Twinning Partnership Network: A Learning and Experience-Sharing Network Among Health Professionals in Rwanda to Improve Health Services.

We describe the development, implementation, and evaluation of a novel twinning approach: the Twinning Partnership Network (TPN). Twinning is a well-known approach to peer learning that has been used in a variety of settings to build organizational capacity. Although twinning takes many forms, the heart of the approach is that institutions with shared characteristics collaborate via sharing information and experiences to achieve a specific goal. We adapted a twinning partnership strategy developed by the World Health Organization to create a network of like-minded health institutions. The key innovation of the TPN is the network, which ensures that an institution always has a high-performing peer with whom to partner on a specific topic area of interest. We identified 10 hospitals and 30 districts in Rwanda to participate in the TPN. These districts and hospitals participated in a kickoff workshop in which they identified capacity gaps, clarified goals, and selected twinning partners. After the workshop, districts and hospitals participated in exchange visits, coaching visits, and virtual and in-person learning events. We found that districts and hospitals that selected specific areas and worked on them throughout the duration of the TPN with their peers improved their performance significantly when compared with those that selected and worked on other areas. Accreditation scores improved by 5.6% more in hospitals selecting accreditation than those that did not. Districts that selected improving community-based health insurance coverage improved by 4.8% more than districts that did not select this topic area. We hypothesize that these results are due to senior management's interest and motivation to improve in these specific areas, the motivation gained by learning from high-performing peers with similar resources, and context-specific knowledge sharing from peer hospitals and districts.

Meeting Postpartum Women's Family Planning Needs Through Integrated Family Planning and Immunization Services: Results of a Cluster-Randomized Controlled Trial in Rwanda.

OBJECTIVE: The primary objective of this study was to test the effectiveness of integrating family planning service components into infant immunization services to increase modern contraceptive method use among postpartum women. METHODS: The study was a separate sample, parallel, cluster-randomized controlled trial. Fourteen randomly selected primary health facilities were equally allocated to intervention (integrated family planning and immunization services at the same time and location) and control groups (standard immunization services only). At baseline (May-June 2010), we interviewed postpartum women attending immunization services for their infant aged 6 to 12 months using a structured questionnaire. A separate sample of postpartum women was interviewed 16 months later after implementation of the experimental health service intervention. We used linear mixed regression models to test the study hypothesis that postpartum women attending immunization services for their infants aged 6-12 months in the intervention facilities will be more likely to use a modern contraceptive method than postpartum women attending immunization services for their infants aged 6-12 months in control group facilities. RESULTS: We interviewed and analyzed data for 825 women from the intervention group and 829 women from the control group. Results showed the intervention had a statistically significant, positive effect on modern contraceptive method use among intervention group participants compared with control group participants (regression coefficient, 0.15; 90% confidence interval [CI], 0.04 to 0.26). Although we conducted a 1-sided significance test, this effect was also significant at the 2-sided test with alpha = .05. Among those women who did not initiate a contraceptive method, awaiting the return of menses was the most common reason cited for non-use of a method. Women in both study groups overwhelmingly supported the concept of integrating family planning service components into infant immunization services (97.9% in each group), and service data collected during the intervention period did not indicate that the intervention had any negative effect on infant immunization service uptake. CONCLUSION: Integrating family planning service components into infant immunization services can be an acceptable and effective strategy to increase contraceptive use among postpartum women. Additional research is needed to examine the extent to which this integration strategy can be replicated in other health care settings. Future research should also explore persistent misconceptions regarding the relationship between return of menses and return to fertility during the postpartum period.

Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010-2012.

BACKGROUND: Vasectomy is safe and highly effective; however, it remains an underused method of family planning (FP) in Africa. In view of this, three Rwandan physicians were trained in no-scalpel vasectomy with thermal cautery and fascial interposition on the prostatic end as vasectomy trainers in 2010, and this initiative has resulted in over 2900 vasectomy clients from February 2010 to December 2012. STUDY DESIGN: This cross-sectional descriptive study describes vasectomy clients (n=316) and their wives (n=300) from 15 randomly selected hospitals in Rwanda. RESULTS: The vasectomy clients were mainly over age 40, had young children (age <3) and were married and cohabiting. Limited financial resources, satisfaction with existing family size and avoiding side effects from hormonal methods (wives') were key motivators for vasectomy uptake. High rates of previous FP use and high degree of interspousal communication are known correlates of higher FP use. CONCLUSIONS: Future and current Rwandan FP programs and other interested parties will benefit from understanding which couples elect vasectomy, their motivations for doing so and their service utilization experiences. Better integration of vasectomy counseling and postvasectomy procedures will benefit the program. IMPLICATIONS: Until this project, vasectomy projects in sub-Saharan Africa were viewed as unrealistic. This study confirms factors influencing vasectomy uptake identified in earlier research, but does so within a robust sample of vasectomy users and their wives and provides a strong understanding of who likely vasectomy users are in this context. Promotion of vasectomy services should be considered as an essential element of a healthy contraceptive method mix.

Strengthening vasectomy services in Rwanda: introduction of thermal cautery with fascial interposition.

BACKGROUND: Recent developments in vasectomy research indicate that occluding the vas using cautery combined with fascial interposition (FI) significantly lowers failure rates and is an appropriate technology for low-resource settings. We report the introduction of this technique in Ministry of Health (MOH) vasectomy services in Rwanda. DESIGN: In February 2010, an international vasectomy expert trained three Rwandan physicians to become trainers in no-scalpel vasectomy (NSV) with thermal cautery and FI. The training took place over 5 days in five rural health centers. RESULTS: A total of 67 men received vasectomies (11-16 per day) and trainees successfully mastered the new occlusion technique. The MOH is now scaling up NSV with cautery and FI services nationwide. The initial cadre of trainers has subsequently trained 46 other physicians in this vasectomy technique across 27 districts of Rwanda. CONCLUSIONS: No-scalpel vasectomy with thermal cautery and FI was successfully introduced in vasectomy services in Rwanda, and a similar initiative should be evaluated in other national vasectomy services worldwide.