Contraceptive implants: providing better choice to meet growing family planning demand

Mobilizing stakeholders for implant removals in Burkina Faso using landscape assessment data

BACKGROUND

Successful efforts to encourage uptake of subdermal contraceptive implants, with a lifespan of three to five years, necessitate planning to ensure that quality removal services are available when desired. In Burkina Faso, implant use has tripled over the past 8 years and now comprises almost half of the contraceptive method mix. Population Monitoring for Action (PMA) surveys identified barriers to obtaining quality removal when desired, particularly when the implant is not palpable, or providers lack needed skills or supplies. The Expanding Family Planning Choices (EFPC) project supported ministries of health in four countries with evaluation and strengthening of implant removal services.

METHODS

An implant removal landscape assessment was conducted at 24 health facilities in three regions of Burkina Faso with high implant use that included provider observations of implant removal, interviews with providers and health facility managers, and facility readiness surveys. The project used landscape data to mobilize stakeholders through a series of participatory workshops to develop a collaborative roadmap and commit to actions supporting quality implant removals.

RESULTS

Landscape findings revealed key gaps in provision of quality removal services, including high levels of provider confidence for implant insertion and removal (82% and 71%, respectively), low competence performing simple and difficult removals (19.2% and 11.1%, respectively), inadequate supplies and equipment (no facilities had all necessary materials for removal), lack of difficult removal management systems, and a lack of standard data collection tools for removal. Exposure to the data convinced stakeholders to focus on removals rather than expanding insertion services. While not all roadmap commitments were achieved, the process led to critical investments in quality implant removals.

CONCLUSION

Landscape data revealed that facilities lack needed supplies and equipment, and providers lack skills needed to perform quality implant removals, limiting client reproductive choice. Disseminating this data enabled stakeholders to identify and commit to evidence-based priority actions. Stakeholders have since capitalized on program learnings and the roadmap, including following MOH guidance for implant removal supplies and health provider training. Our experience in Burkina Faso offers a replicable model of how data can direct collective action to improve quality of contraceptive implant removals.

Determinants of contraceptive continuation among women in sub-Saharan Africa

BACKGROUND

Contraceptive continuation is an important factor that has significant implications on total fertility rates and reproductive health outcomes, like unintended pregnancies. Therefore, it is imperative to understand the factors that influence women's decision to continue the use of contraceptives. The present study examined the determinants of contraceptive continuation among women in sub-Saharan Africa (SSA).

METHODS

Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of twenty-four (24) countries in SSA. Descriptive and multivariable binary logistic regression analysis were conducted. Frequencies, percentanges, and an adjusted odds ratio with 95% confidence intervals were used to present the results.

RESULTS

Compared to adolescents, adult women aged 45-49 years [aOR: 1.24; CI: 1.13-1.37] had higher odds of contraceptive continuation. The odds of contraceptive continuation were lower among those working [aOR: 0.96; CI: 0.93-0.98] compared to those not working. Also, the study shows that the likelihood of contraceptive continuation was lower among those exposed to family planning messages compared to those not exposed [aOR: 0.91; CI: 0.88-0.93]. Compared to women who used LARCs, women who used pills [aOR: 0.34; CI: 0.33-0.36], injectable [aOR: 0.42; CI: 0.40-0.43], other modern contraceptives [aOR: 0.72; CI: 0.68-0.75] or traditional methods [aOR: 0.50; CI: 0.478-0.523] were less likely to continue with their contraception. Women with one birth [aOR: 0.86; CI: 0.83-0.90] and those with 2 + births in the last five years [aOR: 0.54; CI: 0.512-0.56] reported lower odds of contraceptive continuation as compared to those with no births. Compared to women with no children living, those with 4 + children living had lower odds of contraceptive continuation [aOR: 0.62; CI: 0.57-0.67]. The study also found that the likelihood of contraceptive continuation was higher among those with secondary education [aOR: 1.08; CI: 1.04-1.12] as compared to those with no formal education. Contraceptive continuation was also higher among those who have information on choice [aOR: 3.91; CI: 3.82-4.01], and also higher among those who were undecided about having an additional child [aOR: 1.39; CI: 1.33-1.46]. Compared to West AfricaAngola, women from all other sub-regions were less likely to continue using contraceptives Comoros were more likely to continue with contraception [aOR: 1.49; CI: 1.24-1.78].

CONCLUSION

To improve contraceptive continuation among women of reproductive age, countries in SSA must invest heavily in advocacy and dissemination of family planning messages, and information of choice. Also, much commitment should be directed towards enhancing the use of long-acting reversible contraceptive use.

Client experiences with telehealth using LINE for consultation and assessment of adverse effects of contraceptive implants during the COVID-19 pandemic in Thailand

Objective

This study aimed to examine clients' experiences with telehealth use for contraceptive implant consultation.

Methods

An online, self-administered survey was conducted with women who used contraceptive implants and faced adverse effects, inquired about side effects, or had concerns. Clients received consultations via LINE, which is a free chat application widely used in Thailand. Participants completed a questionnaire regarding their experiences and satisfaction within 7 days after using the service and a follow-up questionnaire to inquire about the need for in-person services 30 days after using the service.

Results

The participants were 200 women, with a response rate of 82%. Overall, 94% of participants were satisfied with the consultation. Moreover, 37.5% received a message response within 6 hours, and most (89.5%) got a response within 24 hours. The three most frequently reported symptoms were abnormal bleeding or spotting, mood swings, and itching or pain at the surgical site. Most adverse effects were managed through online consultation. Approximately one-third of the participants required in-person visits 30 days after telehealth consultation.

Conclusions

Telehealth consultation for contraceptive implant follow-up resulted in high client satisfaction. Most adverse effects could be managed using telehealth services. Therefore, telehealth could ensure sustained accessibility to reproductive healthcare during and post-COVID-19.

Intention to shift from short-acting to long-acting methods of contraceptives and its associated factors in Gondar city, northwest Ethiopia: Using the theory of planned behavior

Background

Despite its effectiveness, the intention, and utilization of long-acting contraceptive methods are very low in many developing countries, and the use of long-acting contraceptive methods has not kept pace with that of short-acting methods such as oral contraceptives and injectables. Therefore, this study aimed to assess the intention of using long-acting contraceptive methods and associated factors among women currently using short-acting contraceptive methods.

Methods

Institution-based cross-sectional study was conducted from March 19 to April 19, 2017. The study included 515 short-acting contraceptive users found in Gondar city who were selected from the study population using a systematic random sampling technique. A structured pre-tested questionnaire based on the theory of planned behavior was used to collect data. Both descriptive and analytical statistical procedures were used. Simple and multiple linear regression analyses were carried out. SPSS version 20 was used for the analysis of the data. Multiple linear regression was carried out to see the association between intention and sociodemographic variables, past contraception experience, attitude, subjective norm, and perceived behavioral control, and with 95% CI and a p-value of <0.05 was used to detect statistical significance.

Results

The magnitude of intention to use long-acting contraceptive methods was 39.8%. Intention to use long-acting contraceptive methods was higher for women whose husbands were farmers when compared to women whose husbands were government employees (β =0.49, 95% CI: 0.41, 0.72). Number of children wanted (β = −0.19, 95% CI: −0.28, −0.1), attitude (β = 0.34, CI: 0.23, 0.46), subjective norm (β = 19, 95% CI: 0.12, 0.27) and perceived behavioral control (β = 0.18, 95% CI: 0.06, 0.3) were factors significantly associated with intention to use long-acting contraceptive methods.

Conclusions

Intention to use long-acting contraceptive methods was low. Interventions that focus on women's attitudes toward long-acting contraceptive methods and support groups, peer education, social mobilization, and persuasive communication could promote the intention to use long-acting contraceptive methods.

Assessing the cost-effectiveness of contraceptive methods from a health provider perspective: case study of Kiambu County Hospital, Kenya

BACKGROUND

Kenya's contraceptive prevalence rate at 53% is low, with wide disparity among the 47 counties that make up the country (2-76%). Significant financial investment is required to maintain this level of contraceptive use and increase it to levels seen in more developed countries. This is in the context of a growing population, declining donor funding, limited fiscal space and competing health challenges. Studies have shown that long-term contraceptive methods are more cost-effective than short-term methods. However, it is unclear if this applies in Sub-Saharan Africa; with limited financial resources, lower social economic status among users, and publicly managed commodity supply chains, in vertical programs largely dependent on donor funding. This study assessed the cost-effectiveness of contraceptive methods used in Kenya.

METHODS

A cross-sectional study was undertaken in a county referral hospital in mid-2018. Purposive sampling of 5 family planning clinic providers and systematic sampling of 15 service delivery sessions per method was done. Questionnaire aided interviews were done to determine inputs required to provide services and direct observation to measure time taken to provide each method. Cost per method was determined using activity based costing, effectiveness via couple year protection conversion factors, and cost-effectiveness was expressed as cost per couple year protection.

RESULTS

The intra-uterine copper device was most cost-effective at 4.87 US dollars per couple year protection followed by the 2-Rod Implant at 6.36, the 1-Rod Implant at 9.50, DMPA at 23.68, while the combined oral contraceptive pills were least cost-effective at 38.60 US dollars per couple year protection. Long-term methods attracted a higher initial cost of service delivery when compared to short-term methods.

CONCLUSION

Long-term contraceptive methods are more cost-effective. As such, investing in long-term contraceptives would save costs despite higher initial cost of service delivery. It is recommended, therefore, that Sub-Saharan Africa countries allocate more domestic financial resources towards availability of contraceptive services, preferably with multi-year planning and budget commitment. The resources should be invested in a wide range of interventions shown to increase uptake of long-term methods, including reduction of cost barriers for the younger population, thereby increasing contraceptive prevalence rates.

The prevalence of Implanon discontinuation and associated factors among Ethiopian women: A systematic review and meta-analysis

Background:

Implanon discontinuation before the recommended time is problematic, as it puts women at risk of unwanted pregnancies and unsafe abortions, along with negative maternal health outcomes. Although the magnitude and determinants of Implanon discontinuation have been studied in Ethiopia, the results were inconsistent, with significant variability. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of Implanon discontinuation and its determinants in Ethiopia.

Methods:

A comprehensive search of studies published before 18 February 2022 was done using electronic databases such as PubMed, Embase, Google Scholar, Scopus, Web of Science, Science Direct, and Cochrane Library. The relevant data were extracted using a Microsoft Excel 2013 and analyzed using STATA Version 16. A random-effect meta-analysis model was used to compute pooled prevalence and odds ratio. The Cochrane Q test statistics and I² tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg’s, and Egger’s tests were used to check for the presence of publication bias.

Results:

A total of 11 studies with 4320 study participants were included in this meta-analysis. The overall pooled prevalence of Implanon discontinuation in Ethiopia was found to be 32.62% (95% confidence interval = 24.10, 41.13). There was significant heterogeneity among the included studies (I² = 97.4%, p < 0.001). However, there was no statistical evidence of publication bias (p = 0.533). Dissatisfied with service provision at the time of insertion (odds ratio = 3.92, 95% confidence interval = 1.54, 6.29), not having pre-insertion counseling (odds ratio = 2.98, 95% confidence interval = 1.91, 5.04), the absence of post-insertion follow-up (odds ratio = 4.03, 95% confidence interval = 2.17, 5.90), and the presence of side effects (odds ratio = 2.93, 95% confidence interval = 1.87, 3.98) were found to be determinants of Implanon discontinuation.

Conclusion:

According to this systematic review and meta-analysis, one-third of Ethiopian women discontinued Implanon before the recommended time (3 years). Program managers and service providers should consider using more evidence-based and participatory counseling approaches to enhance client satisfaction. Furthermore, family planning service delivery points should be equipped to manage and reassure women who are experiencing side effects.

Community and health provider perspectives on the quality of family planning and contraceptive services in Kabwe District, Zambia

Quality family planning and contraceptive (FP/C) services result in positive outcomes such as client satisfaction and sustained use of contraceptives. While most assessments of quality in FP/C services are based on measurable reproductive health outcomes, there is limited consideration of the perspectives and experiences of health providers and community members. This study aimed to address this knowledge gap, by exploring health providers’ and community perspectives on the elements of quality FP/C services in Kabwe district, Zambia. Fourteen focus group discussions and 10 in-depth interviews were conducted in October–December 2016, involving community members, key community stakeholders such as religious and political leaders, health committee members and frontline and managerial healthcare providers. Data were analysed using a thematic approach. According to study participants, quality FP/C services would include provision by skilled personnel with positive attitudes towards clients, availability of preferred methods and affordable products. Additional factors included appropriate infrastructure, especially counselling services spaces and adequate consultation time. Participants stressed the need for reduced waiting time and opportunity for self-expression. The efficiency and effectiveness of service delivery factors, such as information dissemination and community engagement, were also considered important elements of quality FP/C. This study underscores the value of considering both community and health provider perspectives in efforts to improve the quality of FP/C services, with the overall aim of increasing client satisfaction and sustained utilisation. However, service delivery processes must also be addressed in addition to providing for community participation, if quality is to be achieved in FP/C services.

Level and Timing of Implanon Discontinuation and Associated Factors among Women Who Used Implanon in Andabet District, Public Health Facilities, North-West Ethiopia

Background

Implanon discontinuation is unacceptably high in developing countries, including Ethiopia. Furthermore, there is an observed problem of high unintended pregnancy after method discontinuation that strides to program failure. Therefore, the purpose of this study was to assess the level and determinants of Implanon discontinuation among women who used Implanon in Andabet district, public health facilities, North-West Ethiopia, 2017.

Methods

Facility-based cross-sectional study design was employed among 537 women from Feb. 03 to April 28, 2017. Study participants were selected using a systematic random sampling technique. A face-to-face interview was employed to collect data. Epi-Info version 7 was used for data entry and SPSS version 20 for analysis. Both descriptive and analytical statistical analysis was computed. On multivariable binary logistic regression, a p value of less than 0.05 was used to declare statistical significance.

Results

About 37% of Implanon users have discontinued the method before the intended time. About 86% of them discontinued Implanon before two years of insertion. Women who had no live child (AOR = 2.17, 95% CI: 1.25-3.77), women who did not receive preinsertion counseling (AOR = 1.85, 95% CI: 1.15-2.97), women who developed Implanon-related side effect (AOR = 5.17, 95% CI: 3.18-8.40), and women who did not satisfy by the service provided (AOR = 5.40, 95% CI: 3.04-9.57) had higher odds of Implanon discontinuation. On the other hand, women who received appointment follow-up (AOR = 0.23, 95% CI: 0.13-0.41) had lower odds of Implanon discontinuation.

Conclusions

The level of Implanon discontinuation before its intended time was high in the district. Hence, strengthening preinsertion counseling and appointment follow-up as well as improving the clients' level of service satisfaction could increase Implanon's continuation.

Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption

Approximately 214 million women of reproductive age lack adequate access to contraception for their family planning needs, yet patterns of contraceptive availability have seldom been examined. With growing demand for contraceptives in some areas, low contraceptive method availability and stockouts are thought to be major drivers of unmet need among women of reproductive age, though evidence for this is limited. In this research, we examined trends in stockouts, method availability and consumption of specific contraceptive methods in urban areas of four sub-Saharan African countries (Burkina Faso, Democratic Republic of Congo, Kenya and Nigeria) and India. We used representative survey data from the Performance Monitoring for Action Agile Project that were collected in quarterly intervals at service delivery points (SDP) stratified by sector (public vs private), with all countries having five to six quarters of surveys between 2017 and 2019. Among SDPs that offer family planning, we calculated the percentage offering at least one type of modern contraceptive method (MCM) for each country and quarter, and by sector. We examined trends in the percentage of SDPs with stockouts and which currently offer condoms, emergency contraception, oral pills, injectables, intrauterine devices and implants. We also examined trends of client visits for specific methods and the resulting estimated protection from pregnancy by quarter and country. Across all countries, the vast majority of SDPs had at least one type of MCM in-stock during the study period. We find that the frequency of stockouts varies by method and sector and is much more dynamic than previously thought. While the availability and distribution of long-acting reversible contraceptives (LARCs) were limited compared to other methods across countries, LARCs nonetheless consistently accounted for a larger portion of couple years of protection. We discuss findings that show the importance of engaging the private sector towards achieving global and national family planning goals.

Discontinuation rate and associated factors among contraceptive implant users in Kersa district, southwestern Ethiopia

Background

Subdermal contraceptive implant is the most widely used method of long-acting reversible contraception among Ethiopian women. Many, however, discontinue use early, which results in unwanted pregnancies and induced abortions and their associated complications. The aim of this study is to determine the rate of and reasons for discontinuation of the contraceptive implant among users in the Kersa district of southwestern Ethiopia.

Methods

A mixed-method study was carried out between March and April 2019 among 475 women who had been using the contraceptive implant between January 2015 and August 2016 in the Kersa district. Systematic random sampling was used for quantitative data collection and purposive sampling was used for qualitative data collection using 8 focus group discussion and 56 In-depth interviews. A binary logistic regression was carried out for bivariate and multivariable analyses.

Results

One hundred and ten (23.2 %) contraceptive implant users requested removal before 2.5 years of use. The main reasons for the discontinuation were side effects, followed by a desire for pregnancy or to switch to another contraceptive method and misconceptions. Implant discontinuation was associated with a lack of information prior to insertion on the effectiveness of modern contraception (adjusted odds ratio [OR] 2.0; 95 % confidence interval [CI] 1.13, 3.55), being served by a midwife or nurse (adjusted OR 1.8; 95 % CI 1.04, 3.23), and not being told to return to the health facility if any side effects were experienced (adjusted OR 1.8; 95 % CI 1.01, 3.19) (all p < 0.05).

Conclusions

Almost a quarter of the study participants discontinued use of the contraceptive implant before the due date. Public health interventions should focus on providing adequate awareness for family planning users, trainings for the health care workers on effective counselling services, especially on side effect and misconceptions.

Patterns and determinants of modern contraceptive discontinuation among women of reproductive age: Analysis of Kenya Demographic Health Surveys, 2003-2014

Objectives

This study aimed to examine patterns and determinants of modern contraceptive discontinuation among women in Kenya.

Methods

Secondary analysis was conducted using national representative Kenya Demographic and Health Surveys of 2003, 2008/9, and 2014. These household cross-sectional surveys targeted women of reproductive age from 15 to 49 years who had experienced an episode of modern contraceptive use within five years preceding the surveys from 2003 (n = 2686), 2008/9 (n = 2992), and 2014 (5919). The contraceptive discontinuation rate was defined as the number of episodes discontinued divided by the total number of episodes. Weighted descriptive statistics, multivariable logistic regression analysis, and Cox proportional hazards analysis were used to examine the determinants of contraceptive discontinuation.

Results

The 12-month contraceptive discontinuation rate for all methods declined from 37.5% in 2003 and 36.7% in 2008/9 to 30.5% in 2014. Consistently across the three surveys, intrauterine devices had the lowest 12-month discontinuation rate (6.4% in 2014) followed by implants (8.0%, in 2014). In 2014, higher rates were seen for pills (44.9%) and male condoms (42.9%). The determinants of contraceptive discontinuation among women of reproductive age in the 2003 survey included users of short-term contraception methods, specifically for those who used male condoms (hazard ratio [HR] = 3.30, 95% confidence interval [CI] = 2.13–5.11) and pills (HR = 2.68; 95CI = 1.79–4.00); and younger women aged 15–19 year (HR = 2.07; 95% CI = 1.49–2.87) and 20–24 years (HR = 1.94; 95% CI = 1.61–2.35). The trends in the most common reasons for discontinuation from 2003 to 2014 revealed an increase among those reporting side effects (p = 0.0002) and those wanting a more effective method (p<0.0001). A decrease was noted among those indicating method failure (p<0.0001) and husband disapproval (p<0.0001).

Conclusions

Family planning programs should focus on improving service quality to strengthen the continuation of contraceptive use among those in need. Women should be informed about potential side effects and reassured on health concerns, including being provided options for method switching. The health system should avail a wider range of contraceptive methods and ensure a constant supply of commodities for women to choose from. Short-term contraceptive method users and younger women may need greater support for continued use.

Quality of Long-acting Reversible Contraception Provision in Lomé, Togo

Context

Provision of high-quality contraceptive counseling and services is essential to ensure family planning (FP) programs are rights-based and voluntary. Togo’s modern contraceptive use has steadily increased with almost a quarter of the method mix attributed to long-acting reversible contraceptives (LARC). The purpose of this study is to assess the quality of LARC provision in Togo.

Methods

Data for this study were collected in 2016 as part of a larger research study conducted in Lomé, Togo to assess the effectiveness of the ongoing FP service delivery model. Quality of FP service was assessed in terms of program capacity and program performance. Program capacity was measured with five individual variables and program performance was measured with the Method Information Index (MII). Descriptive statistics and mixed effects models were used to assess likelihood of LARC uptake.

Results

Of the 669 clients included in the study, 19.4% received a LARC method. Multivariable results show that LARC uptake is significantly associated with supervisory visit at the facility in the last three months (program capacity indicator) (OR 1.44; 95%CI 1.48–2.39) and is twice as likely for those with a positive MII score, even after controlling for provider and client characteristics (OR 2.1; 95%CI 1.61–2.51).

Conclusion

This study identified supervisory visits and comprehensive contraceptive counseling as the key quality factors positively associated with uptake of LARC. Continued focus on quality of care and provider–client information exchange is necessary to ensure women’s FP needs are met.

Assessing the Usability of a Task-Shifting Device for Inserting Subcutaneous Contraceptive Implants for Use in Low-Income Countries

Women in low- and middle-income countries (LMICs) have limited access to long-acting contraceptives. Access to long-acting contraceptives, such as subcutaneous contraceptive implants, could be increased by task-shifting implant administration from advanced to minimally trained healthcare providers. The objective of this study was to investigate the usability of a task-shifting device for administering subcutaneous contraceptive implants. Healthcare providers (n = 128) from multiple health centers in Ethiopia were trained to administer implants on an arm simulator with the traditional method and a method using the device. Participants were observed while inserting implants into the arm simulator, and procedural error rates were calculated. Observations were analyzed using an iterative inductive coding methodology. For the device-assisted method, minimally trained healthcare providers had larger procedural error rates than other professions (p = 0.002). For the traditional method, physicians had larger procedural error rates than nurses and midwives (p = 0.03). Several procedural errors were identified such as participants inserting and removing the trocar and plunger completely or inserting and/or removing the trocar too far or not enough. These findings reinforce the importance of performing formative usability testing during the early phases of a medical device design process, considering users' mental models, and avoiding assumptions about healthcare providers' abilities.

Perspectives on contraceptive implant use in women living with HIV in Cape Town, South Africa: a qualitative study among primary healthcare providers and stakeholders

BACKGROUND

This study explored primary healthcare provider and HIV/contraception expert stakeholder perspectives on South Africa's public sector provision of contraceptive implants to women living with HIV. We investigated the contraceptive service-impact of official advice against provision of implants to women using the HIV antiretroviral drug, efavirenz, issued by the South African National Department of Health (NDoH) in 2014.

METHODS

Qualitative data was collected in Cape Town in 2017 from primary healthcare contraceptive providers in four clinics that provide implants, as well as from other expert stakeholders selected for expertise in HIV and/or contraception. In-depth interviews and a group discussion explored South Africa's implant introduction and implant provision to women living with HIV. Data was analysed using an inductive thematic analysis approach.

RESULTS

Interviews were conducted with 10 providers and 10 stakeholders. None of the four clinics where the providers worked currently offered the implant to women living with HIV. Stakeholders confirmed that this was consistent with patterns of implant provision at primary healthcare facilities across Cape Town. Factors contributing to providers' decisions to suspend provision of the implant to women living with HIV included: inadequate initial and ongoing provider training; interpretation of NDoH communications about implant use with efavirenz; provider unwillingness to risk harming clients and concerns about professional liability; and other pressures related to provider capacity.

CONCLUSIONS

All South African women, including those living with HIV, should have access to the full range of contraceptive options for which they are medically eligible. Changing guidance should be initiated and communicated in consultation with primary-level providers and service beneficiaries. Guidance issued to providers needs to be clear and fully evidence-informed, and its correct interpretation and implementation facilitated and monitored. Guidance should be accompanied by provider training, as well as counselling messages and tools to support providers. Generalized retraining of providers in rights-based, client-centred family planning, and in particular implant provision for women with HIV, is needed. These recommendations accord with the right of women living with HIV to access the highest possible standard of sexual and reproductive healthcare, including informed contraceptive choice and access to the contraceptive implant.

Physiologically based pharmacokinetic modelling prediction of the effects of dose adjustment in drug-drug interactions between levonorgestrel contraceptive implants and efavirenz-based ART

Background

HIV-positive women receiving efavirenz-based ART and levonorgestrel contraceptive implants are at risk of low levonorgestrel exposure and unintended pregnancy.

Objectives

To investigate clinically applicable dose-adjustment strategies to overcome the known drug-drug interaction (DDI) between levonorgestrel and efavirenz, using a physiologically based pharmacokinetic (PBPK) modelling-based approach.

Methods

A PBPK model was qualified against clinical data to predict levonorgestrel plasma concentrations when standard-dose (150 mg) levonorgestrel implants were administered alone (control group), as well as when standard-dose or increased-dose (300 mg) levonorgestrel implants were coadministered with either 600 or 400 mg of efavirenz.

Results

No difference was seen between in vivo clinical and PBPK-model-simulated levonorgestrel plasma concentrations (P > 0.05). Simulated levonorgestrel plasma concentrations were ∼50% lower at 48 weeks post-implant-placement in virtual individuals receiving standard-dose levonorgestrel with either 600 or 400 mg of efavirenz compared with the control group (efavirenz:control geometric mean ratio = 0.42 and 0.49, respectively). Conversely, increased-dose levonorgestrel in combination with either 600 or 400 mg of efavirenz was sufficient to restore levonorgestrel concentrations to levels similar to those observed in the 150 mg levonorgestrel control group 48 weeks post-implant-placement (efavirenz:control geometric mean ratio = 0.86 and 1.03, respectively).

Conclusions

These results suggest that the clinically significant DDI between efavirenz and levonorgestrel is likely to persist despite efavirenz dose reduction, whereas dose escalation of implantable levonorgestrel may represent a successful clinical strategy to circumvent efavirenz-levonorgestrel DDIs and will be of use to inform clinical trial design to assess coadministration of efavirenz and levonorgestrel implants.

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women's tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services.

Integration of contraceptive services into anticoagulation management services improves access to long-acting reversible contraception

OBJECTIVE

Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use.

STUDY DESIGN

We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3 months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs.

RESULTS

Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use.

CONCLUSION

Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management.

IMPLICATIONS

A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.

Discontinuation rate of Implanon and its associated factors among women who ever used Implanon in Dale District, Southern Ethiopia

BACKGROUND

Early discontinuation of the Implanon contraceptive method and reasons for such discontinuation remains a major concern for family planning programs. In less developed countries, contraceptive discontinuation due to health concerns is generally higher, these complaints are often related to service quality. Significant numbers of women become exposed to conception after discontinuation and accidental pregnancies that end up with abortion & stillbirth. The aim of this study was to assess the early discontinuation rate of Implanon and identify its associated factors among women who ever used Implanon in 2016 in Dale district, Southern Ethiopia.

METHODS

Community based cross-sectional study design was conducted from January to February, 2017. A total number of 711 women who ever used Implanon in 2016 were selected using multistage sampling. The data were entered and cleaned in Epi Info and analyzed using SPSS. Multivariate logistic regression analysis was used to determine the effect of factors on the outcome variables. Finally, the results were presented using adjusted odds ratio (AOR) & confidence interval of 95%.

RESULT

Early Implanon discontinuation rate in this study was 160 (23.4%) with a mean duration of Implanon use of 9.6 ± 2.5 months. The main reasons for discontinuation of Implanon were 55 (34.4%) the facing of side effects. Factors for discontinuation of Implanon were women age 20-24 years (AOR =. 44 (95% CI: 23-. 85), 25-29 years (AOR =. 52 (95% CI: 27-. 96), 35+ years, (AOR =. 08 (95% CI: 02-. 41), less likely to discontinue. Women who weren't counseled about the side effects during Implanon insertion were 1.93 times (AOR = 1.93 (95% CI: 1.27-2.93), women who didn't satisfied by the service (AOR = 2.55(CI: 95%: 1.63-3.97), women who didn't appointed for follow up (AOR = 3.13 (CI: 95%: 2.0-4.95), women who didn't choose the method by themselves (AOR = 1.83 (CI: 95%: 1.18-2.83) and women who didn't have information on family planning before Implanon insertion (AOR = 1.52 (CI: 95%: 1.1-2.28) were the predictors of Implanon discontinuation.

CONCLUSIONS

Implanon discontinuation rate in this study area was high. Appropriate counseling prior to insertion and proper follow up, autonomous choice will improve the continuation rate of Implanon.

Client Perceptions of Quality and Choice at Static, Mobile Outreach, and Special Family Planning Day Services in 3 African Countries

In all 3 countries, nearly all women obtained their method of choice, with more mobile outreach and special family planning day clients having a preexisting preference for implants than static service clients. Clients of all service modalities in all countries reported experiencing most elements of full, free, and informed choice, but there is room for improvement with some aspects, such as counseling about potential side effects and giving clients the opportunity to ask questions.

Background:

Use of long-acting reversible contraceptives (LARCs) has grown rapidly in the Democratic Republic of the Congo (DRC), Tanzania, and Uganda. Uptake of LARCs is particularly high during mobile outreach and special family planning day events. It is therefore important to examine client perceptions of and experiences with full, free, and informed choice (FFIC) in different service delivery modalities.

Methods:

Between April and July 2015, we conducted a cross-sectional family planning client survey to assess FFIC and client satisfaction at static, mobile outreach, and special family planning day services in the DRC (n=9 sites), Tanzania (n=13), and Uganda (n=8). The study investigated clients' perceptions across 13 elements of FFIC, including measures of the quality of counseling and respondent satisfaction with services across the service delivery approaches. Composite FFIC scores were constructed and analyzed as the proportion of women who reported affirmatively to all elements and the mean score of positive responses. Satisfaction was assessed using a 4-point Likert scale. We used logistic regression to assess the association between the primary outcomes and mode of service delivery.

Results:

In total, we interviewed 585 women (n=150 in Uganda, n=200 in Tanzania, and n=235 in the DRC). The large majority of clients in all countries and modalities received their method of choice. Clients of mobile outreach and special family planning days preferred LARCs and permanent methods, particularly implants, compared with clients at static services. Composite measures of FFIC were lower for mobile outreach than for static services in Tanzania among all family planning clients (odds ratio [OR]=0.5; P≤.001) and among LARC clients specifically (OR=0.5; P≤.01); no significant differences were found in the DRC or Uganda. A mean FFIC score among all family planning clients showed that clients in all modalities in all countries reported experiencing most elements of FFIC, with averages ranging from 4.8 to 6.1 of 7 elements. Among LARC clients specifically, mean scores ranged from 8.3 to 9.8 of 11 elements. Where greater proportions of clients experienced higher FFIC, greater proportions of clients also tended to report being “very satisfied” with aspects of services and counseling.

Conclusions:

The results underscore that special family planning days and mobile outreach services are important and viable ways to increase women's access to family planning services, notably to LARCs, but further attention to respecting and fulfilling clients' full, free, and informed choice across all service delivery modalities is required.

Global Health: Science and Practice … 5 Years In

Five years after launching Global Health: Science and Practice, we are seeing signs that we are helping to fill an important gap in program-related evidence. Looking forward, we seek to offer better coverage for topics that are relatively neglected in the global health literature and to publish more papers by authors based in low- and middle-income countries. We invite authors to submit manuscripts on global health programs grounded in evidence from research, evaluation, monitoring data, or experiential knowledge, and encourage readers to access and share our free articles to find scalable approaches and important lessons to inform programs and policy.

Long acting systemic HIV pre-exposure prophylaxis: an examination of the field

Oral pre-exposure prophylaxis for the prevention of HIV-1 transmission (HIV PrEP) has been widely successful as demonstrated by a number of clinical trials. However, studies have also demonstrated the need for patients to tightly adhere to oral dosing regimens in order to maintain protective plasma and tissue concentrations. This is especially true for women, who experience less forgiveness from dose skipping than men in clinical trials of HIV PrEP. There is increasing interest in long-acting (LA), user-independent forms of HIV PrEP that could overcome this adherence challenge. These technologies have taken multiple forms including LA injectables and implantables. Phase III efficacy trials are ongoing for a LA injectable candidate for HIV PrEP. This review will focus on the design considerations for both LA injectable and implantable platforms for HIV PrEP. Additionally, we have summarized the existing LA technologies currently in clinical and pre-clinical studies for HIV PrEP as well as other technologies that have been applied to HIV PrEP and contraceptives. Our discussion will focus on the potential application of these technologies in low resource areas, and their use in global women's health.

Leveraging long acting reversible contraceptives to achieve FP2020 commitments in sub-Saharan Africa: The potential of implants

Background

In developing regions, an estimated 214 million women have an unmet need for family planning. Reaching Family Planning 2020 (FP2020) commitments will require a shift in modern contraceptive promotion, including improved access to long-acting reversible contraceptives (LARCs). Until now, a lack of market data limited understanding of the potential of LARCs to increase contraceptive access and choice.

Methods

From 2015, the FPwatch Project conducted representative surveys in Ethiopia, Nigeria, and Democratic Republic of Congo (DRC) using a full census approach in selected administrative areas. In these areas, every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, market share, availability, price, and outlet readiness to perform services.

Results

Fifty-four percent of outlets in Ethiopia had LARC commodities or services available at the time of the survey, versus 7% and 8% of outlets in Nigeria and DRC, respectively. When present, LARCs were usually available with at least two other methods (99%, 39%, and 84% of public health facilities in Ethiopia, Nigeria and DRC, respectively). Many public facilities had both implants and IUDs in stock (76%, 47%, and 53%, respectively). Lack of readiness to provide LARCs was mostly due to a lack of equipment, private room, or the commodity itself. Market share for implants in the public sector was 60%, 53%, and 37% of Couple Years of Protection (CYP) in Ethiopia, Nigeria, and DRC.

Discussion

Limited availability of LARCs in Nigeria and DRC restricts contraceptive choice and makes it difficult for women to adopt and use modern contraception consistently. Brand-specific subsidies, task shifting, and promotion of methods that require less equipment and training are promising strategies for increasing uptake. Substantial government investment is required to improve availability and affordability. Investment in implants should be prioritized to make progress towards FP2020 commitments.

Liftoff: The Blossoming of Contraceptive Implant Use in Africa

Contraceptive implant use is rising rapidly, substantially, and equitably in many sub-Saharan African countries, across almost all sociodemographic categories. Gains in implant use have exceeded combined gains for IUDs, pills, and injectables. Key contributing factors include sizeable reductions in commodity cost, much-increased commodity supply, greater government commitment to expanded method choice, and wider adoption of high-impact service delivery practices that broaden access and better reach underserved populations. Continued progress in meeting women's reproductive intentions with implants calls for further investment in quality services for both insertion and removal, and for addressing issues of financing and sustainability.

This article draws from national surveys of every sub-Saharan African country with at least 1 recent survey published between 2015 and 2017 and 2 prior surveys from 2003 to 2014. Twelve countries comprising over 60% of the region's population met these inclusion criteria. The analysis considers recent and longer-term changes in 3 key variables: modern contraceptive prevalence rate (mCPR), method-specific prevalence, and a method's share of the current modern method mix. As recently as 2011, implant CPR in sub-Saharan Africa was only 1.1%. Since then, sizeable price reductions, much-increased commodity supply, greater government commitment to rights-based family planning, broader WHO eligibility guidance, and wider adoption of high-impact service delivery practices have resulted in expanded client access and marked increases in implant prevalence and share of the method mix. Ten of the 12 countries now have an implant CPR around 6% or higher, with 3 countries above 11%. Increased implant use has been the main driver of the increased mCPR attained by 11 countries, with gains in implant use alone exceeding combined gains in use of injectables, pills, and intrauterine devices. In countries as diverse as Burkina Faso and Ethiopia, Democratic Republic of the Congo and Ghana, Kenya and Senegal, implant use now accounts for one-fourth to one-half of all modern method use. Implants have become the first or second most widely used method in 10 countries. In the 7 countries with multiple surveys conducted over a 2- to 3-year span between 2013–14 and 2016–17, average annual gains in implant prevalence range from 0.97 to 4.15 percentage points; this contrasts to historical annual gains in use of all modern methods of 0.70 percentage points in 42 sub-Saharan African countries from 1986 to 2008. Implant use has risen substantially and fairly equitably across almost all sociodemographic categories, including unmarried women, women of lower and higher parity, women in all 5 wealth quintiles, younger and older women, and women residing in rural areas. A notable exception is the category of nulliparous married women, whose implant use is mostly below 1%. These attainments represent a major success story not often seen in family planning programming. With continued program commitment and donor support, these trends in implant uptake and popularity are likely to continue for the next few years. This implies even greater need for the international family planning community to maintain its focus on rights-based programming, ensuring reliable access to implant removal as well as insertion services, and addressing issues of financing and sustainability.

Safety, Quality, and Acceptability of Contraceptive Subdermal Implant Provision by Community Health Extension Workers Versus Nurses and Midwives in Nigeria: Protocol for a Quasi-Experimental, Noninferiority Study

Background

As part of its Family Planning 2020 commitment, the Nigerian government is aiming for a contraceptive prevalence rate of 36% by 2018, and in 2014, approved a policy to allow community health extension workers (CHEWs), in addition to doctors, nurses, and midwives, to provide contraceptive subdermal implants. There is a lack of rigorous evidence on the safety of long-acting reversible contraceptive provision, such as implants, among lower cadres of health providers.

Objective

This study aimed to compare implant provision by CHEWs versus nurses and midwives up to 14 days post insertion.

Methods

The quasi-experimental, noninferiority study will take place in public sector facilities in Kaduna and Ondo States. In each state, we will select 60 facilities, and from these, we will select a total of 30 nurses and midwives and 30 CHEWs to participate. Selected providers will be trained to provide implant services. Once trained, providers will recruit a minimum of 8125 women aged between 18 and 49 years who request and are eligible for an implant, following comprehensive family planning counseling. During implant insertion, providers will record data about the process and any adverse events, and 14 days post insertion, providers will ask 4410 clients about adverse events arising from the implant. Supervisors will observe 792 implant insertions to assess service provision quality and ask clients about their satisfaction with the procedure. We will conclude noninferiority if the CI for the difference in the proportion of adverse events between CHEWs and nurses and midwives on the day of insertion or 14 days post insertion lies to the right of −2%.

Results

In September and October 2015, we trained 60 CHEWs and a total of 60 nurses and midwives from 12 local government areas (LGAs) in Kaduna and 23 LGAs in Ondo. Recruitment took place between November 2015 and December 2016. Data analysis is being finalized, and results are expected in March 2018.

Conclusions

The strength of this study is having a standard care (nurse and midwife provision) group with which CHEW provision can be compared. The intervention builds on existing training and supervision procedures, which increases the sustainability and scalability of CHEW implant provision. Important limitations include the lack of randomization due to nurses and midwives in Nigeria working in separate types of health care facilities compared with CHEWs, and that providers self-assess their own practices. It is unfeasible to observe all procedures independently, and observation may change practice. Although providers will be trained to conduct implant removals, the study time will be too short to reach the sample size required to make noninferiority comparisons for removals.

Trial Registration

ClinicalTrials.gov NCT03088722; https://clinicaltrials.gov/ct2/show/NCT03088722 (Archived by WebCite at http://www.webcitation.org/6xIHImWvu)

Perceptions of and barriers to family planning services in the poorest regions of Chiapas, Mexico: a qualitative study of men, women, and adolescents

Background

In the poorest regions of Chiapas, Mexico, 50.2% of women in need of contraceptives do not use any modern method. A qualitative study was needed to design effective and culturally appropriate interventions.

Methods

We used purposive maximum-variation sampling to select eight municipalities with a high proportion of residents in the poorest wealth quintile, including urban, rural, indigenous, and non-indigenous communities. We conducted 44 focus group discussions with 292 women, adolescent women, and men using semi-structured topic guides. We analyzed the data through recursive abstraction.

Results

There were intergenerational and cultural gaps in the acceptability of family planning, and in some communities family planning use was greatly limited by gender roles and religious objections to contraception. Men strongly influenced family planning choices in many households, but were largely unreached by outreach and education programs due to their work hours. Respondents were aware of many modern methods but often lacked deeper knowledge and held misconceptions about long-term fertility risks posed by some hormonal methods. Acute physical side effects also dissuaded use. The implant was a new and highly acceptable method due to ease of use, low upkeep, and minimal side effects; however, it was perceived as subject to stock-outs. Adolescent women reported being refused services at health facilities and requested more reproductive health information from their parents and schools. Mass and social media are growing sources of reproductive health information.

Conclusions

Our study identifies a number of barriers to family planning that have yet to be adequately addressed by existing programs in Chiapas’ poorest regions, and calls for reinvigorated efforts to provide effective, acceptable, and culturally appropriate interventions for these communities.

Electronic supplementary material

The online version of this article (10.1186/s12978-017-0392-4) contains supplementary material, which is available to authorized users.

Factors influencing use of long-acting versus short-acting contraceptive methods among reproductive-age women in a resource-limited setting

Background

Unplanned pregnancy remains a common problem in many resource-limited settings, mostly due to limited access to modern family planning (FP) services. In particular, use of the more effective long-acting reversible contraceptive (LARC) methods (i.e., intrauterine devices and hormonal implants) remains low compared to the short-acting methods (i.e., condoms, hormonal pills, injectable hormones, and spermicides). Among reproductive-age women attending FP and antenatal care clinics in Uganda, we assessed perceptions and practices regarding the use of modern contraceptive methods. We specifically aimed to evaluate factors influencing method selection.

Methods

We performed a mixed-methods cross-sectional study, in which we administered structured interviews to 180 clients, and conducted 4 focus group discussions (FGDs) with 36 clients and 8 in-depth personal qualitative interviews with health service providers. We summarized quantitative data and performed latent content analysis on transcripts from the FGDs and qualitative interviews.

Results

The prevalence of ever use for LARC methods was 23%. Method characteristics (e.g., client control) appeared to drive method selection more often than structural factors (such as method availability) or individual client characteristics (such as knowledge and perceptions). The most common reasons for choosing LARC methods were: longer protection; better child-spacing; and effectiveness. The most common reasons for not choosing LARC methods included requiring a client-controlled method and desiring to conceive in the near future. The most common reasons for choosing short-acting methods were ease of access; lower cost; privacy; perceived fewer side effects; and freedom to stop using a method without involving the health provider. The personal characteristics of clients, which appeared to be important were client knowledge and number of children. The structural factor which appeared to be important was method availability.

Conclusions

Our results suggest that interventions to improve uptake of LARC among reproductive age women in this setting should consider: incorporating desired method-characteristics into LARC methods; targeted promotion and supply of LARC; and increased counselling, sensitization, and education.

Expanding Access to the Intrauterine Device in Public Health Facilities in Ethiopia: A Mixed-Methods Study

Following the introduction of IUDs into the Ethiopian public health sector, use of the method increased from <1% in 2011 to 6% in 2014 in a sample of 40 health facilities. This shift occurred in the context of wide method choice, following provider training, provision of post-training supplies, and community-based awareness creation. The IUD was acceptable to a diverse range of clients, including new contraceptive users, those with little to no education, those from rural areas, and younger women, thus suggesting a strong latent demand for IUDs in Ethiopia.

In Ethiopia, modern contraceptive prevalence among currently married women nearly tripled over the last decade, but the method mix remains skewed toward short-acting methods. Since 2011, the Integrated Family Health Program (IFHP+), jointly implemented by Pathfinder International and John Snow Inc., has supported the Federal Ministry of Health to introduce intrauterine devices (IUDs) in more than 800 health centers across 4 regions to improve access to a wider range of methods. Between March and August 2014, Pathfinder conducted a mixed-methods study in 40 purposively selected health centers to assess shifts in the contraceptive method mix following introduction of IUDs using data from family planning registers; determine the characteristics of IUD users through a cross-sectional survey of 2,943 family planning clients who accepted the IUD; explore reasons for method discontinuation among 165 clients seeking IUD removal services; and identify facilitators and barriers to IUD use through focus group discussions (N = 115 clients) and key informant interviews (N = 36 providers, facility heads, and health office heads). Introduction of IUDs into the 40 health centers participating in the study was correlated with a statistically significant increase in the contribution of all long-acting reversible contraceptives (LARCs)—both IUDs and implants—to the method mix, from 6.9% in 2011 to 20.5% in 2014 (P<.001). Our study found that latent demand for the IUD was more prevalent than anticipated and that the method was acceptable to a broad cross-section of women. Of the 2,943 women who sought IUDs during the 6-month study period, 18.0% were new contraceptive users (i.e., those using a contraceptive method for the first time ever), 44.7% reported no educational attainment, 62.5% were from rural areas, and 59.3% were younger than 30 years old, with almost 3 in 10 (27.7%) under the age of 25. The most commonly cited reason for seeking IUD removal services was a desire to become pregnant (43% of women). Qualitative data indicated that while acceptability of the method is growing, limited community awareness, myths and misconceptions about the IUD, and infrastructure deficits at health centers must be addressed to further expand access to a broad range of contraceptive methods.

Unintended Pregnancies Observed With Combined Use of the Levonorgestrel Contraceptive Implant and Efavirenz-based Antiretroviral Therapy: A Three-Arm Pharmacokinetic Evaluation Over 48 Weeks

BACKGROUND

Levonorgestrel subdermal implants are preferred contraceptives with an expected failure rate of <1% over 5 years. We assessed the effect of efavirenz- or nevirapine-based antiretroviral therapy (ART) coadministration on levonorgestrel pharmacokinetics.

METHODS

This nonrandomized, parallel group, pharmacokinetic evaluation was conducted in three groups of human immunodeficiency virus-infected Ugandan women: ART-naive (n = 17), efavirenz-based ART (n = 20), and nevirapine-based ART (n = 20). Levonorgestrel implants were inserted at baseline in all women. Blood was collected at 1, 4, 12, 24, 36, and 48 weeks. The primary endpoint was week 24 levonorgestrel concentrations, compared between the ART-naive group and each ART group by geometric mean ratio (GMR) with 90% confidence interval (CI). Secondary endpoints included week 48 levonorgestrel concentrations and unintended pregnancies.

RESULTS

Week 24 geometric mean levonorgestrel concentrations were 528, 280, and 710 pg/mL in the ART-naive, efavirenz, and nevirapine groups, respectively (efavirenz: ART-naive GMR, 0.53; 90% CI, .50, .55 and nevirapine: ART-naive GMR, 1.35; 90% CI, 1.29, 1.43). Week 48 levonorgestrel concentrations were 580, 247, and 664 pg/mL in the ART-naive, efavirenz, and nevirapine groups, respectively (efavirenz: ART-naive GMR, 0.43; 90% CI, .42, .44 and nevirapine: ART-naive GMR, 1.14; 90% CI, 1.14, 1.16). Three pregnancies (3/20, 15%) occurred in the efavirenz group between weeks 36 and 48. No pregnancies occurred in the ART-naive or nevirapine groups.

CONCLUSIONS

Within 1 year of combined use, levonorgestrel exposure was markedly reduced in participants who received efavirenz-based ART, accompanied by contraceptive failures. In contrast, nevirapine-based ART did not adversely affect levonorgestrel exposure or efficacy.

CLINICAL TRIALS REGISTRATION

NCT01789879.

The Levonorgestrel Intrauterine System: Reasons to Expand Access to the Public Sector of Africa

The levonorgestrel intrauterine system has: (1) excellent effectiveness, (2) high satisfaction levels, (3) non-contraceptive benefits, and (4) potential to help reinvigorate interest in intrauterine contraception. The time is ripe for ministries and donor agencies to work together to make the product widely available across Africa.

Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria

BACKGROUND

Contraceptive use remains low in Nigeria, with only 11% of women reporting use of any modern method. Access to long-acting reversible contraceptives (LARCs) is constrained by a severe shortage of human resources. To assess feasibility of task shifting provision of implants, we trained community health extension workers (CHEWs) to insert and remove contraceptive implants in rural communities of Bauchi and Sokoto states in northern Nigeria.

METHODS

We conducted 2- to 3-week training sessions for 166 selected CHEWs from 82 facilities in Sokoto state (September 2013) and 84 health facilities in Bauchi state (December 2013). To assess feasibility of the task shifting approach, we conducted operations research using a pretest-posttest design using multiple sources of information, including surveys with 151 trained CHEWs (9% were lost to follow-up) and with 150 family planning clients; facility observations using supply checklists (N = 149); direct observation of counseling provided by CHEWs (N = 144) and of their clinical (N = 113) skills; as well as a review of service statistics (N = 151 health facilities). The endline assessment was conducted 6 months after the training in each state.

RESULTS

CHEWs inserted a total of 3,588 implants in 151 health facilities over a period of 6 months, generating 10,088 couple-years of protection (CYP). After practicing on anatomic arm models, most CHEWs achieved competency in implant insertions after insertions with 4-5 actual clients. Clinical observations revealed that CHEWs performed implant insertion tasks correctly 90% of the time or more for nearly all checklist items. The amount of information that CHEWs provided clients increased between baseline and endline, and over 95% of surveyed clients reported being satisfied with CHEWs' services in both surveys. The study found that supervisors not only observed and corrected insertion skills, as needed, during supervisory visits but also encouraged CHEWs to conduct more community mobilization to generate client demand, thereby promoting access to quality services. CHEWs identified a lack of demand in the communities as the major barrier for providing services.

CONCLUSION

With adequate training and supportive supervision, CHEWs in northern Nigeria can provide high-quality implant insertion services. If more CHEWs are trained to provide implants and greater community outreach is conducted to generate demand, uptake of LARCs in Nigeria may increase.

Factors influencing uptake of contraceptive implants in the immediate postpartum period among HIV infected and uninfected women at two Kenyan District Hospitals

Background

Family planning is a cost effective strategy for prevention of mother to child transmission of HIV and reduction of maternal/infant morbidity and mortality. Contraceptive implants are a safe, effective, long term and reversible family planning method whose use remains low in Kenya. We therefore set out to determine and compare the uptake, and factors influencing uptake of immediate postpartum contraceptive implants among HIV infected and uninfected women at two hospitals in Kenya.

Methods

This cross sectional study targeted postpartum mothers at two Kenyan district hospitals (one urban and one rural). All participants received general family planning and method specific (Implant) counseling followed by immediate insertion of contraceptive implants to those who consented. The data was analyzed by descriptive analysis, T-test, Chi square tests and logistic regression.

Results

One hundred eighty-five participants were enrolled (91 HIV positive and 94 HIV negative) with a mean age of 26 years. HIV positive mothers were significantly older (27.5 years) than their HIV negative counterparts (24.5 years), P = 0.001. The two groups were comparable in education, employment, marital status and religious affiliation. Overall, the uptake of contraceptive implants in the immediate postpartum period was 50.3 % and higher among HIV negative than HIV positive participants (57 % vs. 43 %, P = 0.046). Multivariate analysis revealed that a negative HIV status (P = 0.017) and prior knowledge of contraceptive implants (P = 0.001) were independently associated with increased uptake of contraceptive implants.

Conclusion

There was a high uptake of immediate postpartum contraceptive implants among both HIV infected and un-infected women; efforts therefore need to be made in promoting this method of family planning in Kenya and providing this method to women in the immediate postpartum period so as to utilize this critical opportunity to increase uptake and reduce the high unmet need for family planning.

A bright future for IUD use in Africa?

High uptake of IUDs under the mobile outreach service delivery model in Kenya bodes well for IUDs in sub-Saharan Africa, if delivered with good access and quality.

Progestin-only contraception: injectables and implants

Progestin-only contraceptive injectables and implants are highly effective, longer-acting contraceptive methods that can be used by most women in most circumstances. Globally, 6% of women using modern contraception use injectables and 1% use implants. Injectables are the predominant contraceptive method used in sub-Saharan Africa, and account for 43% of modern contraceptive methods used. A lower-dose, subcutaneous formulation of the most widely used injectable, depot-medroxyprogesterone acetate, has been developed. Implants have the highest effectiveness of any contraceptive method. Commodity cost, which historically limited implant availability in low-resource countries, was markedly lowered between 2012 and 2013. Changes in menstrual bleeding patterns are extremely common with both methods, and a main cause of discontinuation. Advice from normative bodies differs on progestin-only contraceptive use by breastfeeding women 0-6 weeks postpartum. Whether these methods are associated with HIV acquisition is a controversial issue, with important implications for sub-Saharan Africa, which has a disproportionate burden of both human immunodeficiency virus (HIV) and maternal mortality.

Rationale, design, and cohort enrolment of a prospective observational study of the clinical performance of the new contraceptive implant (Femplant) in Pakistan

Introduction

The use of hormonal implants has gained positive traction in family planning programs in recent times. Compared to other popular methods, such as long-term reversible intrauterine devices, the use of hormonal implants as a family planning method has distinct advantages in terms of long-term efficiency and better user compliance and availability. This paper presents a study protocol to document and evaluate the efficacy, safety, and acceptability of Femplant (contraceptive implant) in Pakistan during the first year of its use among married women of reproductive age (18–44 years) at clinics in two provinces of Pakistan (Sindh and Punjab).

Materials and methods

A total of 724 married women were enrolled in a noncomparative prospective observational study. The study involved six government clinics from the Population Welfare Department in Sindh Province and 13 clinics run by the Marie Stopes Society (a local nongovernmental organization) in both provinces. The participation of women was subject to voluntary acceptance and medical eligibility. All respondents were interviewed at baseline and subsequently at each scheduled visit during the study period. Side effects, complications and adverse events, if any, were recorded for every participant at each visit to the facility.

Discussion

Over the next 5-year period (2013–2018), 27 million hormonal implants will be made available in lower- to middle-income countries by international donors and agencies. The evidence generated from this study will identify factors affecting the acceptability and satisfaction of end users with Femplant (Sino-implant II). This will help to guide policies to enhance access to and the use of long-acting contraceptive implants in Pakistan and similar developing countries.

Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

Contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub-Saharan Africa. Marie Stopes International (MSI) offers implants as one of many family planning options. Between 2008 and 2012, MSI scaled up voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. High levels of client satisfaction were attained alongside service provision scale up by using existing MSI service delivery channels-mobile outreach, social franchising, and clinics-to implement strategies that broadened access for underserved clients and maintained service quality. Use of adaptive and context-specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. Accounting for 70% of the implants delivered by MSI in 2012, mobile outreach services through dedicated MSI provider teams played a central role in scale-up efforts, fueled in part by the provision of free or heavily subsidized services. Social franchising also demonstrated promise for future program growth, along with MSI clinics. Continued high growth in implant provision between 2011 and 2012 in all sub-Saharan African countries indicates the region's capacity for further service delivery expansion. Meeting the expected rising demand for implants and ensuring long-term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. MSI's experience can be instructive for future efforts to ensure contraceptive access and choice in sub-Saharan Africa, especially as the global health community works to achieve its Family Planning 2020 (FP2020) commitments to expand family planning access to 120 million new users.

Use of modern contraception increases when more methods become available: analysis of evidence from 1982-2009

OBJECTIVE

To examine how much contraceptive use increases as additional methods are made available to populations.

METHODS

We used data estimating contraceptive use from representative national surveys and data estimating method availability from special surveys to make comparisons for 6 modern contraceptive methods, in each of 6 years: 1982, 1989, 1994, 1999, 2004, and 2009. To estimate method availability, we used various method accessibility rules governing different proportions of the total population (ranging from 20% to 80%) that must have access to a method in order for it to qualify as "available."

RESULTS

Contraceptive use is greater when more methods are available to a large portion of the population, both cross-sectionally and over time. The addition of 1 method available to at least half the population correlates with an increase of 4-8 percentage points in total use of the 6 modern methods, for example, from 40% to 44% or 48%. A consistent pattern emerges for the relationship of contraceptive use and choice among multiple methods.

CONCLUSIONS

Use of contraception may be increased by extending the availability of current methods, by improving features of current methods, or by introducing new methods. A wider choice of methods also improves the ability to meet the individual needs of women and couples. Although the method mix has been improving over time, current availability is far from ideal; in 2009, only about 3.5 methods, on average, were available to at least half of the population in the 113 countries included in our analysis.

Meeting the need for modern contraception: effective solutions to a pressing global challenge

Voluntary family planning is one of the most efficacious and cost-effective means of improving individual health, gender equity, family well-being, and national development. Increasing contraceptive use and reducing unmet need for family planning are central to improving maternal health (UN Millennium Development Goal 5). In less-developed regions of the world, especially Sub-Saharan Africa and South Asia, human and financial resources are limited, modern contraceptive use is relatively low, unmet need for modern contraception is high, and consequently maternal morbidity and mortality are high. However, the international community is showing renewed commitment to family planning, a number of high impact program practices have been identified, and a number of Sub-Saharan African countries (e.g. Ethiopia, Malawi, and Rwanda) have successfully made family planning much more widely and equitably available. The International Federation of Gynecology and Obstetrics (FIGO) has joined with other international and donor organizations in calling for increased funding and more effective programming to improve maternal health and family planning in low-resource countries. Continued engagement by FIGO, its member societies, and its individual members will be helpful in addressing the numerous barriers that impede universal access to modern contraception in low-resource countries.