examining the feasibility of postpartum iud services in rwanda
TRANSCRIPT
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Examining the Feasibility of Postpartum IUD Services in Rwanda Study Findings Theresa Hoke, PhD, MPH July 19, 2012
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Study Goal
Produce experience-based guidance regarding • the feasibility of offering postpartum IUD
insertion services in hospitals and health centers in Rwanda
• the factors influencing successful implementation
• with an eye on eventual scale-up
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Service Implementation Sites
Huye: Kabutare Hospital Rubona HC Kinyamakara HC
Gakenke: Ruli Hospital Coko HC Rushashi HC
Karongi: Kibuye Hospital Rubengera HC Kirambo HC
Kirehe: Kirehe Hospital Kirehe HC Mulindi HC
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Intervention Components
• Training: postpartum FP counseling; IUD insertion and removal
• Performance standards • Adjustments to ANC
and maternity procedures
• Equipment and commodities
• Supportive supervision • Postpartum FP brochure 4
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• Examine the degree to which postpartum IUD service components are offered in accordance with performance standards;
• Examine providers’ perspectives regarding the responsibility of
offering postpartum IUD services; • Assess clients’ perspectives toward postpartum IUD services
Study Objectives
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6
• Interviews with all antenatal care (ANC) and maternity providers
responsible for client counseling and actual insertion in participating sites
• Observation of client-provider interactions in ANC • Observation of rotations in the participating maternities to assess
provision of postpartum IUD service • Interviews with women who are 3-5 months postpartum
Evaluation Methods: Post-intervention Data Collection
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RESULTS
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Summary of Recorded Services (as of February 2012)
Health Centers
(n = 8)
District Hospitals
(n = 4)
Total
(n=12)
Post-placental insertions
118 34 152
Postpartum insertions
82 60 142
Intra-cesarean insertions
NA 184 184
Total insertions 200 278 478
Follow-up visits 122 142 264
Expulsions/removals 8 7 15
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Number of Insertions by Facility (as of February 2012)
0
20
40
60
80
100
120
140
160
1 2 3 4 5 6 7 8 9 10 11 12
intra-cesareanvaginal
Health Centers Hospitals
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Provider Knowledge: Issues Covered by Postpartum FP Counseling Score
• Healthy timing and spacing of pregnancy • Lactational amenorrhea (LAM) • Safe and effective FP methods for postpartum women • Eligibility criteria for postpartum IUD • Perspectives on the appropriateness and advantages of the
postpartum IUD as a contraceptive method
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Median Postpartum FP Counseling Score
0369
12151821242730333639
Trained in PPFPNot trained
N= 26 N = 38
TOTAL POSSIBLE SCORE = 39
50% “competent”
Med
ian
Sco
re
81% “competent”
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Median Postpartum FP Counseling Score—by Professional Designation
0369
12151821242730333639
DoctorNurse
N= 10 N = 54
TOTAL POSSIBLE SCORE = 39
Med
ian
Sco
re
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Provider Competence: Issues Covered by Postpartum IUD Clinical Score
• Infection prevention • Eligibility criteria for postpartum IUD • Insertion procedures • Timing of routine follow-up visits • Normal side effects associated with IUD • Issues indicating need for medical attention
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Median Postpartum IUD Clinical Score
0
3
6
9
12
15
18
21
24
PPIUD insertion training
Trained by peerN= 21 N = 6
TOTAL POSSIBLE SCORE = 23
86% “competent”
83% “competent”
Med
ian
Sco
re
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Median Postpartum IUD Clinical Score—by Professional Designation
0
3
6
9
12
15
18
21
24
Doctor
NurseN= 7 N = 20
TOTAL POSSIBLE SCORE = 23
Med
ian
Sco
re
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Provider Attitudes: Advantages of Postpartum IUD Insertion Compared to Interval Insertion
Advantages Doctors N= 10
Nurses N=54
Insertion is more convenient for the client 90% 69%
Insertion is more convenient for the provider 70% 50%
Insertion is easier/less painful 60% 50%
Normal side effects of the IUD insertion are masked by normal symptoms following delivery
30% 28%
Ensures postpartum family planning protection for the woman 70% 76%
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Provider Attitudes toward Service Provision
• 94% of all 64 providers say counseling clients on postpartum IUD services should be part of their job
• Among those trained to perform insertions (N = 27)
– 96% would like provision of postpartum IUD insertion services to be a normal part of their work
– 100% are “strongly in favor” of the service expanding to other health facilities in Rwanda
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Observation of Service Delivery: Counseling on Postpartum FP during Antenatal Care
Message Group Education N= 41 sessions
Individual Counseling N= 335 sessions
Healthy timing and spacing of pregnancy
62% 36%
Following child birth, risk of pregnancy before menses return
83% 33%
LAM criteria 60% 26%
Difference between short-acting and long-acting FP methods
52% 27%
IUD as a contraceptive option 98% 62%
IUD can be inserted immediately following delivery
86% 50%
Asks client about her choice of postpartum contraception
NA 93%
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Observation of Service Delivery: Counseling on Postpartum FP at the Maternity
Service provision Observed shifts N= 180
Group education on family planning delivered in post-labor ward
17%
Individual counseling about postpartum IUD
36%
Provider asks woman in labor if she has chosen the postpartum IUD as her method
50%
Provider trained to do postpartum IUD is present or on call
82%
IUD commodities are available
99%
Sterilized insertion equipment is available
97%
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Client Recollection of Counseling on Postpartum IUD Delivered during Antenatal Care (N=277)
Not at allIndividual/coupleGroupIndividual + group
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Client Perspectives on Postpartum IUD: “Why did you not consider postpartum IUD insertion?”
Reason for not being interested Clients
N=251
Not interested in IUD as my FP method
37%
Did not know enough about the IUD
36%
Not interested in any FP method immediately after birth
14%
Not ready to decide about the IUD
6%
Did not think my partner would approve
6%
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Client Perspectives on Postpartum IUD
Question posed to client Clients N=277
Ever heard of the IUD?
51%
Of those….
N = 142
Knows a woman who has ever used the IUD
32%
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Client Perspectives: “Can you tell me any good things you have heard about the IUD?”
Beliefs about advantages Clients
N= 142
Can use for a long time 39%
Very effective in preventing pregnancy 37%
It does not contain hormones 18%
Does not require many returns to the health facility 13%
Easy to use 6%
Does not interfere with sex 6%
Quick return to fertility following removal 6%
Does not know any good things 24%
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Client Perspectives: “Can you tell me any bad things you have heard about the IUD?”
Beliefs about drawbacks Clients
N= 142
Can cause infection 17%
Can travel to other parts of the woman’s body 16%
Causes increased bleeding 16%
Can perforate the uterus 5%
It can be expelled 5%
Causes health problems for the woman 5%
Interferes with sexual intercourse 4%
Causes more pain during menstruation 4%
Does not know any bad things 28%
No response 20%
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Key Lessons from Post-Intervention Evaluation
• Most providers demonstrated the job knowledge to deliver postpartum IUD services
• Providers expressed willingness to deliver the services • Insertion services can be successfully delivered in hospitals
and health centers alike • Services are not delivered as systematically as desired • Most postpartum women did not consider postpartum IUD as
a contraceptive option • Knowledge gaps are one factor contributing to low client
uptake of postpartum IUD services
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Where do we go from here? In Rwanda…
• Anticipate MOH decision to scale postpartum IUD service
• Technical foundation is in place
• Attention must be directed toward – supportive leadership – provider motivation – demand-generation
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Globally: • Proactively disseminate evidence that postpartum IUD
services can feasibly be incorporated into routine, public sector health services in sub-Saharan Africa
• Share lessons learned about factors influencing programmatic success
• Contribute findings to postpartum IUD section of the USAID-sponsored postpartum family planning toolkit
Where do we go from here?