Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling.

INTRODUCTION: High-quality contraceptive counseling is critical for supporting full, free, and informed contraceptive decision-making. However, the quality of family planning counseling remains poor globally and is too often not tailored to the individual client. The Counseling for Choice (C4C) approach comprises provider tools and training to structure counseling to center clients' self-identified priorities and to provide relevant information and anticipatory side effects counseling. METHODS: Providers at 25 public and 20 private facilities in Malawi were trained in the C4C approach. Between October and December 2018, we enrolled women seeking contraceptive services in intervention facilities and in matched comparison clinics in a quasi-experimental study. We collected data immediately before and after contraceptive services were received. We used multilevel logistic regression to compare dimensions of women's counseling experience. RESULTS: Of 1,179 participants, women counseled by C4C-trained providers rated their providers higher on several quality dimensions, including enabling informed decision-making (11.1% of the comparison group rated their provider as excellent versus 34.4% in intervention), respectful care (35.0% comparison versus 51.3% intervention), and information given about side effects (38.1% comparison versus 72.5% intervention). CONCLUSION: In Malawi, C4C improved the quality of care that clients received and their client experience relative to standard counseling. Counseling approaches that center clients' priorities and provide enhanced anticipatory side effects counseling show promise in improving contraceptive counseling experiences and the quality of care that clients receive.

Leveraging the Client-Provider Interaction to Address Contraceptive Discontinuation: A Scoping Review of the Evidence That Links Them.

Despite considerable investment and effort, unmet need for contraception remains an obstacle to improved family planning outcomes. One influencing factor is the frequency of contraceptive discontinuation among users who desire to prevent pregnancy, often due to method-related concerns and side effects. Contraceptive users have the right to be supported during counseling to voluntarily choose methods that align with their individual needs and preferences. Contraceptive counseling, as a key component of quality of care, is particularly important for providers to reduce unmet need among their clients. This scoping review examined the state of the evidence on contraceptive counseling and its impact on discontinuation. The review first examines the association between quality of care and contraceptive discontinuation, then looks to what the current body of evidence suggests are women's contraceptive counseling priorities, and lastly, explores whether specific counseling tools and approaches have been evaluated with discontinuation as an outcome. The results identified general principles and priorities for good counseling including person-centeredness, client-tailored information exchange, clear and concise information on side effects and bleeding changes, reducing providers' implicit and explicit biases, and trust and respect between the client and provider. The review of the literature also found that evidence to support the use of specific counseling tools and approaches to reduce contraceptive discontinuation is insufficient; research should be designed to determine which specific elements of the client-provider interaction can be improved to significantly impact contraceptive discontinuation. This evidence could inform how the global community of practice might improve and leverage specific counseling approaches and tools to address the most common predictors of discontinuation.

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.

Detailed Methodology for Systematic Reviews of Interventions to Improve the Sexual and Reproductive Health of Young People in Low- and Middle-Income Countries.

The goal of this project was to systematically review and compile evidence on interventions in low- and middle-income countries, which targeted three adverse health-related outcomes for young people (ages 10-24): (1) early pregnancy and repeat pregnancy; (2) child marriage; and (3) sexually transmitted infections including human immunodeficiency virus. We searched the gray and published literature to identify interventions and developed a scoring system to assess whether these interventions and their evaluations were of high quality. The three review articles in this volume focus on behavioral outcomes and provide a summary of interventions and evaluations that were both successful and unsuccessful in their impact on the targeted outcomes. This commentary provides the details of the methodology that are common across all three review articles.

Interventions to Prevent Child Marriage Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature.

Child marriage, defined as marriage before the age of 18 years, is a human rights violation that can have lasting adverse educational and economic impacts. The objective of this review was to identify high-quality interventions and evaluations to decease child marriage in low- and middle-income countries. PubMed, Embase, PsycInfo, CINAHL Plus, Popline, and the Cochrane Databases were searched without language limitations for articles published through November 2015. Gray literature was searched by hand. Reference tracing was used, as well as the unpacking of systematic reviews. Retained articles were those that were evaluated as having high-quality interventions and evaluations using standardized scoring. Eleven high-quality interventions and evaluations were abstracted. Six found positive results in decreasing the proportion married or increasing age at marriage, one had both positive and negative findings, and four had no statistical impact on the proportion married or age at marriage. There is wide range of high-quality, impactful interventions included in this review which can inform researchers, donors, and policy makers about where to make strategic investments to eradicate marriage, a current target of the Sustainable Development Goals. Despite the cultural factors that promote child marriage, the diversity of interventions can allow decision makers to tailor interventions to the cultural context of the target population.

Interventions to Prevent Sexually Transmitted Infections, Including HIV, Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature.

Sexually transmitted infections (STIs), including HIV, are prevalent among adolescents and can have lasting adverse health consequences. The objective of this review is to identify high-quality interventions and evaluations to decrease STI transmission and related risky behaviors among young people in low- and middle-income countries. PubMed, Embase, PsycInfo, Cinahl Plus, Popline, and the Cochrane Databases were searched without language limitations for articles published through November 2015. Gray literature was searched by hand. Reference tracing was utilized, as well as the unpacking of systematic reviews. Retained articles were those that were evaluated as having high-quality interventions and evaluations using standardized scoring. Twenty-one high-quality interventions and evaluations were abstracted. Three reported declines in STI diagnoses, three reported declines in STI symptoms, six showed declines in risky sexual behavior, seven reported increases in abstinence, 11 found increases in condom use, and five reported increases in health care utilization. There is a wide range of rigorously evaluated high-quality interventions included in this review that can inform researchers, donors, and policy makers about where to make strategic investments to decrease the spread of STIs, including HIV. With the recent advent of biomarkers, researchers can use a gold standard measure to assess intervention impact. The diversity of interventions can allow decision makers to tailor interventions to the context, age range, and gender of the target population.

Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature.

Adolescent pregnancy, particularly unintended pregnancy, can have lasting social, economic, and health outcomes. The objective of this review is to identify high-quality interventions and evaluations to decrease unintended and repeat pregnancy among young people in low- and middle-income countries. PubMed, Embase, PsycInfo, Cinahl Plus, Popline, and the Cochrane Databases were searched for all languages for articles published through November 2015. Gray literature was searched by hand. Reference tracing was utilized, as well as unpacking systematic reviews. Selected articles were those that were evaluated as having high-quality interventions and evaluations using standardized scoring. Twenty-one high-quality interventions and evaluations were abstracted. Nine reported statistically significant declines in pregnancy rates (five cash transfer programs, one education curriculum, two life-skills curricula, and a provision of contraception intervention), seven reported increases in contraceptive use (three provision of contraception interventions, two life-skills curricula, a peer education program, and a mass media campaign), two reported decreases in sexual activity (a cash transfer program and an education and life-skills curriculum), and two reported an increase in age of sexual debut (both cash transfer programs). The selected high quality, effective interventions included in this review can inform researchers, donors, and policy makers about where to make strategic investments to decrease unintended pregnancy during young adulthood. Additionally, this review can assist with avoiding investments in interventions that failed to produce significant impact on the intended outcomes. The diversity of successful high-quality interventions, implemented in a range of venues, with a diversity of young people, suggests that there are multiple strategies that can work to prevent unintended pregnancy.