Postpartum long-acting contraception uptake and service delivery outcomes after a multilevel intervention in Kigali, Rwanda

Abstract

IntroductionPostpartum family planning (PPFP) is critical to reduce maternal–child mortality, abortion and unintended pregnancy. As in most countries, the majority of PP women in Rwanda have an unmet need for PPFP. In particular, increasing use of the highly effective PP long-acting reversible contraceptive (LARC) methods (the intrauterine device (IUD) and implant) is a national priority. We developed a multilevel intervention to increase supply and demand for PPFP services in Kigali, Rwanda.MethodsWe implemented our intervention (which included PPFP promotional counselling for clients, training for providers, and Ministry of Health stakeholder involvement) in six government health facilities from August 2017 to October 2018. While increasing knowledge and uptake of the IUD was a primary objective, all contraceptive method options were discussed and made available. Here, we report a secondary analysis of PP implant uptake and present already published data on PPIUD uptake for reference.ResultsOver a 15-month implementation period, 12 068 women received PPFP educational counselling and delivered at a study facility. Of these women, 1252 chose a PP implant (10.4% uptake) and 3372 chose a PPIUD (27.9% uptake). On average providers at our intervention facilities inserted 83.5 PP implants/month and 224.8 PPIUDs/month. Prior to our intervention, 30 PP implants/month and 8 PPIUDs/month were inserted at our selected facilities. Providers reported high ease of LARC insertion, and clients reported minimal insertion anxiety and pain.ConclusionsPP implant and PPIUD uptake significantly increased after implementation of our multilevel intervention. PPFP methods were well received by clients and providers.

Implementation and evaluation of a large-scale postpartum family planning program in Rwanda: study protocol for a clinic-randomized controlled trial

“…which was provided to 12,068 pregnant and postpartum women/couples in health facilities and the surrounding community. During our pilot, LARC uptake up to 6 weeks after delivery increased significantly (with 3372 PPIUD inserted representing a 2710% increase compared to the 6 months prior to our pilot, and 1252 implants inserted representing a 178% increase compared to the 6 months prior to our pilot), PPFP feasibility and acceptability were high among providers and clients, and side-effects were rare [5,6].…”

“…All facilities have the infrastructure for PPFP provision and procurement; though no formal PPFP initiatives are currently taking place, PP implant insertions are infrequent, and no providers are trained to insert PPIUDs. Our team has worked in these clinics (conducting clinic logbook data abstraction, implementing couples' HIV counseling and testing, implementing interval LARC services, and surveying providers and patients) for over 10 years [6,[14][15][16][17][18][19][20][21].…”

Implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning, a mixed-methods systematic review

“…The studies werereported from 37 countries, from all regions, and from LMIC and High-income countries. Eight studies were reported from the USA [ 27 – 34 ]; four from Tanzania [ 35 – 38 ], two from Sri Lanka [ 39 , 40 ], Nigeria [ 41 , 42 ], Nepal [ 43 , 44 ], Rwanda [ 45 , 46 ], Bangladesh [ 38 , 47 ], and one study from Benin [ 48 ], Bolivia [ 49 ], Burkina Faso [ 50 ], Chad [ 48 ], Côte d’Ivoire [ 48 ], Democratic Republic of Congo [ 50 ], Guatemala [ 51 ], India [ 52 ], Liberia [ 53 ], Mexico [ 49 ], Niger [ 48 ], Pakistan [ 54 ], Senegal [ 48 ], Togo [ 48 ], and Turkey [ 55 ].…”

Provision of postpartum long-acting reversible contraception: A quality improvement intervention with pre- and postintervention evaluation.

“…A pre-intervention insertion rate of 7.7 PPIUDs/ month, increased to 214.6 insertions/month. [7] This study is an example of addressing contraceptive insufficiencies by targeting multiple levels of care and counselling patients at multiple visits and having the capacity to provide chosen contraception as desired. An intervention of this scale within our communities may influence any stigma associated with LARCs and help to increase LARC uptake Many HIV-positive patients in the intervention group of this study showed interest in the use of an implant, but because of the current national policy of not providing implants to HIV-positive women using enzyme-inducing treatment, were counselled against this choice.…”