The scale-up and integration of contraceptive service delivery into nursing school training in the Democratic Republic of the Congo

Abstract

In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools.

Expanding contraceptive choice among first-time mothers age 15–24 in Kinshasa: The Momentum pilot project

“…Regarding differences by household wealth in Momentum's effect on informed choice, we do not know if FTMs' socioeconomic status shaped how they were counseled by Momentum nursing students and whether the counseling approach facilitated FTMs' recall of counseling content. In the DRC, the use of medical/nursing students for community-based distribution of contraceptives, including both DMPA-SC and Implanon NXT, increased contraceptive access and uptake ( 23 ) and this approach has been institutionalized by the 6ème Direction of the Ministry of Health, which is responsible for the network of nursing schools throughout the DRC ( 24 ).…”

“…The project had negligible effects on empowering FTMs to make decisions about the current contraceptive method and future programs need to address this issue. Although the nursing student model for administering contraception, including injectables and implants has been institutionalized in the nursing curriculum in the DRC ( 23 , 33 ), the scale-up of Momentum approach would require that attention be given to resupply, correct disposal of medical waste, and the establishment of referral linkages between nursing schools and fixed health facilities for management of side effects and LARC removal.…”

Task-shifting and family planning continuation: contraceptive trajectories of women who received their method at a community-based event in Kinshasa, DRC

“…Methods are provided for free or at a heavily discounted prices, and the student CBDs are trained to provide client-centered counseling. Programmatic evaluation of the NS model indicated the student CBDs were motivated by working in a group and highly valued the opportunity to practice their counseling and service provision skills during the campaigns [ 14 ]. Under the existing model, NS students participate in three to four campaigns per year in 93 health zones across the seven provinces where the model is currently implemented.…”

“…Under the existing model, NS students participate in three to four campaigns per year in 93 health zones across the seven provinces where the model is currently implemented. As of 2022, the intervention covered a third of the country and scale-up has continued with additional donors and partners [ 14 ].…”

Task-shifting and family planning continuation: contraceptive trajectories of women who received their method at a community-based event in Kinshasa, DRC

“…Under this model, NS students participate in three to four campaigns per year in the 93 health zones and seven provinces where the model is currently implemented. The ongoing institutionalization process includes cost-sharing some aspects of the training and students' equipment with the Ministry of Health, but most of the service delivery components are still dependent on external funding [13].…”