Successful programmatic approaches to facilitating IUD uptake: CARE's experience in DRC

Effectiveness of an educational intervention on knowledge and practice of young midwifery college students about IUD and Pap smear, Babol, Iran

OBJECTIVES

The high status of midwifery within the Millennium Development Goals (MDGs) is closely tied to enhancing clinical education. The purpose of this study was to review the effect of education on the knowledge and practice of midwifery students about Intrauterine Device (IUD) and Pap smears.

METHODS

This quasi-experimental study was conducted over the course of four semesters, involving 128 bachelor of midwifery students. The sampling method was non-random, utilizing convenience sampling. Four consecutive 45 min weekly sessions were held, which included three theory sessions and one practical training session. Education was conducted in face-to-face training sessions using different methods such as lectures, question and answer, slide shows, educational films and brochures, and training participants with moulage. The data were gathered using a questionnaire covering demographic characteristics, various aspects of IUD and Pap smear knowledge, along with checklists for IUD insertion and Pap smear. Paired-samples T-test and multiple regression test were used to analyze the data. A significance level of p<0.05 was set for the analysis.

RESULTS

The results of this study showed that there was a significant difference in the average knowledge across various aspects of IUD and Pap smear before and after the intervention (p<0.001). On multiple regression analysis, residence and income significantly influenced knowledge (β=0.313, p=0.001 and β=-0.384, p=0.001, respectively). Also, multiple regression analysis indicated that the use of IUD among family or friends and age significantly impacted practice (β=-0.450, p=0.005 and β=-0.206, p=0.030, respectively).

CONCLUSIONS

The educational intervention yielded a noticeable enhancement in the knowledge and practical skills of midwifery students. These students tend to achieve higher levels of success and deliver superior services to both patients and clients.

Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

BACKGROUND

Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

METHODS

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

RESULTS

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

CONCLUSION

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization. Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Immediate IUD insertion after second trimester abortion: implications for service delivery

Background

The availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care. Findings from a recent randomized controlled trial (RCT) in South Africa comparing immediate to delayed insertion of the copper intrauterine device (IUD) after medical abortion (MA) at 17-20 gestational weeks showed that immediate insertion resulted in higher IUD use at 6 weeks postabortion, but that expulsion rates were significantly higher than for delayed insertion. This study aims to explore barriers, facilitators, and context-specific factors relevant to the implementation of immediate IUD provision after second trimester medical abortion.

Methods

We performed a qualitative study alongside the RCT in which we conducted in-depth interviews with 14 staff providing healthcare to study participants and 24 study participants. Research questions explored barriers and facilitators to implementation of immediate IUD insertion, contraceptive decision-making, and the impact of context and supplementary trial activities on service provision. Interviews were recorded and transcribed, with translation into English if needed. We performed a triangulated thematic analysis at the level of the transcribed interview text.

Results

Contraceptive counselling at the abortion facility by a study nurse improved knowledge, corrected misconceptions, and increased demand for the IUD postabortion. Women expressed a clear preference for immediate insertion. Convenience, protection from pregnancy and privacy issues were paramount and women expressed preference for engagement with staff who knew their abortion history, and with whom they had an established connection. Doctors and nurses were generally in favour of immediate insertion and said it could be incorporated into standard care if women wanted this. This contrasted with the need for interventions by the research team to reinforce adherence by staff to provide contraception as allocated during the trial.

Conclusions

Women and staff favour immediate IUD insertion after second trimester medical abortion, but service delivery may require structures that ensure timely insertion postabortion, continuity of care, communication that mitigates loss to follow-up and training of staff to ensure competence.

Towards achieving the family planning targets in the African region: a rapid review of task sharing policies

Background

Expanding access and use of effective contraception is important in achieving universal access to reproductive healthcare services, especially in low- and middle-income countries (LMICs), such as those in sub-Saharan Africa (SSA). Shortage of trained healthcare providers is an important contributor to increased unmet need for contraception in SSA. The World Health Organization (WHO) recommends task sharing as an important strategy to improve access to sexual and reproductive healthcare services by addressing shortage of healthcare providers. This study explores the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries. This evidence is aimed at promoting the implementation and scale-up of task sharing programmes in SSA countries by WHO.

Methodology and findings

We employed a rapid programme review (RPR) methodology to generate evidence on task sharing for family planning programmes from five SSA countries namely, Burkina Faso, Cote d’Ivoire, Ethiopia, Ghana, and Nigeria. This involved a desk review of country task sharing policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, WHO regional meeting reports on task sharing for family planning; and information from key informants on country background, intervention packages, impact, enablers, challenges and ways forward on task sharing for family planning. The findings indicate mainly the involvement of community health workers, midwives and nurses in the task sharing programmes with training in provision of contraceptive pills and long-acting reversible contraceptives (LARC). Results indicate an increase in family planning indicators during the task shifting implementation period. For instance, injectable contraceptive use increased more than threefold within six months in Burkina Faso; contraceptive prevalence rate doubled with declines in total fertility and unmet need for contraception in Ethiopia; and uptake of LARC increased in Ghana and Nigeria. Some barriers to successful implementation include poor retention of lower cadre providers, inadequate documentation, and poor data systems.

Conclusions

Task sharing plays a role in increasing contraceptive uptake and holds promise in promoting universal access to family planning in the SSA region. Evidence from this RPR is helpful in elaborating country policies and scale-up of task sharing for family planning programmes.

Adolescent Women with Unintended Pregnancy in Low- and Middle-Income Countries: Reasons for Discontinuation of Contraception

STUDY OBJECTIVE

To investigate the reasons for discontinuation of the last contraceptive method used among adolescent women with a current unintended pregnancy.

DESIGN

Demographic and health, cross-sectional, surveys.

SETTING

Thirty-five low- and middle-income countries.

PARTICIPANTS

We selected 2173 girls aged 15-19 years with a current unintended pregnancy, using a multistage cluster random sampling method.

INTERVENTIONS

A questionnaire administered by trained interviewers, which included sociodemographic as well as individual maternal and contraceptive history, was used to collect data.

MAIN OUTCOME MEASURES

The prevalence of contraception utilization and the contribution of each reason for contraceptive discontinuation before the current unintended pregnancies.

RESULTS

Almost three-quarters of adolescent women were not using any contraception before the current unintended pregnancy, and less than 1 in 100 was using a long-acting modern method. Among girls who last used a traditional method, 111/150 (74.0%) discontinued because of failure. Among girls who last used a long-acting modern method, 7/11 (63.6%) discontinued because of health concerns and side effects.

CONCLUSION

This study highlights that approximately 80.0% of adolescent women with an unintended pregnancy in 35 low- and middle-income countries were either nonusers or using traditional methods. An additional 20.4% were using a short-acting modern method. Long-acting methods would have prevented the overwhelming majority of unintended pregnancies, including the vast numbers from contraceptive failure.

Contraceptive use among adolescent and young women in North and South Kivu, Democratic Republic of the Congo: A cross-sectional population-based survey

BACKGROUND

Adolescent girls in humanitarian settings are especially vulnerable as their support systems are often disrupted. More than 20 years of violence in the Democratic Republic of the Congo (DRC) has weakened the health system, resulting in poor sexual and reproductive health (SRH) outcomes for women. Little evidence on adolescent contraceptive use in humanitarian settings is available. CARE, International Rescue Committee (IRC), and Save the Children, in collaboration with the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative, Columbia University, have supported the Ministry of Health (MOH) since 2011 to provide good quality contraceptive services in public health facilities in conflict-affected North and South Kivu. In this study, we analyzed contraceptive use among sexually active young women aged 15-24 in the health zones served by the partners' programs.

METHODS AND FINDINGS

The partners conducted cross-sectional population-based surveys in program areas of North and South Kivu using two-stage cluster sampling in six health zones in July-August 2016 and 2017. Twenty-five clusters were selected in each health zone, 22 households in each cluster, and one woman of reproductive age (15-49 years) was randomly selected in each household. This manuscript presents results from a secondary data analysis for 1,022 women aged 15-24 who reported ever having sex: 326 adolescents (15-19 years) and 696 young women (20-24 years), 31.7% (95% confidence interval [CI] 29.5-34.1), of whom were displaced at least once in the previous five years. Contraceptive knowledge was high, with over 90% of both groups able to name at least one modern contraceptive method. Despite this high knowledge, unmet need for contraception was also high: 31.7% (95%CI 27.9-35.7) among 15-19-year-olds and 40.1% (95% CI 37.1-43.1, p = 0.001) among 20-24-year-olds. Current modern contraceptive use (16.5%, 95% CI 14.7-18.4) was similar in both age groups, the majority of whom received their method from a supported health facility. Among current users, more than half of 15-19-year-olds were using a long-acting reversible contraceptive (LARC; 51.7%, 95% CI 41.1-61.9) compared to 36.5% of 20-24-year-olds (95% CI 29.6-43.9, p = 0.02). Age, younger age of sexual debut, having some secondary education, being unmarried, and having begun childbearing were associated with modern contraceptive use. The main limitations of our study are related to insecurity in three health zones that prevented access to some villages, reducing the representativeness of our data, and our defining sexually active women as those who have ever had sex.

CONCLUSIONS

In this study, to our knowledge one of the first to measure contraceptive prevalence among adolescents in a humanitarian setting, we observed that adolescent and young women will use modern contraception, including long-acting methods. Meaningful engagement of adolescent and young women would likely contribute to even better outcomes. Creating an enabling environment by addressing gender and social norms, however, is key to reducing stigma and meeting the demand for contraception of young women. As we continue to build such supportive environments, we can see that they will use effective contraception when contraceptive services, including short- and long-acting methods, are available, even in protracted crisis settings.