Findings and Lessons Learned From Strengthening the Provision of Voluntary Long-Acting Reversible Contraceptives With Postabortion Care in Guinea.

Integrating voluntary family planning into postabortion care (PAC) presents a critical opportunity to reduce future unintended pregnancies. Although Guinea has low contraceptive prevalence overall, acceptance of long-acting reversible contraceptives (LARCs) among PAC clients is higher than among interval LARC users and higher than the national average. In 2014, we assessed the extent of LARC provision within PAC services and the factors influencing integration. Primary and secondary data collected from 143 interviews, 75 provider assessments, and facility inventories and service statistics from all 38 public facilities providing PAC in Guinea allowed exploration of voluntary family planning uptake in the context of PAC. Study findings showed that 38 of 456 (8.3%) public health facilities or 38 of 122 (31.1%) facilities with a mandate to manage obstetric complications provided PAC services. Service statistics from 4,544 PAC clients in 2013 indicate that 95.2% received counseling and 73.0% voluntarily left the facility with contraception, with 29.6% of acceptors choosing a LARC. Family planning within PAC was emphasized in advocacy, policy and guidelines, quality improvement, and supervision, and the range of contraceptive options for postabortion clients was expanded to enable them to avoid a second unintended pregnancy. Factors that influenced provision of family planning within PAC included (1) the ability of champions both within and outside the Ministry of Public Health to advocate for PAC and leverage donor resources, (2) the incorporation of PAC with postabortion family planning into national policies, standards, and guidelines, (3) training of large numbers of providers in PAC and LARCs, and (4) integration of LARCs within PAC into quality improvement and supervision tools and performance standards. Guinea has gradually scaled up provision of PAC services nationwide and its experience may offer learning opportunities for other countries; however, continued advocacy for further expansion to more rural areas of the country and among private health facilities is necessary.

Counseling at all contacts for postpartum contraceptive use: can paper-based tools help community health workers improve continuity of care? A qualitative study from Ethiopia.

Background: Globally, there has been a resurgence of interest in postpartum family planning (PPFP) to advance reproductive health outcomes. Few programs have systematically utilized all contacts a woman and her baby have with the health system, from pregnancy through the first year postpartum, to promote PPFP. Nested into a larger study covering two districts, this study assessed the use, acceptability, and feasibility of tools for tracking women's decision-making and use of PPFP in the community health system in Oromia region, Ethiopia. Community-level tracking tools included a modified Integrated Maternal and Child Health (IMCH) card with new PPFP content, and a newly developed tool for pregnant and postpartum women for use by Women Development Armies (WDAs). Proper completion of the tools was monitored during supervision visits. Methods: In-depth interviews and focus group discussions were conducted with health officials, health extension workers, and volunteers. A total of 34 audio-files were transcribed and translated into English, double-coded using MAXQDA, and analyzed using a thematic approach. Results: The results describe how HEWs used the modified IMCH card to track women's decision making through the continuum of care, to assess pregnancy risk and to strengthen client-provider interaction. Supervision data demonstrated how well HEWs completed the modified IMCH card. The WDA tool was intended to promote PPFP and encourage multiple contacts with facilities from pregnancy to extended postpartum period. HEWs have reservations about the engagement of WDAs and their use of the WDA tool. Conclusions: To conclude, the IMCH card improves counseling practices through the continuum of care and is acceptable and feasible to apply. Some elements have been incorporated into a revised national tool and can serve as example for other low-income countries with similar community health systems. Further study is warranted to determine how to engage WDAs in promoting PPFP.

Expanding the Single-Visit Approach for Cervical Cancer Prevention: Successes and Lessons From Burkina Faso.

BACKGROUND: Cervical cancer accounts for 23% of cancer incidence and 22% of cancer mortality among women in Burkina Faso. These proportions are more than 2 and 5 times higher than those of developed countries, respectively. Before 2010, cervical cancer prevention (CECAP) services in Burkina Faso were limited to temporary screening campaigns. PROGRAM DESCRIPTION: Between September 2010 and August 2014, program implementers collaborated with the Ministry of Health and professional associations to implement a CECAP program focused on coupling visual inspection with acetic acid (VIA) for screening with same-day cryotherapy treatment for eligible women in 14 facilities. Women with larger lesions or lesions suspect for cancer were referred for loop electrosurgical excision procedure (LEEP). The program trained providers, raised awareness through demand generation activities, and strengthened monitoring capacity. METHODS: Data on program activities, service provision, and programmatic lessons were analyzed. Three data collection tools, an individual client form, a client registry, and a monthly summary sheet, were used to track 3 key CECAP service indicators: number of women screened using VIA, proportion of women who screened VIA positive, and proportion of women screening VIA positive who received same-day cryotherapy. RESULTS: Over 4 years, the program screened 13,999 women for cervical cancer using VIA; 8.9% screened positive; and 65.9% received cryotherapy in a single visit. The proportion receiving cryotherapy on the same day started at a high of 82% to 93% when services were provided free of charge, but dropped to 51% when a user fee of $10 was applied to cover the cost of supplies. After reducing the fee to $4 in November 2012, the proportion increased again to 78%. Implementation challenges included difficulties tracking referred patients, stock-outs of key supplies, difficulties with machine maintenance, and prohibitive user fees. Providers were trained to independently monitor services, identify gaps, and take corrective actions. CONCLUSIONS: Following dissemination of the results that demonstrated the acceptability and feasibility of the CECAP program, the Burkina Faso Ministry of Health included CECAP services in its minimum service delivery package in 2016. Essential components for such programs include provider training on VIA, cryotherapy, and LEEP; provider and patient demand generation; local equipment maintenance; consistent supply stocks; referral system for LEEP; non-prohibitive fees; and a monitoring data collection system.

Increasing Use of Postpartum Family Planning and the Postpartum IUD: Early Experiences in West and Central Africa.

A global resurgence of interest in the intrauterine device (IUD) as an effective long-acting reversible contraceptive and in improving access to a wide range of contraceptive methods, as well as an emphasis on encouraging women to give birth in health care facilities, has led programs to introduce postpartum IUD (PPIUD) services into postpartum family planning (PPFP) programs. We describe strategic, organizational, and technical elements that contributed to early successes of a regional initiative in West and Central Africa to train antenatal, maternity, and postnatal care providers in PPFP counseling for the full range of available methods and in PPIUD service delivery. In November 2013, the initiative provided competency-based training in Guinea for providers from the main public teaching hospital in 5 selected countries (Benin, Chad, Côte d'Ivoire, Niger, and Senegal) with no prior PPFP counseling or PPIUD capacity. The training was followed by a transfer-of-learning visit and monitoring to support the trained providers. One additional country, Togo, replicated the initiative's model in 2014. Although nascent, this initiative has introduced high-quality PPFP and PPIUD services to the region, where less than 1% of married women of reproductive age use the IUD. In total, 21 providers were trained in PPFP counseling, 18 of whom were also trained in PPIUD insertion. From 2014 to 2015, more than 15,000 women were counseled about PPFP, and 2,269 women chose and received the PPIUD in Benin, Côte d'Ivoire, Niger, Senegal, and Togo. (Introduction of PPIUD services in Chad has been delayed.) South-South collaboration has been central to the initiative's accomplishments: Guinea's clinical centers of excellence and qualified trainers provided a culturally resonant example of a PPFP/PPIUD program, and trainings are creating a network of regional trainers to facilitate expansion. Two of the selected countries (Benin and Niger) have expanded their PPFP/PPUID training programs to additional sites. Inspired after learning about the initiative at a regional meeting, Togo has outperformed the original countries involved in the initiative by training more providers than the other countries. Challenges to scale-up include a lack of formal channels for reporting PPFP and PPIUD service delivery outcomes, inconsistent coordination of services across the reproductive health continuum of care, and slow uptake in some countries. Continued success will rely on careful recordkeeping, regular monitoring and feedback, and strategic data use to advocate scale-up.

Implementation of the Standards-Based Management and Recognition approach to quality improvement in maternal, newborn, and child health programs in low-resource countries.

The Standards-Based Management and Recognition (SBM-R; Jhpiego, Baltimore, MD, USA) approach to quality improvement was developed by Jhpiego to respond to common challenges faced by health systems in low-resource settings, including poor pre-service education, lack of resources for conventional supervisory models, and weak health information systems. Since its introduction in Brazil in 1997, SBM-R has been implemented in approximately 30 countries and continues expanding to new places and service delivery areas. The present article: (1) describes key steps in the SBM-R methodology focusing on provider performance assessment using evidence-based standards; and (2) presents examples of improvements in provider performance in maternal, newborn, and child health care following SBM-R implementation derived from routine program data, quasi-experimental evaluations, and in-depth case studies. SBM-R incorporates evidence-based methods that are known to have positive effects on healthcare quality, including audit and feedback, educational outreach visits, and checklist usage; however, further rigorous research is needed to document the population-level impacts of the SBM-R approach.