Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives

FIGO and ICM joint statement on contraception: 2024

Contraception, and the opportunity and ability to decide the timing, number, and spacing of one's pregnancies, is not just critical for maternal and infant health, but necessary for the attainment of basic reproductive rights. Short inter-pregnancy intervals have significant consequences for both maternal and newborn mortality, including preterm birth and maternal anemia, and they are a key cause of preventable deaths worldwide. Addressing the unmet need for contraception could have widespread implications for health equity and access. Integrating comprehensive contraceptive services into various health settings including antenatal care, postpartum care, and child immunization visits is vital. Contraceptive counseling should be holistic, and should involve shared decision-making and patient autonomy. Contraceptive counseling is particularly important in the post-pregnancy period, where loss to follow-up may be high, and for adolescents and other vulnerable populations who are often overlooked in these discussions. Addressing the unmet need for contraception requires collaboration and teamwork among healthcare professionals, particularly midwives and physicians, who have the opportunity to amplify one another's efforts, share best practices, advocate for broader contraceptive services, and strengthen training among midwifery and medical trainees. Members of FIGO and ICM have worked together to produce this joint statement, identifying priorities within contraceptive provision and underlining key collaborative strategies to address the unmet need for contraception.

Factors influencing maternal death surveillance and review implementation in Dodoma City, Tanzania. A qualitative case study

Background

With 295 000 maternal deaths in 2017, 94% in low- and middle-income countries, maternal death is a matter of global public health concern. To address it, Maternal Death Surveillance and Response (MDSR) strategy was introduced in 2013 by the World Health Organization. With a reported maternal mortality ratio of 556:100000 per live births, Tanzania adopted the strategy in 2015. Studies are needed to understand factors influencing the implementation of MDSR in this specific setting.

Aims and Objectives

The study aimed to assess the processes influencing MDSR implementation in Dodoma city council.

Methods

A qualitative case study was conceptualized according to the Consolidated Framework for Implementation Research, focusing on implementation process domain. Members of MDSR committees were enrolled by purposeful sampling in the five health centres in Dodoma where the strategy was fully implemented and functional. In-depth interviews were conducted with key informants concerning the implementation processes influencing MDSR. Saturation was reached with the 15th respondent. Qualitative inductive content analysis was used to analyse data.

Results

The inclusiveness in participatory planning process, stakeholders' readiness and accountability and collective learning were acknowledged as factors positively influencing the implementation of MDSR strategy by respondents. The interaction and alignment of influential factors were essential for successful implementation.

Conclusions

MDSR implementation is positively influenced by factors that interact and converge in the building of a learning health system, to increase knowledge through practice and improve practice through knowledge. Further studies are needed to analyse the influence of additional factors at different levels of implementation to fully understand and empower the MDSR implementation network, and to better target the goal of closing the knowledge to practice loop.

Impact of a post-partum family planning intervention on contraception and fertility in Tanzania: two-year follow-up of a cluster-randomised controlled trial

PURPOSE

We evaluate contraceptive use and pregnancy two years following an intervention in Tanzania, which provided antenatal post-partum family planning counselling and post-partum intrauterine device (PPIUD) services following delivery.

METHODS

We analyse data from five hospitals in Tanzania using a difference-in-difference cluster randomised design, with randomisation at the hospital level. We use women-level data collected at the index birth and a follow-up survey two years later among 6,410 women. Outcomes (overall modern contraceptive use, contraceptive type, pregnancy) are modelled with an intent-to-treat (ITT) approach using linear regression. We compare with the complier average causal effect (CACE) of the intervention among those counselled.

RESULTS

The intervention increased long-term PPIUD use by 5.8 percentage points (95% CI: 0.7-11.2%) through substitution away from other modern methods. There was no impact on overall modern contraceptive prevalence or pregnancy. Only 29% of women reported receiving PPIUD counselling. When accounting for this in the CACE analysis we saw a larger impact with 25.7% percentage point increase in PPIUD use (95% CI: 22.7-28.6%).

CONCLUSION

The intervention provided women an additional contraceptive choice, resulting in higher use of PPIUD over two years. Increase in PPIUD use was brought about by shifting methods, not creating new modern contraceptive users.

Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review

Background

Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.

Methods

We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.

Results

Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.

Conclusion

The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Postnatal clubs for integrated postnatal care in Johannesburg, South Africa: a qualitative assessment of implementation

BACKGROUND

South Africa has reported challenges in retaining women in Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs postnatally. Due to the success of PMTCT in the antenatal period, proportionally more infant transmissions now occur after delivery. The Médecins sans Frontières (MSF) Postnatal Club (PNC) model allows for integrated postnatal care and support. Anova Health Institute implemented the model in primary health facilities in Johannesburg as part of a planned national scale-up. We aimed to assess the implementation of these PNCs.

METHODS

We used the RE-AIM (Reach, Adoption, Implementation, Maintenance) framework to assess implementation success and explore factors influencing implementation. In-depth interviews were conducted with 15 PNC staff, both clinicians and lay counsellors, using convenience sampling, from 12 facilities in Johannesburg. Data were analysed thematically using the RE-AIM framework.

RESULTS

PNC were perceived to have many benefits for postnatal clients and their infants: providers reported reduced waiting times, reduced number of clinic visits and that PNC provided clients with a space to form cohesive group dynamics thereby contributing to retention and adherence to antiretroviral therapy. However, it was found that lacking resources (e.g., space, medical equipment, staff) negatively impacted reach, implementation and sustainability. At times the PNC model was altered to accommodate the availability of resources (e.g., counselling mothers individually). Additionally, providers expressed concerns about lack of stakeholder adoption and emphasized the importance of involving facility leadership for successful integration of the model into routine primary healthcare.

CONCLUSION

Our study found incomplete implementation of PNC in most of the participating facilities attributed to lack of resources and stakeholder buy-in. This underscores the need for increased support at management level to ensure sustainability. Effective collaboration between all stakeholders would allow better use of existing resources. Further studies are needed to evaluate whether all components of the model need to be implemented fully to ensure optimal outcomes, and to identify implementation strategies to facilitate scale-up.

Provider perspectives in implementing the Postpartum Intrauterine Device Initiative in Sri Lanka: a qualitative study

BACKGROUND

Integration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery.

METHODS

We applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Findings indicated that providers were willing to adopt the intervention and reiterated the importance of postpartum family planning. However, the intervention was not consistently implemented as intended, including provider bias in counselling and lack of attention to women's preferences. Organisational barriers to implementation included time constraints and inadequate training. Providers suggested that a range of paramedical staff be trained in counselling and PPIUD insertion to mitigate barriers and to facilitate scaling up the intervention.

CONCLUSIONS

To improve and scale up the PPIUD Initiative, training efforts should be expanded to primary and secondary care facilities and implementation strategies better utilised (eg, on-the-job training). The training can be strengthened by improving providers' knowledge of all types of methods and interpersonal communication skills, and emphasising the importance of unbiased, evidence-based contraceptive counselling techniques.

'I haven't heard much about other methods': quality of care and person-centredness in a programme to promote the postpartum intrauterine device in Tanzania

BACKGROUND

Programmes promoting the postpartum intrauterine device (PPIUD) have proliferated throughout South Asia and sub-Saharan Africa in recent years, with proponents touting this long-acting reversible contraceptive (LARC) method's high efficacy and potential to meet contraceptive unmet need. While critiques of LARC-first programming abound in the Global North, there have been few studies of the impact of LARC-centric programmes on patient-centred outcomes in the Global South.

METHODS

Here, we explore the impact of a PPIUD intervention at five Tanzanian hospitals and their surrounding satellite clinics on quality of contraceptive counselling and person-centred care using 20 qualitative in-depth interviews with pregnant women seeking antenatal care at one of those clinics. Using a modified version of the contraceptive counselling quality framework elaborated by Holt and colleagues, we blend deductive analysis with an inductive approach based on open coding and thematic analysis.

RESULTS

Interpersonal aspects of relationship building during counselling were strong, but a mix of PPIUD intervention-related factors and structural issues rendered most other aspects of counselling quality low. The intervention led providers to emphasise the advantages of the IUD through biased counselling, and to de-emphasise the suitability of other contraceptive methods. Respondents reported being counselled only about the IUD and no other methods, while other respondents reported that other methods were mentioned but disparaged by providers in relation to the IUD. A lack of trained providers meant that most counselling took place in large groups, resulting in providers' inability to conduct needs assessments or tailor information to women's individual situations.

DISCUSSION

As implemented, LARC-centric programmes like this PPIUD intervention may decrease access to person-centred contraceptive counselling and to accurate information about a broad range of contraceptive methods. A shift away from emphasising LARC methods to more comprehensive, person-centred contraceptive counselling is critical to promote contraceptive autonomy.