Building on safety, feasibility, and acceptability: the impact and cost of community health worker provision of injectable contraception.

Dawn Chin-Quee,Reuben Kamoto Mbewe,Conrad Otterness,Mavis Mwale Nduna,Lydia Jumbe,Morrisa Malkin,John Bratt

doi:10.9745/ghsp-d-13-00025

Abstract

A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas. One way to fill this gap is for community health workers (CHWs) to provide injectable contraceptives, an intervention for which there is growing evidence and international support. In 2009, with approval from the Government of Zambia (GoZ), FHI 360 collaborated with ChildFund Zambia to design and implement such an intervention as part of its existing CHW family planning program. The safety of CHW provision of injectable DMPA (depot medroxyprogesterone acetate) was measured by client reports and by a 21-item structured observation checklist. Feasibility and acceptability were measured by interviews with CHWs and a subset of DMPA clients. The impact of adding DMPA to pill and condom provision was assessed by family planning uptake among the clients of trained CHWs from February 2010 to February 2011. Costs were documented using spreadsheets over the period November 2009 to February 2011. Scores were high on all measures of safety, feasibility, and acceptability. Couple-years of protection (CYP, protection from pregnancy for 1 year) was provided to 51 condom clients, 391 pill clients, and 2,206 DMPA clients. Of the 1,739 clients new to family planning, 85% chose injectable DMPA, while 13% chose pills and 2% chose condoms. Continuation rates were also high, at 63% after 1 year as compared with 47% for pill users. Incremental costs per couple-year were US$21.24 if 50% of users continue with CHW-provided DMPA. The study affirms that the provision of injectable contraceptives by CHWs is safe, acceptable, and feasible in the Zambian context, with very high rates of uptake in hard-to-reach areas. High continuation rates among clients mean that costs of the intervention can be low when added to an existing community-based distribution program-a finding that is relevant to program replication (now underway in Zambia).

Highlights

A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas
The safety of community health worker (CHW) provision of injectables was measured by depot medroxyprogesterone acetate (DMPA) client reports and by a 21-item structured observation checklist (SOC) divided into 2 scales that measured infection prevention (11 items) and injection procedures (10 items)
There was improvement from the first to the last DMPA injection evaluated during the practicum, but the starting point was high to begin with

Summary

Introduction

A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas. Many sub-Saharan African (SSA) countries face critical shortages of doctors, nurses, and midwives.[1] This deficit inhibits efforts to expand access to family planning services, especially in rural areas, where access to modern contraceptive methods is limited and few trained personnel are available to provide these services. Task sharing has been employed as a strategy to address this problem by delegating health care tasks that are usually carried out by doctors and nurses to a lower-level provider who is more accessible to the community. Success in Uganda, Ethiopia, and other SSA countries suggests that the role of CHWs need no longer be limited to distribution of condoms and oral contraceptive pills or referral to higher-level providers

Methods

Results

Conclusion