Expanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa

Abstract

BackgroundClients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods.MethodsWe examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients.ResultsFollowing the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects.ConclusionsThe intervention failed to improve PMTCT clients’ knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

“…All integration models were facility‐based, primarily in HIV care and treatment settings, but also included two clinics for the prevention of perinatal HIV transmission (Hoke et al. ; Sarnquist et al. ).…”

“…), the informed and voluntary use of contraception (Hoke et al. ), and the need to support and never dissuade women who want to become pregnant (Phiri et al. ).…”

Integrating Prevention Interventions for People Living With HIV Into Care and Treatment Programs

“…98,99 All 12 intervention studies were conducted in sub-Saharan Africa. FP interventions included a facilitated referral model, 61 integration of FP services into HIV clinical care, 62,64–68 an education video to promote long-acting methods of contraception, 63,70,71 and group education sessions. 69 …”

“…60–71 Most of these studies reported significant increases in contraceptive uptake as a result of the intervention, 61,62,65–68,70,71 although 2 studies reported null effects. 64,69 Of the 4 studies that included pregnancy incidence as an outcome, 2 found a significant reduction in pregnancy incidence, 68,71 and 2 found no change in pregnancy incidence as a result of the intervention. 62,65 Taken together, these studies provide good evidence that FP interventions can have a high impact on improving contraceptive uptake but the impact on pregnancy incidence remains uncertain.…”

Achieving pregnancy safely for HIV‐serodiscordant couples: a social ecological approach

“…In the structural domain, healthcare providers often lack clinical guidance, training and support in counselling serodiscordant couples on how to achieve pregnancy safely, or how to integrate training into individualized counselling messages [18,21–23]. Additionally, provider training in SRHR service delivery is not always effective due to underlying health system constraints [24]. Lack of knowledge and training among healthcare providers may help to explain reports of stigma and discrimination experienced within the healthcare system by people living with HIV who desire a child, including coercive and forced sterilization [25,26] that are human rights violations [18,27,28].…”