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.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

BACKGROUND: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. METHODS: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). RESULTS: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. CONCLUSION: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

Safety and Acceptability of Community-Based Distribution of Injectable Contraceptives: A Pilot Project in Mozambique.

Mozambique has witnessed a climbing total fertility rate in the last 20 years. Nearly one-third of married women have an unmet need for family planning, but the supply of family planning services is not meeting the demand. This study aimed to explore the safety and effectiveness of training 2 cadres of community health workers-traditional birth attendants (TBAs) and agentes polivalentes elementares (APEs) (polyvalent elementary health workers)-to administer the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), and to provide evidence to policy makers on the feasibility of expanding community-based distribution of DMPA in areas where TBAs and APEs are present. A total of 1,432 women enrolled in the study between February 2014 and April 2015. The majority (63% to 66%) of women in the study started using contraception for the first time during the study period, and most women (over 66%) did not report side effects at the 3-month and 6-month follow-up visits. Very few (less than 0.5%) experienced morbidities at the injection site on the arm. Satisfaction with the performance of TBAs and APEs was high and improved over the study period. Overall, the project showed a high continuation rate (81.1%) after 3 injections, with TBA clients having significantly higher continuation rates than APE clients after 3 months and after 6 months. Clients' reported willingness to pay for DMPA (64%) highlights the latent demand for modern contraceptives. Given Mozambique's largely rural population and critical health care workforce shortage, community-based provision of family planning in general and of injectable contraceptives in particular, which has been shown to be safe, effective, and acceptable, is of crucial importance. This study demonstrates that community-based distribution of injectable contraceptives can provide access to family planning to a large group of women that previously had little or no access.

Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: client, counselor and facility-level considerations.

BACKGROUND: Governments and donors encourage the integration of family planning into voluntary HIV counseling and testing (VCT) services. We aimed to determine whether VCT counselors could feasibly offer family planning and whether clients would accept such services. DESIGN AND METHODS: We employed a quasi-experimental, pre and postintervention survey design, interviewing 4019 VCT clients attending eight Ethiopian public sector facilities and 4027 additional clients 18 months after introducing family planning services in the same facilities. We constructed sex-stratified multilevel models assessing three outcomes: whether clients received contraceptive counseling, whether clients obtained contraceptive methods during VCT and whether clients intended to use condoms consistently after VCT. RESULTS: Clients demonstrated lower than expected immediate need for contraception. After intervention, only 29% of women had sex in the past 30 days, and 74% of these women were already using contraceptives. Despite the relatively low risk this population had for unwanted pregnancy, family planning counseling in VCT increased from 2 to 41% for women and from 3 to 29% for men (P < 0.01). Approximately, 6% of clients received contraceptive methods. However, sexually active men and women and those with more perceived HIV risk were more likely to obtain contraceptives and intend to use condoms consistently. Men attending facilities with higher client loads were 88% less likely to receive family planning information and 93% less likely to receive contraceptives than those attending facilities with lower client loads. Male and female clients whose counselors perceived contraceptive availability to be adequate were four and two times more likely, respectively, to receive contraceptive methods than those counseled by providers who felt supplies were inadequate (P < 0.01). CONCLUSION: Integrating VCT and family planning services is likely to be an effective programmatic option, but populations at risk for HIV or unintended pregnancy should be targeted.

Unmet need for contraception among HIV-positive women in Lesotho and implications for mother-to-child transmission.

In Lesotho, the risk of mother-to-child-transmission (MTCT) of HIV is substantial; women of childbearing age have a high HIV prevalence rate (26.4%), low knowledge of HIV status and a total fertility rate of 3.5 births per woman. An effective means of preventing MTCT is to reduce unwanted fertility. This paper examines the unmet need for contraception to limit and space births among HIV-positive women in Lesotho aged 15-49 years, using the 2004 Lesotho Demographic and Health Survey. HIV-positive women have their need for contraception unmet in almost one-third of cases, and multivariate analysis reveals this unmet need is most likely amongst the poor and amongst those not approving of family planning. Urgent action is needed to lower the level of unmet need and reduce MTCT. A constructive strategy is to improve access to family planning for all women in Lesotho, irrespective of HIV status, and, more specifically, integrate family planning with MTCT prevention and voluntary counselling and testing services.

Changing patterns of maternal mortality (HIV/AIDS related) in poor countries.

Maternal mortality is greatest in poor countries and it is in exactly these countries that the human immunodeficiency virus (HIV) poses an added challenge in attaining the Millennium Development Goals. The prevalence of HIV infection in many poor countries continues to rise. South Africa is an example of how some of the challenges can be addressed. Recommendations by the South African National Committee on the Confidential Enquiry into Maternal Deaths stressed the importance of addressing the antenatal, intrapartum and postpartum care of women, laying emphasis on the need for societal support, including nutritional and emotional support, reproductive health services including contraception, provider-initiated counselling and testing (PICT) and prevention. Antenatal care needs to be targeted for support and early intervention when abnormalities are detected, including the initiation of highly active antiretroviral therapy when necessary. Intrapartum care needs to be conducted in a hygienic environment with access to operative delivery. More attention needs to be paid to postpartum care because most women tend to succumb to puerperal sepsis. Ethical principles must be upheld when managing women with HIV infection.

Factors associated with adolescent abortion in a rural area of Bangladesh.

This study examines levels and trends in abortion among adolescent girls in 1982-98 and identifies groups of adolescents who are at high risk for having an abortion. The study used data sets collected in Matlab in Bangladesh where the Center for Health and Population Research at ICDDR,B, has maintained a demographic surveillance system, since 1966. Both bivariate and multivariate techniques of analysis were employed. We also used qualitative information derived from in-depth interviews with adolescents. The incidence of abortion was 35 times higher for unmarried than for married adolescents. Abortion ratios were also higher for adolescents who were <18 years old and for those with more than primary education. A little less than half of the abortions were induced by biomedical health workers (by means of menstrual regulation) which means that traditional providers fulfilled an important function in this rural area. The findings suggest that high-quality abortion services provided to adolescents in the framework of comprehensive reproductive health services will help to lower abortions in general and of unsafe abortions provided by traditional providers in particular.

An economic appraisal of alternative strategies for the delivery of MCH-FP services in urban Dhaka, Bangladesh.

The strategy of distributing maternal and child health and family planning (MCH-FP) services at the doorsteps of the clients--through routine visits to the eligible couples by trained fieldworkers--has been instrumental in increasing the contraceptive prevalence rate (CPR), reducing fertility and attaining a considerably high immunization coverage of children and women in Bangladesh. The doorstep strategy, however, appeared to be labour-intensive and costly. With the maturity of the programme, priorities of the national MCH-FP programme have shifted to a stage that calls for more cost-effective service-delivery strategies, capable of offering a broader package of reproductive and other essential health services. The main objective of the present study was to examine the cost and effectiveness implications of the alternative strategies of delivering services from fixed sites--field-tested within an ICDDR,B operations research--in comparison to the conventional (existing) doorstep strategy. The key findings of the economic appraisal indicated that, at the end of the operations research intervention, both cost per birth averted and cost per QALY gained were lowest for the option of delivering services from static (fixed-site) clinics: US$13 and US$17 compared with the corresponding values of US$18 and US$42 for the doorstep strategy. Provision of health and family planning services from clinics--complemented with a reduced system of outreach workers to inform and target the hard-to-reach clients--was found to be the most cost-effective service-delivery alternative.