Exploring provider preference and provision of abortion methods and stigma: Secondary analysis of a United Kingdom provider survey.

INTRODUCTION: Method choice is an important component of quality abortion care and qualitative research suggests that abortion stigma can influence provider preference and provision of abortion methods. This study is the first to explore the relationships between abortion providers' method preferences, their provision of medication or instrumentation abortion or both methods, and abortion stigma. METHODS: We conducted secondary analysis of a survey of United Kingdom (UK) abortion providers (N = 172) to describe and compare providers' self-reported method preferences and provision. We used multinomial logistic regression to assess the association between method preference and provider experiences of abortion stigma (measured using a revised Abortion Provider Stigma Scale (APSS)), adjusting for relevant provider and facility characteristics. RESULTS: Almost half (52%) of providers reported that they only provided medication abortion care, while 5% only provided instrumentation abortion care and 43% provided both methods. Most (62%) preferred to provide both methods while 32% preferred to provide only medication abortion and 6% only instrumentation abortion. There was no significant difference in revised APSS scores by provider method preference or provision. DISCUSSION: Most surveyed UK abortion providers prefer to offer both methods, but over half only provide medication abortion. This may reflect patients' preferences for medication abortion, and health system and legal constraints on instrumentation abortion. Addressing these systemic constraints on method provision could expand patient choice. Providers' method preference was not significantly associated with provider stigma but future research should consider the influence of structural stigma on method provision at the health system level.

A non-inferiority analysis of hemoglobin levels in postpartum IUD users in Bangladesh.

OBJECTIVE: The objective of this study was to compare postpartum hemoglobin (Hb) between postpartum intrauterine device (PPIUD) and non-PPIUD users. METHODS: A sample of 3697 postpartum women (475 PPIUD users, 3222 non-PPIUD users) from 5 tertiary referral hospitals in Bangladesh were assessed at multiple time points between 6 weeks and 12 months postpartum. Non-inferiority linear regression analysis compared changes in Hb levels at 29-52 weeks postpartum between the two groups. Non-inferiority was declared if the lower 95% confidence interval of the estimated difference in Hb change since delivery between PPIUD and non-PPIUD users was greater than -0.05 g/dl. RESULTS: At approximately 9 months postpartum, 276 women in the PPIUD group (58.1%) and 1086 women in the comparison group (33.7%) attended follow-up. In total, 57.9% of PPIUD users and 61.0% of non-PPIUD users had taken iron supplementation. Change in Hb was 0.02 g/dl (95% CI: -0.16, 0.19) higher in the PPIUD users than the comparison group. The lower limit of the 95% CI was greater than -0.05 g/dl, providing good evidence that PPIUD users were non-inferior to the comparison group in their Hb levels. CONCLUSION: In the presence of offering iron supplementation, and an uptake of just over 60%, no difference in anemia was observed between the PPIUD and control group.

Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention.

INTRODUCTION: This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. METHODS: This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. RESULTS: In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV's involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. CONCLUSION: The FCHVs' knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.

Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania.

INTRODUCTION: Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors. METHODS: A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted. RESULTS: Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.