Institutionalizing postpartum intrauterine device (IUD) services in Sri Lanka, Tanzania, and Nepal: study protocol for a cluster-randomized stepped-wedge trial

Background: During the year following the birth of a child, 40% of women are estimated to have an unmet need for contraception. The copper IUD provides safe, effective, convenient, and long-term contraceptive protection that does not interfere with breastfeeding during the postpartum period. Postpartum IUD (PPIUD) insertion should be performed by a trained provider in the early postpartum period to reduce expulsion rates and complications, but these services are not widely available. The International Federation of Obstetricians and Gynecologists (FIGO) will implement an intervention that aims to institutionalize PPIUD training as a regular part of the OB/GYN training program and to integrate it as part of the standard practice at the time of delivery in intervention hospitals. Methods: This trial uses a cluster-randomized stepped wedge design to assess the causal effect of the FIGO intervention on the uptake and continued use of PPIUD and of the effect on subsequent pregnancy and birth. This trial also seeks to measure institutionalization of PPIUD services in study hospitals and diffusion of these services to other providers and health facilities. This study will also include a nested mixed-methods performance evaluation to describe intervention implementation. Discussion This study will provide critical evidence on the causal effects of hospital-based PPIUD provision on contraceptive choices and reproductive health outcomes, as well as on the feasibility, acceptability and longer run institutional impacts in three low- and middle-income countries. Trial registration Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1160-0) contains supplementary material, which is available to authorized users

Effect of a postpartum family planning intervention on postpartum intrauterine device counseling and choice: evidence from a cluster-randomized trial in Tanzania

BACKGROUND: The World Health Organization recommends postpartum family planning (PPFP) for healthy birth spacing. This study is an evaluation of an intervention that sought to improve women's access to PPFP in Tanzania. The intervention included counseling on PPFP during antenatal and delivery care and introducing postpartum intrauterine device (PPIUD) insertion as an integrated part of delivery services for women electing PPIUD in the immediate postpartum period. METHODS: This cluster-randomized controlled trial recruited 15,264 postpartum Tanzanian women aged 18 or older who delivered in one of five study hospitals between January and September 2016. We present the effectiveness of the intervention using a difference-in-differences approach to compare outcomes, receipt of PPIUD counseling and choice of PPIUD after delivery, between the pre- and post-intervention period in the treatment and control group. We also present an intervention adherence-adjusted analysis using an instrumental variables estimation. RESULTS: We estimate linear probability models to obtain effect sizes in percentage points (pp). The intervention increased PPIUD counseling by 19.8 pp (95% CI: 9.1 - 22.6 pp) and choice of PPIUD by 6.3 pp (95% CI: 2.3 - 8.0 pp). The adherence-adjusted estimates demonstrate that if all women had been counseled, we would have observed a 31.6 pp increase in choice of PPIUD (95% CI: 24.3 - 35.8 pp). Among women counseled, determinants of choosing PPIUD included receiving an informational leaflet during counseling and being counseled after admission for delivery services. CONCLUSIONS: The intervention modestly increased the rate of PPIUD counseling and choice of PPIUD, primarily due to low coverage of PPIUD counseling among women delivering in study facilities. With universal PPIUD counseling, large increases in choice of PPIUD would have been observed. Giving women informational materials on PPIUD and counseling after admission for delivery are likely to increase the proportion of women choosing PPIUD. TRIAL REGISTRATION: Registered with clinicaltrials.gov (NCT02718222) on March 24, 2016, retrospectively registered.4041 - Susan Thompson Buffett FoundationPublished versio

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

Do Natural Methods Count? Underreporting of Natural Contraception in Urban Burkina Faso

Natural methods of contraception were widely used in developed countries until the late 1960s to space and limit childbirth. In France, when the first contraceptive surveys were conducted, researchers noticed that the use of natural methods was underreported, and questions to correct for this bias were subsequently added. The Demographic and Health Surveys do not currently include questions specific to natural methods. We added such questions to the standard DHS question regarding current contraceptive use when we conducted the Health and Demographic Surveillance System of Ouagadougou (2010 Ouaga HDSS) health survey in Burkina Faso among 758 women aged 15–49. Doing so enabled us to find a notable increase in the proportion of women in union who reported practicing contraception: 58 percent, compared with 38 percent in Ouagadougou in the 2010 Burkina Faso DHS. Thirty-two percent of women reported using modern medical methods or condoms in both surveys, but use of natural methods was much greater in the 2010 Ouaga HDSS health survey (26 percent) than in the 2010 Burkina Faso DHS (5 percent). Many women classified as having unmet need for family planning in Ouagadougou by the DHS data are in fact users of natural methods. Additional questions that would measure use of natural methods more completely should be tested in different settings

Religious differences in child vaccination rates in urban Africa: Comparison of population surveillance data from Ouagadougou, Burkina Faso

Many studies have shown a significant relationship between religion and health in Western countries. In developing countries, however, there is a dearth of scientific studies on the matter. Using data from the Ouagadougou Health and Demographic Surveillance System, this paper examines religious differences in child vaccination rates in five districts of Ouagadougou, Burkina Faso. It tests the applicability of the selectivity hypothesis, which holds that religious differences in health come from underlying differences in the socioeconomic and demographic composition of religious communities. In our study population, even when socioeconomic and demographic characteristics are taken into account, an effect of religion on child vaccination rates was observed. This suggests that religious disparities in child vaccination rates are not solely due to the makeup of different religious communities, but also to ideological differences and/or to diffusion effects from interactions within religious groups. The religious differences demonstrated here suggest that a greater emphasis should be put on community-based approaches involving religious leaders when addressing health disparities

Understanding premarital pregnancies among adolescents and young women in Ouagadougou, Burkina Faso

In developing countries, young women between 15 and 24 years of age account for more than 40% of unsafe abortions due to the high number of unwanted and/or out-of-wedlock pregnancies. However, much about the profile of adolescents and young women who usually experience premarital pregnancies remains unknown. This study sought to understand the risk of pregnancy before marriage among adolescents and young women in Ouagadougou, Burkina Faso. By using longitudinal data from a demographic surveillance system, we tested the explanatory power of two theoretical assumptions on premarital childbearing in sub-Saharan Africa, which assumptions are the cultural inheritance model and the social capital model. The results confirmed the explanatory power of the cultural inheritance model on the one hand and partially confirmed the power of the social capital model on the other hand. These results highlight the need for a multipronged approach to sexual and reproductive health for young people. Efforts against premarital pregnancies among adolescents and young women would be more effective if they were based on participatory approaches, incorporating actions at both community and institutional levels, as suggested by the recent Global Accelerated Action for the Health of Adolescents logical framework

Additional file 2: of Institutionalizing postpartum intrauterine device (IUD) services in Sri Lanka, Tanzania, and Nepal: study protocol for a cluster-randomized stepped-wedge trial

Example recruitment scripts and informed consent forms from Nepal. Recruitment script and informed consent form for women and providers in Nepal. (DOCX 29 kb

Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study

Objectives Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal.Methods We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred.Findings The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day.Conclusion Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals