Evaluation of Senegal supply chain intervention on contraceptive stockouts using routine stock data.

BACKGROUND: Until 2011, stockouts of family planning commodities were common in Senegalese public health facilities. Recognizing the importance of addressing this problem, the Government of Senegal implemented the Informed Push Model (IPM) supply system, which involves logisticians to collect facility-level stock turnover data once a month and provide contraceptive supplies accordingly. The aims of this paper were to evaluate the impact of IPM on contraceptive availability and on stockout duration. METHODS AND FINDINGS: To estimate the impact of the IPM on contraceptive availability, stock card data were obtained from health facilities selected through multistage sampling. A total number of 103 health facilities pertaining to 27 districts and nine regions across the country participated in this project. We compared the odds of contraceptive stockouts within the health facilities on the 23 months after the intervention with the 18 months before. The analysis was performed with a logistic model of the monthly time-series. The odds of stockout for any of the five contraceptive products decreased during the 23 months post-intervention compared to the 18 months pre-intervention (odds ratio, 95%CI: 0.34, 0.22-0.51). To evaluate the impact of the IPM on duration of stockouts, a mixed negative binomial zero-truncated regression analysis was performed. The IPM was not effective in reducing the duration of contraceptive stockouts (incidence rate ratio, 95%CI: 0.81, 0.24-2.7), except for the two long-acting contraceptives (intrauterine devices and implants). Our model predicted a decrease in stockout median duration from 23 pre- to 4 days post-intervention for intrauterine devices; and from 19 to 14 days for implants. CONCLUSIONS: We conclude that the IPM has resulted in greater efficiency in contraceptive stock management, increasing the availability of contraceptive methods in health facilities in Senegal. The IPM also resulted in decreased duration of stockouts for intrauterine devices and implants, but not for any of the short-acting contraception (pills and injectables).

A mystery shopper study identifying practice-level barriers to adolescent IUD access in western Pennsylvania.

OBJECTIVE(S): To identify practice-level barriers that adolescents experience when seeking a hormonal intrauterine device (IUD). STUDY DESIGN: We secret-shopped gynecological practices within a health system using a script targeting potential practice-level barriers. RESULTS: We assessed 50 of a targeted 50 practices; only 8 (16%) would schedule a contraceptive appointment that permitted same-day IUD placement. Twenty-eight (56%) respondents stateda parent must accompany the adolescent. CONCLUSION: Practice-level barriers toadolescentIUD access exist that are inconsistent with best-practice guidelines and Pennsylvania state law. IMPLICATIONS: Practice staff and providers need more medical and legal education regarding IUD provision to adolescents.

Increasing access to intrauterine contraceptive device uptake in Ghana: stakeholders views on task sharing service delivery with community health nurses.

INTRODUCTION: Evidence supporting successful task sharing to increase Intrauterine Contraceptive Device (IUD) uptake exist in some developing countries that have challenges with availability of trained health professionals. Although Community Health Nurses (CHNs) in Ghana are trained to provide primary health care including emergency deliveries in rural communities, they are not professionally mandated to provide IUD services. OBJECTIVES: To explore stakeholders' views on task sharing IUD services with CHNs in Ghana. METHODS: This qualitative case study was conducted in Accra, Ghana between June and September 2018. Focus group discussions and in-depth interviews were used to collect data from purposively selected participants. Included in the study were policy makers, policy implementing institutions, service regulators, Non-Governmental Organisations, field providers and service end users. Interviews were recorded and transcribed verbatim. We manually performed thematic analysis of data and findings were appropriately described by paraphrasing and/or quoting relevant responses verbatim. RESULTS: There is a general mixed feeling towards task sharing IUD services with community health nurses in Ghana. Policy makers, programmers, gynaecologists and IUD users interviewed believed that CHNs are capable of providing safe IUD services when well trained, adequately resourced and supervised. Based on some field experiences of complications associated with IUD insertions, participants who were midwives clearly indicated the need for effective training and careful implementation strategies. CONCLUSIONS: Despite concerns about user safety, respondents endorsed task-sharing IUD services with trained CHNs in Ghana. Implementation study focusing on competency-based IUD training for selected CHNs is recommended to provide empirical evidence to back policy decisions. FUNDING: Marie Stopes Ghana funded the field work.

Experiencia en la colocación del DIUPP / Experience in the placement of the Diupp

Family planning is a key intervention to decrease the mortality rates and maternal morbidity, and neonatal mortality rates of children by mean of the preventiion of unwanted pregnancies, the same as pregnancies that happen very clsely to another previous one with little space between them. Several studies performed in different parts of the world have demonstrated adverse results related specially with the spaciament of the pregnancies. The risks are particularly higher with women wich get pregnant les after than a previous deliver, spontaneous abortion or induced abortion. The instrauterine device (ID) is a family planning higly efficacious with a prolongued action and reversible, that offers security to most postpartum women, including those who are still nursing. The primary aim of the present report was to determine the frequency in the placement of the DIUPP in our Obstetrical Department between 01/06/2017 and 30/06/2018, and in a second instance, to describe the method for placement of the DIUPP, to determine the curve of learning, to measure the rate of expulsion of the device, and to evaluate the conformity of the users of the method. Unplanned pregnancies have strongly increased, and for that circumstance, we believe that with new strategies, such as it is with the post-event anticonception, we can improve the reproducive health (AU)

Intrauterine Device Training Workshop for Preclinical Medical Students.

Introduction: Medical school reproductive health curricula often lack adequate education regarding intrauterine devices (IUDs). When placed in clinical scenarios, students may have insufficient knowledge and training to counsel patients about IUDs. Methods: We developed a workshop for preclinical medical students and assessed whether it improved knowledge of and comfort with counseling patients on IUDs. The workshop consisted of a 45-minute lecture and a 45-minute IUD simulation training. Each session was taught to groups of 40 to 50 students. The workshop was evaluated between January 2016 and November 2017. Participants completed pre- and postsurveys. The primary outcome was comfort level with IUD counseling. Results: One hundred forty-two students completed the workshop, and 137 completed both pre- and postsurveys (96% response rate). At baseline, more than half (56%, n = 77) had not seen an IUD inserted. Students scoring 75% or higher on the IUD knowledge questions increased from 51% (n = 70) on presurveys to 87% (n = 119) on postsurveys (p < .0001). Students agreeing or strongly agreeing that they felt comfortable counseling patients on IUDs increased from 27% (n = 37) to 92% (n = 122, p < .0001) on postsurveys. All students felt the workshop was worthwhile. Discussion: Preclinical students showed increased knowledge of and comfort with IUDs after a simple IUD simulation. Medical schools could utilize this workshop to ensure students have hands-on training and experience related to IUDs prior to clinical rotations and for their future careers.

Organizational barriers to the availability and insertion of intrauterine devices in Primary Health Care Services. / Barreiras organizacionais para disponibilização e inserção do dispositivo intrauterino nos serviços de atenção básica à saúde.

OBJECTIVE: To identify organizational barriers to IUD availability in Primary Health Care services from the perspective of women's health coordinators. METHOD: This is a quantitative study carried out with women's health officials from the municipalities of the southern macro region of Minas Gerais, Brazil, with an on-line completion of a structured instrument and a descriptive data analysis. RESULTS: 79 technicians participated in the study. Among the municipalities, 15.2% do not provide IUDs and 8.3% do not refer women to other services, 53.7% do not provide IUDs at basic health units. Among those who provide the IUD, 68.7% do not have a specific protocol and 10.5% do not adopt pregnancy as a condition that makes it impossible to insert the IUD, and 80.6% adopt unnecessary conditions, such as vaginal infection. As a criterion for IUD access, 86.5% referred to a medical prescription, 71.6% required exams, 44.6% were over 18 years of age and 24.4% participation in groups, none based on scientific evidence. Only the doctor inserted the IUD. CONCLUSION: Problems in the access to the IUD were identified due to organizational barriers to its availability and insertion, such as the lack of availability of the method or the excess of unnecessary criteria to make it available.

Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the United States, 2008-2013.

OBJECTIVE: To measure rates of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, and tubal sterilization during delivery hospitalizations and correlates of their use. METHODS: This retrospective cohort study used the 2008-2013 National Inpatient Sample, a publicly available all-payer database. We identified delivery hospitalizations with the International Classification of Diseases, 9th Revision, Clinical Modification codes for intrauterine device insertion, contraceptive implant insertion, and tubal sterilization. We used weighted multivariable logistic regression to examine associations between predictors (age, delivery mode, medical comorbidity, payer, hospital type, geographic region, and year) and likelihood of LARC and sterilization and to compare characteristics of LARC and sterilization users. RESULTS: Our sample included 4,691,683 discharges, representing 22,667,204 delivery hospitalizations. Long-acting reversible contraception insertion increased from 1.86 per 10,000 deliveries (2008-2009) to 13.5 per 10,000 deliveries (2012-2013; P<.001); tubal sterilization remained stable (711-683 per 10,000 deliveries; P=.24). In multivariable analysis adjusting for all predictors, compared with neither LARC nor sterilization, LARC use was highest among women with medical comorbidities (count per 10,000 deliveries: 15.04, standard error 2.11, adjusted odds ratio [OR] 1.92, 95% confidence interval [CI] 1.72-2.13), nonprivate payer (13.50, standard error 2.14, adjusted OR 5.23, 95% CI 3.82-7.16), and at urban teaching hospitals (14.92, standard error 2.25, adjusted OR 20.85, 95% CI 12.73-34.15). Sterilization was least likely among women aged 24 years or younger (251.04, standard error 4.88, adjusted OR 0.12 95% CI 0.12-0.13, compared with 35 years or older) and most likely with cesarean delivery (1,568.74, standard error 20.81, adjusted OR 6.25, 95% CI 5.88-6.63). Comparing only LARC and sterilization users, LARC users tended to have nonprivate insurance (84.95% compared with 57.17%, adjusted OR 1.90, 95% CI 1.38-2.63) and deliver at urban teaching hospitals (94.65% compared with 45.47%, adjusted OR 38.39, 23.52-62.64) in later study years (2012-2013; 55.72% compared with 32.18%, adjusted OR 8.26, 95% CI 4.42-15.44, compared with 2008-2009). CONCLUSION: Long-acting reversible contraception insertion increased from 1.86 to 13.5 per 10,000 deliveries but remained less than 2% of the sterilization rate. Inpatient postpartum LARC insertion is more likely among sicker, poorer women delivering at urban teaching hospitals.

Meeting the Contraceptive Needs of a Community: Increasing Access to Long-Acting Reversible Contraception.

To control their reproductive lives, women must have access to all contraceptive methods including the most effective reversible methods, intrauterine devices, and implants. The Contraceptive CHOICE Project, a study of 9,256 women in St. Louis, showed that when barriers to contraception are removed, many women choose intrauterine devices and implants, substantially reducing rates of unintended pregnancy and abortion. This article discusses strategies we learned from the CHOICE Project to improve uptake of the most effective contraceptive methods.

California Family Planning Health Care Providers' Challenges to Same-Day Long-Acting Reversible Contraception Provision.

OBJECTIVE: To assess the extent to which practices offering family planning services are able to offer intrauterine devices (IUDs) and implants in one visit and to identify the reasons why multiple visits may be required. METHODS: In the fall of 2011, 1,000 California family planning providers were asked about their long-acting reversible contraception delivery practices in a probability survey. We used multivariable logistic regression to examine practice characteristics associated with same-day provision of IUDs and implants. RESULTS: Among the 636 responding practices, 67% offered an IUD and 40% offered a contraceptive implant onsite. Among those with onsite provision, the majority required two or more visits to place an IUD (58%); almost half required two visits to place an implant (47%). Nearly all Planned Parenthood practices could place an IUD (95%) or implant (95%) at the initial visit, whereas the majority of all other practice types could not. The main reasons for delaying IUD and contraceptive implant provision included the need to screen and wait for test results (68% and 24%, respectively) and clinic flow and scheduling issues (50% and 64%, respectively). Multivariable analyses indicated that Planned Parenthood practices were significantly more likely than private practices to have same-day insertion protocols. CONCLUSION: Most of the family planning providers surveyed have not adopted same-day long-acting reversible contraception insertion protocols and face barriers to same-day provision. LEVEL OF EVIDENCE: III.

Barriers to preventing unintended pregnancies and sexually transmitted infections as experienced by women in Fort Dauphin, southeast Madagascar.

OBJECTIVES: As part of a broader investigation into maternal and child health, this study aimed to explore barriers to preventing unintended pregnancies and sexually transmitted infections (STIs) for women in southeast Madagascar, in order to inform the development of interventions by a local non-governmental organisation. METHODS: A year-long mixed methods study was conducted. Qualitative information was obtained from 246 participants through focus groups, single-event and serial qualitative interviews. Quantitative data was collected through a closed-ended questionnaire with a sample of 373 women of reproductive age. Data was analysed using pre-determined and emerging themes. RESULTS: Family planning and sexual health services are not well integrated into other health services, nor routinely offered. Barriers to contraceptive use include actual or perceived side effects of hormonal methods, inaccurate information from health providers, and lack of support from partners or family members. STI prevalence is high, concurrent sexual relationships are common, and condom use is limited. CONCLUSIONS: Women's ability to prevent unintended pregnancies and STIs could be improved through measures aiming to dispel misconceptions about eligibility for and perceived risks of hormonal contraceptives, increase support for family planning among partners and families, and reframe the socio-cultural meaning of condom use in sexual relationships.

Couple years protection lost, a new tool for family planning programs to prioritize stockout interventions.

OBJECTIVE: To develop and evaluate a new measure--couple years protection lost (CYPL)--to identify facilities with the most damaging contraceptive stockouts and therefore direct program response. METHODS: As part of a prospective descriptive study, data were gathered on stocks of contraceptives (oral contraceptive pill, intrauterine device, and two types of implant) at 10 family planning facilities in Abuja, Nigeria, between January and August 2012. CYPL values-a summation of average client volume across contraceptive methods multiplied by the number of stockouts and the USAID couple years of protection value for each method-were calculated for each facility. RESULTS: Over the 8-month study period, the 10 facilities had CYPL values ranging from 15.7 to 588.7. Two facilities had a similarly high number of stockouts (9 vs 8), but completely different CYPL values (462.1 vs 15.7). CONCLUSION: By utilizing the CYPL measure, health programs can target family planning facilities with the most damaging stockouts first and thus strategically reduce the negative impact of contraceptive stockouts.

Demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos Town, North West Ethiopia.

BACKGROUND: Ethiopia is the second most populous country in sub Saharan Africa with high total fertility rate, and high maternal and child mortality rates. In sub Saharan African countries, including Ethiopia, even though studies show that demand for contraception is high, the practice is low. Particularly, in Ethiopia, despite the fact that practices on long acting and permanent methods are believed to be low, there are limited evidences on the real magnitude of demand for the methods. METHODS: To assess demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos town, Amhara Regional State, North West Ethiopia, A community based cross sectional study was conducted, from April 08-19, 2012. Systematic sampling technique was used to select 523 study participants. Pre tested structured Amharic version questionnaire was used to collect the data through interview. Both bivariate and multiple logistic regressions were used to identify associated factors. RESULTS: Among 519 respondents, 323 (62.2%) were using modern family planning (FP) methods in which 101 (19.5%) were using long acting and permanent contraceptive methods (LAPMs). Among all respondents, 171 (32.9%) had unmet need for LAPMs. The total demand for LAPMs was 272 (52.4%) of which 37.1% were satisfied and 62.9% unsatisfied demand. Being in the older age group (40-44 years) [AOR = 2.8; 95% CI:1.12, 9.55], having no desire for more child [AOR = 20.37; 95% CI:9.28, 44.72], desire to have a child after 2 years [AOR = 6.4; 95%CI:3.04,13.47], not ever heard of modern FP [AOR = 5.73; 95% CI:1.26, 25.91], not ever using of modern FP [AOR = 1.89; 95% CI:1.01, 3.55] and having no spousal discussion in the last six month [AOR = 1.642, 95% CI: 1.049, 2.57) were some of the factors significantly associated with demand for LAPMs. CONCLUSIONS: Demand and unmet need for LAPMs were high in the study area. Therefore raising awareness of the community, counseling/discussion about the methods with all clients, encouraging spousal involvement are fundamental areas of intervention. Moreover, increasing the availability and accessibility of LAPMs is required to meet the unmet needs.

Are modern contraceptives acceptable to people and where do they source them from across Nigeria?

BACKGROUND: Understanding the extent that different modern contraceptives are acceptable to different populations groups and where they get the commodities from will help in developing specific interventions that will help to scale-up the availability of the contraceptives. METHODS: The study took place in urban and rural sites in six states across Nigeria. Data on acceptability and sources of the contraceptives was collected from at least 770 randomly selected mostly female householders from each state respectively using a questionnaire. Acceptability of the different contraceptives was scored by the respondents on a scale of 1 (lowest) to 10 (highest). The relationships between acceptability and sources of the contraceptives with socio-economic status and geographic location of the respondents were examined. RESULTS: The use of modern contraceptives in general was acceptable to 87% of the respondents. Male condom was the most acceptable means of contraceptive with an average score of 5.0. It was followed by implants with and oral contraceptive pill with average scores of 4.0, whilst IUD was the least acceptable with an average score of 2.9. The private sector was the major source of contraceptives to different population groups. Both male and female condoms were mostly procured from patent medicine dealers (PMD) and pharmacy shops. Intra Uterine Devices (IUDs) and implants were mostly sourced from public and private hospitals in the urban areas, whilst injectibles were mostly sourced from private hospitals. Oral contraceptives were mostly sourced from pharmacy shops and patent medicine dealers. There were SES and geographic differences for both acceptability and sources of the contraceptives. Also, the sources of different contraceptives depended on the type of the contraceptive. CONCLUSION: The different contraceptives were acceptable to the respondents and the major source of the contraceptives was the private sector. Hence, public-private partnership arrangements should be explored so that universal coverage with contraceptives could be easily achieved. Interventions should be developed to eliminate the inequities in both acceptability and sources of different contraceptives. The acceptability of all the contraceptives should be enhanced with relevant behaviour change communication interventions especially in areas with the lowest levels of acceptability.

Revitalizing long-acting reversible contraceptives in settings with high unmet need: a multicountry experience matching demand creation and service delivery.

BACKGROUND: Contraception in many developing countries is characterized by high unmet need, irregular access, low utilization and presumed demand for long-acting reversible contraceptives (LARCs). STUDY DESIGN: A 13-country initiative focused on increasing consumer demand and high quality services for intrauterine devices (IUDs) began in 2009. Services were provided through (a) private sector-franchised or affiliated clinics; (b) providers seconded to the public sector and (c) special "event" days. Client intake data are used to compare the profile of IUD acceptors with IUD users from representative national datasets of select countries, as well as examine trends in IUD uptake. RESULTS: During 2009-2010, 575,601 IUDs were inserted across the 13 countries. Compared to national IUD users, users in this project were slightly younger and less educated. Among IUD acceptors, 24% used no modern method at the time of IUD initiation, and 28% reported injectable use in the three previous months. CONCLUSIONS: Convenient, quality, affordable services with demand creation can result in significant uptake of LARCs in settings with low use.

Evidence-based IUD practice: family physicians and obstetrician-gynecologists.

BACKGROUND AND OBJECTIVES: Family physicians and obstetrician-gynecologists provide much of contraceptive care in the United States and have a shared goal in preventing unintended pregnancy among patients. We assessed their competency to offer women contraceptives of the highest efficacy levels. METHODS: We conducted a national probability survey of family physicians and obstetrician-gynecologists (n=1,192). We measured counseling and provision practices of intrauterine contraception and used multivariable regression analysis to evaluate the importance of evidence-based knowledge to contraceptive care. RESULTS: Family physicians reported seeing fewer contraceptive patients per week than did obstetrician-gynecologists and were less likely to report sufficient time for counseling. While 95% of family physicians believed patients were receptive to learning about intrauterine contraception, fewer than half offered counseling or the method. Only half were trained to competence to offer intrauterine contraception, while virtually all obstetrician-gynecologists were. Both family physicians and obstetrician-gynecologists were unlikely to have adequate knowledge of the women who would be good candidates for intrauterine contraception-as gauged by the Centers for Disease Control and Prevention Medical Eligibility Criteria for contraception-and consequently did not offer the method to a wide range of eligible patients. CONCLUSIONS: Most family physicians providing contraceptive care were not offering methods with top-tier effectiveness, although they reported interest in updating contraceptive skills through training. Obstetrician-gynecologists had technical skills to offer intrauterine contraception but still required education on patient selection. Greater hands-on training opportunities for family physicians, and complementary education on eligible method candidates for obstetrician-gynecologists, can increase access to intrauterine contraception by women seeking contraceptive care.

Nurse auxiliaries as providers of intrauterine devices for contraception in Guatemala and Honduras.

Nurse auxiliaries staff the majority of primary health service delivery outlets in low-income countries, particularly in rural areas with high unmet need for contraception. Yet often service delivery guidelines prohibit them from providing contraceptive methods such as the intrauterine device (IUD). Operations research in Guatemala and Honduras in 1997-2005, described in this paper, have shown that nurse auxiliaries can provide IUDs in a safe and clinically appropriate fashion, which can help improve women's choice of methods and decrease costs in health centres with physicians and professional nurses, and health posts. Empowering these health workers requires commitment at the health system and policy levels to a long-term strategy in which small pilot studies are first conducted, followed by phased scaling-up of the strategies, which can require several years. Training can be conducted both in high volume clinics or on-site in health posts. Simple measures such as mentioning the method during counselling and to users of different services and providing women and communities with printed materials have been effective in increasing requests for IUDs. These studies also showed that nurse auxiliaries can take on other reproductive health services, such as contraceptive injections.

Peripartum contraceptive attitudes and practices.

During pregnancy and the postpartum period, women may be more receptive to different methods of contraception for postpartum use. Few studies have focused on the peripartum population. In this study, currently pregnant and postpartum women were surveyed about their attitudes toward contraception, particularly in relation to the index pregnancy. Important contraceptive attributes for women included reliability, efficacy, and safety during breast-feeding, especially in the postpartum period. Over 80% of women surveyed were using contraception prior to pregnancy, but nearly 20% were not satisfied with the method used. Dissatisfaction with their method was more likely among women whose pregnancy was unplanned (36% vs. 9%). Over 40% of peripartum women indicated a desire to change their contraceptive after delivery. Sixty-five percent of women had received only limited information about intrauterine contraception before the survey. The results indicate that childbirth has a profound effect on contraceptive priorities and desires, especially toward long-term methods.

AIDS and public policy: the lessons and challenges of "success" in Thailand.

Thailand's public policy on AIDS is widely cited as one of the few examples of an effective national AIDS prevention program anywhere in the world. The Thai experience shows that a national response that mobilized key government and NGO partners and targeted the highest-risk transmission can be effective in reducing the scope of the epidemic, even when action is delayed. Based on interviews with policymakers, AIDS program managers, technical specialists, donors, and NGOs and on a review of the data, we highlight the lessons from public policy on AIDS in Thailand for other developing countries, review the state of the Thai epidemic and public policy in 2000, and identify three strategic priorities for the next phase of the response.

New contraceptive options.

New contraceptive modalities that are being introduced into the US marketplace reflect many changes in the delivery of existing steroidal products. These products are available now not only as oral medications but also as transdermal, intravaginal, intrauterine, and implantable or injectable devices. Each of these has its own unique profile and enhances the ability of consumers to pick and choose the product that is most acceptable to them. However, development of new barrier contraceptives, particularly those that have the potential to reduce the heterosexual transmission of HIV or to reduce a bacterial infection such as Chlamydia or Neisseria gonorrhea, continues to be moving forward in clinical trials. These products can have a lower efficacy compared with the steroidal products but, because of their other benefits, may be of significant medical use.