Couple-Years of Protection Indicator: New Global Guidance for Updating Existing Methods and Adding New Methods.

BACKGROUND: Couple-years of protection (CYP) is an indicator that allows for monitoring and evaluating of family planning (FP) program performance through simple calculations. The CYP for each contraceptive method is calculated by multiplying the number of contraceptive commodity units distributed to clients over a 1-year period by a conversion factor that quantifies the duration of contraceptive protection provided per unit distributed. CYP calculations across methods were previously updated in 2000 and 2011, resulting in changes in methodology, factor inclusion, and specific methods. Since the 2011 update, changes and additions to the modern contraceptive method mix required new CYP conversion factors for 4 methods of contraception: Levoplant implant, progestin-only pills (POPs), Caya diaphragm, and the hormonal intrauterine device. METHODS: We conducted literature reviews of both published and gray literature and consulted with experts to identify updated data on continuation rates, duration of efficacy, and method effectiveness for the 4 methods. New CYP conversion factors were calculated for the 4 methods either by using the same calculation used previously for the method considering new data or, for new methods, using calculations for similar methods. RESULTS: New CYP conversion factors were assigned to the 4 methods of contraception covered in this update: Levoplant, 2.5 CYP per implant inserted; POPs, 0.0833 CYP per pack (i.e., 12 cycles per CYP); Caya diaphragm, 1 CYP per device, and hormonal intrauterine device, 4.8 CYP per device inserted. CONCLUSIONS: CYP is an important indicator for FP programs. As new methods of contraception are developed and new evidence is generated for current methods, the indicator may need to be updated. A standard process for updating and documenting future CYP updates is recommended.

Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal.

Introduction: Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges. Methods: We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals. Results: 72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals. Conclusion: Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

"PrEP should be available all the time and everywhere": A qualitative assessment of family planning and PrEP integration in Lesotho.

Background: Lesotho has a high HIV burden, with women disproportionately affected. Increased access points for HIV prevention services, including oral pre-exposure prophylaxis (PrEP), should be considered. Using family planning (FP) settings for PrEP services may contribute to greater uptake of HIV prevention methods. Methodology: This formative qualitative assessment was conducted in Maseru District, Lesotho and included in-depth interviews with 15 key informants, 10 FP providers in public facilities and community sites, and 15 FP and PrEP clients from facility and community sites. Interviews were audio recorded and in lieu of producing transcripts, teams completed semi-structured data extraction tables after each interview. Findings were compiled and synthesized by participant group into matrices and themes identified through deductive and inductive analysis. Results: Policy makers were generally supportive of integration but felt hampered by lack of integration policies and separation of HIV and FP departments at Ministry of Health. Funders stressed the need for coordination among partners to avoid duplication of efforts. Partners felt clients would be interested in PrEP/FP integration and that PrEP demand creation and education were crucial needs. Most providers supported integration, stressing the potential benefit to clients. Barriers discussed included heavy workloads, staff shortages, training needs, separate registers for FP and PrEP, and commodity stock-outs. Providers discussed strengthening integrated services through training, increasing staffing, having job aids and guidelines, merging the FP and PrEP registers, and marketing services together to create demand for both. Clients were overwhelmingly willing to have longer visits to receive comprehensive services and were supportive of receiving PrEP services from FP providers. Clients not using PrEP expressed willingness and interest to use. Clients' suggestions for successful integration included consulting with youth, conducting community outreaches, and improving provider availability. Conclusions: Existing FP platforms are established and well-utilized; thus providing opportunities for integrating PrEP. This assessment found support across all groups of respondents for providing PrEP within FP settings and identified a number of facilitators and barriers to integration. As PrEP rollout is relatively nascent in many countries, deepening the evidence base early will enable the utilization of findings to build stronger integrated programs with wider coverage.

Making Removals Part of Informed Choice: A Mixed-Method Study of Client Experiences With Removal of Long-Acting Reversible Contraceptives in Senegal.

BACKGROUND: Ensuring access to removal services for implants and intrauterine devices (IUDs) is essential to realize informed choice and voluntary family planning. We document removal desires and experiences among women who received an implant or IUD from the public sector in 3 districts of Senegal. METHODS: We conducted a phone survey of 1,868 implant and IUD users, 598 follow-up surveys with those who had ever asked a provider for a removal, and 24 in-depth interviews (IDIs) with women who had ever wanted an implant removal. We analyzed survey data descriptively and IDI data thematically. RESULTS: Fifty-eight percent of implant users and 54% of IUD users reported having wanted a removal. Desired pregnancy and contraceptive-induced menstrual changes (CIMCs) were the main reasons for removal desires. Fifty-four percent of implant users and 55% of IUD users who asked a provider for a removal reported challenges accessing services, with over two-thirds noting long lines or wait times. Sixty-three percent of implant users and 73% of IUD users who saw a provider were satisfied with the outcome of their first interaction. Over 90% of participants had not been told about the removal cost at insertion. Almost all participants who had their method removed obtained a complete removal during their first clinical procedure. Around two-thirds of participants who obtained a removal did not take up another method at that time. IDIs confirmed the influence of CIMCs on removal desires and show some partner influence is common in removal decision making. Barriers include lack of available qualified providers and supplies. Provider interactions play an important role in satisfaction with removal services. CONCLUSION: Participants' experiences accessing removal services were generally positive. Areas of potential improvement include client flow, counseling messages at insertion, and when advising clients to keep their method, pricing, and post-removal reinsertion or method switching.

Ensuring sufficient service capacity for removals of long-acting reversible contraceptives: a mixed-method study of provider experiences in Senegal.

Background: As the number of implants and intrauterine devices (IUD) used in sub-Saharan Africa continues to grow, ensuring sufficient service capacity for removals is critical. This study describes public sector providers' experiences with implant and IUD removals in two districts of Senegal. Methods: We conducted a cross-sectional study with providers trained to insert implants and IUDs from all public facilities offering long-acting reversible contraceptives. Data collection elements included a survey with 55 providers and in-depth interviews (IDIs) with eight other providers. We performed descriptive analysis of survey responses and analyzed qualitative data thematically. Results: Nearly all providers surveyed were trained in both implant and IUD insertion and removal; 42% had received training in the last two years. Over 90% of providers felt confident inserting and removing implants and removing IUDs; 15% were not confident removing non-palpable implants and 27% IUDs with non-visible strings. Challenges causing providers to refer clients or postpone removals include lack of consumables (38%) for implants, and short duration of use for implants (35%) and IUDs (20%). Many providers reported counseling clients presenting for removals to keep their method (58% implant, 31% IUD), primarily to attempt managing side effects. Among providers with removal experience, 78% had ever received a removal client with a deeply-placed implant and 33% with an IUD with non-visible strings. Qualitative findings noted that providers were willing to remove implants and IUDs before their expiration date but first attempted treatment or counseling to manage side effects. Providers reported lack of equipment and supplies as challenges, and mixed success with difficult removals. Conclusions: Findings on provider capacity to perform insertions and regular removals are positive overall. Potential areas for improvement include availability of equipment and supplies, strengthening of counseling on side effects, and support for managing difficult removals.

What Goes In Must Come Out: A Mixed-Method Study of Access to Contraceptive Implant Removal Services in Ghana.

BACKGROUND: Access to quality removal services is a key component of informed choice in contraceptive implant use; however, limited data exist on users' access to removal services. In Ghana, implants are available across the country and are the most commonly used contraceptive method among married women. METHODS: From October 2017 and January 2018, we conducted a phone survey with a stratified random sample of 1,159 women who had obtained an implant from a public-sector Ghana Health Service clinic in 2 regions and 1,073 women who had an implant inserted through Marie Stopes International Ghana (MSIG) mobile outreach in 2 other regions. We also interviewed 50 women just after receiving an implant removal from MSIG. We conducted follow-up in-depth interviews with 20 implant acceptors and 15 implant providers across the 4 study regions. RESULTS: More than four-fifths of women in both service delivery contexts knew that their implant could be removed before its labeled duration. Nearly half of public sector clients and one-third of outreach clients reported that their provider only told them of removal access at the place of insertion. Among women obtaining their implant in the public and outreach sectors, respectively, 32% and 21% reported ever wanting it removed and 61% and 55% who attempted removal obtained a removal on the first attempt. An additional 17% in each context were successful in having their implant removed within 1 week of the first attempt. Most women obtained removal from the same place they received their insertion (81% public, 70% outreach). Most women reported their overall removal experience was very or somewhat easy (74% public, 68% outreach). Challenges included cost, provider availability, interactions with providers, and difficult removals. CONCLUSIONS: Access to implant removal is not universal in Ghana. Strengthening removal services in both the public and outreach sectors is needed to ensure comprehensive access.

Planning for Outcomes (P4O) Modeling Tool: Estimating the Impact of Changing the Proportion of Injectable Progestins in the Contraceptive Method Mix.

BACKGROUND: Observational studies raise concern about a potential link between injectable progestin contraceptive use and HIV acquisition risk. This possible link is particularly relevant in sub-Saharan Africa where HIV risk is high and the method mix is skewed toward injectables. We developed the Planning for Outcomes (P4O) model (https://planning4outcomes.ctiexchange.org/) to predict changes in maternal and child health (MCH) and HIV outcomes that could occur if the proportion of injectables in the method mix is changed. METHODS: P4O incorporates evidence-based assumptions to predict yearly changes in unintended pregnancies, morbidity/mortality, HIV infections (women and infants), and anticipated health care costs associated with changing the proportions of injectable users in 22 selected countries. Users of this model designate all countries or a subset and adjust inputs including percentage of injectable users who discontinue, percentage of discontinuers who begin use of an alternative method, hazard ratio for HIV infection with injectable use, method mix used by injectable discontinuers, annual probabilities of method-specific pregnancy and mother-to-child transmission of HIV, condom effectiveness against HIV, risk of HIV during pregnancy, and HIV incidence among women of reproductive age. RESULTS: Illustrative results from all sub-Saharan African countries combined and from selected countries demonstrate the potential of P4O to inform program planning and procurement decisions. In countries with high use of long-acting reversible contraception, the removal of injectables from the method mix is associated with improvement in MCH and HIV indicators if most injectable users switch to more effective methods (e.g., implants). In countries with high use of short-acting methods (e.g., condoms), the model predicts mostly negative MCH outcomes. CONCLUSIONS: Policy makers and program planners may use P4O to inform programming and policy decisions. In all scenarios, programmatic preparation to accommodate changes to the contraceptive method mix, considerations of how the individual desires of women will be addressed, and potential burden of anticipated MCH-related costs warrant advanced consideration.

Lessons from a geospatial analysis of depot medroxyprogesterone acetate sales by licensed chemical sellers in Ghana.

OBJECTIVES: To map access to depot medroxyprogesterone acetate (DMPA) from licensed chemical sellers (LCS); to estimate the proportion of women of reproductive age in areas with access; and to examine affordability and variability of costs. METHODS: A geospatial analysis was conducted using data collected from 298 women who purchased DMPA from 49 geocoded LCS shops in the Amansie West and Ejisu-Juabeng districts of Ghana from June 4 to August 31, 2012. The women reported on cost and average distance traveled to purchase DMPA. RESULTS: In Amansie West, 21.1% of all women of reproductive age lived within average walking distance and 80.4% lived within average driving distance of an LCS. In Ejisu-Juabeng, 41.9% and 60.1% of women lived within average walking and driving distance, respectively. Distribution of affordability varied across each district. CONCLUSIONS: Access to LCS shops is high, and training LCS to administer DMPA would increase access to family planning in Ghana, with associated time and cost savings.

Injectable contraceptive sales at licensed chemical seller shops in ghana: access and reported use in rural and periurban communities.

CONTEXT: Most women in Ghana obtain oral contraceptives and condoms from shops run by licensed chemical sellers, but such shops are not legally permitted to sell the country's most widely used method, the injectable. Allowing shops to sell the injectable could increase access to and use of the method. METHODS: In 2012-2013, semistructured telephone interviews were conducted among convenience samples of 94 licensed chemical seller shop operators in two districts who were trained to sell the injectable and of 298 women who purchased the method from these shops. Follow-up interviews were conducted with 92 clients approximately three months after their initial injectable purchase. RESULTS: Ninety-seven percent of shop operators reported selling the injectable, and 94% felt sufficiently trained to provide family planning methods and services. Virtually all sellers (99%) referred clients to a hospital or health facility for injection; none provided injections themselves. Fifty-six percent of injectable clients were new family planning users. Of those who completed a follow-up interview, 79% had purchased the injectable again from a shop. Virtually all clients (97%) reported getting their injection at the health facility to which they were referred by the seller. Women cited trust, convenience and commodities being in stock as key reasons for purchasing from a shop. CONCLUSION: Licensed chemical seller shop operators can safely sell the injectable and refer clients to health facilities for screening, counseling and injection.

Provision of DMPA by community health workers: what the evidence shows.

BACKGROUND: To reduce a large unmet need for family planning in many developing countries, governments are increasingly looking to community health workers (CHWs) as an effective service delivery option for health care and as a feasible option to increase access to family planning services. This article synthesizes evidence on the feasibility, safety and effectiveness of community-based delivery of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). STUDY DESIGN: Manual and electronic search and systematic review of published and unpublished documents on delivery of contraceptive injectables by CHWs. RESULTS: Of 600 identified documents, 19 had adequate information on injectables, almost exclusively intramuscular DMPA, provided by CHWs. The data showed that appropriately trained CHW demonstrate competency in screening clients, providing DMPA injections safely and counseling on side effects, although counseling appears equally suboptimal in both clinic and community settings. Clients and CHWs report high rates of satisfaction with community-based provision of DMPA. Provision of DMPA in community-based programs using CHWs expanded access to underserved clients and led to increased uptake of family planning services. CONCLUSIONS: We conclude that DMPA can be provided safely by appropriately trained and supervised CHWs. The benefits of community-based provision of DMPA by CHWs outweigh any potential risks, and past experiences support increasing investments in and expansion of these programs.