Family Planning Service Delivery Research Articles

The impact of COVID-19 on health financing in Kenya.

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Unraveling the Intersection of Socio-Economic Dynamics and Family Planning Accessibility: Insights from Women of Reproductive Age in Kween District, Eastern Uganda

The provision and utilization of Family Planning (FP) services play a pivotal role in not only safeguarding women's health but also significantly enhancing the overall well-being of their partners, children, and the wider societal fabric. Studies have estimated that optimizing FP services could potentially save 32% of maternal lives and 10% of child lives. In light of these critical implications, this research delves into the multifaceted factors hindering women's access to Family Planning Services within the precincts of the Kween district. Employing a cross-sectional descriptive study design, this investigation focuses on women aged between 18-49 years. Data collection involved survey questionnaires administered to a strategically sampled group of 40 women. The quantitative data underwent meticulous analysis utilizing SPSS version 20, while qualitative data was subjected to content and thematic analysis, presenting findings in a verbatim format. The study revealed that while 47.5% of women were utilizing modern FP methods, encompassing pills, implants, and injectables, there existed a notable unmet contraceptive need of 25%, coupled with a 22.5% contraceptive discontinuation rate. The primary deterrent to accessing modern FP methods stemmed from acceptability issues entrenched in prevailing myths, notably the erroneous beliefs associating Family Planning with infertility and the culturally unfavorable birth of twins. Moreover, the discontinuation of modern FP methods predominantly stemmed from reported side effects such as excessive bleeding, backaches, and headaches. Additionally, the research underscored a correlation between the utilization of modern FP methods, women's educational attainment, and demographic factors like the number of living male children and participation in polygamous marriages. Intriguingly, religious affiliations had a limited impact on FP method utilization, as women demonstrated a tendency to contravene religious doctrines to access FP services despite religious opposition. This study illuminates critical barriers obstructing women's access to and sustained use of modern FP methods in the Kween district, emphasizing the urgency for tailored interventions addressing socio-cultural misconceptions, side-effect management, and demographic sensitivities to foster more inclusive and effective FP service delivery in similar contexts. Keywords: Family Planning, Contraceptives, Injectables, Implants.

Representative bureaucracy and family planning service delivery in Tanzania

AbstractWe apply the theory of representative bureaucracy to examine if gender congruence between family planning care providers and service recipients correlates with communication behaviors during consultation. We use nationally representative administrative data from Tanzania's Demographic and Health Survey (DHS). We apply a series of logistic and ordered logistic regression analyses and find that gender congruence is correlated with both family planning service recipients' and care providers' communication behaviors. Despite confirming the principal tenets of the theory of representative bureaucracy, we also document mixed results when considering the moderating effects of service recipients' prior experience with service on communication behaviors. Taken together, representation has a positive effect on female providers' communication behavior. Yet, for service recipients, its benefits are contingent upon the type of outcome assessed and prior experience with service. We discuss the policy and practical implications of our study in the context of the benefits and limits of representation.

A qualitative study of influences on the uptake of contraceptive services among people of reproductive age in Uganda

BackgroundUganda has registered an increased investment in family planning (FP) programs, which has contributed to improvement in knowledge of modern contraceptive methods being nearly universal. However, this has not matched the uptake of modern methods or the reduction in the unmet need for FP. This may be explained by the different influences which include health workers, family, and friends. Due to the limited uptake of contraceptive methods, a program on improving awareness, access to, and uptake of modern contraceptives is being implemented in selected regions in Uganda. We, therefore, conducted a formative study to determine the influences on contraceptive uptake at the onset of this program.MethodsUsing a qualitative study design, we conducted thirty-two focus group discussions and twenty-one in-depth interviews involving men and women of reproductive age. We also carried out twenty-one key informant interviews with people involved in FP service delivery. Data was collected in four districts where implementation of the program was to take place. Audio recorders were used to collect data and tools were translated into local languages. A codebook was developed, and transcripts were coded in vivo using the computer software Atlas-ti version 7 before analysis. Ethical clearance was obtained from institutional review boards and informed consent was sought from all participants.ResultsFrom the study, most married people mentioned health workers as their main influence while adolescents reported their peers and friends. Religious leaders and mothers-in-law were reported to mainly discourage people from taking up modern contraceptive methods. The cultural value attached to having many children influenced the contraceptive use decision among people in rural settings. Other influences included a person’s experience and housing.ConclusionsHealth workers, religious leaders, and mothers determine the uptake of contraceptive services. The study recommends the consideration of the role of these influences in the design of FP program interventions as well as more involvement of health workers in sensitization of communities about contraceptive methods.

Community and Health Care Provider Perspectives on Barriers to and Enablers of Family Planning Use in Rural Sindh, Pakistan: Qualitative Exploratory Study.

Unmet need for family planning in Pakistan is high, with 17% of all married women wanting to avoid or delay pregnancy. However, they cannot owing to a lack of access to modern contraception and sociocultural hindrances. With the modern contraceptive prevalence rate stagnant at approximately 25% over the last 5 years, it is important to explore barriers and enablers to modern contraception uptake to reduce maternal and child mortality and improve reproductive health outcomes for young girls and women. A formative research approach was taken to explore community member and health care provider perspectives on access to and use of family planning methods in 2 rural districts of Sindh, Pakistan. The broader goal of this study was to provide evidence to design and implement a socioculturally appropriate family planning intervention within the existing service delivery platforms to increase modern contraceptive uptake in the context of rural Sindh. A qualitative exploratory design was used. Between October 2020 and December 2020, 11 focus group discussions and 11 in-depth interviews were conducted. Focus group discussions were held with men and women from the community, including adolescents, to build an understanding of community beliefs and concepts regarding modern contraceptive methods. In-depth interviews were conducted with health care workers and explored intersections between family planning and reproductive health service delivery at the facility and outreach levels. The findings revealed that limited financial autonomy, restricted women's mobility, discriminatory gender norms, and cultural practices left women with little opportunity for independent decision-making on the use of modern contraceptive methods. Furthermore, facility-level and supply-side barriers, including frequent stock-outs of modern contraceptives combined with a lack of capacity of health workers to provide quality family planning services and counseling, played an important role in demotivating women from seeking services. In addition, a lack of integration of family planning with maternal and child health service delivery at the health system level was emphasized as a major missed opportunity for contraceptive uptake. Several demand-side barriers to family planning uptake were also highlighted. These included husbands' or in-laws' disapproval, social stigma, and perceived fear of side effects regarding modern family planning method use. More importantly, a lack of adolescent-friendly reproductive health services and spaces for counseling was identified as a critical intervention area. This study provides qualitative evidence on issues related to the effectiveness of family planning interventions, specifically in the context of rural Sindh. The findings emphasize the need to design socioculturally appropriate and health system-relevant family planning interventions-the effectiveness of which can be improved through their integration with maternal and child health service delivery mechanisms, consistent service provision, and opportunities for the capacity building of the health care workforce. RR2-10.2196/35291.

Adapting Family Planning Service Delivery in Title X and School-Based Settings during COVID-19: Provider and Staff Experiences.

The COVID-19 pandemic introduced urgent and unique challenges to family planning providers and staff in ensuring continued access to high-quality services, particularly for groups who experience greater barriers to accessing services, such as women with systemically marginalized identities and adolescents and young adults (AYA). While research has documented key adaptations made to service delivery during the early phase of the pandemic, limited studies have used qualitative methods. This paper draws on qualitative interview data from family planning providers and staff in Title-X-funded clinics and school-based clinics-two settings that serve populations that experience greater barriers to accessing care-to (a) describe the adaptations made to service delivery during the first year of the pandemic and (b) explore provider and staff experiences and impressions implementing these adaptations. In-depth interviews were conducted with 75 providers and staff between February 2020 and February 2021. Verbatim transcripts were analyzed via inductive content analysis followed by thematic analysis. Four key themes were identified: (1) Title-X- and school-based staff made multiple, concurrent adaptations to continue family planning services; (2) providers embraced flexibility for patient-centered care; (3) school-based staff faced unique challenges to reaching and serving youth; and (4) COVID-19 created key opportunities for innovation. The findings suggest several lasting changes to family planning service delivery and provider mindsets at clinics serving populations hardest hit by the pandemic. Future studies should evaluate promising practices in family planning service delivery-including telehealth and streamlined administrative procedures-and explore how these are experienced by diverse patient populations, particularly AYA and those in areas where privacy or internet access are limited.

Exploring the effects of COVID-19 on family planning: results from a qualitative study in rural Uganda following COVID-19 lockdown

BackgroundThe COVID-19 pandemic has likely affected the already high unmet need for family planning in low- and middle-income countries. This qualitative study used Andersen’s Behavioral Model of Health Service Use as a theoretical framework to explore the possible ways in which the COVID-19 pandemic, including the impact of a 3-month government mandated lockdown, might affect family planning outcomes in rural Uganda. A secondary aim was to elicit recommendations to improve family planning service delivery in the context of COVID-19.MethodsBetween June and October 2020, we conducted four focus group discussions with men and women separately (N = 26) who had an unmet need for family planning, and 15 key-informant interviews with community leaders and family planning stakeholders. Data were analyzed using thematic analysis.ResultsWe identified a significant disruption to the delivery of family planning services due to COVID-19, with potential negative effects on contraceptive use and risk for unintended pregnancy. COVID-19 had a negative effect on individual enabling factors such as family income, affecting service access, and on community enabling factors, such as transportation barriers and the disruption of community-based family planning delivery through village health teams and mobile clinics. Participants felt COVID-19 lockdown restrictions exacerbated existing contextual predisposing factors related to poverty and gender inequity, such as intimate partner violence and power inequities that diminish women’s ability to refuse sex with their husband and their autonomy to use contraceptives. Recommendations to improve family planning service delivery in the context of COVID-19 centered on emergency preparedness, strengthening community health systems, and creating new ways to safely deliver contractive methods directly to communities during future COVID-19 lockdowns.ConclusionsThis study highlights the consequences of COVID-19 lockdown on family planning distribution, as well as the exacerbation of gender inequities that limit women’s autonomy in pregnancy prevention measures. To improve family planning service uptake in the context of COVID-19, there is a need to strengthen emergency preparedness and response, utilize community structures for contraceptive delivery, and address the underlying gender inequities that affect care seeking and service utilization.

Need for Standardized Measure of Modern Method Availability: Assessment of Indicators Using Health Facility Data from Three Country Contexts.

The concept of contraceptive method choice is complex and difficult to measure, usually requiring multiple metrics that represent the service environment, access, and acceptability. One of the most used measures for the family planning service delivery environment is method availability, or specifically, the contraceptive options that are available to clients at any given family planning service delivery point. Despite the importance of the measure, indicator definitions vary widely and are not standardized. We identified six versions of the method availability indicator and calculated each version using Service Provision Assessment data from three countries with varying family planning profiles, health service structures, and from different geographic areas: Bangladesh, the Democratic Republic of Congo, and Haiti. We compared method availability estimates by urban/rural location, facility type, and across country context. Our results showed a wide variability in method availability estimates depending on the indicator used. Generally, indicators requiring a particular mix of method types had lower estimates of method availability than indicators only requiring a minimum number of methods. Results are discussed and recommendations are made to standardize indicator language and guidance. We further recommend the standardization of an indicator with a minimum mix of method types to ensure that a variety of method preferences can be met.

Contraceptive use and fertility control in rural and urban communities of Lagos Nigeria.

It is predicted that the population of sub-Saharan Africa will be thrice its size by the end of the 21st century. Our study compared patterns, incentives and disincentives for the uptake of contraceptives in rural and urban communities of Lagos, Nigeria. This is a population-based cross-sectional study on 1445 women of reproductive ages 15-49 years using a cluster sampling technique and a pre-tested, interviewer-administered electronic questionnaire in 2020. Data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 26.0 and ethical approval was obtained for the study. About 32.4% of the respondents were rural dwellers and 67.6% were urban residents. The overall mean age was 31.7 ± 7.8 years. In terms of pattern, slightly over half (53.3%) of all respondents had ever used family planning (FP), including modern contraceptives and slightly less than a third (30.8%) currently use FP methods in both rural and urban communities, respectively. Predominant disincentives for non-use of FP include a desire to retain fertility, lack of further need, unbearable side effects and lack of spousal support. The odds of being an urban dweller currently using a method of contraceptive method is 4.169 times higher for earners above ₦60,000, which is twice the minimum wage compared to those without income (adjusted odd's ratio: 4.169, 95% confidence interval: 1.395-12.462). Sustained effort is required to improve contraceptive uptake, FP service delivery and demand satisfaction for modern contraceptives to enable the achievement of demographic dividends and gains.

What is the relationship between contraceptive services and knowledge of abortion availability and legality? Evidence from a national sample of women and facilities in Ethiopia.

In Ethiopia, abortions are legal for minors and for rape, incest, foetal impairment or maternal disability. Knowledge of abortion legality and availability is low, and little effort has been made to disseminate this information for fear of invoking anti-abortion sentiment; instead, systems rely on health providers as information gatekeepers. This study explores how exposure to and interaction with family planning service delivery environment, specifically (1) availability of contraceptive and facility-based abortion services within 5 km of one's residence and (2) contact with a health provider in the past 12 months, relate to women's knowledge of the legality of accessing abortion services and of where to access facility-based abortion services. We used data from a nationally representative sample of 8719 women in Ethiopia and a linked health facility survey of 799 health facilities. Our outcome of interest was a categorical variable indicating if a woman had (1) knowledge of at least one legal ground for abortion, (2) knowledge of where to access abortion services, (3) knowledge of both or (4) knowledge of neither. We conducted multilevel, multinomial logistic regressions, stratified by residence. Approximately 60% of women had no knowledge of either a legal ground for abortion or a place to access services. Women who visited a health provider or who were visited by a health worker in the past 12 months were significantly more likely to know about abortion legality and availability. There were no differences based on whether women lived within 5 km of a facility that offered contraception and abortion services. We find that health workers are likely valuable sources of information; however, progress to disseminate information may be slowed if it relies on uptake of services and limited outreach. Efforts to train providers on legality and availability are critical, as is additional research on knowledge dissemination pathways.

Evaluation of family planning service delivery in Gondar city public health facilities, Northwest Ethiopia: A cross-sectional study

Family planning program is low-cost and an effective way to lower maternalmortality by reducing the number of high-risk births. Despite the effectiveness of the program, availability of materials, equipment and trained healthcare providers were some of the challenges in sub-Saharan African countries including Ethiopia. Determining the implementation status and identifying gaps is the aim of this evaluation. A facility-based cross-sectional evaluation design with mixed method approach was employed. Quantitative data was collected through the exit interview of 477 clients from March 25-April 25, 2020. The evaluation focused on three dimensions: availability, compliance, and acceptability with multiple data sources. The quantitative data were entered in to Epi-data version 4.6 and exported to SPSS version 25 for analysis. Multivariable logistic regression was done to determine factors associated with client satisfaction. The qualitative data were transcribed, translated and analyzed by using thematic analysis. The evaluation finding was computed and compared with the preset criteria for the final judgment. The majority of the health care providers (69.8%) got family planning training in the past two years. Three health facilities (37.5%) had 24hrs electricity with backup generators whereas only 25% of the health facilities had functional piped water inside the service room. Only two (25%) health facilities had a separate room for family planning service and 37.5% of health facilities had national FP guidelines. The overall availability of required resources for family planning service at Gondar city public facilities were 62.1%. Only twenty one (26.3%) of health providers dressed based on dressing code of ethics and none of them had ID during our observation. The overall compliance level of health care providers during providing family planning services were 75.5%. About 53.9% of the clients were satisfied with family planning service provided at Gondar city public health facilities.-and-were significantly associated variables with client satisfaction. The overall implementation of family planning service in Gondar city public health facilities with the three evaluation dimensions were judged as fair based on pre-setting judgment matrix. It is better to improve the service through training of healthcare providers, distributed family planning guidelines to health facilities and shortening of waiting time for service.

Primary Health Care Management Effectiveness as a Driver of Family Planning Service Readiness: A Cross-Sectional Analysis in Central Mozambique.

The effectiveness of facility-level management is an important determinant of primary health care (PHC) reach and quality; however, the nature of the relationship between facility-level management and health system effectiveness lacks sufficient empirical grounding. We describe the association between management effectiveness and facility readiness to provide family planning services in central Mozambique. We linked data from the Ministry of Health's 2018 Service Availability and Readiness Assessment and a second 2018 health facility survey that included the World Bank's Service Delivery Indicators management module. Our analysis focused on 68 public sector PHC facilities in Manica, Sofala, Tete, and Zambézia provinces in which the 2 surveys overlapped. We used logistic quantile regression to model associations between management strength and family planning service readiness. Of the 68 facility managers, 47 (69.1%) were first-time managers and (18) 26.5% had received formal management training. Managers indicated that 63.6% of their time was spent on management responsibilities, 63.2% of their employees had received a performance review in the year preceding the survey, and 12.5% of employee incentives were linked to performance evaluations. Adjusting for facility type and distance to the provincial capital, facility management effectiveness, and urban location were significantly associated with higher levels of readiness for family planning service delivery. We found that a higher degree of management effectiveness is independently associated with an increased likelihood of improved family planning service readiness. Furthermore, we describe barriers to effective PHC service management, including managers lacking formal training and spending a significant amount of time on nonmanagerial duties. Strengthening management capacity and reinforcing management practices at the PHC level are needed to improve health system readiness and outputs, which is essential for achieving global Sustainable Development Goals and universal health coverage targets.

Integrated delivery of family planning and childhood immunisation services: A causal loop analysis of service responsiveness in Malawi

Evidence suggests that integrating family planning (FP) services with childhood immunisations can increase postpartum contraceptive use by providing timely contact with FP services during the year following childbirth. However, little is known about clients' experiences of FP services within this context. Systems thinking was applied to examine the responsiveness of FP services that were integrated with childhood immunisations in routine outreach clinics across two districts of Malawi. A causal loop analysis of qualitative data captured through 1) structured exit interviews with clients (n=146) and 2) semi-structured interviews with clients (n=23) and their FP providers (n=10) was carried out to explain the system dynamics influencing the responsiveness of integrated FP services. Through this analysis, six feedback loops were identified as having a balancing effect on service responsiveness. Importantly, the clinic's client load was found to drive the responsiveness experienced by clients in the studied context. Overall, the results suggest that efforts to enhance the responsiveness of integrated FP services in outreach clinics should focus on 1) enhancing the providers' ability to alter the client flow in response to fluctuations in the clinic's client load, and 2) ensuring that an appropriate buffer of FP supplies is available in clinics to enable clients to consistently receive their preferred contraceptive irrespective of surges in demand. This study represents the first attempt at modelling the responsiveness of integrated FP services and its findings can be used to inform the design and delivery of FP services that are integrated with childhood immunisations in different settings.

Integrated delivery of family planning and childhood immunization services: a qualitative study of factors influencing service responsiveness in Malawi.

Evidence from several countries in sub-Saharan Africa suggests that the integration of family planning (FP) with childhood immunization services can help reduce the unmet need for FP among postpartum women without undermining the uptake of immunizations. However, the quality and responsiveness of FP services that are integrated with childhood immunizations remain understudied. A qualitative study was conducted in two districts of Malawi, which examined the factors influencing the responsiveness of FP services that were integrated with childhood immunizations in monthly public outreach clinics. Semi-structured interviews with clients (n = 23) and FP providers (n = 10) and a clinic audit were carried out in six clinics. Hardware (material) and software (relational) factors influencing service responsiveness were identified through thematic and framework analyses of interview transcripts, and clinic characteristics were summarized from the audit data to contextualize the qualitative findings. Overall, 13 factors were found to influence service responsiveness in terms of the ease of access, choice of provider, environment, service continuity, confidentiality, communication, dignity and FP counselling afforded to clients. Among these factors, hardware deficiencies, including the absence of a dedicated building for the provision of FP services and the lack of FP commodities in clinics, were perceived to negatively affect service responsiveness. Crucially, the providers’ use of their agency to alter the delivery of services was found to mitigate the negative effects of some hardware deficits on the ease of access, choice of provider, environment and confidentiality experienced by clients. This study contributes to an emerging recognition that providers can offset the effect of hardware deficiencies when services are integrated if they are afforded sufficient flexibility to make independent decisions. Consideration of software elements in the design and delivery of FP services that are integrated with childhood immunizations is therefore critical to optimize the responsiveness of these services.

Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!

Family planning (FP) is a human right, and ensuring women’s access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country’s overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public–private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis. The persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery challenge our progress in Ethiopia. The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. Current policies and services must adapt, maintain, and build upon these gains and focus on targeted actions in areas identified for improvement. We must sustain the hard-fought gains of the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond—Leaving No One Behind.

Integrated delivery of family planning and childhood immunisation services: a mixed methods assessment of service responsiveness

BackgroundPostpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients’ experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation.MethodsThe responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson’s chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics.ResultsResponsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients’ exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers’ individual behaviours were found to be critical to service responsiveness.ConclusionsThis study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.

Survival time to Implanon discontinuation and its predictors among a cohort of Implanon users who enrolled in public hospitals of southern Ethiopia, 2021: a retrospective cohort study

BackgroundPieces of evidence strongly indicate that providing high-quality family planning services is accompanied by an increase in contraceptive uptake and a decrease in contraception discontinuation. Contraceptive, especially Implanon discontinuation is a global issue that could be linked to a summary outcome indicator of poor family planning service quality. Although Implanon is becoming more popular among Ethiopian contraceptive users, little is known regarding the survival and predictors of discontinuation. The study aimed at exploring the survival and predictors of Implanon discontinuation among women enrolled in family planning units of Public hospitals in southern Ethiopia, 2021.MethodsA hospital-based retrospective cohort study was conducted among Implanon users who enrolled in family planning units of Public Hospitals. Five years of medical records, from January 1, 2016, to December 30, 2020, were reviewed. A total of 502 women were selected by using a random sampling technique. A standardized abstraction tool was used to collect data from medical records and registration books. The data were entered into Epidata Version 3.1 and then exported to STATA 14 for analysis. The median was calculated in the case of survival time. Across covariates, the Kaplan Meier survival curve was used to estimate time to Implanon discontinuation. To identify statistically significant predictors of Implanon discontinuation, a multivariable Cox proportional hazard model was fitted.ResultsThe incidence rate of Implanon discontinuation was 1.87(95% CI = 1.63, 2.15) per 100 person-months of observation. The overall estimated survival probability at the end of 24 and 36 months was 67.4% (95%CI, 62.5, 71.8) and 25.9% (95%CI, 18.4, 34.1) months respectively. Residence [AHR = 1.50; 95%CI: 1.09, 2.08], parity [AHR = 2.02; 95%CI: 1.65, 3.67], pre-insertion counselling [AHR = 2.41; 95%CI: 1.72, 3.70], experiencing heavy vaginal bleeding [AHR = 3.91; 95%CI: 2.67, 5.32], post-insertion follow up [AHR = 3.15; 95%CI:2.11, 4.75] were identified as a significant predictors of Implanon discontinuation.ConclusionThe risk Implanon of discontinuation was high, especially at 24 and 36 months. In family planning service delivery points, health care providers should pay special attention to clients who live in rural areas and do not have children. In addition, health care providers should provide pre-insertion counseling and post-insertion follow-up that focus on potential side effects. Finally, family planning units need to engage in early side effect management and reassurance to mitigate discontinuation.

Absenteeism among family planning providers: a mixed-methods study in western Kenya.

Public-sector healthcare providers are on the frontline of family planning service delivery in low- and middle-income countries like Kenya, yet research suggests public-sector providers are frequently absent. The current prevalence of absenteeism in Western Kenya, as well as the impact on family planning clients, is unknown. The objective of this paper is to quantify the prevalence of public-sector healthcare provider absenteeism in this region of Kenya, to describe the potential impact on family planning uptake and to source locally grounded solutions to provider absenteeism. We used multiple data collection methods including unannounced visits to a random sample of 60 public-sector healthcare facilities in Western Kenya, focus group discussions with current and former family planning users, key informant interviews (KIIs) with senior staff from healthcare facilities and both governmental and non-governmental organizations and journey mapping activities with current family planning providers and clients. We found healthcare providers were absent in nearly 60% of unannounced visits and, among those present, 19% were not working at the time of the visit. In 20% of unannounced visits, the facility had no providers present. Provider absenteeism took many forms including providers arriving late to work, taking an extended lunch break, not returning from lunch or being absent for the entire day. While 56% of provider absences resulted from sanctioned activities such as planned vacation, sick leave or off-site work responsibilities, nearly half of the absences were unsanctioned, meaning providers were reportedly running personal errands, intending to arrive later or no one at the facility could explain the absence. Key informants and focus group participants reported high provider absence is a substantial barrier to contraceptive use, but solutions for resolving this problem remain elusive. Identification and rigorous evaluation of interventions designed to redress provider absenteeism are needed.

Impact of family planning logistic management models on uptake of contraceptives in selected states in Nigeria: A comparative retrospective analysis

Background: Use of contraceptives improves individual and national health outcomes and indices as it prevents maternal mortality and morbidity, child mortality, incidence of sexually transmitted infections and retains adolescents and young girls in school with improvement in the economic earning power. Contraceptive Logistics is the supply of contraceptives in the right quantity and quality at the right place at the right time for the right cost to the right people. The Contraceptive Logistics Management System in Nigeria stipulates that to ensure uninterrupted product availability and minimal stock out, Family Planning Service Delivery Points (SDPs) are to be re-supplied on a bi-monthly basis to bring their stock level to a maximum of 4 months of stock at any given time. Method: A retrospective analysis of the impacts of the three logistic models operational in six southern states in Nigeria under the auspice of UNFPA funded family planning logistics supply chain. Three outcomes of interest used to assess the impacts were stock out rates, gaps in supply and proportion of new users of contraceptives. The three models of family planning logistics reviewed were direct government last mile distribution with external funding, direct government last mile distribution without external funding and a third party private logistic company last mile distribution Result: The stock out rates for the direct government logistics with external funding was 6-20%, the direct government logistics last mile distribution (LMD) without external funding had a stock out rate of 20-58% and the private logistic company last mile distribution had a stock out rate of 10-30%. In terms of the gap in supply, the supply gap with the direct government LMD with external funding model was 48%, while the direct government LMD with no external funding model had a supply gap of 73% and the private company LMD logistics model had a low supply gap of 28%. The proportion of FP users who were new users was 19% in the direct government LMD with external funding, 8% in direct government LMD without external funding, and 16% in private logistic company LMD. Discussion: Direct government last mile distribution (LMD) with external funding reached the highest number of new FP users followed by private logistic company LMD and therefore contributed the greatest to the reduction of unmet need in family planning and increasing the contraceptive prevalence rates. The highest stock out rate of contraceptives was associated with direct government LMD without external funding and the least stock out rate was associated with same direct government LMD but with external funding. The greatest gap in supply of contraceptives was seen with direct government LMD without external funding followed by direct government LMD with external funding. Private company LMD had the least supply gap in contraceptives.

\u201c\u2026the availability of contraceptives is everywhere.\u201d: coordinated and integrated public family planning service delivery in Rwanda

BackgroundContraceptive use in Rwanda tripled since 2005. This study aims to understand the role of coordinated and integrated public family planning service delivery in achieving this increase in contraceptive use in Rwanda.MethodsThis qualitative study in 2018 included eight focus group discussions with family planning providers and 32 in-depth interviews with experienced family planning users.ResultsResults indicate a well-coordinated public family planning service delivery system with community health workers and nurses filling different and complementary roles in meeting family planning client needs at the local level. In addition, integration of family planning into other maternal and child health services is the norm.ConclusionsThe coordination and integration of family planning across both providers and services may help explain the rapid increase in Rwanda’s contraceptive use and has potential applications for enhancing family planning service delivery in other settings.