Safety, Quality, and Acceptability of Contraceptive Subdermal Implant Provision by Community Health Extension Workers Versus Nurses and Midwives in Nigeria: Protocol for a Quasi-Experimental, Noninferiority Study

Abstract

Background: As part of its Family Planning 2020 commitment, the Nigerian government is aiming for a contraceptive prevalence rate of 36% by 2018, and in 2014, approved a policy to allow community health extension workers (CHEWs), in addition to doctors, nurses, and midwives, to provide contraceptive subdermal implants. There is a lack of rigorous evidence on the safety of long-acting reversible contraceptive provision, such as implants, among lower cadres of health providers.Objective: This study aimed to compare implant provision by CHEWs versus nurses and midwives up to 14 days post insertion. Methods:The quasi-experimental, noninferiority study will take place in public sector facilities in Kaduna and Ondo States. In each state, we will select 60 facilities, and from these, we will select a total of 30 nurses and midwives and 30 CHEWs to participate. Selected providers will be trained to provide implant services. Once trained, providers will recruit a minimum of 8125 women aged between 18 and 49 years who request and are eligible for an implant, following comprehensive family planning counseling. During implant insertion, providers will record data about the process and any adverse events, and 14 days post insertion, providers will ask 4410 clients about adverse events arising from the implant. Supervisors will observe 792 implant insertions to assess service provision quality and ask clients about their satisfaction with the procedure. We will conclude noninferiority if the CI for the difference in the proportion of adverse events between CHEWs and nurses and midwives on the day of insertion or 14 days post insertion lies to the right of −2%.

Provision of injectable contraceptives by community health workers in sub-Saharan Africa: a systematic review of safety, acceptability and effectiveness

“…In just a decade, its use increased by two folds and it is said to provide protection for more than 42 million women worldwide on a yearly basis [3]. However, more than 200 million women in developing countries wishing to avoid pregnancy do not have access to modern contraceptives [4][5][6][7]. Injectable contraceptives like depot-medroxyprogesterone acetate (DMPA) stand as the fifth most commonly used contraceptive method worldwide and the most popular contraceptive method in SSA.…”

“…It is estimated that the global shortage of healthcare staff in SSA will expand from 12 to 18 million by 2030, with a 6 million shortage in Africa [12]. As a result, urban areas enjoy a greater package of trained healthcare personnel as opposed to rural areas [4,5,[13][14][15]. Consequently, stark differences exist between rural and urban areas in terms of contraceptive prevalence rate (CPR) and total fertility rate (TFR) [5].…”

“…As a result, urban areas enjoy a greater package of trained healthcare personnel as opposed to rural areas [4,5,[13][14][15]. Consequently, stark differences exist between rural and urban areas in terms of contraceptive prevalence rate (CPR) and total fertility rate (TFR) [5]. Take for instance, in Zambia, the CPR amongst married women is 42% for a corresponding TFR of 4.3 in urban areas as opposed to a CPR of 28% and a TFR as high as 7.5 in rural areas [16].…”

“…Take for instance, in Zambia, the CPR amongst married women is 42% for a corresponding TFR of 4.3 in urban areas as opposed to a CPR of 28% and a TFR as high as 7.5 in rural areas [16]. In Nigeria, contraceptive prevalence is just 9% in rural areas versus 27% in urban areas [5]. This urban-rural discrepancy would only keep rising if access to family planning (FP) methods, including injectable contraceptives will continue to be restricted to women in well-resourced areas if policies limiting the delivery of injectable contraceptives to clinical settings remain untouchable [6].…”

Acceptability of contraceptive implants at the maternity ward of the Matam Communal Medical Center

“…6 In sub-Saharan Africa, where the burden of maternal mortality is the highest, this prevalence is still very low, 0.4% in Nigeria. 7 In Guinea, contraceptive prevalence has evolved very slowly, during the IUD and subcutaneous implants has remained very low (1%)8.…”