Introduction of Community-Based Provision of Subcutaneous Depot Medroxyprogesterone Acetate (DMPA-SC) in Benin: Programmatic Results.

The Republic of Benin faces high maternal, newborn, and child mortality; low modern contraceptive use; and a critical shortage of health workers. In 2013, the Government of Benin made 3 reproductive health commitments to improve national health indicators, including expanding provision of family planning services at the community level through task sharing. Since 2016, the Advancing Partners & Communities (APC) project has been helping the Benin Ministry of Health (MOH) provide subcutaneous depot medroxyprogesterone acetate (DMPA-SC; brand name Sayana Press) through facility-based health care providers and community health workers known as relais communautaires (RCs). DMPA-SC is an easy-to-administer, discreet injectable contraceptive that provides 3 months of protection from pregnancy. Beginning in May 2017, the government introduced DMPA-SC through a phased approach in 10 health zones, which encompassed 149 health centers and 614 villages. Between June 2017 and June 2018, the MOH and APC trained 278 facility-based providers and 917 RCs to provide DMPA-SC, and nearly 11,000 doses were subsequently administered to 7,997 women at facilities and in communities. This article presents findings from an assessment of community-level and health facility service data collected during the first 13 months of DMPA-SC introduction in Benin. Because of this intervention, nearly 35,000 women received family planning counseling and 7,997 women chose DMPA-SC. At the community level, 3,111 DMPA-SC users were first-time users of modern contraception. The initial success of the DMPA-SC rollout in Benin shows promise for helping the country meet its reproductive health commitments.

Task shifting in maternal and newborn care: a non-inferiority study examining delegation of antenatal counseling to lay nurse aides supported by job aids in Benin.

BACKGROUND: Shifting the role of counseling to less skilled workers may improve efficiency and coverage of health services, but evidence is needed on the impact of substitution on quality of care. This research explored the influence of delegating maternal and newborn counseling responsibilities to clinic-based lay nurse aides on the quality of counseling provided as part of a task shifting initiative to expand their role. METHODS: Nurse-midwives and lay nurse aides in seven public maternities were trained to use job aids to improve counseling in maternal and newborn care. Quality of counseling and maternal knowledge were assessed using direct observation of antenatal consultations and patient exit interviews. Both provider types were interviewed to examine perceptions regarding the task shift. To compare provider performance levels, non-inferiority analyses were conducted where non-inferiority was demonstrated if the lower confidence limit of the performance difference did not exceed a margin of 10 percentage points. RESULTS: Mean percent of recommended messages provided by lay nurse aides was non-inferior to counseling by nurse-midwives in adjusted analyses for birth preparedness (ß = -0.0, 95% CI: -9.0, 9.1), danger sign recognition (ß = 4.7, 95% CI: -5.1, 14.6), and clean delivery (ß = 1.4, 95% CI: -9.4, 12.3). Lay nurse aides demonstrated superior performance for communication on general prenatal care (ß = 15.7, 95% CI: 7.0, 24.4), although non-inferiority was not achieved for newborn care counseling (ß = -7.3, 95% CI: -23.1, 8.4). The proportion of women with correct knowledge was significantly higher among those counseled by lay nurse aides as compared to nurse-midwives in general prenatal care (ß = 23.8, 95% CI: 15.7, 32.0), birth preparedness (ß = 12.7, 95% CI: 5.2, 20.1), and danger sign recognition (ß = 8.6, 95% CI: 3.3, 13.9). Both cadres had positive opinions regarding task shifting, although several preferred 'task sharing' over full delegation. CONCLUSIONS: Lay nurse aides can provide effective antenatal counseling in maternal and newborn care in facility-based settings, provided they receive adequate training and support. Efforts are needed to improve management of human resources to ensure that effective mechanisms for regulating and financing task shifting are sustained.

Antenatal counseling in maternal and newborn care: use of job aids to improve health worker performance and maternal understanding in Benin.

BACKGROUND: Antenatal care provides an important opportunity to improve maternal understanding of care during and after pregnancy. Yet, studies suggest that communication is often insufficient. This research examined the effect of a job aids-focused intervention on quality of counseling and maternal understanding of care for mothers and newborns. METHODS: Counseling job aids were developed to support provider communication to pregnant women. Fourteen health facilities were randomized to control or intervention, where providers were trained to use job aids and provided implementation support. Direct observation of antenatal counseling sessions and patient exit interviews were undertaken to assess quality of counseling and maternal knowledge. Providers were also interviewed regarding their perceptions of the tools. Data were collected before and after the job aids intervention and analyzed using a difference-in-differences analysis to quantify relative changes over time. RESULTS: Mean percent of recommended messages provided to pregnant women significantly improved in the intervention arm as compared to the control arm in birth preparedness (difference-in-differences [ΔI-C] = +17.9, 95%CI: 6.7,29.1), danger sign recognition (ΔI-C = +26.0, 95%CI: 14.6,37.4), clean delivery (ΔI-C = +21.7, 95%CI: 10.9,32.6), and newborn care (ΔI-C = +26.2, 95%CI: 13.5,38.9). Significant gains were also observed in the mean percent of communication techniques applied (ΔI-C = +28.8, 95%CI: 22.5,35.2) and duration (minutes) of antenatal consultations (ΔI-C = +5.9, 95%CI: 3.0,8.8). No relative increase was found for messages relating to general prenatal care (ΔI-C = +8.2, 95%CI: -2.6,19.1). The proportion of pregnant women with correct knowledge also significantly improved for birth preparedness (ΔI-C = +23.6, 95%CI: 9.8,37.4), danger sign recognition (ΔI-C = +28.7, 95%CI: 14.2,43.2), and clean delivery (ΔI-C = +31.1, 95%CI: 19.4,42.9). There were no significant changes in maternal knowledge of general prenatal (ΔI-C = -6.4, 95%CI: -21.3,8.5) or newborn care (ΔI-C = +12.7, 95%CI: -6.1,31.5). Job aids were positively perceived by providers and pregnant women, although time constraints remained for health workers with other clinical responsibilities. CONCLUSIONS: This study demonstrates that a job aids-focused intervention can be integrated into routine antenatal care with positive outcomes on provider communication and maternal knowledge. Efforts are needed to address time constraints and other communication barriers, including introduction of on-going quality assessment for long-term sustainability.