Integration of family planning services into HIV services in Nigeria: Evidence from the Performance Monitoring and Accountability 2020 survey in seven states.

Despite global calls for stronger linkages between family planning and HIV, a growing body of evidence in sub-Saharan Africa suggests that the integration of family planning and HIV service delivery is suboptimal in some countries. In this study, we assess the integration and quality of family planning services in health facilities that provide HIV-related services in Nigeria. This study analysed secondary data from the Performance Monitoring and Accountability 2020 cross-sectional survey conducted between May and July 2016 in seven states in Nigeria. Our study sample was restricted to 290 health facilities providing HIV services. We performed descriptive statistics and binary logistic regression analyses. Ninety-five per cent of the health facilities reported offering family planning counselling, provision of family planning methods, and/or referral for family planning methods to clients accessing HIV services. About 84% of these health facilities with integrated family planning and HIV services reported that they discussed the preferred method, dual methods, instructions and side effects of the chosen method, and the reproductive intentions with clients during an HIV consultation. None of the health facilities' characteristics was significantly associated with the integration of family planning services into HIV services. Private health facilities (aOR 0.3, 95% CI 0.07-0.92), urban health facilities (aOR 3.8, 95% CI 1.64-8.76), and provision of postnatal care (aOR 3.9, 95% CI 1.10-13.74) were statistically associated with the quality of family planning services provided to clients accessing HIV services. Family planning services were integrated into HIV services in a majority of the health facilities in our study. However, our findings indicate the need for improvement in the quality of family planning services provided to clients accessing HIV services.

Integration of family planning services with HIV treatment for women of reproductive age attending ART clinic in Oromia regional state, Ethiopia.

BACKGROUND: In settings where HIV prevalence is high, management of sexual and reproductive health is critical to reducing HIV transmission and maternal mortality. Integration of family planning with HIV services is appropriate for HIV therapy, HIV prevention, and care in a resource-limited country s like Ethiopia. The study aimed at examining the status of integration of family planning services with HIV treatment and factors associated with successful integration of family planning and HIV services for women of reproductive age in Oromia, Ethiopia for better health outcomes. METHODS: The research design of this study was a quantitative survey, non-experimental, explorative and descriptive. A questionnaire was used to collect data from women living with HIV attending ART clinics in the special zone of surrounding Finfinne, Oromia Region in five health centers. Simple random sampling was used to select 654 respondents. Data was analysed through the use of Statistical Package for Social Sciences version 23.0. Bivariate and multivariate logistic regressions were performed to identify factors associated integration of family planning with HIV services with the significant association at an adjusted odds ratio (AOR) with a 95% confidence interval (CI) to controlled effects of possible confounders from the final model. RESULT: The response rate of this study was 97.6% (654/670). The ages of those who responded to the administered questionnaires ranged between 18 and 49 years. The mean age of the respondents was 31.86 years with an SD of ± 6.0 years. Most of the respondents in the sample were in the age group 26-35 (n = 374, 57%), and only 96 (14.7%) were in the age group 18-25. This overall integration of FP-HIV services among reproductive-age women living with HIV in Oromia regional state of special zone health centers was found to be 55.8%. Almost all respondents (n = 635, 97.1%) preferred integrated family planning and HIV services from the same facility and the same providers. the study found that 622 (95%) were most satisfied with the utilization of integrated family planning/HIV services. CONCLUSION: This study established that in overall, the integration of family planning/HIV services was relatively moderate among women of reproductive age living HIV. The identified factors that affected the integration of family planning with HIV services were the level of education, occupational status, residence, discussion of family planning with healthcare providers, fertility desire and CD4 counts.

These study findings are strongly in favour of integrated services offering multiple health services at the same facility by the same provider. Service integration based on the needs of women of reproductive age was found to be necessary in public health facilities where people have access only to primary healthcare facilities.Integrated family planning with HIV (FP-HIV) services contribute to women's wellbeing by addressing a wide range of health needs and offering convenience of receiving multiple services a single visit. Integrated FP-HIV services further address women's vulnerability to other sexual reproductive health problems.Integrated FP-HIV services should contribute to comprehensive national family planning programs to enable the provision of full access to a variety of contraceptive methods. The latter should enable couples and individuals to obtain services at a one-stop supermarket to achieve optimal reproductive and sexual health to meet their needs.The findings from study generated adequate knowledge and equipped managers with skills integrating family planning with HIV services among women of reproductive age in Oromia regional state, Ethiopia.The study's findings have emphasized the urgent need to fully implement action focusing on integrating family planning/HIV services for women of reproductive age living HIV and attending ART clinics. The study prioritized the need to strengthen the capacity of health centers to provide quality FP-HIV.

[Contraceptive use by married women or concubines living in rural areas in Burkina Faso: a qualitative study of free voucher use]. / Utilisation des contraceptifs par les femmes rurales mariées ou en concubinage au Burkina Faso: une analyse qualitative de l'utilisation d'un bon gratuit.

INTRODUCTION: low levels of contraceptive use in Western Africa are responsible for high fertility rates, which limits economic development. The cost of modern contraceptives is a significant constraint, then the government of Burkina Faso has implemented free family planning. Given this new policy, we provided rural women with a healthcare voucher giving free access to modern contraceptives. We conducted an analysis of the determinants of good free voucher use in order to implement adequate government policy. METHODS: six months after the distribution of vouchers to women living in 30 villages in the Houet Province, we conducted a focus-group study based on individual in-depth health care provider interviews in partner healthcare centers. RESULTS: the benefits of family planning, free contraceptive use, husband's approval and moral obligation were factors facilitating voucher use. The desire to become pregnant, husband's opposition, women's reluctance, women's lack of knowledge of contraceptives and factors associated with the intervention were the leading reasons for not using the vouchers. CONCLUSION: the promotion of modern contraceptive use among married women or concubines requires a holistic approach combining free access to modern contraceptives, effective policies involving men in family planning and the reduction of fertility preferences among the couples.

An overview of the sexual and reproductive health status and service delivery among Syrian refugees in Jordan, nine years since the crisis: a systematic literature review.

BACKGROUND: The Syrian refugee crisis has led to massive displacement into neighboring countries including Jordan. This crisis has caused a significant strain on the sexual and reproductive health (SRH) services to the host communities and Syrian refugees. The Minimum Initial Service Package (MISP) is a standard package of services that should be implemented at the onset of an emergency. Due to their importance in protracted humanitarian crisis, this systematic review aimed to assess the utilization of SRH and MISP after 9 years of the crisis. METHODS: We searched PubMed, Medline/Ovid and Scopus for both quantitative and qualitative studies from 1 January 2011 to 30 November 2019. Our search included both free text key words and Medical Subject Headings (MeSH) for various forms and acronmym of the following terms: (Sexual and) Reproductive Health, Sexual/Gender-based/Family/Intimate partner violence, Minimum Initial Service Package, MISP, Women, Girls, Adolescents, Syrian, Refugee, Jordan, Humanitarian crisis, War, (armed) conflict, and Disaster. Boolean operators and star truncation (*) were used as needed. We further conducted an in-depth review of the available grey literature published during the same timeframe. Using a narrative synthesis approach, two authors independently extracted and analyzed data from published papers. After removal of duplicates, screening, and assessing for eligibility of 161 initially identified citations, 19 papers were selected for review. RESULTS: Findings from this review indicated a number of barriers to access, utilization, and implementation of SRH services, including lack of reliable information on sexual and gender-based violence (SGBV), aggravation of early marriages by crisis setting, gaps in the knowledge and use of family planning services, inadequate STIs and HIV coverage, and some issues around the provision of maternal health services. CONCLUSION: The findings from this review are suggestive of a number of barriers pertaining to access, utilization, and implementation of SRH services. This is especially true for transitioning from MISP to comprehensive SRH services, and particularly for refugees outside camps. Following are needed to address identified barriers: improved inter-agency coordination, better inclusion/engagement of local initiatives and civil societies in SRH services delivery, improved quality of SRH services, adequate and regular training of healthcare providers, and increased awareness of Syrian women and adolescent girls. Also, more implementing research is required to identify ways to transition SRH provision from the MISP to comprehensive care for the Syrian refugee population in Jordan.

Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda.

BACKGROUND: When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS: In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS: Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS: Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.

Association of husbands' education status with unintended pregnancy in their wives in southern Ethiopia: A cross-sectional study.

BACKGROUND: Unintended pregnancy rates are substantially higher in developing regions, have significant health consequences, and disproportionately affect subgroups with socio-economic disadvantage. We aimed to examine whether there is an association between husbands' education status and their wives unintended pregnancy in southern Ethiopia. METHODS: The data source for this study was from a cross-sectional study on iron-folate supplementation and compliance in Wolaita, South Ethiopia. Data were collected from October to November 2015 in 627 married pregnant women regarding their husbands' education status, socio-demographic characteristics, and if they wanted to become pregnant at the time of survey using an interviewer administered questionnaire. Logistic regression was used to estimate Odds Ratios (ORs) with associated z-tests and 95% Confidence Intervals (95% CI) for variables associated with unintended pregnancy. RESULTS: The proportion of unintended pregnancy in this sample was 20.6%. Husbands' education status, age, residence, and using family planning methods were associated with unintended pregnancy (all P-values < 0.05). Multivariable models consistently showed that being married to a husband with at least some college or university education was associated with a decreased OR for unintended pregnancy after controlling for age and use of family planning at conception period (OR 0.36 [95%CI: 0.17, 0.82]) and age and rural residence (OR 0.40 [95%CI: 0.18, 0.90]). CONCLUSION: Unintended pregnancy among Ethiopian woman was consistently associated with being married to least educated husbands in southern Ethiopia. Increasing age and living in a rural vs urban area were also independently associated with unintended pregnancy. Strategies for addressing family planning needs of women with poorly educated husbands should be the subject of future research.

Integrating HIV Pre-Exposure Prophylaxis into Family Planning Care: A RE-AIM Framework Evaluation.

We aimed to systematically evaluate the feasibility of integrating HIV prevention services, including pre-exposure prophylaxis (PrEP), into a family planning setting in a high-prevalence community. We used the RE-AIM Framework (Reach, Efficacy, Adoption, Implementation, Maintenance) to evaluate the integration of HIV prevention services into a family planning clinic over 6 months. Before the integration, PrEP was not offered. We implemented a staff training program on HIV PrEP. We determined the proportion of women presenting to the clinic who were screened, eligible for, and initiated PrEP through chart review. We assessed staff comfort with PrEP pre- and post-integration. We compared planned and actual implementation, interviewed staff to determine barriers and facilitators, and tracked systems adaptations. We assessed maintenance of PrEP after the study concluded. There were 640 clinical encounters for 515 patients; the rate of HIV counseling and PrEP screening was 50%. The rate was 10% in month 1 and peaked to 65% in month 3. Nearly all screened patients were eligible for PrEP (98.4%) and 15 patients (6%) initiated PrEP. Staff knowledge and comfort discussing PrEP improved after education. Facilitators included partnering with local experts, continuing education, clinical tools for providers, and patient education materials. Barriers included competing priorities during clinical encounters, limited woman-centered patient education materials, and insurance-related barriers. Embedding HIV prevention services in the family planning setting was feasible in this pilot. The proportion of women screened for PrEP rapidly increased. In this high HIV prevalence community, nearly all screened women were eligible and 6% initiated PrEP.

Predictive factors to access and use of family planning services by rural and semi-urban dwellers in Afikpo North Local Government area, Ebonyi State, Nigeria.

Pregnancy and childbirth are important periods when women of reproductive age frequently come in contact with healthcare facilities and providers. These periods afford them the privilege for discussion and decision on post-partum family planning with healthcare providers. Male partner consent has been shown to have a positive impact on access and uptake of modern contraception. This study was aimed at assessing the availability, uptake and male partner consent for post-partum family planning (PPFP) amongst rural and semi-urban dwellers in Afikpo North local government area of Ebonyi state, Nigeria. The study conducted on 205 postpartum women, 40 health workers at the primary health centres (PHCs) and traditional birth attendants (TBAs) in Afikpo North LGA were selected by a random sampling technique. Information was obtained via 3 categories of interviewer-administered questionnaire for the different categories of individuals involved in the study. Data analyses was done using SPSS version 21.0. The overall findings showed a high prevalence of grand multiparity (51.2%) and child-bearing at extremities of reproductive age (20.5%) despite generally good awareness of modern contraception (92.7%) and availability of family planning services and modern birth control methods in all the PHC facilities. Of note is that a good percentage of the women received antenatal care (38.1%) or had their last delivery at TBAs places (42.4%) despite the fact that only 60% of the TBAs are aware of modern family planning methods and none of them offer family planning services. The prevalence of modern contraceptive usage was 41.5% and the male partner consent was present in 72.9% of modern contraceptive users. Despite high level of awareness and availability of modern family planning services, the TBAs should be more sensitized in order to improve the uptake of PPFP.

Male partner influence on family planning and contraceptive use: perspectives from community members and healthcare providers in KwaZulu-Natal, South Africa.

BACKGROUND: South Africa faces numerous reproductive challenges that include high rates of unplanned and adolescent pregnancies. The uptake and utilization of family planning services and modern contraception methods depend on numerous factors. The male partner plays a key role in reproductive health but data on this topic are outdated or have a predominant HIV prevention focus. The purpose of this paper is to explore the influence of male partners on family planning and contraceptive (FP/C) uptake and use within the contemporary South African setting, and to identify further areas of exploration. METHODS: This qualitative study was conducted in a community and healthcare provision setting in the eThekwini District in KwaZulu-Natal province, South Africa. Data were collected from twelve community-based focus group discussions (n = 103), two healthcare providers focus group discussions (n = 16), and eight key informant individual in-depth interviews. Following a constructionist paradigm and using the health utilization behaviour model, data were analysed using thematic analysis, allowing a robust and holistic exploration of the data. RESULTS: The data from this study revealed the complex and evolving role that male partners play in FP/C uptake and use within this setting. Key themes from the data elucidated the dual nature of male involvement in FP/C use. Culturally influenced gender dynamics and adequate understanding of FP/C information were highlighted as key factors that influenced male attitudes and perceptions about contraceptive use, whether positively or negatively. Male opposition was attributed to limited understanding; misunderstandings about side-effects; male dominance in relationships; and physical abuse. These factors contributed to covert or discontinued use by female partners. Pathways identified through which male partners positively influenced FP/C uptake and access include: social support, adequate information, and shared responsibility. CONCLUSIONS: Understanding the role that male partners play in FP/C uptake and use is important in preventing unintended pregnancies and improving family planning policy and service delivery programmes. By identifying the barriers that male partners present, appropriate strategies can be implemented. Equally important is identifying how male partners facilitate and promote adherence and use, and how these positive strategies can be incorporated into policy to improve the uptake and use of FP/C.

Are users of modern and traditional contraceptive methods in Jordan different?

BACKGROUND: The level of current use of modern family planning is the most widely used indicator for evaluating the success of national family planning programmes. Recently the prevalence of traditional methods has increased in Jordan, which may lead to undesired pregnancy. AIMS: The main objective of the study was to assess the trends of modern and traditional contraceptive use in Jordan with a focus on examining the differences between the users of each method. METHODS: A secondary data analysis of the Jordan 2012 Population and Family Health Survey data was carried out. The survey used a multistage cluster random sample. Bivariate analysis was conducted to identify the difference between modern and traditional contraceptive users. A logistic regression model was used to study significant covariates. RESULTS: Among 10 801 currently married women aged 15-49 years surveyed, 38.8% were not using any contraceptive method, 18.9% used traditional methods, and 42.3% relied on modern contraceptive methods. Logistic regression analysis revealed 4 significant predictors of using modern contraceptive methods: location in Central Region, residence in urban areas, age and parity. CONCLUSION: Women, particularly those resident in the southern region, should be encouraged to use modern contraceptive methods and this may be achieved by empowering them with more information about sources of these methods that are available to them. Family planning interventions should focus on younger and high parity women as they were more likely to use traditional methods.

Association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia.

BACKGROUND: The postpartum period provides an important opportunity to address unmet need for contraception and reduce short birth intervals. This study aims to assess the association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia. METHODS: Data for this analysis come from the 2011 to 2016 Ethiopian Demographic and Health Surveys (EDHS) and include nearly 5000 married women of reproductive age with a recent birth. Multivariate logistic regression was conducted to investigate the relationship between skilled maternal healthcare and postpartum contraceptive use. RESULTS: Between rounds of the 2011 and 2016 EDHS, the postpartum contraceptive prevalence increased from 15 to 23% and delivery in public facilities, use of skilled birth assistance, and skilled antenatal care also grew. In both survey rounds, educated women had approximately twice the odds of postpartum contraceptive use, compared with non-educated women, while an initially significant relationship between wealth and postpartum contraceptive use diminished in significance by 2016. Women with a desire to limit future pregnancy had five to six times the odds of postpartum contraceptive use in both survey rounds, and women in 2016 - unlike those in 2011 - with a desire to delay pregnancy were significantly more likely to use contraception (adjusted odds ratio (AOR) = 4.38, 95% CI: 1.46-13.18) compared to women who wanted another child soon. In 2011, no statistically significant associations were found between any maternal healthcare and postpartum contraceptive use. In contrast, in 2016, postpartum contraceptive use was significantly associated with an institutional delivery (AOR = 1.71, 95% confidence interval (CI): 1.12-2.62) and skilled antenatal care (AOR = 2.41, 95% CI: 1.41-4.10). No significant relationship was observed in either survey round between postpartum contraceptive use and skilled delivery or postnatal care. CONCLUSIONS: A comparison of postpartum women in the 2011 and 2016 EDHS reveals increased use of both contraception and skilled maternal healthcare services and improved likelihood of contraceptive use among women with an institutional delivery or antenatal care, perhaps as a result of increased attention to postpartum family planning integration. Additionally, results suggest postpartum women are now using contraception to space future pregnancies, with the potential to help women achieve more optimal birth intervals.

Health Care Provider Perceptions of the Safety of IUDs for Women with HIV.

CONTEXT: Women who are living with HIV use IUDs at a lower rate than the general population, and it is unclear whether health care providers' misconceptions about IUD safety contribute to this disparity. METHODS: A 2013-2014 nationwide survey of 1,998 U.S. family planning providers assessed perceptions of IUD safety for women with HIV or other medical conditions. Multivariable logistic regression was used to examine associations between provider characteristics and whether individuals believed IUDs were safe for HIV-positive women. Data from public-sector providers and office-based physicians were analyzed separately. RESULTS: Seven in 10 providers considered IUDs safe for women with HIV, and there were no differences by provider type. Among public-sector providers, some of the characteristics associated with believing that IUDs were unsafe for seropositive women were working at a clinic without Title X funding (odds ratio, 1.5), not being trained in IUD insertion (2.1) and not using the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for clinical guidance (1.8). Office-based physicians who did not use the guidelines also had an increased likelihood of believing that IUDs were unsafe for women with HIV (2.9), and physicians who had completed training 25 or more years ago were more likely than those who had done so less than five years ago to consider IUDs unsafe (3.3). CONCLUSIONS: Greater use of evidence-based contraceptive guidance such as the U.S. MEC may help inform provider perceptions of IUD safety and hence contribute to increased contraceptive choice for women with HIV.

Planning and preparation for pregnancy among women with and without a history of infertility.

OBJECTIVES: Preconception counseling, maternal health-related habits, diet, folic acid consumption, substances abuse, may all impact the outcome of pregnancy. The aim of this study was to compare the planning and preparation for pregnancy among pregnant women with and without infertility. MATERIAL AND METHODS: A survey of health behaviors prior to and during pregnancy that could affect pregnancy outcomes, including laboratory tests performed, stimulant usage, initiation of prenatal care, and folic acid intake, was conducted among 400 pregnant women. The study group included 121 women (30.25%) diagnosed with prior infertility, while the control group included 279 women (69.74%) who did not report any problems conceiving. RESULTS: All patients (100%) from the study group and 70,97% from the control group planned their pregnancy(p < 0.0001). Patients in the study group performed significantly more laboratory tests prior to pregnancy, including: complete blood count, urine analysis, fasting blood glucose concentration, testing for toxoplasmosis, and Pap smear, compared with the control group (p < 0.0001). There was no difference between groups regarding the knowledge of when and why folic acid supplementation is required (p > 0.05). CONCLUSIONS: Effective education of women, regarding pregnancy planning and behaviours, that may impact pregnancy outcome is still a serious challange to public health in Poland. Our study indicates that reaching general population with the education is most important to achieve best results in preconceptional care.

Impact of integration of sexual and reproductive health services on consultation duration times: results from the Integra Initiative.

The lack of human resources is a key challenge in scaling up of HIV services in Africa's health care system. Integrating HIV services could potentially increase their effectiveness and optimize the use of limited resources and clinical staff time. We examined the impact of integration of provider initiated HIV counselling and testing (PITC) and family planning (FP counselling and FP provision) services on duration of consultation to assess the impact of PITC and FP integration on staff workload. This study was conducted in 24 health facilities in Kenya under the Integra Initiative, a non-randomized, pre/post intervention trial to evaluate the impact of integrated HIV and sexual and reproductive health services on health and service outcomes. We compared the time spent providing PITC-only services, FP-only services and integrated PITC/FP services. We used log-linear regression to assess the impact of plausible determinants on the duration of clients' consultation times. Median consultation duration times were highest for PITC-only services (30 min), followed by integrated services (10 min) and FP-only services (8 min). Times for PITC-only and FP-only services were 69.7% higher (95% Confidence Intervals (CIs) 35.8-112.0) and 43.9% lower (95% CIs -55.4 to - 29.6) than times spent on these services when delivered as an integrated service, respectively. The reduction in consultation times with integration suggests a potential reduction in workload. The higher consultation time for PITC-only could be because more pre- and post-counselling is provided at these stand-alone services. In integrated PITC/FP services, the duration of the visit fell below that required by HIV testing guidelines, and service mix between counselling and testing substantially changed. Integration of HIV with FP services may compromise the quality of services delivered and care must be taken to clearly specify and monitor appropriate consultation duration times and procedures during the process of integrating HIV and FP services.

Maximizing Opportunities: Family Planning and Maternal, Infant, and Young Child Nutrition Integration in Bondo Sub-County, Kenya.

Purpose This article shares learning from an innovative demonstration program integrating maternal, infant, and young child nutrition (MIYCN) and family planning (FP) services in western Kenya, providing recommendations for future work to expand MIYCN and FP integration. Description Six health facilities reorganized to integrate MIYCN and FP services and community health volunteers (CHVs) promoted MIYCN and FP in adjacent communities in Bondo Sub-County over a 1-year period. At the facility level, each provider was directed to provide both sets of services in a single room during FP, antenatal care, postnatal care, or child consultation visits (a "one stop shop" approach). At community level, CHVs were to conduct household visits equipped with new integrated materials and incorporate MIYCN and FP within community activities. Assessment Although the "one stop shop" approach, where one provider offers all integrated services in one room, was initially proposed for all facilities, this worked most effectively in the dispensary and health centers. The sub-county hospital adapted the approach such that integrated services were offered by more than one provider during a visit, with clients linked from one provider to another through same-day intra-facility referrals. CHVs were generally able to incorporate MIYCN and FP content within household visits and community activities; however some knowledge gaps were noted after initial training, necessitating additional refresher training. Conclusion This demonstration experience revealed that future replication efforts should enable sub-county team leadership, assess facility readiness, streamline data collection, build local buy-in, and prioritize dispensaries and health centers with high client loads.

Evaluating the comparative effectiveness of different demand side interventions to increase maternal health service utilization and practice of birth spacing in South Kivu, Democratic Republic of Congo: an innovative, mixed methods approach.

BACKGROUND: In this protocol we describe a mixed methods study in the province of South Kivu, Democratic Republic of Congo evaluating the effectiveness of different demand side strategies to increase maternal health service utilization and the practice of birth spacing. Conditional service subsidization, conditional cash transfers and non-monetary incentives aim to encourage women to use maternal health services and practice birth spacing in two different health districts. Our methodology will comparatively evaluate the effectiveness of different approaches against each other and no intervention. METHODS/DESIGN: This study comprises four main research activities: 1) Formative qualitative research to determine feasibility of planned activities and inform development of the quantitative survey; 2) A community-based, longitudinal survey; 3) A retrospective review of health facility records; 4) Qualitative exploration of intervention acceptability and emergent themes through in-depth interviews with program participants, non-participants, their partners and health providers. Female community health workers are engaged as core members of the research team, working in tandem with female survey teams to identify women in the community who meet eligibility criteria. Female community health workers also act as key informants and community entry points during methods design and qualitative exploration. Main study outcomes are completion of antenatal care, institutional delivery, practice of birth spacing, family planning uptake and intervention acceptability in the communities. Qualitative methods also explore decision making around maternal health service use, fertility preference and perceptions of family planning. DISCUSSION: The innovative mixed methods design allows quantitative data to inform the relationships and phenomena to be explored in qualitative collection. In turn, qualitative findings will be triangulated with quantitative findings. Inspired by the principles of grounded theory, qualitative analysis will begin while data collection is ongoing. This "conversation" between quantitative and qualitative data will result in a more holistic, context-specific exploration and understanding of research topics, including the mechanisms through which the interventions are or are not effective. In addition, engagement of female community health workers as core members of the research team roots research methods in the realities of the community and provides teams with key informants who are simultaneously implicated in the health system, community and target population.

Feasibility and acceptability of introducing routine antenatal contraceptive counselling and provision of contraception after delivery: the APPLES pilot evaluation.

OBJECTIVE: To determine the feasibility and acceptability of routine antenatal contraceptive counselling and contraception provision including long-acting reversible contraception (LARC) postpartum. DESIGN: Health service research evaluation. SETTING: Community antenatal clinics and hospital maternity settings in National Health Service, Scotland UK. POPULATION: Women booked for antenatal care. METHODS: Contraceptive counselling with a community midwife (22 weeks' gestation) and provision of contraception (with facilitated access to LARC methods) prior to discharge from maternity hospital. Evaluation consisted of (i) self administered questionnaire (32-34 weeks) of women's views of antenatal contraceptive counselling, (ii) database review of contraceptive methods provided at discharge, and (iii) focus groups with midwives and obstetricians. MAIN OUTCOME MEASURES: Women's views on antenatal contraceptive counselling. Secondary outcomes included (i) uptake of LARC methods and (ii) barriers and facilitators to providing antenatal counselling and contraception. RESULTS: There were 1369 women in the cohort. Questionnaires were distributed to 1064 women (78%) and completed by 794 (75%). In all, 78% of respondents (n = 621) discussed contraception antenatally with a community midwife and 74% (n = 461) found this helpful. Although 43% of respondents (n = 341) were planning to use LARC, only 9% of the cohort (118 of 1369) received LARC prior to discharge. Community midwives indicated that antenatal contraceptive counselling was now embedded in their role, but hospital staff indicated that workloads impacted upon ability to provide contraception for women. CONCLUSIONS: Antenatal contraceptive counselling, delivered by community midwives, is feasible and highly acceptable to women. However, providing contraception and LARC for women before they are discharged home remains a challenge. TWEETABLE ABSTRACT: Giving contraceptive advice antenatally is feasible and acceptable.

Predictors of nurses' and midwives' intentions to provide maternal and child healthcare services to adolescents in South Africa.

BACKGROUND: Adolescent mothers are at a much higher risk for maternal mortality compared to mothers aged 20 years and above. Newborns born to adolescent mothers are also more likely to have low birth weight, with the risk of long-term effects such as early onset of adult diabetes than newborns of older mothers. Few studies have investigated the determinants of adequate quality maternal and child healthcare services to pregnant adolescents. This study was conducted to gain an understanding of nurses' and midwives' intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa. METHODS: A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Pearson's correlation analysis was conducted to determine the association between knowledge, attitude, subjective norms, self-efficacy, and intention variables for FP and MCH services. A 2-step linear regression analysis was then conducted for both FP and MCH services to predict the intentions to provide FP and MCH services to adolescents. RESULTS: Self-efficacy to conduct MCH services (ß = 0.55, p < 0.01) and years of experience as a nurse- midwife (ß = 0.14, p < 0.05) were associated with stronger intentions to provide the services. Self-efficacy to provide FP services (ß = 0.30, p < 0.01) was associated with stronger intentions to provide FP services. CONCLUSIONS: Self-efficacy has a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. There is a need to improve and strengthen nurses' and midwives' self-efficacy in conducting both MCH and FP services in order to improve the quality and utilization of the services by adolescents in South Africa.

Midwives as drivers of reproductive health commodity security in Kaduna State, Nigeria.

OBJECTIVES: The significant improvement in the contraceptive prevalence rate in Kaduna State, Nigeria, from 8.4% in 2008 to 18.5% in 2013 is a notable achievement. This article analyses the role of midwives as drivers of reproductive health commodity security (RHCS) and their impact on contraceptive use in Kaduna State. METHODS: The United Nations Population Fund (UNFPA) supported the bimonthly review resupply meetings facilitated by midwives at State and local government area (LGA) levels. The midwives deliver contraception to the LGAs for onward distribution to 6974 of the 25,000 health facilities across the country according to usage data from the previous 2 months. They also collect requisition, issue and resupply form data from the previous 2 months. RESULTS: The active participation of midwives at the bimonthly meetings improved data timeliness by 23% and data completeness by 50% in 1 year. Only one health facility ran out of intrauterine devices and only 17% reported running out of female condoms. The total number of contraceptives issued increased from 31,866 in 2012 to 177,828 in 2013, resulting in a couple-year protection increase from 3408 in 2012 to 102,207 in 2013. CONCLUSIONS: Creation of increased demand and engagement of midwives in providing family planning services, especially long-acting contraceptive methods, coupled with the removal of cost to the user and the strengthening of the supply chain have been major factors in more than doubling the contraceptive prevalence rate.

Does service integration improve the sexual and reproductive healthcare of women living with HIV?

The sexual and reproductive health (SRH) care needs of a cohort of HIV-positive women were studied pre- and post-integration of genitourinary medicine (GUM) and SRH services. Pre-integration, 24.9% of women at risk of pregnancy were using an effective method of contraception, with a non-significant improvement post-integration to 39.3%. Pre-integration, 47.6% of pregnancies were unplanned, whilst 50% were still unplanned post-integration. Cervical cytology uptake within the previous 12 months improved significantly. It appears that the integration of services alone does not improve all aspects of the SRH of women living with HIV and additional novel strategies should be explored.