Evaluation of a multi-level intervention to improve postpartum intrauterine device services in Rwanda

Abstract

Background. The copper intrauterine device is one of the most safe, effective, and cost-effective methods for preventing unintended pregnancy. It can be used postpartum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. Methods. We developed a multi-level intervention to increase uptake of the postpartum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of PPIUD counseling and service delivery. Formative work informed development of a PPIUD counseling flipchart to be delivered during antenatal care, labor and delivery, infant vaccination visits, or in the community. Two-day didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Counseling data were collected in government clinic logbooks. Insertions and follow-up data were collected in logbooks created for the implementation. Data were collected by trained government clinic staff and abstracted/managed by study staff. Stakeholders were involved from intervention development through dissemination of results. Results. Two hospitals (and their two associated health centers) and two additional health centers were selected. In 6-months prior to our intervention, 7.7 PPIUDs/month were inserted on average at the selected facilities. From August 2017-July 2018, we trained 83 counselors and 39 providers to provide PPIUD services. N=9,020 women received one-on-one PPIUD counseling after expressing interest in family planning who later delivered at a selected health facility. Of those, n=2,575 had PPIUDs inserted (average of 214.6 insertions/month), a 29% uptake. Most PPIUDs (62%) were inserted within 10 minutes of delivery of the placenta. Conclusions. This successful, comprehensive intervention has the potential to make a significant impact on PPIUD uptake in Rwanda. The intervention is scalable and adaptable to other sub-Saharan African countries.

Immediate postpartum intrauterine contraceptive device utilization and influencing factors in Addis Ababa public hospitals: a cross-sectional study

“…Immediate PPIUCD utilization among participants who gave birth in Addis Ababa public hospitals was 26.6% (95%CI: 21.3, 31.8). Similar figure of PPIUCD utilization was reported in Sidama region, Ethiopia [31] and another study in Rwanda [32]. This is higher than the national report of Ethiopian mini DHS 2019 which is 2% [22].…”

A mixed-methods study of factors influencing postpartum intrauterine device uptake after family planning counseling among women in Kigali, Rwanda

“…Community health workers (CHWs) and providers can offer counseling to educate women about PPFP, including LARCs 1) during routine antenatal care (ANC) visits, 2) during or after labor and delivery (L&D), 3) pre-discharge/post-partum and 4) at infant vaccination visits [ 13 ]. LARCs can be provided while women are at the health facility during delivery or at infant vaccination visits.…”

“…Projet San Francisco (PSF) developed a multi-level intervention to improve PPFP services in Rwanda with a focus on PPLARC which was implemented in August of 2017 [ 13 ]. Based on input from stakeholders, providers, CHWs, and couples/clients, a promotional and educational flipchart was developed to educate women about the PPIUD (along with the full menu of PPFP contraceptive options) to be delivered to women or couples during routine ANC, labor, within 48 hours postpartum, infant vaccination services and in the community by CHWs [ 13 ]. Providers from 6 government facilities including hospitals and clinics went through a 2-day didactic session followed by practical training including PPIUD insertion and removal, mock counseling sessions, and post-training tests.…”

“…CHWs who worked with pregnant women and newborns received 1-day training to review the flipchart. After the first year of implementation, there was a PPIUD acceptance rate of 29% among 9073 women who received one-on-one PPFP counseling [ 13 ].…”

Antibiotic-resistant Neisseria gonorrhoeae and changes to the 2019 Rwandan National STI Guidelines

“…CFHR has worked closely with the Rwanda Ministry of Health on research for improved HIV/STI and reproductive health care in government-run health centers for many years. [12][13][14] In 2019, the Rwanda National Guidelines 10 were updated based on these findings and changed first-line treatment for NG to ceftriaxone (250 mg ceftriaxone IM single dose). These recommendations are in line with the World Health Organization (WHO) 15 ; though notably, they do differ from the 2021 CDC NG treatment guidelines (which recommend 500 mg ceftriaxone IM single dose for persons weighting < 150 kg).…”