Associations Between Abortion Services and Acceptance of Postabortion Contraception in Six Indian States.

Women receiving induced abortions or postabortion care are at high risk of subsequent unintended pregnancy, and intervals of less than six months between abortion and subsequent pregnancy may be associated with adverse outcomes. This study highlights the prevalence and attributes of postabortion contraceptive acceptance from 2,456 health facilities in six major Indian states, among 292,508 women who received abortion care services from July 2011 through June 2014. Eighty-one percent of the women accepted postabortion contraceptive methods: 53 percent short-term, 11 percent intrauterine devices, and 16 percent sterilization. Postabortion contraceptive acceptance was highest among women who were aged 25 years and older, received first-trimester services, received induced abortion, attended primary-level health facilities, and had medical abortions. Doctors receiving post-training support were more likely to offer contraceptives, but no association was observed between such support and acceptance of IUDs or sterilization. Comprehensive service-delivery interventions, including ensuring availability of skilled providers and contraceptive commodities, offering clinical mentoring for providers, identifying and addressing provider bias, and improving provider counseling skills, can increase postabortion contraceptive acceptance and reduce unintended pregnancy.

Expanding availability of safe abortion services through private sector accreditation: a case study of the Yukti Yojana program in Bihar, India.

BACKGROUND: Recognizing the need to increase access to safe abortion services to reduce maternal mortality and morbidity, the state government of Bihar, India introduced an innovative mechanism of accrediting private health care facilities. The program, Yukti Yojana ('a scheme for solution'), accredits eligible health facilities and supports them in providing abortion-related services free of charge to rural and low-income urban women. This paper describes implementation of Yukti Yojana. METHODS: A descriptive analysis of abortion services provided under the Yukti Yojana program was conducted using four data sources: 1) assessment of accredited facilities over 6 months; 2) induced and incomplete abortion service registers; 3) client exit interviews and associated direct observation of client-provider interaction for a sample of accredited facilities; and 4) in-depth interviews with providers and key stakeholders responsible for providing or influencing abortion services. These analyses assessed characteristics of women receiving abortion services, quality of care and client satisfaction, and barriers and facilitating factors of a successful accreditation process. RESULTS: Forty-nine private facilities were accredited during the first two years of the program, and 84 % had begun providing abortion services, in all 27,724 women were served. Overall, 53 % of beneficiaries reported holding a "Below Poverty Line" card, while 71 % had low living standard. The majority of women (n = 569) reported satisfaction (90 %) with their care, while 68 % perceived good quality of services. Having a government-led initiative was considered a key element of success, while stringent requirements for site approval, long waiting time for accreditation, complicated and delayed reimbursement process and low reimbursement fees for abortion services were identified as barriers to implementation. CONCLUSIONS: Yukti Yojana provides a model for successfully involving private OB/GYNs and general physicians to deliver safe abortion services to poor women on a large scale and offers additional evidence that public-private partnerships can be used to ensure availability of high-quality maternal health services to women in low-income countries. Private facility accreditation also offers a promising solution to the limited availability of safe abortion services in low resource settings such as Bihar, India.

Increases in self-reported consistent condom use among male clients of female sex workers following exposure to an integrated behaviour change programme in four states in southern India.

PURPOSE: As part of the Avahan India AIDS Initiative, a behaviour change communication programme sought to increase consistent condom use (CCU) among male clients of female sex workers (FSWs) in four Indian states through the use of outdoor static promotional materials, interpersonal communication and mid-media activities. This paper presents key findings related to programme coverage levels, trends over time in self-reported condom use, and correlations between levels of exposure to programme activities and self-reported condom use. METHODS: Five stratified two-stage cluster sample surveys were conducted between April 2006 and November 2008 (sample sizes ranged from 1741 to 2041). The independent samples were composed of clients of FSWs in selected clusters. Multivariate logistic regression was used to model whether behavioural outcomes varied between baseline and endline, and whether they varied with levels of exposure to the intervention. RESULTS: Over two-thirds of men in each survey round recalled one or two of the main intervention channels. An increase in CCU with FSWs was found between baseline and endline (63.6% vs 86.5; p<0.01). Men exposed to two intervention channels reported higher CCU than men exposed to none or only static outdoor media (89.4% vs 82.0%, p<0.05). This trend was sustained for condom use at last sex (96.2% vs 92.6%, p<0.05). CONCLUSION: Evaluation suggests that a multi-channel behavioural intervention delivered at sites where FSWs are solicited can increase CCU among male clients of FSWs. Further research is needed on the dynamics of exposure to multiple communication channels and the contributions of complementary interventions.

Lot quality assurance sampling for monitoring coverage and quality of a targeted condom social marketing programme in traditional and non-traditional outlets in India.

OBJECTIVES: This study reports on the results of a large-scale targeted condom social marketing campaign in and around areas where female sex workers are present. The paper also describes the method that was used for the routine monitoring of condom availability in these sites. METHODS: The lot quality assurance sampling (LQAS) method was used for the assessment of the geographical coverage and quality of coverage of condoms in target areas in four states and along selected national highways in India, as part of Avahan, the India AIDS initiative. RESULTS: A significant general increase in condom availability was observed in the intervention area between 2005 and 2008. High coverage rates were gradually achieved through an extensive network of pharmacies and particularly of non-traditional outlets, whereas traditional outlets were instrumental in providing large volumes of condoms. CONCLUSION: LQAS is seen as a valuable tool for the routine monitoring of the geographical coverage and of the quality of delivery systems of condoms and of health products and services in general. With a relatively small sample size, easy data collection procedures and simple analytical methods, it was possible to inform decision-makers regularly on progress towards coverage targets.