Post-abortion fertility desires, contraceptive uptake and unmet need for family planning: voices of post-abortion care clients in Tanzania.

Post-abortion care (PAC) integrates elements of care that are vital for women's survival after abortion complications with intervention components that aid women in controlling their fertility, and provides an optimal window of opportunity to help women meet their family planning goals. Yet, incorporating quality family planning services remains a shortcoming of PAC services, particularly in low- and middle-income countries. This paper presents evidence from a mixed method study conducted in Tanzania that aimed at explaining factors that contribute to this challenge. Analysis of data obtained through client exit interviews quantified the level of unmet need for contraception among PAC clients and isolated the factors associated with post-abortion contraceptive uptake. Qualitative data analysis of interviews with a subset of these women explored the multi-level context in which post-abortion pregnancy intentions and contraceptive behaviours are formed. Approximately 30% of women interviewed (N=412) could recall receiving counselling on post-abortion family planning. Nearly two-thirds reported a desire to either space or limit childbearing. Of those who desired to space or limited childbearing, approximately 20% received a contraceptive method before discharge from PAC. The factors significantly associated with post-abortion contraceptive acceptance were completion of primary school, prior use of contraception, receipt of PAC at lower level facilities and recall of post-abortion family planning counselling. Qualitative analysis revealed different layers of contextual influences that shaped women's fertility desires and contraceptive decision-making during PAC: individual (PAC client), spousal/partner-related, health service-related and societal. While results lend support to the concept that there are opportunities for services to address unmet need for post-abortion family planning, they also attest to the synergistic influences of individual, spousal, organizational and societal factors that influence whether they can be realized during PAC. Several strategies to do so emerged saliently from this analysis. These emphasize customized counselling to enable client-provider communication about fertility preferences, structural intervention aimed at empowering women to assert those objectives in family and health care settings, availability of information and services on post-abortion fertility and contraceptive eligibility in PAC settings and interventions to facilitate constructive spousal communication on family planning and contraceptive use, after abortion and in general.

Safety of Tubal Occlusion by Minilaparotomy Provided by Trained Clinical Officers Versus Assistant Medical Officers in Tanzania: A Randomized, Controlled, Noninferiority Trial.

BACKGROUND: Tubal occlusion by minilaparotomy is a safe, highly effective, and permanent way to limit childbearing. We aimed to establish whether the safety of the procedure provided by trained clinical officers (COs) was not inferior to the safety when provided by trained assistant medical officers (AMOs), as measured by major adverse event (AE) rates. METHODS: In this randomized, controlled, open-label noninferiority trial, we enrolled participants at 7 health facilities in Arusha region, Tanzania, as well as during outreach activities conducted in Arusha and neighboring regions. Consenting, eligible participants were randomly allocated by a research assistant at each site to minilaparotomy performed by a trained CO or by a trained AMO, in a 1:1 ratio. We asked participants to return at 3, 7, and 42 days postsurgery. The primary outcome was the rate of major AEs following minilaparotomy performed by COs versus AMOs, during the procedure and through 42 days follow-up. The noninferiority margin was 2%. The trial is registered with ClinicalTrials.gov, Identifier NCT02944149. RESULTS: We randomly allocated 1,970 participants between December 2016 and June 2017, 984 to the CO group and 986 to the AMO group. Most (87%) minilaparotomies were conducted during outreach services. In the intent-to-treat analysis, 0 of 978 participants had a major AE in the CO group compared with 1 (0.1%) of 984 in the AMO group (risk difference: -0.1% [95% confidence interval: -0.3% to 0.1%]), meeting the criteria for noninferiority. We saw no evidence of differences in measures of procedure performance, participant satisfaction, or provider self-efficacy between the groups. CONCLUSIONS: Tubal occlusion by minilaparotomy performed by trained COs is safe, effective, and acceptable to women, and the procedure can be safely and effectively provided in outreach settings. Our results provide evidence to support policy change in resource-limited settings to allow task shifting of minilaparotomy to properly trained and supported COs, increasing access to female sterilization and helping to meet the rising demand for the procedure among women wanting to avoid pregnancy. They also suggest high demand for these services in Tanzania, given the large number of women recruited in a relatively short time period.

Safety of tubal ligation by minilaparotomy provided by clinical officers versus assistant medical officers: study protocol for a noninferiority randomized controlled trial in Tanzanian women.

BACKGROUND: Female sterilization by tubal ligation is a safe, extremely effective, and permanent way to limit childbearing. It is the most popular modern contraceptive method worldwide. The simplest way to provide tubal ligation is by a procedure called minilaparotomy, generally performed with the client under local anesthesia with systemic sedation and analgesia. In Tanzania, unmet need for family planning is high and has declined little in the past decade. Access to tubal ligation is limited throughout the country, in large part because of a lack of trained providers. Clinical officers (COs) are midlevel health workers who provide diagnosis, treatment, and minor surgeries. They are more prevalent than physicians in poorer and rural communities. Task shifting-the delegation of some tasks to less-specialized health workers, including task shifting of surgical procedures to midlevel cadres-has improved access to lifesaving interventions in resource-limited settings. It is a cost-effective way to address shortages of physicians, increasing access to services. The primary objective of this trial is to establish whether the safety of tubal ligation by minilaparotomy provided by COs is noninferior to the safety of tubal ligation by minilaparotomy provided by physicians (assistant medical officers [AMOs]), as measured by rates of major adverse events (AEs) during the procedure and through 42 days of follow-up. METHODS/DESIGN: In this facility-based, multicenter, noninferiority randomized controlled trial, we are comparing the safety of tubal ligation by minilaparotomy performed by trained COs versus by trained AMOs. The primary outcome is safety, defined by the overall rate of major AEs occurring during the minilaparotomy procedure and through 42 days of follow-up. The trial will be conducted among 1970 women 18 years of age or older presenting for tubal ligation at 7 study sites in northern Tanzania. DISCUSSION: If no major safety issues are identified, the data from this trial may facilitate changes in the Tanzanian government's regulations, allowing appropriately trained COs to provide tubal ligation by minilaparotomy. Positive findings may have broader implications. Task shifting to provide long-acting contraceptives, if proven safe, may be an effective approach to increasing contraceptive access in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02944149 . Registered on 14 October 2016.