Quality and Cost Interventions During the Extended Perinatal Period to Increase Family Planning Use in Kinshasa, DRC: Results From an Initial Study.

BACKGROUND: Most women worldwide do not desire another pregnancy within a year after giving birth, but uptake of modern contraception during this time period is low. We independently tested 2 approaches to increasing contraceptive uptake and the 2 approaches combined using a quasi-experimental study design in Kinshasa, the Democratic Republic of the Congo. METHODS: The primary analytic data came from client exit interviews conducted post-intervention (N=563) from 4 study groups. The first arm (n=150) received free family planning, and the second arm (n=113) a quality inputs intervention involving systematic screening, referral, and immediate provision of long-acting reversible contraceptives (LARCs) after labor and delivery. The third arm (n=150) received a combination of the 2 interventions, and the fourth (n=150) no intervention. Family planning service statistics were also collected throughout the intervention period. RESULTS: Women in the quality arm (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.8 to 10.9) and free/quality arm (OR=6.7; 95% CI, 2.8 to 16.1) were more likely to be properly screened for family planning than women in the control group, but paper referral was seldom implemented in any group. Women in the free arm (OR=3.8; 95% CI, 1.6 to 9.0) and in the free/quality arm (OR=11.0; 95% CI, 4.3 to 27.9) were more likely than the control group to report being properly counseled on family planning. Clients were more likely to be modern contraceptive users (excluding condoms) in the free arm (OR=3.2; 95% CI, 1.4 to 7.2) and in the free/quality arm (OR=8.6; 95% CI, 3.9 to 19.0) than in the control group. Clients in all study arms were more likely to use a LARC compared with the control group (Quality arm: OR=2.9; 95% CI, 1.1 to 7.9. Free arm: OR=5.6; 95% CI, 2.3 to 13.7. Free/quality arm: OR=8.4; 95% CI, 3.4 to 20.6). Service statistics from the combined intervention arm showed that a significantly greater proportion of family planning adoption occurred within the immediate postpartum period (0 to 2 days) in the quality arm (P<.001) and free/quality arm (P<.001) than in the control arm. Quality inputs, free contraceptives, and the combined intervention had positive impacts on aspects of screening and contraceptive uptake. The combined intervention performed best by all measures. CONCLUSION: Providing family planning, including LARCs, in the immediate postpartum period, implementing a systematic screening and referral system, and providing free methods may improve family planning access and uptake in the extended perinatal period in this environment.

Integrating family planning promotion into the work of environmental volunteers: a population, health and environment initiative in Kenya.

Voluntary use of family planning is instrumental to the health and social well-being of women, families and communities.Although contraceptive use in Sub-Saharan Africa is increasing, unmet need for family planning remains high. Even within countries that have achieved increases in contraceptive prevalence, use remains low among some population subgroups. Contraceptive prevalence is generally lower in rural areas than in cities, and is consistently lower among women in the lowest wealth quintile than among those in the highest. Achieving progress in health and social indicators, such as those captured by the Millennium Development Goals, depends on expanding family planning services to poor, remote rural areas in Africa.

Unmet need for contraception among clients of FP/HIV integrated services in Nigeria: the role of partner opposition.

While women are aware of family planning (FP) methods in Nigeria, the unmet need for modern contraception remains high. We assessed the association between male partner opposition to FP and unmet need for modern contraception among women seeking anti-retroviral therapy (ART), HIV counseling and testing (HCT) and prevention-of-mother-to-child-transmission of HIV (PMTCT) services in Cross-River State, Nigeria. This secondary analysis used data from a facility-based FP/HIV integration study. Logistic regression was used to model the association of interest. Unmet need for modern contraception was high among all clients--ART (49%), HCT (75%), and PMTCT (32%). Perceived partner opposition to FP was widespread (> or = 70%); however, multivariate analysis showed no significant association with unmet need for modern contraception. Significant covariates were woman's age, marital status, parity, and previous use of modern contraception. Efforts to improve modern contraceptive use among women at risk of HIV infection in Nigeria should contemplate involving their male partners.

Integrating family planning messages into immunization services: a cluster-randomized trial in Ghana and Zambia.

OBJECTIVE: To determine whether integrating family planning (FP) messages and referrals into facility-based, child immunization services increase contraceptive uptake in the 9- to 12-month post-partum period. METHODS: A cluster-randomized trial was used to test an intervention where vaccinators were trained to provide individualized FP messages and referrals to women presenting their child for immunization services. In each of 2 countries, Ghana and Zambia, 10 public sector health facilities were randomized to control or intervention groups. Shortly after the introduction of the intervention, exit interviews were conducted with women 9-12 months postpartum to assess contraceptive use and related factors before and after the introduction of the intervention. In total, there were 8892 participants (Control Group Ghana, 1634; Intervention Group Ghana, 1129; Control Group Zambia, 3751; Intervention Group Zambia, 2468). Intervention effects were evaluated using logistic mixed models that accounted for clustering in data. In addition, in-depth interviews were conducted with vaccinators, and a process assessment was completed mid-way through the implementation of the intervention. RESULTS: In both countries, there was no significant effect on non-condom FP method use (Zambia, P = 0.56 and Ghana, P = 0.86). Reported referrals to FP services did not improve nor did women's knowledge of factors related to return of fecundity. Some providers reported having made modifications to the intervention; they generally provided FP information in group talks and not individually as they had been trained to do. CONCLUSION: Rigorous evidence of the success of integrated immunization services in resource poor settings remains weak.

Does free pregnancy testing reduce service denial in family planning clinics? A cluster-randomized experiment in Zambia and Ghana.

BACKGROUND: In many countries, pregnancy tests are not freely available in family planning clinics. As a result, providers sometimes deny services to non-menstruating clients due to uncertainty about pregnancy. Few clients are actually pregnant, yet denied clients run the risk of becoming pregnant, and those sent to pharmacies pay inflated prices for inexpensive tests. To assess the programmatic effect of free pregnancy testing, we conducted cluster-randomized trials in Ghana and Zambia, assessing clients' uptake of contraception in family planning clinics. METHODS: In each country, 5 clinics were randomized to intervention status and 5 to control. Service data from 2,028 new, non-menstruating clients in Zambia and 1,556 in Ghana were collected. Intervention clinics received supplies of pregnancy tests, and staff were instructed to use tests as needed to help exclude pregnancy. Control clinics received no intervention. The primary outcome was the proportion of non-menstruating clients denied an effective contraceptive method. Cost-effectiveness was also evaluated. RESULTS: In Zambia, clients in intervention and control clinics faced a similar risk of service denial at baseline, 15% and 17%, respectively. At follow-up, denial remained unchanged at 17% in control clinics, but decreased significantly to 4% in intervention sites. Clients in Zambia were 4.4 (95% confidence interval [CI] = 1.3-14.4) times more likely to be denied a method in control sites versus intervention sites (P<.01). Results from Ghana were inconclusive. Cost of a "denial averted" in Zambia was estimated to be US$0.59. INTERPRETATION: Zambia results suggest that availability of free pregnancy testing significantly reduced contraceptive service denial, although results from Ghana preclude an unqualified recommendation. Authors conclude that free pregnancy testing in family planning clinics may make strong public health sense in those developing countries where denial to non-menstruating clients remains a problem. Although pregnancy can usually be excluded with a client history, pregnancy tests are often necessary.

Changes in contraceptive use following integration of family planning into ART Services in Cross River State, Nigeria.

One strategy for meeting the contraceptive needs of HIV-positive women is to integrate family planning into HIV services. In 2008 in Cross River State, Nigeria,family planning was integrated into antiretroviral (ART) services in five local government areas. A basic family planning/HIV integration model was implemented in three of these areas, and an enhanced model in the other two. We conducted baseline interviews in 2008 and follow-up interviews 12-14 months later with 274 female ART clients aged 18-45 in 2009 across the five areas. Unmet need for contraception was high at baseline (28-35 percent). We found that modern contraceptive use rose in the enhanced and basic groups; most of the increase was in consistent condom use. Despite an increase in family planning counseling by ART providers, referrals to family planning services for noncondom methods were low. We conclude by presenting alternative strategies for family planning/HIV integration in settings where large families and low contraceptive use are normative.