Expanding Contraceptive Method Choice With a Hormonal Intrauterine System: Results From Mixed Methods Studies in Kenya and Zambia.

INTRODUCTION: Few women in low- and middle-income countries have access to the hormonal intrauterine system (IUS). Past research from a small number of facilities and the private sector suggest the IUS could be an important addition to the contraceptive method mix because it is the only long-acting method some women will adopt and users report high satisfaction and continuation. We aimed to determine whether these promising results were applicable in public facilities in Kenya and Zambia. METHODS: We used a mixed-methods approach with program monitoring data, interviews with women who received an IUS, and qualitative focus group discussions with providers. Data were collected in 2017-2019. RESULTS: Facilities in Kenya and Zambia reported 1,985 and 428 IUS insertions, respectively. If the IUS had not been available, 30% of adopters would have chosen a short-acting method. Women and providers gave diverse reasons for adopting the IUS, with the desire for fewer side effects being frequently mentioned in focus group discussions. Many IUS adopters first heard of the method on the day it was inserted (70% in Kenya, 47% in Zambia), yet providers reported that many women were unwilling to try a method they were just hearing about for the first time. Satisfaction and continuation were high: 86% of adopters in Kenya were still using the method 3-6 months after insertion and 78% were in Zambia (average 10 months post insertion). Providers also reported that most IUS adopters were satisfied; they rarely returned with complaints that could not be addressed with additional counseling. CONCLUSION: Expanding IUS access through the public sector shows promise to increase contraception use and continuation in low- and middle-income countries. Efforts to strengthen availability should consider demand and engage directly with various communities, including youth, around availability of a new long-acting option.

Feasibility of training Zambian nurse-midwives to perform postplacental and postpartum insertions of intrauterine devices.

OBJECTIVE: To explore the feasibility of competency-based training of Zambian nurse-midwives in postplacental and postpartum intrauterine device (PPIUD) insertion and to estimate learning curves for this procedure. METHODS: A pilot service-delivery project was conducted, involving 9 nurse-midwives who participated in a 10-day PPIUD insertion training course at the University Teaching Hospital, Lusaka, Zambia. US and Zambian clinicians taught the didactic and practical curriculum. Checklists were used for standardization and a pelvic model was developed to achieve PPIUD insertion competency in the classroom before moving to clinical practice. Patients were recruited during prenatal visits, in early labor, and postpartum. Informed, voluntary consent was obtained. All clinical PPIUD insertions were supervised or performed by experienced trainers. RESULTS: All 9 nurse-midwives achieved competency on the pelvic model after 3 attempts. During the training period, 38 PPIUDs were inserted in postpartum women; no complications occurred. By the end of training, 4 of the nurse-midwives were deemed competent to independently insert PPIUDs. On average, 4 PPIUD insertions were needed to achieve clinical competency. CONCLUSIONS: Concentrated, competency-based training in PPIUD insertion is feasible in an African setting. Replication of such training could increase the popularity and prevalence of PPIUD use among African women.

Dedicated providers of long-acting reversible contraception: new approach in Zambia.

BACKGROUND: Long-acting reversible contraception (LARC) is underused in many countries in sub-Saharan Africa. Many previous attempts to increase uptake of this important class of contraception have not been successful. STUDY DESIGN: This program in Zambia employed 18 dedicated providers of LARC, placed them in high volume public sector facilities and collected routine, anonymous information over a 14-month period. We tallied uptake of LARC, analyzed user characteristics to see what populations were reached by the program and compared this to nationally representative data. We also estimated costs per couple-year of protection of the program. RESULTS: In a 14-month period, 33,609 clients chose either a subdermal implant (66%) or an intrauterine device (34%). The program reached a younger and lower parity population compared to nationally representative surveys of Zambian women using contraception. The estimated program costs, including the value of donated commodities, averaged $13.0 per couple-year of protection. CONCLUSION: By having the necessary time, skills and materials - as well as a mandate to both generate informed demand and provide quality services - dedicated providers of LARC can expand contraceptive choice. This new approach shows what can be achieved in a short period and in a region of the world where uptake of LARC is limited.