (OR = 1.31, 95% CI = 1.10, 1.55) when compared to participants who did not use a MWH.

Conclusions

This is the first study to quantitatively examine the relationship between the use of MWHs and antenatal and postnatal uptake. Developing a comprehensive package of services for maternal and newborn care has the potential to improve acceptability, accessibility, and availability of healthcare services for maternal and newborn health. Maternity waiting homes have the potential to be used as part of a multi-pronged approach to improve maternal and newborn outcomes.

Trial registration

National Institutes of Health Trial Registration NCT02620436, Impact Evaluation of Maternity Homes Access in Zambia, Date of Registration - December 3, 2015.

Uptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators

OBJECTIVE

Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa.

STUDY DESIGN

We reviewed literature on tubal ligation among African women published between January 1, 2000 and October 30, 2017. We searched PubMed, Global health, EMBASE, Web of science, and Google scholar for quantitative, qualitative, and mixed methods studies which reported on barriers and/or facilitators to uptake of tubal ligation in sub-Saharan Africa. Finally, we conducted a narrative synthesis and categorized our findings using a framework based on the social ecological model.

RESULTS

We included 48 articles in the review. Identified barriers to tubal ligation among women included individual-level (myths and misconceptions, fear of surgery, irreversibility of procedure, religious beliefs), interpersonal-level (male partner disapproval), and organizational-level (lack of healthcare worker expertise and equipment) factors. Facilitating factors included achievement of desired family size and perceived effectiveness (individual-level), supportive male partners and knowing other women with permanent contraception experience (interpersonal-level), and finally, subsidized cost of the procedure and task-sharing with lower cadre healthcare workers (organizational-level).

CONCLUSIONS

Barriers to, and facilitators of permanent contraception among women in sub-Saharan Africa are multilevel in nature. Strategies countering these barriers should be prioritized, as effective contraception can promote women's health and economic development in sub-Saharan Africa. In addition to these strategies, more quantitative research is needed to further understand patient-level factors associated with uptake of permanent contraception among women.

Inequities in maternal health services utilization in Ethiopia 2000-2016: magnitude, trends, and determinants

BACKGROUND

Inequities in maternal health services utilization constitute a major challenge in maternal mortality reduction in Ethiopia. We sought to assess magnitude, trends, and determinants of inequities in maternal health services utilization in Ethiopia from 2000 to 2016.

METHODS

The study utilized data from the 2000 and 2016 Ethiopia Demographic and Health Surveys, which were done based on a cross sectional survey design. The wealth-related inequities were assessed by concentration curve and horizontal inequity indices. Trends in inequities were assessed by comparing the concentration indices of maternal health services utilization variables between the 2000 and 2016 surveys using Wagstaff two groups concentration indices comparison method. Finally, the inequities were decomposed into its contributing factors using Wagstaff method of analysis.

RESULTS

Wealth-related inequities were significantly high in 2016: with horizontal inequities indices and residual regression error of antenatal care, skilled birth attendance, and postnatal care service utilization (- 0.09 and - 0.01), (- 0.06 and 0.01), and (- 0.11 and 0.0001), respectively. These indices increased significantly in 2016 when it is compared with the 2000 indices' with the respective concentration indices difference of - 0.05, 0.05, and - 0.07. The related all p-values were < 0.0001. The main determinants of inequities were low-economic status, illiteracy, rural residence, no occupation, and fewer accesses to mass media.

CONCLUSIONS

In Ethiopia, maternal health services utilization inequities were significantly high and increased in 2016 compared to 2000. Women who are poor, rural resident, uneducated, unemployed, and fewer mass media exposed are the most disadvantaged. Targeting maternal health interventions for the underserved women is essential to reduce maternal mortality in the country.

Prevalence and determinants of contraceptive utilization among married women at Dabat Health and Demographic Surveillance System site, northwest Ethiopia

BACKGROUND

Despite the enormous benefits of family planning services, the contraceptive utilization still remains low in Sub-Saharan Africa. There is regional variation in modern contraceptive utilization in Ethiopia. Therefore, this study was aimed to determine the prevalence of modern contraceptive utilization and determinants in Dabat demographic and health surveillance system site, northwest Ethiopia.

METHODS

A re-census was carried out in Dabat Health and Demographic Surveillance System (HDSS) site from October to December 2014. Data of 8271 married women collected in the re-census was used. The outcome variable was current utilization of any modern contraceptive methods whereas socio demographic and economic variables were the potential determinants considered. Bi-variable and multivariable binary logistic regression along with odds ratio and 95% confidence interval were used to describe the strength of association.

RESULTS

Prevalence of modern contraceptive utilization among married women in Dabat DHSS site was found to be 32.5% (95%CI: 31.5, 33.5%). After adjusting for covariates; the odds of using modern contraceptive were 2.35 times, 1.91 times, and 1.39 times higher among women of secondary and above educational level, urban residents, and women having six and above living children, respectively.

CONCLUSION

Modern contraceptive utilization was found to be very low. Effort has to be applied to improve women's educational level that increases their understanding of reproductive health issues. It is also important to give special emphasis for rural residents, those aged 20-40 years, and those with six or more living children while serving for modern contraceptive methods.

The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa - A review

BACKGROUND

The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:To describe the effects of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSATo describe the integration of PMTCT and its extent within broader programs and health systems.

METHODS

Articles published in English and French over the period 1st January 2007 (the year of publication of WHO/UNICEF guidelines on global scale-up of the PMTCT) to 31 November 2016 on PMTCT programs in SSA were sought through searches of electronic databases (Medline and Google Scholar). Articles describing the impact (positive and negative effects) of PMTCT on other health care services and those describing its integration in health systems in SSA were eligible for inclusion. We assessed 6223 potential papers, reviewed 225, and included 57.

RESULTS

The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.

CONCLUSIONS

PMTCT services increase to some extent the availability, accessibility and utilisation of antenatal care and services beyond HIV care. Vertical PMTCT programs work, when well-funded and well-managed, despite poorly functioning health systems. The beneficial synergies between PMTCT and other services are widely suggested, but there is a lack of large-scale evidence of this.

Achieving pregnancy safely for HIV-serodiscordant couples: a social ecological approach

The recognition and fulfilment of the sexual and reproductive health and rights (SRHR) of all individuals and couples affected by HIV, including HIV-serodiscordant couples, requires intervention strategies aimed at achieving safe and healthy pregnancies and preventing undesired pregnancies. Reducing risk of horizontal and vertical transmission and addressing HIV-related infertility are key components of such interventions. In this commentary, we present challenges and opportunities for achieving safe pregnancies for serodiscordant couples through a social ecological lens. At the individual level, knowledge (e.g. of HIV status, assisted reproductive technologies) and skills (e.g. adhering to antiretroviral therapy or pre-exposure prophylaxis) are important. At the couple level, communication between partners around HIV status disclosure, fertility desires and safer pregnancy is required. Within the structural domain, social norms, stigma and discrimination from families, community and social networks influence individual and couple experiences. The availability and quality of safer conception and fertility support services within the healthcare system remains essential, including training for healthcare providers and strengthening integration of SRHR and HIV services. Policies, legislation and funding can improve access to SRHR services. A social ecological framework allows us to examine interactions between levels and how interventions at multiple levels can better support HIV-serodiscordant couples to achieve safe pregnancies. Strategies to achieve safer pregnancies should consider interrelated challenges at different levels of a social ecological framework. Interventions across multiple levels, implemented concurrently, have the potential to maximize impact and ensure the full SRHR of HIV-serodiscordant couples.

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.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

Evidence on the feasibility, effectiveness, and cost‐effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community‐wide and HIV‐specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.

Postpartum family planning: current evidence on successful interventions

We reviewed existing evidence of the efficacy of postpartum family planning interventions targeting women in the 12 months postpartum period in low- and middle-income countries. We searched for studies from January 1, 2004 to September 19, 2015, using the US Preventive Services Task Force recommendations to assess evidence quality. Our search resulted in 26 studies: 11 based in sub-Saharan Africa, six in the Middle East and North Africa, and nine in Asia. Twenty of the included studies assessed health facility-based interventions. Three were focused on community interventions, two had community and facility components, and one was a workplace program. Overall quality of the evidence was moderate, including evidence for counseling interventions. Male partner involvement, integration with other service delivery platforms, such as prevention of mother-to-child transmission of HIV and immunization, and innovative product delivery programs may increase knowledge and use during the postpartum period. Community-based and workplace strategies need a much stronger base of evidence to prompt recommendations.

Use of HIV counseling and testing and family planning services among postpartum women in Kenya: a multicentre, non-randomised trial

BACKGROUND

Addressing the postnatal needs of new mothers is a neglected area of care throughout sub-Saharan Africa. The study compares the effectiveness of integrating HIV and family planning (FP) services into postnatal care (PNC) with stand-alone services on postpartum women's use of HIV counseling and testing and FP services in public health facilities in Kenya.

METHODS

Data were derived from samples of women who had been assigned to intervention or comparison groups, had given birth within the previous 0-10 weeks and were receiving postnatal care, at baseline and 15 months later. Descriptive statistics describe the characteristics of the sample and multivariate logistic regression models assess the effect of the integrated model of care on use of provider-initiated testing and counseling (PITC) and FP services.

RESULTS

At the 15-month follow-up interviews, more women in the intervention than comparison sites used implants (15 % vs. 3 %; p < 0.001), while injectables were the most used short-term method by women in both sites. Women who wanted to wait until later to have children (OR = 1.3; p < 0.01; 95 % CI: 1.1-1.5), women with secondary education (OR = 1.2; p < 0.05; 95 % CI: 1.0-1.4), women aged 25-34 years (OR = 1.2; p < 0.01; 95 % CI: 1.1-1.4) and women from poor households (OR = 1.6; p < 0.001; 95 % CI: 1.4-1.9) were associated with FP use. Nearly half (47 %) and about one-third (30 %) of mothers in the intervention and comparison sites, respectively, were offered PITC. Significant predictors of uptake of PITC were seeking care in a health center/dispensary relative to a hospital, having a partner who has tested for HIV and being poor.

CONCLUSIONS

An integrated delivery approach of postnatal services is beneficial in increasing the uptake of PITC and long-acting FP services among postpartum women. Also, interventions aimed at increasing male partners HIV testing have a positive effect on the uptake of PITC and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01694862.

Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence

INTRODUCTION

This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs).

METHODS

We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used.

RESULTS

Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions.

CONCLUSIONS

This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.

Strategies for improving postpartum contraceptive use: evidence from non-randomized studies

BACKGROUND

Nearly two-thirds of women in their first postpartum year have an unmet need for family planning. Adolescents often have repeat pregnancies within a year of giving birth. Women may receive counseling on family planning both antepartum and postpartum. Decisions about contraceptive use made right after counseling may differ considerably from actual postpartum use. In earlier work, we found limited evidence of effectiveness from randomized trials on postpartum contraceptive counseling. For educational interventions, non-randomized studies may be conducted more often than randomized trials.

OBJECTIVES

We reviewed non-randomized studies of educational strategies to improve postpartum contraceptive use. Our intent was to examine associations between specific interventions and postpartum contraceptive use or subsequent pregnancy.

SEARCH METHODS

We searched for eligible non-randomized studies until 3 November 2014. Sources included CENTRAL, PubMed, POPLINE, and Web of Science. We also sought current trials via ClinicalTrials.gov and ICTRP. For additional citations, we examined reference lists of relevant reports and reviews.

SELECTION CRITERIA

The studies had to be comparative, i.e., have intervention and comparison groups. The educational component could be counseling or another behavioral strategy to improve contraceptive use among postpartum women. The intervention had to include contact within six weeks postpartum. The comparison condition could be another behavioral strategy to improve contraceptive use, usual care, other health education, or no intervention. Our primary outcomes were postpartum contraceptive use and subsequent pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. We computed the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous measures, both with 95% Confidence Intervals (CI). Where studies used adjusted analyses for continuous outcomes, we presented the results as reported by the investigators. Due to differences in interventions and outcome measures, we did not conduct meta-analysis. To assess the evidence quality, we used the Newcastle-Ottawa Quality Assessment Scale.

MAIN RESULTS

Six studies met our inclusion criteria and included a total of 5143 women. Of three studies with self-reported pregnancy data, two showed pregnancy to be less likely in the experimental group than in the comparison group (OR 0.48, 95% CI 0.27 to 0.87) (OR 0.60, 95% CI 0.41 to 0.87). The interventions included a clinic-based counseling program and a community-based communication project.All studies showed some association of the intervention with contraceptive use. Two showed that treatment-group women were more likely to use a modern method than the control group: ORs were 1.77 (95% CI 1.08 to 2.89) and 3.08 (95% CI 2.36 to 4.02). In another study, treatment-group women were more likely than control-group women to use pills (OR 1.78, 95% CI 1.26 to 2.50) or an intrauterine device (IUD) (OR 3.72, 95% CI 1.27 to 10.86) but less likely to use and injectable method (OR 0.23, 95% CI 0.05 to 1.00). One study used a score for method effectiveness. The methods of the special-intervention group scored higher than those of the comparison group at three months (MD 13.26, 95% CI 3.16 to 23.36). A study emphasizing IUDs showed women in the intervention group were more likely to use an IUD (OR 1.79, 95% CI 1.20 to 2.69) and less likely to use no method (OR 0.48, 95% CI 0.31 to 0.75). In another study, contraceptive use was more likely among women in a health service intervention compared to women in a community awareness program at four months (OR 1.79, 95% CI 1.40 to 2.30) or women receiving standard care at 10 to 12 months (OR 2.08, 95% CI 1.58 to 2.74). That study was the only one with a specific component on the lactational amenorrhea method (LAM) that had sufficient data on LAM use. Women in the health service group were more likely than those in the community awareness group to use LAM (OR 41.36, 95% CI 10.11 to 169.20).

AUTHORS' CONCLUSIONS

We considered the quality of evidence to be very low. The studies had limitations in design, analysis, or reporting. Three did not adjust for potential confounding and only two had sufficient information on intervention fidelity. Outcomes were self reported and definitions varied for contraceptive use. All studies had adequate follow-up periods but most had high losses, as often occurs in contraception studies.