Integrating postpartum IUD counselling and insertion into routine maternity care in Nepal: Assessing trends over time.

To meet the postpartum family planning (PPFP) needs of women in Nepal, an intervention was launched to integrate PPFP counselling and postpartum IUD (PPIUD) insertion into maternity care. Women delivering in study hospitals over a period of 18 months were interviewed at the time of delivery and at 15 months following the end of the study enrollment period to assess if the impact of the intervention observed at the end of the study was maintained. Data were collected prior to the intervention, at the middle month of the intervention roll out, at the end of the enrollment period and 15 months after the end of the enrollment period. We compared PPFP counselling and insertion rates before, during, at the end of and after the intervention study period, using cross-tabulation and chi-square tests. Overall, PPFP counselling rates increased from 11% at the baseline month to 45% at the end of the enrollment in February 2017 and remained the same 15 months later in July 2018. PPIUD uptake, however, rose from a negligible 0.1% at the baseline to 4.3% in February 2017, but declined to 3.4% in July 2018. PPIUD uptake among women who were counselled showed a similar trend, increasing from 1.9% at the baseline to 9.6% in February 2017 and declining to 6.0% in July 2018. The intervention had an appreciable continued impact on PPIUD counselling rates and although PPIUD uptake rose during the intervention, this trend was not observed in the 15 months post-study follow up. The impact of the intervention was greater and persistent in hospitals that had a longer period of exposure to intervention. The results suggest that counselling was well integrated with the maternity care, though uptake of PPIUD dropped after intervention activities such as active monitoring, technical supervision, provision of IUDs and training were withdrawn. Trial registration: This study has been registered with Clinical Trial.gov. The registration number is NCT02718222. Details about the study design have been published by Canning et al, 2016.

Addressing Men's Health Needs in Nepal: An Ignored Public and Clinical Health Concern.

Despite men's poorer outcomes than women in many health issues such as life expectancy, ischemic heart disease, hypertension, diabetes, HIV/AIDS, traffic-related injuries, drug and alcohol abuse, etc, Nepal's health care strategy does not have an adequately focused program to address men's health needs. This comment aims to illustrate the differences in selected health indicators between men and women and suggest Nepal's health sector strategy 2022-2030 should address to advance men's health needs. Keywords: Health policy; men's health; Nepal.

Does family planning counseling reduce unmet need for modern contraception among postpartum women: Evidence from a stepped-wedge cluster randomized trial in Nepal.

BACKGROUND: Postpartum women have high rates of unmet need for modern contraception in the two years following birth in Nepal. We assessed whether providing contraceptive counseling during pregnancy and/or prior to discharge from the hospital for birth or after discharge from the hospital for birth was associated with reduced postpartum unmet need in Nepal. METHODS: We used data from a larger a stepped-wedge, cluster randomized trial, including contraceptive counselling in six tertiary hospitals. Group 1 hospitals (three hospitals) initiated the intervention after three months of baseline data collection, while Group 2 hospitals (three hospitals) initiated the same intervention after nine months. We have enrolled 21,280 women in the baseline interviews and conducted two follow-up interviews with them, one and two years after they had delivered in one of our study hospitals. We estimated the effect of counseling and its timing (pre-discharge, post- discharge, both, or neither) on unmet need for modern contraception in the postpartum period, using random-effects logistic regressions. RESULTS: Unmet need for modern contraception was high (54% at one year and 50% at two years). Women counseled in either the pre-discharge period (Odds ratio [OR] 0·86; 95% CI: 0·80, 0·93) or in the post-discharge period (OR 0·86; 95% CI: 0·79, 0·93) were less likely to have an unmet need in the postpartum period compared to women with no counseling. However, women who received counseling in both the pre- and post-discharge period were 27% less likely than women who had not received counseling to have unmet need (OR 0.73; 95% CI: 0·67, 0·80). CONCLUSIONS: Counseling women either before or after discharge reduces unmet need for postpartum contraception but counseling in both periods is most effective.

Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health in Nepal.

The national lockdown imposed in Nepal as a response to the COVID-19 pandemic is having indirect consequences on sexual and reproductive (SRH) in Nepal. Although the Government of Nepal and partners have committed to ensuring the continuity of SRH services during the pandemic, this comment aims to illustrate the potential impacts to SRH if these commitments are not met. Keywords: COVID-19; Nepal; reproductive health; sexual health.

Provider and Women Characteristics as Risk Factors for Postpartum Copper IUD Expulsion and Discontinuation in Nepal.

CONTEXT: Providers' and women's characteristics are associated with postpartum copper IUD (PPIUD) outcomes, but the relationship between providers' level of experience and PPIUD expulsion and discontinuation has not been established. METHODS: Data on 1,232 women and 118 providers who took part in a randomized trial of a PPIUD counselling and provision intervention in Nepal between 2015 and 2017 were used to identify associations between providers' and women's characteristics and PPIUD outcomes. Multinomial logistic regression models were used to estimate PPIUD expulsion and discontinuation risks at two years after insertion. RESULTS: Thirteen percent of women had had partial or complete expulsions and 29% had discontinued PPIUD use by two years. Having a provider who had done at least 10 previous insertions was associated with lower risk of expulsion rather than continuation (relative risk ratio, 0.5) relative to having a less-experienced provider. Women had a higher risk of both expulsion and discontinuation relative to continuation if they were younger than 21 rather than aged 26-30 (2.4 and 1.7, respectively) or if they belonged to the Dalit rather than Brahmin caste (2.2 and 1.9, respectively). Women whose husbands did not live at home also had elevated discontinuation risks. CONCLUSION: The findings highlight the need for increased training and supervision of providers during their first 10 PPIUD insertions. Counselling on risk of expulsion may especially benefit younger and Dalit women, and should include partners and other family members to avoid any stigma surrounding PPIUD use by women whose partner is away from home for a prolonged period.

RESUMEN Contexto: Las características de proveedores de servicios de salud y mujeres están asociadas con los resultados del DIU de cobre posparto (DIUPP), pero no se ha establecido la relación entre la experiencia de los proveedores de servicios de salud y la expulsión y discontinuación del DIUPP. Metodos: Se utilizaron datos de 1,232 mujeres y 118 proveedores de servicios de salud que participaron en un ensayo aleatorio de una intervención de consejería y provisión de DIUPP en Nepal entre 2015 y 2017, para identificar asociaciones entre las características de proveedores de servicios de salud y mujeres y los resultados relacionados con el DIUPP. Se utilizaron modelos de regresión logística multinomial para estimar los riesgos de expulsión y discontinuación de DIUPP dos años después de la inserción. Resultados: El 13% de las mujeres había tenido expulsiones parciales o completas y el 29% había descontinuado el uso de DIUPP a los dos años. Haber tenido un proveedor con experiencia de al menos 10 inserciones previas en comparación con un proveedor con menos experiencia se asoció con un menor riesgo de expulsión en lugar de continuación (índice de riesgo relativo 0.5). Las mujeres tuvieron un mayor riesgo tanto de expulsión como de discontinuación si eran menores de 21 años, en lugar de tener entre 26 y 30 (2.4 y 1.7, respectivamente), o si pertenecían a la casta dalit en lugar de a la casta brahmán (2.2 y 1.9, respectivamente). Las mujeres cuyos maridos no vivían en casa también tenían un riesgo elevado de discontinuación del tratamiento. Conclusión: Los hallazgos destacan la necesidad de una mayor capacitación y supervisión de los proveedores de servicios de salud durante sus primeras 10 inserciones de DIUPP. La consejería sobre el riesgo de expulsión podría beneficiar especialmente a las mujeres más jóvenes y que pertenecen a la casta dalit; y debe incluir a las parejas y otros miembros de la familia para evitar cualquier estigma en torno al uso de DIUPP por parte de las mujeres cuya pareja está fuera de casa durante un período prolongado.

RÉSUMÉN Contexte: Les caractéristiques des prestataires et des femmes sont associées aux résultats du DIU au cuivre post-partum (DIUPP), mais le rapport entre l'expérience des prestataires, l'expulsion du DIUPP et l'arrêt de la méthode n'a pas été établi. Méthodes: Les données relatives à 1 232 femmes et 118 prestataires ayant participé à un essai randomisé d'intervention de conseil et de pose d'un DIUPP au Népal entre 2015 et 2017 ont permis d'identifier les associations entre les caractéristiques des prestataires et des femmes et les résultats relatifs au DIUPP. Les risques d'expulsion du DIUPP et d'arrêt de la méthode ont été estimés à deux ans après la pose par modélisation de régression logistique multinomiale. Résultats: Treize pour cent des femmes avaient connu une expulsion partielle ou complète et 29% avaient arrêté l'utilisation du DIUPP en l'espace de de deux ans. Le fait d'avoir un prestataire ayant pratiqué au moins 10 poses antérieures s'est avéré associé à un risque moindre d'expulsion que de continuation (rapport de risque relatif de 0,5), par rapport au fait d'avoir eu un prestataire moins expérimenté. Les femmes couraient un plus grand risque d'expulsion aussi bien que d'arrêt de la méthode si elles avaient moins de 21 ans par rapport à la tranche d'âge de 26 à 30 ans (2,4 et 1,7, respectivement) ou si elles appartenaient à la caste des Dalits plutôt que des Brahmanes (2,2 et 1,9, respectivement). Les femmes dont le mari ne vivait pas sous le même toit présentaient aussi de plus hauts risques d'arrêt. Conclusion: Les résultats révèlent clairement la nécessité d'une formation et d'un encadrement accrus des prestataires lors de leurs 10 premières poses de DIUPP. Le conseil relatif au risque d'expulsion pourrait bénéficier tout particulièrement aux femmes plus jeunes et de la caste des Dalits. Il doit aussi inclure les partenaires et d'autres membres de la famille pour éviter toute stigmatisation concernant l'utilisation du DIUPP par les femmes dont le partenaire est absent pendant une période prolongée.