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.

Effectiveness of a quality improvement intervention to increase adherence to key practices during female sterilization services in Chhattisgarh and Odisha states of India.

BACKGROUND: In response to longstanding concerns around the quality of female sterilization services provided at public health facilities in India, the Government of India issued standards and quality assurance guidelines for female sterilization services in 2014. However, implementation remains a challenge. The Maternal and Child Survival Program rolled out a package of competency-based trainings, periodic mentoring, and easy-to-use job aids in parts of five states to increase service providers' adherence to key practices identified in the guidelines. METHODS: The study employed a before-and-after quasi-experimental design with a matched comparison arm to examine the effect of the intervention on provider practices in two states: Odisha and Chhattisgarh. Direct observations of female sterilization services were conducted in selected public health facilities, using a checklist of 30 key practices, at two points in time. Changes in adherence to key practices from baseline to endline were compared at 12 intervention and 12 comparison facilities using a difference in difference analysis. RESULTS: Several key practices were well-established prior to the intervention, with adherence levels over 90% at baseline, including hemoglobin and urine testing, use of sterile surgical gloves and instruments, and recommended surgical technique. However, adherence to many other practices was extremely low at baseline. The program significantly increased adherence to nine practices, including those related to ascertaining client's medical eligibility, client-provider interaction, the consent process, and post-operative care. The greatest improvement was observed in the provision of written instructions for clients prior to discharge. At endline, however, adherence remained below 50% for 14 practices. CONCLUSION: Low adherence to key practices at baseline confirmed the need for quality improvement interventions in female sterilization services. While the intervention improved adherence to certain practices around admission and post-operative care, inadequate human resources and infrastructure, among other factors, may have blunted the impact of the intervention.

Competency-based training "Helping Mothers Survive: Bleeding after Birth" for providers from central and remote facilities in three countries.

OBJECTIVE: To validate a new training module for skilled and semiskilled birth attendants authorized to provide care at birth-Helping Mothers Survive: Bleeding After Birth (HMS:BAB)-aimed at reducing postpartum hemorrhage, the leading cause of maternal mortality worldwide. BAB training involves single-day, facility-based training that emphasizes simulation of scenarios related to prevention, detection, and management of postpartum hemorrhage. METHODS: A total of 155 skilled and semiskilled birth attendants participated in training in India, Malawi, and Zanzibar, Tanzania. Knowledge and confidence were assessed before and after training. Skills and acceptability were assessed after training. RESULTS: Knowledge and confidence scores improved significantly from pre- to post-training among all cadres in all three countries. The proportion of providers with passing knowledge scores increased significantly from pre- to post-training among all cadres except for those already high at baseline. On three post-training skills tests the overall proportion of individuals with a passing score ranged from 83% to 89%. CONCLUSION: BAB training in prevention and management of postpartum hemorrhage increased knowledge and confidence among skilled and semiskilled birth attendants. Further studies are needed to determine the impact of this training on skills retention and clinical outcomes following postpartum hemorrhage, after broader implementation of the training program.