Introducing Long-Acting Contraceptive Removal Indicators in a Pilot Study in Mozambique: Dynamics of Discontinuation and Implications for Quality of Care.

INTRODUCTION: The recent increase in the use of long-acting reversible contraceptives (LARCs) will result in an equal increase in the need for removals. Few countries monitor the number of LARC removals and even fewer track reasons for removal, discontinuation, and method switching. We conducted a mixed-method study to pilot the introduction of 5 LARC removal indicators in Mozambique: (1) reason for seeking removal, (2) duration of use, (3) removal outcome, (4) reason for referral, and (5) family planning (FP) outcome. We assessed providers' perceptions about the feasibility and utility of tracking these indicators and reviewed the findings to ascertain the quality-of-care concerns. METHODS: We used a purposive, multistage sampling technique to select 19 intervention facilities in Nampula and Sofala provinces. Over 6 months, we abstracted data on the 5 indicators from an FP register addendum to determine when and why clients seek LARC removals and identify service quality issues that need to be addressed in the FP program. We used a supportive supervision checklist to assess the time taken to record data on the indicators and perceived benefits and challenges encountered by providers during record keeping. RESULTS: Of the 795 clients who sought a LARC removal, 112 women (14.1%) opted not to have the removal after counseling. The most frequently reported reasons for seeking a removal were: the method was on-schedule for removal or past its expiration date (29.5%), complaints of side effects (25.8%), and desire to be pregnant (22.9%). Health care providers reported no major challenges in recording information in the addendum. Reasons for and timing of removal pointed to the need for strengthening FP counseling. CONCLUSION: Collecting, synthesizing, and interpreting data from the LARC removal indicators was feasible and provided valuable insights to improve the quality of care to enhance clients' reproductive health care and contraceptive choices.

Scaling Up a Strengthened Youth-Friendly Service Delivery Model to Include Long-Acting Reversible Contraceptives in Ethiopia: A Mixed Methods Retrospective Assessment.

BACKGROUND: Donor funded projects are small scale and time limited, with gains that soon dissipate when donor funds end. This paper presents findings that sought to understand successes, challenges and barriers that influence the scaling up and sustainability of a tested, strengthened youth-friendly service (YFS) delivery model providing an expanded contraceptive method choice in one location - the YFS unit - with additional units in Amhara and Tigray, Ethiopia. METHODS: This retrospective mixed methods study included interviews with key informants (KIs) (qualitative arm) and analysis of family planning (FP) uptake statistics extracted from the sampled health facilities (quantitative arm). A multistage convenience purposive sampling technique was adopted to randomly select 8 health facilities aligned with respective woredas, zones and regional health bureaus (RHBs). A semi-structured interview guide soliciting information on 6 scaling-up elements (stakeholder engagement, roles and responsibility, policy environment, financial resources, quality of voluntary FP services and data availability and use) guided the interviews. Fifty-six KI interviews were conducted with policy-makers, program managers, and clinic staff. Recurring themes were triangulated across administrative levels and implementing partners. Relevant FP data (acceptor status, age and method uptake) were extracted from the 8 sampled health facilities for a thirteen-month period. Qualitative findings triangulated with FP service statistics assessed the influence of the 6 scaling-up elements with trends in long-acting reversible contraceptive (LARC) uptake before and after training. RESULTS: Our findings depict that respondents were knowledgeable and supportive of an expanded method mix. Statistically significant increases in long-acting contraceptive uptake were noted at 2 of the 8 health centers. Fidelity to the tested model was operationally constrained; respondents frequently mentioned trained staff absences and turnover as obstacles in offering quality FP services. CONCLUSION: Despite conducive policy environment, supportive stakeholders, favorable environment, and financial support for trainings, statistically significant increases in LARC uptake occurred at only 2 of the 8 health centers; indicating the influence of weak health systems, poor quality of voluntary FP services and a ceiling effect. Scale-up processes must consider potential bottlenecks of weak health systems and availability of financial resources by addressing these as crucial elements in any systematic scale-up framework.

The Effect of Peer Education in Dispelling Myths and Misconceptions about Long-Acting Reversible Contraception among Ethiopian Youth.

Robust evidence, including systematic reviews and recommendations from the 2016 Lancet Commission on Adolescent Health and Wellbeing, does not wholly support the unambiguous endorsement of peer-led community-based interventions. This study evaluated the effectiveness of an intensive three-day training for peer educators (PE) on dispelling myths and misconceptions about long-acting reversible contraceptives (LARCs) among Ethiopian youth. Post-training, PEs conducted demand-generation activities with their peers to encourage LARCs referrals. A convenience purposive sampling technique was used to select 20 health centers where peer educators referred clients: 10 each in Amhara and Tigray regions. The health centers were randomly allocated to the intervention (five) and non-intervention (five) study arms. Data were abstracted from the peer educators' monthly reporting forms over an 11-month period: 5 months pre-intervention and 6 months post-intervention. Analysis of family planning and LARCs referrals and chi-square tests of association were conducted. Odds of LARCs referrals at pre-intervention (0.96), fell to 0.83 for the post-intervention phase (p-value <0.6). Challenges, largely with data collection and reporting, may have exposed the study to Type II errors. We recommend focused and rigorous data collection in a multi-country 2X2 factorial design cluster randomized holistic intervention (service providers/clinic and PEs/community) trial to comprehensively determine effectiveness on demand for and uptake of LARCs among youth.

Strengthening Youth Friendly Health Services through Expanding Method Choice to include Long-Acting Reversible Contraceptives for Ethiopian Youth.

Despite robust evidence regarding long-acting reversible contraceptive (LARC) low failure rates, immediate return to fertility and safety, LARC uptake among youth is low. We evaluated the effect on contraceptive uptake of training youth-friendly service providers to counsel and provide all contraceptive methods including LARCs in the same unit. A convenience purposive sampling technique was used to select 20 youth friendly health units; ten each in Amhara and Tigray regions, Ethiopia; randomly allocated to the intervention (five) and non-intervention (five) arms. Data were abstracted from the family planning registers over an eleven-month period: three months pre-intervention and eight months post-intervention. Analysis of contraceptive uptake and chi-square tests of association were conducted. The number of LARCs new acceptors in the intervention arm was 781 (pre-intervention=116; post intervention=665) as compared to 358 in the non-intervention arm (pre-intervention=95; post intervention=263). Odds of adopting LARCs at pre-intervention (0.70); rose to 1.30 for the post-intervention phase (p-value <0.0001); comparing intervention to non-intervention study arms. Training youth friendly service providers to counsel and provide all contraceptive methods including LARCs in one location resulted in higher LARCs uptake for all sexually active young women; including those planning on delaying their first pregnancy.

Estimating the incidence of abortion in Pakistan.

This study applies an indirect estimation method to develop comprehensive national and provincial estimates of the prevalence of abortion and abortion-related morbidity in Pakistan. Data from a health facilities survey and a health professionals survey from 2002 are analyzed to develop estimates of postabortion hospitalizations and of the abortion rate, abortion ratio, and unwanted pregnancy rate. We estimate that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1,000 women aged 15-49. The abortion rate is found to be higher in provinces where contraceptive use is lower and where unwanted childbearing is higher. The unwanted pregnancy rate is estimated at 77 per 1,000 women, or about 37 percent of all pregnancies. Abortions account for termination of one in seven pregnancies. An estimated 197,000 women are treated annually in public hospitals and private teaching hospitals for induced abortion complications, a number equivalent to an annual rate of 6.4 women hospitalized as a result of unsafe induced abortions per 1,000 women aged 15-49.

Creating windows of opportunity for policy change: Incorporating evidence into decentralized planning in Kenya.

PROBLEM: Because researchers and policy-makers work in different spheres, policy decisions in the health arena are often not based on available scientific evidence. APPROACH: We describe a model that illustrates the policy process and how to work strategically to translate knowledge into policy actions. Several types of activity--agenda-setting, coalition building and policy learning--together can create a window of opportunity for policy change. LOCAL SETTING: Activities were undertaken as part of the Kenyan Ministry of Health's new decentralized planning-process. The objective was to ensure that the results of a national assessment of health services were used in the preparation of district-level health plans. RELEVANT CHANGES: Following the intervention, 70 district-level, evidence-based work plans were developed and approved by the Kenyan Ministry of Health. LESSONS LEARNED: Substantial investment and effort are needed to bring stakeholders together to work towards policy change. More in-depth evaluation of these efforts can aid understanding of how systematic approaches to policy change can be replicated elsewhere.

Intimate partner violence before and during pregnancy: experiences of postpartum women in Karachi, Pakistan.

OBJECTIVE: To assess the magnitude and determinants of intimate partner violence before and during pregnancy and attitude regarding domestic violence among a cohort of recently delivered women in Karachi, Pakistan. METHODS: A total of 300 women occupying every alternate bed in the postnatal wards of a public tertiary hospital were administered a structured questionnaire. RESULTS: Forty four percent (44%) of women reported lifetime marital physical abuse, 23% during the index pregnancy. Among the 132 women who were ever physically abused, all reported verbal abuse and 36% sexual coercion. The statistically significant risk factors, wife's education, consanguinity, and duration of marriage, were similar for lifetime marital abuse and during pregnancy. Over half (55%) of the women believed that antenatal care clinics were a good time to enquire about domestic violence. CONCLUSION: Annually an estimated one million pregnant Pakistani women are physically abused at least once during pregnancy. Reproductive health stakeholders should be encouraged to advocate for domestic violence screening.

She may reach a facility but will still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan.

OBJECTIVE: To assess the availability, utilization and functional capacity of the public health delivery system in terms of human resources, equipment, supplies and health provider knowledge regarding management of obstetric complications. METHODS: A cross-sectional study was conducted in March 2003 for Multan's public health delivery system. A complete inventory of equipment, supplies, drugs, staff availability and knowledge of obstetric complications management were assessed. RESULTS: The number and distribution of public sector facilities serving a population of 3.2 million was well beyond the minimum requirement for basic obstetric care but fell short for comprehensive Emergency Obstetrical Care (EmOC). Utilization patterns were skewed to the tertiary facility for normal and complicated deliveries. Partograms were not available, magnesium sulphate was only available at the tertiary facility, while basic supplies like iron and folate tablets, broad spectrum antibiotics, oxytocics, gloves and sutures were not available at primary or secondary facilities. Knowledge scores regarding management of obstetric complications were less than average, especially among nurses at basic or comprehensive EmOC facilities. Intensity of labour pains (nurses 59%) at basic EmOC facility and cervical dilatation by doctors at basic and comprehensive facilities were the most frequent responses for monitoring in labour. CONCLUSION: Strengthening the four interlinked health system elements--human resources, access to, use and quality of services is essential though not sufficient.

Frequency and determinants of vaginal infection in postpartum period: a cross-sectional survey from low socioeconomic settlements, Karachi, Pakistan.

OBJECTIVE: To determine the frequency and factors associated with perceived vaginal infections among married women in their postpartum period. METHODS: A cross-sectional study was conducted from July 2000 to October 2000 in five squatter settlements of Karachi, Pakistan. These squatter settlements were selected on the basis of an existing surveillance system run by female community health workers for maternal and child healthcare which identified women who had delivered 42-56 days prior to the date of interview. Vaginal infection was considered present when a mother perceived foul smelling vaginal discharge during the postpartum period. Mothers were interviewed to gain insight into socioeconomic and demographic variables, materials used to staunch lochia, duration of labour, personal and perineal hygiene and past obstetric history. RESULTS: A total of 525 women were interviewed. The estimated prevalence of perceived vaginal infection was 5.1%. Factors associated with perceived vaginal infections included, delivery conducted by a non-medical personnel (AOR 3.5, CI 1.3-9.5) and use of unhygienic cloth or cotton for staunch of lochia (AOR 2.7, CI 1.1-6.2). CONCLUSION: Among women who reported perceived vaginal infection, a higher proportion were delivered by non-medical personnel, and used unhygienic material (cloth or cotton) for staunch of lochia as compared to women who did not perceive vaginal infection. We recommend deliveries to be conducted by trained personnel and provision of health education for persons who conduct delivery and women to use hygienic material for staunch of lochia during post partum period.

A quality of care issue: appropriate use and efficacy knowledge of five contraceptive methods: views of men and women living in low socioeconomic settlements of Karachi, Pakistan.

OBJECTIVE: To assess knowledge regarding availability, affordability, appropriate use and efficacy for five non-permanent contraceptive methods. METHODS: Married Muslim women and men (500 each) were randomly selected from two low socioeconomic settlements in Karachi, Pakistan. Interviews to assess their knowledge on a range of contraceptive and abortion themes were conducted. Four hundred men and 357 women were selected from this larger sample based on their knowledge of condoms, withdrawal, oral pills, injectables and IUDs. RESULTS: Nearly half of the sampled men (56%) and women (48%) were contraceptive users. Knowledge regarding contraception, a specific method, its availability and affordability was high. Appropriate use knowledge for condoms was 73% among men (users 78%, non-users 60%; p-value < or = 0.001 ) and 5% among women. Efficacy knowledge was generally poor. CONCLUSIONS: Low knowledge levels regarding appropriate use and efficacy even among contraceptive users suggests, that quality of family planning services should not be limited to service delivery issues but extend to appropriate use and efficacy knowledge levels among clients.

The quest for small family size among Pakistani women--is voluntary termination of pregnancy a matter of choice or necessity?

OBJECTIVE: To present the socio-biologic predictors of induced abortion among married women residing in low income squatter settlements of Karachi, Pakistan. METHODS: A cross-sectional survey was conducted in three squatter settlements of Karachi from June to August 1997. Interviews were conducted on 1,214 married women assessing past pregnancy history, literacy and employment status of self and spouse and specifically probing for past history of seeking an induced abortion. RESULTS: Fifty women reported an induced abortion during last three years prior to survey. Of these, forty percent (20/50) of abortion seekers were using some method of family planning before conceiving the index pregnancy. Post abortion family planning method use was adopted by 50% (25/50) of the abortion seekers. The most parsimonious multivariate logistic regression model included grand-multigravidity (OR 2.6 CI, 1.3 - 5.2), literate status of the woman (OR 1.9 CI, 1.0 - 3.4) and the 26-35 age group (OR 3.0 CI, 1.4 - 6.6). CONCLUSIONS: Unplanned/mistimed pregnancies generally result from high unmet need and ineffective use of contraceptives and culminate through induced abortions. We propose that improvement in the quality of family planning counseling should be targeted to effective use of a method, back-up support in case of method failure and the health consequences of unsafe abortions.

Newborn care practices in low socioeconomic settlements of Karachi, Pakistan.

To explore traditional neonatal beliefs and care practices and to assess the predictors for giving prelacteal feeds, a qualitative and quantitative study was conducted in low socioeconomic settlements of Karachi, Pakistan. Five focus group discussions and 15 in-depth semi-structured interviews were conducted in July and August 2000; structured questionnaires were administered to 525 recently delivered women through November. Antenatal care coverage was common; a little over half of the women delivered at home with traditional birth attendants. Among the 387 women who reported at least one antenatal visit, most (78.6%) reported receiving counseling on breastfeeding by their healthcare provider. A significant proportion of women (44.8%) reported giving lacteals; colostrum (41.7%) or animal/formula milk (3.1%), as the first feed. Newborns were bathed immediately (82.1%) after delivery as the vernix was considered 'dirty looking' (78.5%), and it was felt it should be removed. To foster muscle relaxation (80.2%) and strengthen the bones (43.0%), daily massage was universally practiced, mustard oil (75.9%) being the most frequently used lubricant. Risky feeding practices such as giving prelacteals (55.0%) or supplementary feeds (71.3%), or delaying first feed (30.9%) were common. During the neonatal period, breast milk was the preferred feed (98.6%); however, honey (28.7%), ghutti (27.8%) and water (11.8%) were also given in order to 'reduce colic' or 'act as a laxative', which were perceived health benefits mentioned by mothers and traditional birth attendants. Ethnicity and birth attendant at delivery were strong predictors for women who gave prelacteals (after adjusting for education, socioeconomic status and facility delivery). Although administration of colostrum as the first feed was relatively common in this setting, the predominance of other risky traditional newborn care practices stresses the need for promoting health education programs on improving newborn care practices.

Health service utilization for perceived postpartum morbidity among poor women living in Karachi.

To explore traditional beliefs and practices, to assess puerperal morbidity, and to understand care-seeking behaviors, a qualitative and quantitative study was conducted in low socio-economic settlements of Karachi, Pakistan. Five focus group discussions and 15 in-depth interviews were conducted in July and August 2000. 525 Muslim women, who were 6-8 weeks post-partum, were then interviewed at home. Maternal care was relatively good-more than three-quarters of recent mothers sought antenatal care and more than half (267/525) delivered in a hospital or maternity home. Counseling to attend post-partum clinics among facility deliveries was 16% (43/267), of which only 26% (11/43) attended. Practices during the delivery and puerperium, such as massaging the vaginal walls with mustard oil during labor to facilitate delivery and inserting vaginal or rectal herbal pessaries to facilitate 'shrinkage of the uterus' and/or 'strengthening of the backbone', were pervasive. The core symptoms that are clinically significant during the puerperium are heavy vaginal bleeding and high fever, since they are potentially fatal symptoms if appropriate and timely care is not sought. About half of the study women (53.3%) reported at least one illness symptom, high fever (21.1%), heavy vaginal bleeding (13.9%), and foul smelling vaginal discharge (9.6%). Women did not know the underlying biologic cause of their perceived post-partum morbidity; weakness was frequently mentioned. Women sought care initially from close relatives or traditional healers and if they continued to suffer from their morbidity they finally approached a trained health care (allopathic) provider. The high prevalence of perceived post-partum morbidity illustrates the demand for post-partum community-based health care programs. We suggest promoting maternal health education that encourages women to seek appropriate and timely care by accessing public or private health services.

Do mothers-in-law matter? Family dynamics and fertility decision-making in urban squatter settlements of Karachi, Pakistan.

The perspectives of mothers-in-law about intra-household decision-making, family size and family planning are investigated, and their views compared with those of their sons and daughters-in-law. Women (717 daughters-in-law), their husbands (717 sons) and their 522 mothers-in-law were interviewed in eight squatter settlements in Karachi, Pakistan. Decisions about the schooling and health care of children, and the purchase of jewellery, are perceived to lie within the nuclear family domain (i.e. husband and wife). There was a difference in mothers-in-law's, daughters-in-law's and sons' desire to have more children. Twenty-eight per cent of mothers-in-law versus 58%, of daughters-in-law did not want more grandsons/sons and 36%, of mothers-in-law versus 66% of daughters-in-law did not want more granddaughters/daughters. The difference was markedly greater among the mother-in-law/daughter-in-law pairs than in the mother/son pairs. Overall, the mother-in-law's role seems to be somewhat overshadowed by that of her son (family male member), except for limiting family size. It is suggested that mothers-in-law should be included in Information-Education-Communication (IEC) campaigns about family planning.

Validation of verbal autopsy to determine the cause of 137 neonatal deaths in Karachi, Pakistan.

Verbal autopsy (VA) aims to estimate a community's mortality experience in the absence of contact with formal registration or health care systems. Application of VA to neonatal deaths is problematic as the agonal phase of a neonatal death tends to be indistinct. This is the first attempt to validate the technique exclusively on newborns who died. Seriously ill neonates (n = 137) were enrolled from the Civil Hospital, Karachi, Pakistan, between 31 October 1993 and 31 July 1994. All died as newborns, and caregivers were interviewed at home 3-230 days later. Surveillance physicians completed case questionnaires in the hospital, and investigator physicians assigned the main and associated causes of death using clinical criteria. Field questionnaires including a verbatim open-ended history, and syndrome modules were completed by a field worker, and investigator physicians again assigned the main and associated causes of death based on three diagnostic methods: verbatim alone, modules alone and verbatim and modules combined. We assessed the validity of VA by comparing field against hospital diagnoses by diagnostic (verbatim vs. modules vs. both) and analytic method (main vs. any diagnosis). VA identified at least one diagnosis accurately in 71% of the newborns. VA underdiagnosed low birthweight and prematurity in the field. Verbatim and modules diagnostic method comparing any field against main hospital diagnoses revealed high sensitivities for too early/too small syndrome (90%) and neonatal tetanus (84%). VA correctly identified some important causes of neonatal death in the field. Assigning multiple diagnoses using both open- and closed-ended questions increases the likelihood of correct ascertainment.

Where is the "E" in MCH? The need for an evidence-based approach in safe motherhood.

Measuring the impact of obstetric interventions on maternal mortality and/or morbidity is especially difficult in developing countries, where most maternal deaths occur. Therefore, program planning has been based on theory rather than proved effectiveness. After reviewing both the strategies that have been promoted to reduce maternal mortality and the adequacy of existing evidence used to justify their selection, the investigators highlight reasons why rigorous criteria for the selection and evaluation of interventions should be adopted. Adequate evaluation of intervention effectiveness under real-life conditions in developing countries is an efficient way to identify interventions for large-scale program replication and could speed progress in reducing maternal deaths.

Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan.

OBJECTIVE: Population-based surveys were conducted in selected clusters of Pakistan's least developed provinces, Balochistan and North-West Frontier Province (NWFP), including the Federally Administered Tribal Areas (FATA), to assess levels and causes of neonatal and postneonatal mortality. METHODS: Interviews were conducted in a total of 54 834 households: Balochistan, 20 486; NWFP, 26 175; and FATA, 8173. Trained interviewers administered questionnaires after obtaining verbal informed consent from the respondents. Verbal autopsy interviews were conducted for infant deaths reported for the previous year. FINDINGS: The infant mortality rate based on combined data from the different sites was 99.7 per 1000 live births (range 129.0-70.1). The contribution of neonatal deaths to all infant deaths was much higher for NWFP (67.2%), where the overall rate was lowest, than for Balochistan (50.8%) and FATA (56.8%). Around 70% of all neonatal deaths occurred in the early neonatal period. The three main clinical causes of infant deaths were diarrhoea syndrome (21.6%), tetanus (11.7%) and acute respiratory infections (11.6%). In the neonatal period, however, tetanus (18.3%), small size for gestational age or low birth weight (15.3%), and birth injury (12.0%) accounted for nearly half (45.6%) of all deaths, while the contributions of diarrhoea syndrome (5.1%) and acute respiratory infections (6.0%) were less significant (11.1%). Tetanus was the cause of death for 21.7% and 17.1% of all infant deaths in FATA and NWFP respectively. CONCLUSION: The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to maternal tetanus immunization, safe delivery and cord care.