Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

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.

Socio-demographic and antenatal care-related factors associated with early post-partum family planning use in Ethiopia: evidence from Ethiopian Demographic and Health Survey 2016 data

Introduction

Initiation of family planning in the early post-partum period is a strategic move to reduce maternal, neonatal, and child mortality due to the negative consequences of short interbirth interval and the complications of unintended pregnancy. Antenatal care (ANC) is the noteworthy predictor of scaling up early initiation of post-partum family planning (PPFP) and preventing unintended pregnancy before menses resume. Despite the great role of ANC, information is scant about the effect of content, timing, and the number of ANC visits on the early initiation of PPFP in Ethiopia.

Objective

This study aimed to assess the association of ANC services with the early initiation of PPFP in Ethiopia.

Methods

The study was based on Ethiopian Demographic and Health Survey 2016 data, which was a cross-sectional survey from 18 January 2016 to 27 June 2016. A total weighted sample size of 2,920 post-partum women was included. A multilevel logistic regression model was used because of the hierarchical data, and variables with a p-value of ≤0.2 in the bivariable multilevel analysis were taken to multivariable multilevel analysis. An adjusted odds ratio with a 95% confidence interval (CI) was used to declare both the direction and strength of the association, and variables with a p-value of <0.05 were considered as statistically significant for the outcome variable.

Results

The early initiation of PPFP was 20.4%. Women with at least four ANC visits [adjusted odds ratio (AOR) = 1.31; CI 1.12-2.32], women who started ANC within the first trimester (AOR = 1.25; CI 1.10-2.23), complete routine ANC (AOR = 1.11; CI 1.01-2.03), post-natal care (AOR = 1.45; CI 1.19-1.87), resumption of menses (AOR = 1.67; CI 1.18-1.93), urban residency (AOR = 2.14; CI 1.18-2.51), and high community women's education (AOR = 1.71; CI 1.51-2.11) were variables significantly associated with the early initiation of PPFP.

Conclusion

The early initiation of PPFP in Ethiopia was very low. Attention needs to be given to the quality of ANC, post-natal care, resumption of menses, residency, and community-level education of women to increase the prevalence of the early initiation of PPFP in Ethiopia. Therefore, the government should design a program targeting the quality of ANC in rural communities, considering women without menses and scaling up the education of women at the community level to the culture of the early initiation of PPFP in order to achieve reduced maternal, neonatal, and child mortality.

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.

Understanding the Effect of a Healthcare Provider-Led Family Planning Support Intervention on Contraception use and Pregnancy Desires among Postpartum Women Living with HIV in Southwestern Uganda

Modern contraceptive prevalence among women living with HIV (WLWH) in Uganda is still low at 45%, and up to a third of women are likely to discontinue the method within the first year of initiation. This increases risks of unplanned pregnancies, perinatal HIV transmission and pregnancy complications. We aim to explore and explain the mechanism of effect of a family planning support intervention investigated in a randomized controlled trial conducted between October 2016 and June 2018 among 320 postpartum WLWH at a referral hospital in Southwestern Uganda that led to improved uptake, decreased contraception discontinuation and lowered pregnancy rates. Thirty WLWH and 10 of their primary sexual partners who participated in this trial were purposively selected and interviewed in the local language; interviews were digitally recorded. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Up to 83% of women wanted to avoid pregnancy within the first year postpartum. Qualitative data showed that contraception uptake and use were influenced by: 1) Participant awareness and understanding of different methods available; 2) Participant perception of offered health services; 3) Healthcare provider (HCP) socio-cultural sensitivity to individual experiences and (mis)conceptions surrounding contraception; 4) Having tactile engagement, follow-up reminders and a reference to prompt action or discussions with partners. Supportive and culturally sensitive HCPs and systems facilitated information sharing leading to increased patient awareness and understanding of the contraceptive methods, and improved health user experience, care engagement, confidence and willingness to take up and continue using modern contraceptive methods.

Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review

Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.

Mbarara University Research Training Initiative: Experiences and Accomplishments of the MEPI Junior D43 TW010128 Award in Uganda

OBJECTIVE

In 2015, Mbarara University of Science and Technology was awarded the Mbarara University Research Training Initiative (MURTI) under grant number D43 TW010128 to build capacity of junior faculty to become the next generation of researchers in Africa. In this paper, we document the experiences and achievements of the research capacity building efforts at MUST.

METHODS

We conducted a descriptive evaluation study which involved document review and in-depth interviews. We used "Reach" and 'Effectiveness' from the RE-AIM framework to guide the document review, and the organizational theory of implementation effectiveness to guide the in-depth interviews.

RESULTS

In the MURTI program, we conducted 17 short courses between August 2015 and July 2021, a total of 6597 attendances were recorded. The most attended courses were responsible conduct of research (n = 826), qualitative research methods (n = 744), and data management (n = 613). Thirty-three fellows were recruited and funded to conduct mentored research leading to 48 publications and 14 extramural grant applications were yielded. From the in-depth interviews, the participants appreciated the research training program, the enhanced research skills attained, and the institutional capacity built. They attributed the success of the program to the training approach of using short courses, readiness of the junior faculty to change, and the supportive environment by the mentors and trainers in the program.

CONCLUSION

The D43 TW010128 research training grant-built capacity for the junior faculty at MUST, enhanced their research skills, promoted research capacity institutionally and provided career development for the junior faculty. This was possible due to the positive attitude of the junior faculty (organizational readiness) to change and the supportive environment (mentors and trainers) during implementation of the grant. These two factors provided a favorable institutional climate that guaranteed success of the funding goals.

Attitudes Toward Pregnancy Among Women Enrolled in Prevention of Mother-to-Child Transmission of HIV (PMTCT) Services in Moshi, Tanzania

For pregnant women living with HIV (WLWH), feelings about pregnancy may influence their emotional well-being and health seeking behaviors. This study examined attitudes toward pregnancy and associated factors among women enrolled in prevention of mother-to-child transmission of HIV (PMTCT) services in Moshi, Tanzania. 200 pregnant WLWH were enrolled during their second or third trimester of pregnancy and completed a structured survey. Univariable and multivariable regression models examined factors associated with attitudes toward pregnancy, including demographics, interpersonal factors, and emotional well-being. Attitudes toward the current pregnancy were generally positive, with 87% of participants reporting feeling happy about being pregnant. In the final multivariable model, having higher levels of partner support, being newly diagnosed with HIV, and having fewer children were significantly associated with more positive attitudes toward their pregnancy. Findings point to a need for tailored psychosocial support services in PMTCT, as well as comprehensive reproductive health care for WLWH.

Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial

BACKGROUND

Despite low pregnancy intentions, many women accessing contraception discontinue use, increasing the risk of unwanted pregnancies among women living with HIV (WLWH). We evaluate whether a family planning support intervention, inclusive of structured immediate one-on-one postpartum counseling, and a follow-up mechanism through additional health information and SMS reminders affects continuous contraceptive use and pregnancy incidence among recently postpartum WLWH.

METHODS

We performed a randomized controlled trial between October 2016 and June 2018 at a referral hospital in southwestern Uganda. We included adult WLWH randomized and enrolled in a 1:1 ratio to receive family planning support or standard of care (control) and completed an interviewer-administered questionnaire at enrolment, 6 and 12 months postpartum. Our two primary outcomes of interest were; continuous use of contraception, and incidence of pregnancy. Secondary outcomes included contraception uptake, method change, discontinuation and pregnancy intentions. The trial was registered with clinicaltrials.gov (NCT02964169).

RESULTS

A total of 317(99%) completed all study procedures. Mean age was 29.6 (SD = 6.0) vs 30.0 (SD = 5.9) years for the intervention vs control groups respectively. All women were enrolled on ART. Total women using contraception continuously were 126 (79.8%) in the intervention compared to 110 (69.2%) in control group (odds ratio (OR) = 1.75; confidence interval (CI) = 1.24-2.75, P = 0.003). Pregnancy rates were 2% (N = 3) in the intervention vs 9% (N = 14) in the control group (OR = 0.20, 95% CI = 0.05-0.62, P = 0.006). Pregnancy intention was lower in the intervention vs control group (OR = 0.23, 95% CI = 0.08-0.64, P = 0.002). Women actively enrolled on contraception reduced more in the control compared to the intervention group (OR = 3.92, 95% CI = 1.66-9.77, P = 0.001). Women enrolled on each contraceptive method did not differ by group except for implants. More women initiating contraception use within three months postpartum had better continued use for either intervention (N = 123, 97.6% vs N = 3,2.4%) or control group (N = 86,78.2% vs N = 24,21.8%). Method-related side effects were less reported in the intervention group (OR = 0.25, 95% CI = 0.10-0.60, P = 0.001).

CONCLUSION

We found that sustained and structured family planning support facilitates continuous use of contraception and lowers rates of pregnancy amongst postpartum WLWH in rural southwestern Uganda. Women who initiated contraception within three months postpartum were more likely to maintain continuous use of contraception than those initiating later. Further evaluation of actual and perceived facilitators to the continuous contraception use by this support intervention will help replication in similar settings.

TRIAL REGISTRATION

NCT02964169.

Survival Time to Modern Contraceptive Uses from the Resumption of Sexual Intercourse Among Postpartum Women in Ethiopia

Background

The timing of contraceptive use is important for a woman who intends to avoid pregnancy during the postpartum period and it has key implications for reproductive health outcomes. Therefore, this study aimed to determine the time it takes to start modern contraceptive uses from the resumption of sexual intercourse among postpartum women in Ethiopia and to identify its predictors.

Methods

A cross-sectional study using the 2016 Ethiopia Demographic and Health Survey (EDHS) was applied. The data were analyzed with SPSS version 20. Kaplan–Meier estimates were performed to explain time-to- modern contraceptive use. Cox-proportional hazard regression analysis was conducted to identify predictors. The adjusted hazard ratio (AHR) with a 95% confidence interval was considered to declare a statistically significant association.

Results

The total weighted sample comprised 1178 women. The median survival time to modern contraceptive use after birth was 4 months. In this study, the risk of modern contraceptive use was 1.29 times (AHR: 1.29; 95% CI: 1.04–1.61) higher among urban resident, 1.26 times (AHR: 1.26; 95% CI: 1.09–1.47) higher among women’s attended primary education and 1.19 times (AHR: 1.19; 95% CI: 1.02–1.38) higher among women’s accessed media. But, the risk of modern contraceptive use was lower among breastfeeding women by 17% (AHR: 0.83; 95% CI: 0.74–0.95).

Conclusion

The median survival timing of modern contraceptive use from the resumption of sexual intercourse was four months. Women residing in urban area, who attended primary education and accessed to media shorten the time to use contraceptives after birth, whereas women breastfed their infant lengthen the time to use a modern contraceptive. Therefore, the health-care provider should enhance modern contraceptive use through health education and promotion to curb down the four months lag period identified by considering the spotted factors.