Assessment of Family Planning Service Availability and Readiness in 10 African Countries

A qualitative exploration of how a community engagement approach influences community and health worker perceptions related to family planning service delivery in Togo

Background

There is a growing body of evidence that asserts community engagement approaches can improve the quality of reproductive health services. Family planning (FP) programs in Togo are implementing such approaches, which aim to mobilize both health workers and communities to improve FP service quality and FP uptake. However, there is not enough known about the enabling factors and challenges associated with implementation, or the extent to which the programs improve outcomes leading to contraceptive uptake.

Methods

We qualitatively explored how a community engagement approach influenced health worker and community perceptions related to FP service delivery in and around the city of Lomé, Togo, within the context of the broader integration of social and behavior change and service delivery. We conducted 18 in-depth interviews with health workers and 9 focus group discussions with community members.

Results

We found the approach, which included community dialogues, site walkthrough visits and the development of community action plans, worked synergistically together to support collaborative action between communities and health workers to increase mutual understanding of their collective needs related to FP services. Community members cited improved reception at the health facilities by health workers and indicated that the site walkthrough visits created a greater sense of empathy towards the providers and the challenges faced in their work environment. Health workers acknowledged a greater understanding of barriers at the community level following community dialogues, particularly among community members that are not routinely encountered at the health facility for reproductive health services such as men and youth. We found limited implementation of health facility improvements included in community action plans because they were dependent on commitment from community leadership and the need to mobilize additional support or financial resources.

Conclusion

Community engagement approaches are a promising mechanism to support collaboration and enhance mutual understanding between health workers and communities to achieve improved FP service quality. Future programs should consider incorporating additional mechanisms to monitor community action plans and provide support to address structural challenges at the facility level particularly those that require financial resources.

Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

Family planning integration in Ethiopia's primary health care system: a qualitative study on opportunities, challenges and best practices

BACKGROUND

Family planning (FP) service integration into primary health care (PHC) is an effective approach to realize reproductive autonomy, increase the use of contraceptives, and improve maternal and child health outcomes. The Ethiopian government promotes integration of FP services into primary health care (PHC). However, there is paucity of evidence on the status of FP service integration. The aim of this study is to explore the state of FP integration into PHC services and identify facilitators and barriers to integration.

METHODS

A qualitative study nested with a larger national study was conducted from July to October 2022. A total of 60 interviews were conducted with FP stakeholders including, government organizations, non-governmental organizations, donors, service providers, and clients. Interviews were audio recorded, transcribed, and coded using OpenCode 4.03. The coded data were analyzed using framework analysis approach, using the Primary Health Care Performance Initiative (PHCPI) framework. Direct quotes and results from the coding and categorization were used to develop the report.

RESULTS

Family planning is largely provided in designated units by dedicated staff within PHC facilities. The provision of integrated FP service within each service unit is in its early stage. Successful examples of integration include integration of FP with postnatal care, abortion care, and youth-friendly service centers. Facilitators of integration include commitment of the government and partners, the presence of policies and guidelines, and positive attitude of service providers and clients. However, integration of FP also faces challenges that are largely related to challenges of the FP program even before integration. These include resource shortage, health workers shortage, health workers' capacity/skill gaps, misconceptions about FP, religious and socio-cultural norms, and lack of awareness.

CONCLUSIONS

Integration of FP with PHC services in the Ethiopian public health facilities is viable. Pre-existing challenges of the FP program continued to be barriers to integration. Expanding the experiences of good practices in the integration of FP with post abortion care, post-natal care, and youth-friendly service centers to other components of PHC warrants attention. Addressing both supply- and demand-side challenges of the FP program is needed to facilitate the integration of FP with other PHC services.

Assessing the readiness of health facilities to provide family planning services in low-resource settings: Insights from nationally representative service provision assessment surveys in 10 Countries

BACKGROUND

Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools-which break down health systems into measurable, trackable components-are one useful way to assess service readiness and the ability of health institutions to deliver FP services.

METHODS

Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities' readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan, Bangladesh, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and the Democratic Republic of the Congo (DRC). We analyzed data from public and private health facilities in Afghanistan (84), Bangladesh (1,303), Kenya (567), Malawi (810), Namibia (357), Nepal (899), Rwanda (382), Senegal (334), Tanzania (933), and the DRC (1,061) for a total of 6,730 facilities. We used 17 items/indicators recommended by the Service Availability and Readiness Assessment to measure a health facility's readiness to provide FP services across four domains.

RESULTS

Only 3.6% to 34.1% of the health facilities were reporting at least 75% (12-13 of 17) of the relevant items for FP service provision. Most of the health facilities in the countries under investigation suffered from lack of readiness, meaning that they did not fulfill at least 75% of the standards (12-13 items of 17 items on the availability of trained staff and guidelines, equipment, and commodities components). The factors associated with higher readiness scores varied among the 10 countries analyzed. Regression models showed that increases in the number of FP healthcare providers available at a health facility and infection control measures for FP exams were factors linked to increased readiness scores in all 10 countries. The low readiness of health facilities to provide FP services in the countries studied showed that the health systems in these low-resource settings faced significant problems with providing FP services. Differences in country-specific variability in the characteristics linked with better preparedness ratings could be attributed to data collected across different years in different nations or to country-specific healthcare financing policies.

CONCLUSIONS

To increase a health facility's readiness to offer FP services, country-specific factors must be addressed, in addition to common factors found in all 10 countries. Further research is required to determine the causes of country-level differences in FP tracer item availability to develop targeted and effective country-specific strategies to improve the quality of FP services in the SA and SSA regions and address unmet need for FP.

Health facility readiness to screen, diagnose and manage substance use disorders in Mbale district, Uganda

BACKGROUND

Substance use disorders (SUD) pose a significant public health problem in Uganda. Studies indicate that integrating mental health services into Primary Health Care can play a crucial role in alleviating the impact of SUD. However, despite ongoing efforts to integrate these services in Uganda, there is a lack of evidence regarding the preparedness of health facilities to effectively screen and manage SUD. Therefore, this study aimed to assess the readiness of health facilities at all levels of the health system in Mbale, Uganda, to carry out screening, diagnosis, and management of SUD.

METHODS

A health facility-based cross-sectional study was carried out among all the 54 facilities in Mbale district. A composite variable adapted from the WHO Service Availability and Readiness Assessment manual (2015) with 14 tracer indicators were used to measure readiness. A cut-off threshold of having at least half the criteria fulfilled (higher than the cutoff of 7) was classified as having met the readiness criteria. Descriptive analyses were performed to describe readiness scores across various facility characteristics and a linear regression model was used to identify the predictors of readiness.

RESULTS

Among all health facilities assessed, only 35% met the readiness criteria for managing Substance Use Disorders (SUD). Out of the 54 facilities, 42 (77.8%) had guidelines in place for managing SUD, but less than half, 26 (48%), reported following these guidelines. Only 8 out of 54 (14.5%) facilities had staff who had received training in the diagnosis and management of SUD within the past two years. Diagnostic tests for SUD, specifically the Uri stick, were available in the majority of facilities, (46/54, 83.6%). A higher number of clinical officers working at the health centres was associated with higher readiness scores (score coefficient 4.0,95% CI 1.5-6.5).

CONCLUSIONS

In this setting, a low level of health facility readiness to provide screening, diagnosis, and management for substance use disorders was found. To improve health facility readiness for delivery of care for substance use disorders, a frequent inventory of human resources in terms of numbers, skills, and other resources are required in this resource-limited setting.

Strengthening systems to provide long-acting reversible contraceptives (LARCs) in public sector health facilities in Uganda and Zambia: Program results and learnings

INTRODUCTION

In Uganda and Zambia, both supply- and demand-side factors hamper availability of long-acting reversible contraceptives (LARCs), including implants and intrauterine devices (IUDs), at public sector facilities. This paper discusses results of a program aimed at increasing access to and uptake of LARC services in public sector facilities through capacity building of government health workers, strengthening government supply chains, and client mobilization.

METHODS

From 2018-2021, the Ministries of Health (MOHs) in Uganda and Zambia and Clinton Health Access Initiative (CHAI) worked to increase readiness to provide LARC services within 51 focal facilities in Uganda and 85 focal facilities in Zambia. Annual facility assessments of LARC-related resources were conducted and routine service delivery data were monitored.

RESULTS

At baseline, few focal facilities had supplies and skilled staff to provide LARC services. At endline, over 90% of focal facilities in both countries had a provider trained to provide both implants and IUDs and 55% had the commodities and equipment needed for implant provision. In Uganda and Zambia, respectively, 65% and 38% of focal facilities had commodities and equipment for IUD provision at endline. Both programs observed significant increases in the number of implants provided at focal facilities; in Uganda implant volumes increased five-fold from 4,560 at baseline to 23,463 at endline, and in Zambia implant volumes increased nearly four-fold from 1,884 at baseline to 7,394 at endline. Uganda did not observe growth in IUD volumes, whereas Zambia observed significantly increased IUD service volumes from 251 at baseline to 3,866 at endline.

CONCLUSIONS

Public sector facilities can be rapidly and sustainably capacitated to provide LARCs when both catalytic and systems strengthening interventions are deployed for health worker capacity building, supply chain management, and community mobilization to ensure client flow. Investments should be intentionally sequenced and coordinated to generate a virtuous cycle that enables continued LARC service provision.

Health facility availability and readiness for family planning and maternity and neonatal care services in Nepal: Analysis of cross-sectional survey data

OBJECTIVES

To determine the availability and readiness of health facilities to provide family planning, antenatal care and basic emergency obstetric and newborn care in Nepal in 2021. Secondary objectives were to identify progress since 2015 and factors associated with readiness.

METHOD

This is a secondary analysis of cross-sectional Nepal Health Facility Survey (NHFS) data collected in 2015 and 2021. The main outcome measures were availability and readiness of family planning, antenatal care, and basic emergency obstetric and newborn care services. Readiness indices were calculated using WHO-recommended service availability and readiness assessment (SARA) methods (score range 0 to 100%, with 100% indicating facilities are fully prepared to provide a specific service). We used independent t-tests to compare readiness indices in 2015 and 2021. Factors potentially associated with readiness (rurality setting, ecological region, managing authority, management meeting, quality assurance activities, and external supervision) were explored using multivariable linear regression.

RESULTS

There were 940 and 1565 eligible health facilities in the 2015 and 2021 surveys, respectively. Nearly all health facilities provided family planning (2015: n = 919 (97.8%); 2021: n = 1530 (97.8%)) and antenatal care services (2015: n = 920 (97.8%); 2021: n = 1538 (98.3%)) in both years, but only half provided delivery services (2015: n = 457 (48.6%); 2021: n = 804 (51.4%)). There were suboptimal improvements in readiness indices over time: (2015-21: family planning 68.0% to 70.9%, p<0.001, antenatal care 49.5% to 54.1%, p<0.001 and basic emergency obstetric and newborn care 56.7% to 58.0%, p = 0.115). The regression model comprising combined datasets of both NHFSs indicates facilities with regular management meetings and/or quality assurance activities had significantly greater readiness for all three indices. Similarly, public facilities had greater readiness for family planning and basic emergency obstetric and newborn care while they had lower readiness for antenatal care.

CONCLUSIONS

Readiness to deliver family planning, antenatal care and basic emergency obstetric and newborn care services in Nepal remains inadequate, with little improvement observed over six years.

Reasons for modern contraceptives choice and long-acting reversible contraceptives early removal in Amhara Region, Northwest Ethiopia; qualitative approach

BACKGROUND

Women use modern contraceptive methods, mainly either to limit or space pregnancy and both are not identical in their choices. One method may not best fit an individual's need irrespective of the time of spacing. Cognizant of this, the context with which women base in choice of contraceptives, their lived experiences in using, and factors for early removal/ discontinuation of long-acting reversible contraceptives (LARCs) are not much investigated in the study setting and our study aimed to bridge the gap through exploring the underlying reasons.

METHOD

A phenomenological study design was used to explore sampled women's reasons and experiences. Reproductive-aged women (15-49 years) who removed long-acting methods in the past 6 months were included. A criterion sampling approach was employed to recruit study participants. Data was collected using an interview guide for in-depth (IDIs) and key informant interviews and were tape-recorded with interviewees' consent. Audio data were transcribed verbatim and translated into English. The data was first saved in plain text format and imported into Atlas.ti 7.0 software to facilitate coding and categorizing. The content analysis method was used to classify, organize data, and interpret the qualitative data according to key categories.

RESULTS

Several misconceptions about contraceptives (e.g., implants are not appropriate for daily laborers, women who use contraceptives (such as injectables) can only bear girl-child, etc.) were reported by clients and health providers. These misconceptions might not have scientific merit but they are powerful enough to affect actual behaviors toward contraceptives, including early removal. The awareness, attitude, and use of contraceptives tend to be lower in rural areas. For premature removal of LARCs, side effects, and heavy menstrual bleeding, was the most commonly identified reason. The IUCD is the least preferred method and users said it is not comfortable during sex.

CONCLUSION AND RECOMMENDATION

Our study found different reasons and misconceptions for modern contraceptive methods' non-use and discontinuation. Standardized counseling approaches like the REDI (Rapport Building, Exploration, Decision Making, and Implementation) framework should be implemented in the country consistently. Some of the concrete providers' conceptions should be well-studied considering contextual factors to bring scientific evidence.

Barriers to using postpartum family planning among women in Zanzibar, Tanzania

BACKGROUND

Effective family planning is associated with substantial benefits, including reductions in maternal and neonatal mortality due to the avoidance of unintended pregnancies, and contributions to spacing, timing, and limiting births. However, in Zanzibar, Tanzania, the utilization of modern contraceptive methods is low. This study therefore aimed to identify barriers to using postpartum family planning among women in Zanzibar.

METHODS

Five focus group discussions were conducted with 24 women who gave birth in the maternity unit at a reference hospital in Zanzibar during the first quarter of 2022. The discussions took place in Swahili, were performed with the assistance of an interview guide, and were audio recorded, transcribed in Swahili, and translated to English. Data were analysed with qualitative content analysis using an inductive approach.

RESULTS

Barriers to using postpartum family planning in Zanzibar could be summarized in three generic categories. Inadequate knowledge about postpartum family planning is expressed in the subcategories: inadequate knowledge about contraceptive methods and their mode of action, insufficient quality of family planning services, and belief in traditional and natural medicine for family planning. Perceived risks of modern contraceptive methods are described in the subcategories: fear of being harmed, and fear of irregular bleeding. Limited power in one's own decision about contraceptive use consist of the subcategories: the need to involve the husband, and opposition and lack of interest from the husband.

CONCLUSIONS

The participants' current knowledge of postpartum family planning was insufficient to either overcome the fear of side-effects or to understand which side-effects were real and likely to happen. The woman's power in her own decision-making around her sexual reproductive rights is of critical importance. Given the barriers identified in this study, the findings call for increased knowledge about family planning methods and their mode of action, and involvement of the husband throughout pregnancy, childbirth, and the postpartum period in postpartum family planning education and counselling, in Zanzibar and in similar settings.

Modern Postpartum Family Planning and Associated Factors Among Postpartum Women in a Rural District of Ethiopia, 2021: A Cross-Sectional Study

The first year after a woman has given birth is critical for use of contraceptives although many women do not realize that they are at a risk for pregnancy. The main objective of this study was to assess the utilization of modern Postpartum Family Planning (PPFP) and associated factors among postpartum women in a rural district, Ethiopia. A cross-sectional study involving randomly selected 389 postpartum women was conducted in Ambo rural district from May 20, 2021 to June 10, 2021. Data were collected through face to- face interviews, entered into EPI Data version 3.1, and analyzed by SPSS version 25.0. In multivariable binary logistic regression, adjusted odds ratios (AOR) with 95% confidence interval (CI) were computed and statistical significance was declared at p < 0.05. The prevalence of modern PPFP was 72.5% (95% CI: 68%, 77%). Utilization of PPFP was significantly associated with women's self decision making (AOR = 6.43, 95% CI: 1.98, 20.90), counseling during antenatal care (AOR = 9.71, 95% CI: 3.83, 24.61), visit health facility after delivery (AOR = 5.24, 95% CI: 2.32, 11.84), ever heard of modern family planning (AOR = 5.17, 95% CI: 1.88, 14.23), perceived partner approval (AOR = 4.31, 95% CI: 1.62, 11.47), and the lowest income (AOR = 0.12, 95% CI: 0.02, 0.68). The use of modern PPFP in the study area was encouraging, which helps to prevent unplanned and unwanted pregnancies and spacing pregnancies. Therefore, family planning providers should focus on raising women's awareness and counseling their partners as part of a continuum of points of contact to encourage women to use the service.

Barriers to family planning use in the Eastern Democratic Republic of the Congo: an application of the theory of planned behaviour using a longitudinal survey

OBJECTIVE

In the Democratic Republic of the Congo, there is a low adherence of the population to the use of family planning (FP) due to various social barriers. This study aimed to understand the drives from social barriers to the use of FP in women in the Kivu, a region particularly affected by poverty and many years of conflicts. A theory of planned behaviour (TPB) using a generalised structural equation modelling has been applied to understand the complex sociocultural drivers to the intention and the ultimate decision to use FP.

DESIGN

Longitudinal study.

SETTING

A community-based approach was used to investigate FP use in the North and South-Kivu regions.

PARTICIPANTS

Overall, 1812 women 15 years and older were enrolled in the baseline study and 1055 were retrieved during the follow-up.

PRIMARY AND SECONDARY OUTCOMES

FP use and intention to use FP.

RESULTS

The mean age was 36±12.9 years, with a minimum of 15 years old and a maximum of 94 years old. Among sexually active participants, more than 40% used a modern contraceptive method at the last sexual intercourse. Education was positively and significantly associated with intention to use FP (β=0.367; p=0.008). Being married was positively and marginally significantly associated with intention to use FP (β=0.524: p=0.050). Subjective norms were negatively and significantly associated with intention to use FP (β=-0.572; p=0.003) while perceived control was positively associated with intention to use FP (β=0.578; p<0.0001). Education and perceived control were positively and significantly associated with the use of FP (respectively, β=0.422, p=0.017; and β=0.374; p=0.017), while Intention to use FP was positively and marginally significantly associated with the use of FP (β=0.583; p=0.052).

CONCLUSION

TPB helped understand sociocultural barriers to FP use and it can be useful to define adapted strategies in different contexts.

Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study

BACKGROUND

The prevalence of modern contraception use is higher in Kenya than in most countries in Sub-Saharan Africa. The uptake has however slowed down in recent years, which, among other factors, has been attributed to challenges in the supply chain and increasing stockouts of family planning commodities. Research on the frequency of contraceptive stockouts and its consequences for women in Kenya is still limited and mainly based on facility audits.

METHODS

This study employs a set of methods that includes mystery clients, focus group discussions, key informant interviews, and journey mapping workshops. Using this multi-method approach, we aim to quantify the frequency of method denial resulting from contraceptive stockout and describe the impact of stockouts on the lived experiences of women seeking contraception in Western Kenya.

RESULTS

Contraceptives were found to be out of stock in 19% of visits made to health facilities by mystery clients, with all contraceptive methods stocked out in 9% of visits. Women experienced stockouts as a sizeable barrier to accessing their preferred method of contraception and a reason for taking up non-preferred methods, which has dire consequences for heath, autonomy, and the ability to prevent unintended pregnancy. Reasons for contraceptive stockouts are many and complex, and often linked to challenges in the supply chain - including inefficient planning, procurement, and distribution of family planning commodities.

CONCLUSIONS

Contraceptive stockouts are frequent and negatively impact patients, providers, and communities. Based on the findings of this study, the authors identify areas where funding and sustained action have the potential to ameliorate the frequency and severity of contraceptive stockouts, including more regular deliveries, in-person data collection, and use of data for forecasting, and point to areas where further research is needed.

Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal

Introduction

Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges.

Methods

We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals.

Results

72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals.

Conclusion

Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

Association between exposure to family planning messages on different mass media channels and the utilization of modern contraceptives among young women in Sierra Leone: insights from the 2019 Sierra Leone Demographic Health Survey

Background

Access to sexual and reproductive health information enables young women to make appropriate decisions. We examined the association between exposure to family panning messages on different mass media and the use of modern contraceptives among young women in Sierra Leone.

Methods

This was a secondary analysis of the 2019 Sierra Leone Demographic and Health Survey data of young women aged 15–24 years. Multistage stratified sampling was used to select study participants in the survey. We used multivariable logistic regression to determine the association between exposure to family panning messages on different types mass media channels and utilization of modern contraceptives. All our analyses were done using SPSS version 25.

Results

Out of 6055 young women, 1506 (24.9%, 95% CI 24.0–26.2) were utilizing a modern contraceptive method with the prevalence higher among urban women (26.5%) compared to rural women (23.1%). Less than half (45.6%) had been exposed to family planning messages on mass media (radio 28.6%, television 10.6%, mobile phones 4.2% and newspapers or magazines 2.2%). Young women who had exposure to family planning messages on radio (AOR: 1.26, 95% CI 1.06–1.50) and mobile phones (AOR: 1.84, 95% CI 1.25–2.69) had higher odds of using modern contraceptives compared to their counterparts without the same exposure. Furthermore, having access to internet (AOR: 1.45, 95% CI 1.19–1.78), working (AOR: 1.49, 95% CI 1.27–1.74), being older (20–24 years) (AOR: 1.75, 95% CI 1.46–2.10), being married (AOR: 0.33, 95% CI 0.26–0.42), having visited a health facility within the last 12 months (AOR: 1.34, 95% CI 1.10–1.63), having secondary (AOR: 2.83, 95% CI 2.20–3.64) and tertiary levels of education (AOR: 3.35, 95% CI 1.83–6.13), higher parity (having above one child) AOR: 1.57, 95% CI 1.19–2.08) and residing in the southern (AOR: 2.11, 95% CI 1.61–2.79), northwestern (AOR: 1.87, 95% CI 1.39–2.52), northern (AOR: 2.11, 95% CI 1.59–2.82) and eastern (AOR: 1.68, 95% CI 1.27–2.22) regions of residence were associated with higher odds of modern contraceptives utilization.

Conclusion

In Sierra Leon, only one in four young women were using modern contraception and more than half of them had not had any exposure to family planning messages on the different types of mass media channels. Behavior change communicators can prioritize family planning messages using radio, mobile phones and the internet. In order to publicize and encourage young women to adopt healthy behaviours and increase uptake of modern contraceptive.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01974-w.

Primary Health Care Management Effectiveness as a Driver of Family Planning Service Readiness: A Cross-Sectional Analysis in Central Mozambique

INTRODUCTION

The effectiveness of facility-level management is an important determinant of primary health care (PHC) reach and quality; however, the nature of the relationship between facility-level management and health system effectiveness lacks sufficient empirical grounding. We describe the association between management effectiveness and facility readiness to provide family planning services in central Mozambique.

METHODS

We linked data from the Ministry of Health's 2018 Service Availability and Readiness Assessment and a second 2018 health facility survey that included the World Bank's Service Delivery Indicators management module. Our analysis focused on 68 public sector PHC facilities in Manica, Sofala, Tete, and Zambézia provinces in which the 2 surveys overlapped. We used logistic quantile regression to model associations between management strength and family planning service readiness.

RESULTS

Of the 68 facility managers, 47 (69.1%) were first-time managers and (18) 26.5% had received formal management training. Managers indicated that 63.6% of their time was spent on management responsibilities, 63.2% of their employees had received a performance review in the year preceding the survey, and 12.5% of employee incentives were linked to performance evaluations. Adjusting for facility type and distance to the provincial capital, facility management effectiveness, and urban location were significantly associated with higher levels of readiness for family planning service delivery.

CONCLUSIONS

We found that a higher degree of management effectiveness is independently associated with an increased likelihood of improved family planning service readiness. Furthermore, we describe barriers to effective PHC service management, including managers lacking formal training and spending a significant amount of time on nonmanagerial duties. Strengthening management capacity and reinforcing management practices at the PHC level are needed to improve health system readiness and outputs, which is essential for achieving global Sustainable Development Goals and universal health coverage targets.

Bias in product availability estimates from contraceptive outlet surveys: Evidence from the Consumer’s Market for Family Planning (CM4FP) study

Area-based sampling approaches designed to capture pharmacies, drug shops, and other non-facility service delivery outlets are critical for accurately measuring the contraceptive service environment in contexts of increasing de-medicalization of contraceptive commodities and services. Evidence from other disciplines has demonstrated area-based estimates may be biased if there is spatial heterogeneity in product distribution, but this bias has not yet been assessed in the context of contraceptive supply estimates. The Consumer’s Marker for Family Planning (CM4FP) study conducted censuses and product audits of contraceptive outlets across 12 study sites and 2–3 rounds of quarterly data collection in Kenya, Nigeria, and Uganda. We assessed bias in estimates of contraceptive product availability by comparing estimates from simulations of area-based sampling approaches with census counts among all audited facilities for each study site and round of data collection. We found evidence of bias in estimates of contraceptive availability generated from simulated area-based sampling. Within specific study sites and rounds, we observed biased sampling estimates for several but not all contraceptive method types, with bias more likely to occur in sites with heterogeneity in both spatial distribution of outlets and product availability within outlets. In simulations varying size of enumeration areas (EA) and number of outlets sampled per EA, we demonstrated that the likelihood of substantial bias decreases as EA size decreases and as the number of outlets sampled per EA increases. Straightforward approaches such as increasing sample size per EA or applying statistical weights may be used to reduce area-based sampling bias, indicating a pragmatic way forward to improve estimates where design-based sampling is infeasible. Such approaches should be considered in development of improved methods for area-based estimates of contraceptive supply-side environments.

"When you live in good health with your husband, then your children are in good health …." A qualitative exploration of how households make healthcare decisions in Maradi and Zinder Regions, Niger

Background

Gender dynamics influence household-level decision-making about health behaviors and subsequent outcomes. Health and development programs in Niger are addressing gender norms through social and behavior change (SBC) approaches, yet not enough is known about how health care decisions are made and if gender-sensitive programs influence the decision-making process.

Methods

We qualitatively explored how households make decisions about family planning, child health, and nutrition in the Maradi and Zinder regions, Niger, within the context of a multi-sectoral integrated SBC program. We conducted 40 in-depth interviews with married women (n = 20) and men (n = 20) between 18 and 61 years of age.

Results

Male heads of household were central in health decisions, yet women were also involved and expressed the ability to discuss health issues with their husbands. Participants described three health decision-making pathways: (1^st pathway) wife informs husband of health issue and husband solely decides on the solution; (2^nd pathway) wife informs husband of health issue, proposes the solution, husband decides; and (3^rd pathway) wife identifies the health issue and both spouses discuss and jointly identify a solution. Additionally, the role of spouses, family members, and others varied depending on the health topic: family planning was generally discussed between spouses, whereas couples sought advice from others to address common childhood illnesses. Many participants expressed feelings of shame when asked about child malnutrition. Participants said that they discussed health more frequently with their spouses’ following participation in health activities, and some men who participated in husbands’ schools (a group-based social and behavior change approach) reported that this activity influenced their approach to and involvement with household responsibilities. However, it is unclear if program activities influenced health care decision-making or women’s autonomy.

Conclusions

Women are involved to varying degrees in health decision-making. Program activities that focus on improving communication among spouses should be sustained to enhance women role in health decision-making. Male engagement strategies that emphasize spousal communication, provide health information, discuss household labor may enhance couple communication in Niger. Adapting the outreach strategies and messages by healthcare topic, such as couples counseling for family planning versus community-based nutrition messaging, are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13683-y.

DMPA-SC stock: Cross-site trends by facility type

Objectives

To measure trends in the supply of DMPA-SC in public and private health facilities and compare with other prominent modern methods.

Study design

We used repeated cross-sectional data from service-delivery-point surveys in six settings: Burkina Faso, Democratic Republic of Congo (Kinshasa and Kongo Central), Nigeria (Kano and Lagos), and Uganda, each with 3-5 rounds of data collected between 2016 and 2020. We analyzed trends in DMPA-SC availability using percent of service delivery points offering the method and percent experiencing stockouts; trends were compared with those for DMPA-IM, IUD, implants, and other short-acting methods, by facility type.

Results

All settings showed increased offering of DMPA-SC over time for both private and public facilities. Larger proportions of public facilities provided DMPA-SC compared to private facilities (66%–97% vs 16%–50% by 2019–2020). DMPA-SC was provided by fewer facilities than DMPA-IM (90%–100% public, 34%–69% private by 2019–2020), but comparable to implants (83%–100% public, 15%–52% private by 2019–2020) and IUDs (55%–91% public, 0%–44% private by 2019–2020). Trends of DMPA-SC stock varied by setting, with more consistent stock available in private facilities in the DRC and in public facilities in Burkina Faso and Nigeria. Uganda showed decreasing stock in public facilities but increasing stock in private facilities.

Conclusion

DMPA-SC availability has been increasing since its introduction in sub-Saharan Africa, yet significant gaps in stock exist. Countries should consider alternative distribution models to address these issues.

Implications

Our findings may help inform countries about the need to monitor DMPA-SC availability and to consider solutions that ensure contraceptive options are available to women who need them and disruptions to contraceptive use are minimized.

The demand for family planning to limit childbearing satisfied with female permanent contraception in Sub-Saharan Africa: a meta-analysis of demographic and health surveys

OBJECTIVE

To assess the percentage of the demand for family planning to limit childbearing satisfied with female permanent contraception (FPC) in sub-Saharan Africa (SSA) and the disparities by sociodemographic characteristics (educational status, wealth, religion, and area of residence).

STUDY DESIGN

This study was a secondary data analysis of Demographic and Health Surveys conducted in SSA. Countries with a standard DHS conducted between 2010 and 2019 were eligible for inclusion. We performed a meta-analysis with a random-effects model to estimate the percentage of the demand for family planning to limit childbearing satisfied with FPC and differences by sociodemographic characteristics.

RESULTS

Demographic and Health Surveys (2010-2018) of 33 countries, with a total of 67,476 women with a demand for family planning to limit childbearing were included in this study. The pooled percentage of the demand for family planning to limit childbearing satisfied with FPC was 4.13% (95%CI = 2.43-6.23%, I = 99.36%, p = 0.001). The percentage ranged from 0.26% (95%CI = 0.10-0.67) in Angola to 26.85% (95%CI = 25.86-27.85%) in Malawi. The demand for family planning to limit childbearing satisfied with FPC was significantly higher in women from rich households (PR = 1.41, 95%CI = 1.21-1.65, p < 0.001). However, the differences by educational status, religion, or area of residence were not statistically significant.

CONCLUSIONS

The uptake of FPC among women with a demand for family planning to limit childbearing is low in many countries in SSA. Multilevel interventions are needed to address the barriers that may be limiting informed and voluntary uptake of FPC in SSA.

Readiness of health facilities and determinants to manage diabetes mellitus: evidence from the nationwide Service Provision Assessment survey of Afghanistan, Bangladesh and Nepal

Objectives

Using nationally representative surveys, the study’s aims were to: (1) evaluate healthcare facilities’ readiness to provide diabetes mellitus (DM) services and (2) identify the factors that affect DM service readiness.

Data source

Data from Service Provision Assessment surveys conducted in three low-resource South Asian (SA) countries: Afghanistan, Bangladesh and Nepal, were used in this study.

Design

Cross-sectional nationally representative survey

Participants

A total of 117, 317 and 397 public and private health facilities in Afghanistan, Bangladesh and Nepal, respectively were analysed.

Primary outcome

A total of 12 items/indicators were used to measure a health facility’s readiness to provide DM services across four domains.

Results

For DM management, about 39.3%, 58.4% and 58.2% of health facilities in Afghanistan, Bangladesh and Nepal centred around 7–8, 3–6 and 4–6 items. Only 12.8%, 5.0% and 4.8% of healthcare facilities in Afghanistan, Bangladesh and Nepal reported having at least % (9/12) of the necessary items for DM management, and no one reported having all 12 important items for DM management. According to the negative binomial regression models, the factors associated with higher readiness scores vary among the three countries analysed. Regression models also showed that increases in the number of DM care providers and facility types are similar factors linked to increased readiness scores in all three countries.

Conclusions

In order to increase a health facility’s readiness to offer DM care, country-specific factors must be addressed in addition to common factors found in all three countries. Further research is required to determine the cause of country-level differences in tracer item availability in order to develop targeted and effective country-specific strategies to improve care quality in the SA region.

How ready is the system to deliver primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria

Primary health centres are an effective means of achieving access to primary healthcare (PHC) in low- and middle-income countries. We assessed service availability, service readiness and factors influencing service delivery at public PHC centres in Enugu State, Nigeria. We conducted a cross-sectional study of 60 randomly selected public health centres in Enugu using the World Health Organization’s Service Availability and Readiness Assessment (SARA) survey. The most senior health worker available was interviewed using the SARA questionnaire, and an observational checklist was used for the facility assessment. None of the PHC centres surveyed had all the recommended service domains, but 52 (87%) offered at least half of the recommended service domains. Newborn care and immunization (98.3%) were the most available services across facilities, while mental health was the least available service (36.7%). None of the surveyed facilities had a functional ambulance or access to a computer on the day of the assessment. The specific-service readiness score was lowest in the non-communicable disease (NCD) area (33% in the rural health centres and 29% in the urban health centres) and NCD medicines and supplies. Availability of medicine and supplies was also low in rural PHC centres for the communicable disease area (36%) and maternal health services (38%). Basic equipment was significantly more available in urban health centres (P = 0.02). Urban location of facilities and the presence of a medical officer were found to be associated with having at least 50% of the recommended infrastructure / basic amenities and equipment. Continuing medical education, funding and security were identified by the health workers as key enablers of service delivery. In conclusion, despite a focus on expanding primary care in Enugu State, significant gaps exist that need to be closed for PHC to make significant contributions towards achieving universal healthcare, core to achieving the health-related Sustainable Development Goal agenda.

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.

“Antibiotics Can Work as a Contraceptive:” Contraceptive Knowledge and Use Among University Students in Calabar, Nigeria

Introduction: Many sexually active youths who wish to delay pregnancy are not using any form of modern contraceptives. In sub-Saharan Africa, less than 1 in 5 sexually active youth do not use contraceptives. In Nigeria, 48.4% of all sexually active unmarried women have an unmet need for contraception. Although the literature is replete with information on structural barriers to modern contraceptives, there is limited scholarship on contextual factors that may inhibit modern contraceptive use among Nigerian youth. This study uses a qualitative research approach to assess knowledge and use of natural, modern, and folkloric contraceptive methods among a sample of university students in Calabar, Nigeria.

Methods: This study used data from focus group discussions among women and men in university halls of residence, all of whom were unmarried. Also, three male pharmacists and three female community health workers were interviewed. All focus group discussions and interviews took place in August 2017 and were conducted in Calabar Metropolis, Cross River State, Nigeria. The audio recordings were transcribed into detailed summaries of the interviews and focus group discussions. All data analysis was completed using Atlas.Ti (version 8).

Results: University men and women have limited knowledge of and application of natural and modern contraception. Participants listed folkloric methods of contraceptives, including repurposing pharmaceuticals (e.g., antibiotics, quinine, and Andrews Livers Salt-a laxative) as contraceptive agents. Respondents also discussed the use of non-pharmaceuticals such as water, salt solution, and squatting after intercourse as contraceptives. Generally, university students defaulted to withdrawal, calendar method, and emergency contraceptives as preferred methods of contraception. Lastly, condoms were used among participants in causal sexual encounters. In dating relationships, however, both male and female students cited their partners' hesitancy to condom use as such act could indicate distrust.

Conclusion: Awareness and use of modern contraceptives are limited among university students in Calabar, Nigeria. The use of folkloric contraceptives could lead to bodily harm and unintended pregnancy. Further research is needed to elucidate factors that promote use of folkloric methods of contraceptives. Integration of contraceptive awareness into health promotion services for young people may help to dispel myths about folkloric methods of contraceptives while promoting awareness and use of safe and effective contraception.

Women Deprivation Index and Family Planning Utilisation in Urban Geography of West African Countries

Inequalities in health care utilisation and outcomes vary significantly across geographies. Though available evidence suggests disparity in contraceptive uptake in favour of urban compared with rural geographies, there are unassessed nuances among women in urban communities. This study examines some of these disparities within the context of socioeconomic deprivations and family planning utilisation among urban women in West Africa. A secondary analysis of the most recent Demographic and Health Survey dataset of five selected West African countries was conducted, using pooled data of 21,641 women aged 15-49 years. Associations between family planning utilisation and women's deprivation status were investigated using a binary logistic regression model. The findings show that more than one-quarter of the women were severely deprived across the countries except Senegal (17.4%), and the severely deprived consistently have relatively low contraceptive prevalence rates (CPR) (16.0-24.3%) compared with women with no/low deprivation across the countries except Senegal (39.8%). The results for long-acting reversible contraceptives (LARC) were not consistent across the five countries: whereas, LARC utilisation was lower among severely deprived women in Nigeria (9.1%), Guinea (9.6%), and Mali (19.3%), utilisation was similar across the deprivation groups in Benin and Senegal. In the multivariable analyses, the log-odds of modern contraceptive utilisation decreases by 0.27 among the moderately deprived (ß = -0.27, SE = 0.05, p < 0.01) and by 0.75 among the severely deprived women (ß = -0.75, SE = 0.05, p < 0.01) compared with those with no/low deprivation, with variations across the countries. Similarly, the log-odds of LARC utilisation decreases by 0.44-0.72 among the severely deprived women compared with those with no/low deprivation across the countries except Senegal. This study concluded that family planning intervention programmes and policies need to underscore the deprivation context of urban geographies, particularly among women living in informal settlements.

Effect of distance to health facilities and access to contraceptive services among urban Turkish women

OBJECTIVE

Worldwide unmet need for contraception remains high at 21.6%. As access to health facilities is one of the potential barriers to contraceptive uptake, the aim of our study was to evaluate the effect of distance to a health facility, according to its service availability, on contraceptive uptake among married Turkish women.

METHODS

To calculate respondents' distance to a health facility, we used data from a household survey conducted among married women, as well as data from a health facility survey conducted among the facilities that were visited for contraceptive services by the respondents. The data were collected from the Istanbul area of Turkey under the Willows Impact Evaluation project in 2018. Health facilities were categorised according to contraceptive availability and the accurate distance from respondents' homes to each type of health facility was calculated. Logistic regression was used to estimate the effect of distance to each type of health facility on uptake of each type of contraception.

RESULTS

The prevalence of overall contraceptive use among urban Turkish women was 71.9%. The most common method was withdrawal (32.5%), followed by the intrauterine device (IUD) (14.9%) and male condoms (12.4%). Distance to a health facility that did not provide long-acting contraception was not associated with any type of contraceptive use. On the other hand, distance to a health facility that provided long-acting contraception was negatively associated with the use of long-acting methods such as the IUD but was positively associated with the use of short-acting contraception such as condoms.

CONCLUSION

The effect of distance to a health facility on contraceptive use significantly differed according to contraceptive availability at the facility. Further distance to a health facility that provided long-acting contraception decreased the use of long-acting contraception but had a substitute effect on the use of short-acting contraception. We conclude that when women face an accessibility barrier to the provision of long-acting contraception, they modify their behaviour by shifting from long- to short-acting contraception, which is less effective.

Time to Long-Acting Reversible Contraceptive Uptake Over Twelve Months Postpartum: Findings of the Yam Daabo Cluster Randomized-Controlled Trial in Burkina Faso and the Democratic Republic of the Congo

Purpose

An earlier adoption of contraceptive methods during the postpartum period could help women to extend the inter-pregnancy interval. This article aimed to determine and compare the timing of long-acting reversible contraceptives (LARC) use (ie, intrauterine device and implant) in Burkina Faso (BF) and DR Congo (DRC) between the intervention and control groups.

Patients and Methods

A total of 1120 postpartum women were enrolled and followed up to 12 months postpartum. We used Yam-Daabo trial data which was a multi-intervention, single-blinded, cluster-randomised controlled trial done in primary health-care centres (clusters) in both countries. Centres were randomly allocated to receive the six-component intervention or standard antenatal and postnatal care in matched pairs (1:1). We did a secondary analysis using Royston-Parmar’s semi-parametric model to estimate the effect of the interventions on the median time of LARC uptake.

Results

Our analysis included 567 postpartum women in BF (284 in the intervention group and 283 in the control group) and 553 in the DRC (274 in the intervention group and 279 in the control group). After showing an increase in family planning use in these two African countries, Yam Daabo’s interventions showed a reduction of the median time of LARCs adoption in the intervention group compared to the control group in both countries (difference of 39 days in Burkina Faso; difference of 86 days in the DR Congo).

Conclusion

The Yam Daabo intervention package resulted in increased and earlier adoption of LARC in rural settings in Burkina Faso and urban settings in DR Congo. Such an intervention could be relevant in similar contexts in Sub-Saharan Africa with very high fertility rates and high unmet needs for contraception.

Constructing a malaria-related health service readiness index and assessing its association with child malaria mortality: an analysis of the Burkina Faso 2014 SARA data

Background

The Service Availability and Readiness Assessment surveys generate data on the readiness of health facility services. We constructed a readiness index related to malaria services and determined the association between health facility malaria readiness and malaria mortality in children under the age of 5 years in Burkina Faso.

Methods

Data on inpatients visits and malaria-related deaths in under 5-year-old children were extracted from the national Health Management Information System in Burkina Faso. Bayesian geostatistical models with variable selection were fitted to malaria mortality data. The most important facility readiness indicators related to general and malaria-specific services were determined. Multiple correspondence analysis (MCA) was employed to construct a composite facility readiness score based on multiple factorial axes. The analysis was carried out separately for 112 medical centres and 546 peripheral health centres.

Results

Malaria mortality rate in medical centres was 4.8 times higher than that of peripheral health centres (3.5% vs. 0.7%, p < 0.0001). Essential medicines was the domain with the lowest readiness (only 0.1% of medical centres and 0% of peripheral health centres had the whole set of tracer items of essential medicines). Basic equipment readiness was the highest. The composite readiness score explained 30 and 53% of the original set of items for medical centres and peripheral health centres, respectively. Mortality rate ratio (MRR) was by 59% (MRR = 0.41, 95% Bayesian credible interval: 0.19–0.91) lower in the high readiness group of peripheral health centres, compared to the low readiness group. Medical centres readiness was not related to malaria mortality. The geographical distribution of malaria mortality rate indicate that regions with health facilities with high readiness show lower mortality rates.

Conclusion

Performant health services in Burkina Faso are associated with lower malaria mortality rates. Health system readiness should be strengthened in the regions of Sahel, Sud-Ouest and Boucle du Mouhoun. Emphasis should be placed on improving the management of essential medicines and to reducing delays of emergency transportation between the different levels of the health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09994-7.

Increasing Family Planning Access in Kenya Through Engagement of Faith-Based Health Facilities, Religious Leaders, and Community Health Volunteers

The Church Health Association of Kenya (CHAK) partnered with health facilities managed by faith-based organizations (FBOs), religious leaders, and community health volunteers to increase access to family planning in western Kenya. FBO-managed health facilities saw large increases in family planning uptake over the 5-year project, particularly for implants.

Health facilities managed by faith-based organizations (FBOs) are important providers of health care in Kenya but provide only a small proportion of family planning services in the country. From 2013 to 2017, the Christian Health Association of Kenya (CHAK) implemented a project with 6 FBO-managed health facilities to increase voluntary family planning services in western Kenya, in partnership with religious leaders and community health volunteers (CHVs). The project aimed to build capacity of FBO-managed health facilities, increase religious leaders' knowledge of family planning, mobilize communities, improve family planning access and referrals for services, and advocate for improved family planning commodity security from the public sector. Project impact was evaluated using facility-level service statistics, project records and reports, and feedback from religious leaders and CHVs who implemented the project. Facility service statistics showed large increases in family planning visits. Phase 1 (2013–2014) was implemented at 2 health facilities, where client visits for family planning increased sixfold (from 705 to 4,286 visits) with tenfold increases seen in client visits for pills, intrauterine devices, and implants. In Phase 2 (2015–2017), the project was expanded to an additional 4 health facilities and total client visits for family planning nearly doubled (from 7,925 to 14,832 visits). During Phase 2, new client visits for implants increased threefold, making implants the most popular family planning method. Religious leaders who implemented the project reported reaching nearly 700,000 people with family planning messages and referring more than 87,000 clients to health facilities for family planning services. The religious leaders expressed confidence in the effectiveness of the project and in their role in enhancing access to voluntary family planning. Health facilities, religious leaders, and CHVs also reported multiple challenges to implementation, including inconsistent supply of family planning commodities from county health departments. This project demonstrates the potential of FBO-managed facilities and faith leaders to increase family planning demand and service provision, as well as the importance of coordination with the public sector to ensure supply of commodities and support for FBO-managed facilities.