Helping Postpartum Women in Mali Achieve Their Fertility Intentions: Perspectives From Introduction of the Dedicated Postpartum IUD Inserter.

BACKGROUND: Mali has one of the highest maternal mortality ratios in the world coupled with one of the lowest modern contraceptive use rates. Nearly a quarter of the country's 750,000 annual births occur within 24 months of a previous birth, increasing the risks for mothers and babies. Nearly 70% of postpartum women have an unmet need for family planning. In 2016, Population Services International Mali (PSI-Mali) introduced a dedicated postpartum intrauterine device (PPIUD) inserter to replace the technique of using forceps for PPIUD insertion, with the aim of helping to address this substantial family planning gap. METHODS: A mixed-methods approach was used to assess program results and the experiences of PSI-trained providers using the dedicated PPIUD inserter in 5 health facilities in Bamako. We conducted 10 key informant interviews with providers and 4 key informant interviews with operational and clinical staff involved in training and supporting providers. Further data were collected from district health surveys and facility registers. Secondary data encompassed documentation from 2011 through 2017, with the service delivery figures of PPIUD using the dedicated inserter focused on the pilot period of March 2016 through December 2017. Primary data were collected in Mali in July 2017. RESULTS: Between March 2016 and December 2017, PSI-Mali trained 134 providers on the dedicated PPIUD inserter and provided more than 3,500 voluntary PPIUDs. Of the 1,840 voluntary PPIUDs provided in 2017 alone, 67% were provided by facilities trained to use the dedicated PPIUD inserter. Providers stated a preference for the inserter (compared with the use of forceps) due to its ease, speed, and perceived lower associated risks of infection. Service data from the 5 facilities visited showed an overall average PPIUD uptake of 7.3% of deliveries in 2017. Although private facilities had considerably fewer deliveries than public facilities (600-900 compared with 20-30, respectively), a much higher proportion of women delivering in the private facilities chose a PPIUD. CONCLUSION: The acceptance of the dedicated PPIUD inserter by providers may help reduce some of the supply-side barriers that inhibit women's access to postpartum family planning methods. With continued support to providers, coupled with ongoing efforts to address differences in service trends between sectors and demand-side barriers to the PPIUD and family planning more broadly, the dedicated PPIUD inserter could play an important role in responding to the high unmet need among postpartum women in Mali.

Contraceptive counseling for continuation and satisfaction.

PURPOSE OF REVIEW: Quality contraceptive counseling has been identified as a potential means to reduce unintended pregnancy and to increase contraceptive continuation and satisfaction. Past approaches that focused on autonomous decision making and directive counseling have not been shown to meet these goals consistently. Women's health organizations globally are calling for improved counseling through more thorough discussion of side-effects and bleeding changes, and renewed focus on shared decision making and patient-centered care. RECENT FINDINGS: Reproductive life planning can help initiate contraceptive counseling but does not resonate with all patients. A client-centered approach using shared decision making, building trust, and eliciting client preferences has been shown to increase satisfaction and continuation. Patient preferences vary widely and may or may not prioritize extremely high effectiveness. Decision support tools have mixed results, but generally can help improve the method choice process when they are well designed. SUMMARY: Clinicians should strive for good interpersonal relationships with patients, and elicit patient experiences and preferences to tailor their counseling to each individual's needs. Shared decision making with input from both the patient and clinician is preferred by many women, and clinicians should be cognizant of perceptions of pushing any method too strongly, especially among marginalized populations. More research on long-term satisfaction and continuation linked to different counseling practices is needed.