Family Planning Uptake Research Articles

Why does uptake of family planning services remain sub-optimal among Nigerian women? A systematic review of challenges and implications for policy

BackgroundOver the years, family planning uptake in Nigeria has remained low and this is as a result of the various challenges and barriers faced by women. The aim of this study was to systematically review studies on family planning services undertaken in Nigeria in order to understand the challenges to uptake of the services and the policy implications.MethodsA PubMed search was performed in June 2020 and studies that investigated challenges of family planning uptake in Nigeria published in English between 2006 and 2020 were sought. A combination of the search terms family planning, contraceptives, challenges, barriers, Nigeria was used. Review articles, case reports, and case studies were excluded. Studies that did not report barriers or challenges to family planning or contraceptives were excluded.ResultTwenty seven studies carried out in Nigeria which provided sufficient information were identified and used for this review. The Uptake of family planning recorded in the reviewed studies ranges from 10.3 to 66.8%. Challenges that are client related include education, desire for more children, uncertainty about its need, partner disapproval, previous side effects, religious beliefs, culture disapproval, age, marital status, and wealth index, residence, ignorance, embarrassment, domestic violence and sexual factor. Health service related factors identified include cost, difficulty accessing services, and procurement difficulties. Recommendations for family planning propram and policy include targeting of health service delivery for improvement, focus on gender issues and male involvement, involvement of religious leaders, targeting of younger women for better education and counseling, and continuous awareness creation and counseling among others.ConclusionThe review has shown that uptake of family planning remains low in Nigeria and challenges abound. We recommend that strategies that are multi-sectoral should be applied to address the multi-pronged challenges facing uptake of family planning services.

A Short Message Service (SMS) increases postpartum care-seeking behavior and uptake of family planning of mothers in peri-urban public facilities in Kenya.

BackgroundIt is estimated that one third of maternal deaths in Kenya in 2014 could have been prevented by more timely care-seeking. Mobile health interventions are increasingly being recognized as tools for the delivery of health education and promotion. Many maternal deaths occur in the first few weeks after delivery and mothers who are given adequate care in the postpartum period have better health outcomes. Kiambu County, Kenya has a high level of literacy and phone ownership amongst mothers delivering in public hospitals and was chosen as a site for a postpartum short message service intervention.MethodsWomen were recruited after delivery and randomized to receive a package of mobile messages or standard of care only. Messages covered danger signs, general postpartum topics, and family planning. Endline phone surveys were conducted at 8 weeks postpartum to assess knowledge, care seeking behavior and family planning uptake. Analysis was conducted using Stata and is presented in odds ratios.ResultsWomen who received the danger sign messages were 1.6 times more likely to be able to list at least 1 danger sign and 3.51 times more likely to seek treatment if they experienced postpartum danger signs. There was no significant difference in routine postpartum care seeking or care seeking behaviors concerning newborns. Women who received family planning messages were 1.85 times more likely to uptake family planning services compared to controls and 2.1 times more likely to choose a long-acting method.ConclusionsSimple, low-cost mobile interventions can support women in the early postpartum period when the information is targeted to particular points in the postpartum continuum. Additional research is needed to understand the interplay between healthcare providers and mobile health interventions. Health policy makers should consider direct mobile interventions for women as an option for supporting positive maternal health outcomes in certain populations.

Sociocultural and Institutional Constraints to Family Planning Uptake Among Migrant Female Head Porters in Madina, a Suburb of Accra, Ghana

There are many impediments to family planning uptake by migrant women, which are likely to hinder their right to decide and use contraception. In this study, the authors investigated migrant women’s family planning practices. The researchers conducted 22 qualitative interviews with migrant female head porters in a suburban community in Ghana. Our analysis showed that a combination of social and cultural barriers impede effective family planning uptake by migrant female head porters. Further analysis revealed institutional challenges as constraining in access to and utilization of family planning services by migrant female head porters. Based on our analysis, we conclude that migrant female head porters face many barriers to family planning uptake and thus recommend that the government of Ghana (Ministry of Health), policy makers, and other stakeholders take measures to ensure universal access to sexual reproductive health services and reproductive rights.

Perception, pattern of use, partner support and determinants of uptake of family planning methods among women in rural communities in Southeast Nigeria

BackgroundFamily planning is a cost-effective strategy for achieving population development. Family planning uptake is low in sub-Saharan Africa, including Nigeria. We assessed the perception, pattern of use, partner support and determinants of uptake of family planning methods among married women of reproductive age in rural communities of Ebonyi state.MethodsThis is part of a baseline report of a quasi-experimental study. A total of 484 married women of reproductive age were recruited using multistage sampling method. Four focus group discussions (men and women) and pre-tested semi-structured interviewer-administered questionnaires were used to collect information from the participants. Data were analysed using Statistical Package for Social Sciences (SPSS) version 20 software and thematic analysis. Chi-square test and logistic regression were carried out at 5% significance level.ResultsOnly 26.2% of respondents were currently using any method of family planning. The most commonly used method was the natural method (57%). Amongst those who reported using artificial methods, 32.7% used condoms, 27.3% used implant while 23.64 and 16.4% used injectables and pills respectively. Predictors of current use of any family planning method were: older age (AOR = 1.7, 95%CI = 1.01–3.00), having more than five children (AOR = 1.7, 95%CI = 1.05–2.83), minimum of secondary level of education for respondent (AOR = 3.3, CI = 1.60–6.96) and their husband/partner (AOR = 2.0, 95%CI = 1.05–3.92). Qualitative findings showed that only few families were using a method of family planning and those who did not practice family planning perceived it to interfere with God’s plan for fruitfulness and to be counter-productive to household income due to decreased manpower for agricultural activities. Poor partner involvement and support for family planning was also cited as a deterrent by both male and female participants.ConclusionsPerception and use of family planning methods is poor in rural communities of Ebonyi state. Improving uptake of family planning methods in these rural communities will require proper demographic targeting as well as debunking fatalistic views, and cultural and religious myths around family planning.

Feasibility testing of a community dialogue approach for promoting the uptake of family planning and contraceptive services in Zambia

BackgroundCommunity dialogues have been used in participatory approaches in various health prevention and awareness programs, including family planning interventions, to increase understanding and alignment of particular issues from different peoples’ perspectives. The main objective of this paper is to document the feasibility of a community dialogue approach, which aimed to promote dialogue between healthcare providers and community members. The feasibility testing was part of formative-phase research needed to design an intervention, with the ultimate goal of increasing the uptake of family planning and contraception. The community dialogue intervention generated discussions on key approaches to improve family planning and contraception provision and uptake.MethodsKey stages of the community dialogue were undertaken, with representation from healthcare providers and community members. Participants included frontline and managerial health care providers, community health workers, family planning and contraception users, the youth, other stakeholders from the education sector, and civil society. How the dialogue was implemented (operational feasibility) as well as the cultural feasibility of the community dialogue content was evaluated through participant observations during the dialogue, using a standardised feasibility testing tick-list, and through focus group discussions with the stakeholders who participated in the community dialogue.ResultsOverall, 21 of the 30 invited participants attended the meeting- 70% attendance. The approach facilitated discussions on how quality care could be achieved in family planning and contraception provision, guided by the ground rules that were agreed upon by the different stakeholders. A need for more time for the discussion was noted. Participants also noted the need for more balanced representation from adolescents as well as other family planning stakeholders, such as community members, especially in comparison to healthcare providers. Some participants were not comfortable with the language used. Young people felt older participants used complicated terminologies while community members felt the health care providers outnumbered them, in terms of representation.ConclusionGenerally, the community dialogue was well received by the community members and the healthcare providers, as was observed from the sentiments expressed by both categories. Some key considerations for refining the approach included soliciting maximum participation from otherwise marginalized groups like the youth would provide stronger representation.

Facilitating community participation in family planning and contraceptive services provision and uptake: community and health provider perspectives

BackgroundAlthough community participation has been identified as being important for improved and sustained health outcomes, designing and successfully implementing it in large scale public health programmes, including family planning and contraceptive (FP/C) service provision, remains challenging. Zambian participants in a multi-country project (the UPTAKE project) took part in the development of an intervention involving community and healthcare provider participation in FP/C services provision and uptake. This study reports key thematic areas identified by the study participants as critical to facilitating community participation in this intervention.MethodsThis was an exploratory qualitative research study, conducted in Kabwe District, Central Province, in 2017. Twelve focus group discussions were conducted with community members (n = 114), two with healthcare providers (n = 19), and ten in-depth interviews with key community and health sector stakeholders. Data were analyzed using a thematic analysis approach.ResultsFour thematic categories were identified by the participants as critical to facilitating community participation in FP/C services. Firstly, accountability in the recruitment of community participants and incorporation of community feedback in FP/C.programming. Secondly, engagement of existing community resources and structures in FP/C services provision. Thirdly, building trust in FP/C methods/services through credible community-based distributors and promotion of appropriate FP/C methods/services. Fourthly, promoting strategies that address structural failures, such as the feminisation of FP/C services and the lack FP/C services that are responsive to adolescent needs.ConclusionsUnderstanding and considering community members’ and healthcare providers’ views regarding contextualized and locally relevant participatory approaches, facilitators and challenges to participation, could improve the design, implementation and success of participatory public health programmes, including FP/C.

\u201cChildren are a blessing from God\u201d \u2013 a qualitative study exploring the socio-cultural factors influencing contraceptive use in two Muslim communities in Kenya

BackgroundFamily planning (FP) is one of the high impact public health interventions with huge potential to enhance the health and wellbeing of women and children. Yet, despite the steady progress made towards expanding access to family planning, major disparities across different regions exist in Kenya. This study explored the socio cultural factors influencing FP use among two Muslim communities in Kenya.MethodsA qualitative study involving Focus Group Discussions (FGDs) and In-depth Interviews (IDIs) was conducted (from July to October 2018) in two predominant Muslim communities of Lamu and Wajir counties. Open ended questions explore key thematic areas around knowledge, attitudes and understanding of contraception, perceived FP barriers, and decision making for contraceptives, views on Islam and contraception, and fertility preference. All interviews were conducted in the local language, recorded, transcribed verbatim and translated into English. Data was analyzed using thematic content analyses.ResultsAlthough Islam is the predominant religion the two communities, perceptions and belief around FP use were varied. There were differing interpretations of Islamic teaching and counter arguments on whether or not Islam allows FP use. This, in addition to desire for a large family, polygamy, high child mortality and a cultural preference for boys had a negative impact on FP use. Similarly, inability of women to make decisions on their reproductive health was a factor influencing uptake of FP.ConclusionMisinterpretation of Islamic teaching on contraception likely influences uptake of family planning. Cultural beliefs and lack of women’s decision power on fertility preferences were a key inhibitor to FP use. Countering the negative notions of FP use requires active engagement of religious leaders and Muslim scholars who are in position of power and influence at community level.

Evaluation of mainstreaming youth-friendly health in private clinics in Malawi

BackgroundHigh fertility rates and low modern contraceptive use put African youth and adolescents at high risk for health complications, including maternal mortality. Mainstreaming youth-friendly health services (YFHS) into existing services is one approach to improve access to reproductive health services for youth and adolescents. The objective of the evaluation was to assess the effects of a Population Services International (PSI)-sponsored YFHS training package on voluntary uptake of family planning among youth and perceptions of service quality by youth and trained healthcare providers in Malawi.MethodsIn 2018, a mixed-methods convergent parallel design was used to assess relevant monitoring and evaluation documents and service statistics from PSI Malawi and qualitative data on perceptions of service quality from Malawian youth and healthcare providers. The data were assessed through separate descriptive and thematic analysis and integrated to generate conclusions.ResultsResults show that the number of family planning clients ages 15–24 increased from 72 to 2278 per quarter during the implementation of the YFHS training packages, however, positive trends in client numbers were not sustained after youth outreach activities ended. Focus group discussions with 70 youth and adolescents indicated that clinics were perceived as providing high-quality services to youth. The main barriers to accessing the services were cost and embarrassment. Interviews with ten healthcare providers indicated that many made efforts to improve clinic accessibility and understood the barrier of cost and importance of outreach to youth and the broader community.ConclusionsThe findings support research showing positive effects of mainstreaming YFHS when training for healthcare staff is combined with additional YFHS programming components. Furthermore, the findings provide evidence that provider training alone, though beneficial to perceived service quality, is not sufficient to sustain increases in the number of adolescent and youth family planning clients.

Evaluation of a pilot program for task sharing short and long-acting contraceptive methods in Burkina Faso

Background: The Family Health Directorate of the Ministry of Health and Marie Stopes Burkina Faso, with implementing partners, Association Burkinabè pour le Bien-être Familial and Equilibres & Populations collaboratively conducted a pilot project in Burkina Faso focused on “increasing access to family planning (FP) services through task-sharing short- and long-acting family planning methods to primary care cadres.” Four cadres of providers provided intrauterine devices (IUDs) and implants, while community health workers (CHWs) provided pills and subcutaneous injectables. FHI 360 and the Institut Supérieur des Sciences de la Population evaluated the project’s impact on method uptake, client satisfaction, safety, acceptability and the feasibility of task sharing. Methods: The evaluation employed FP service statistics on new users and conducted 425 client exit interviews and 27 in-depth interviews . New FP clients, community representatives, MoH officials, and pilot project-trained FP providers from Dandé and Tougan districts participated in these interviews. Results: Providers, community representatives and government officials all spoke favorably of the pilot project and considered it a boon to women and the communities in which they lived. FP clients were satisfied with their methods and the services they received from their respective providers, and they reported no safety concerns. However, service statistics did not show a clear and steady increase in method uptake for the four methods beyond spikes coinciding with pre-existing free contraceptive weeks. Conclusions: A scale-up plan for 2020-2022 is in place and will purposefully implement sensitization and demand generation activities to improve FP uptake beyond free contraceptive weeks.

Barriers to the uptake of modern family planning methods among female youth of Temeke District in Dar es Salaam, Tanzania: A qualitative study

ObjectivesDespite the accessibility of modern family planning (FP) methods, unwanted pregnancies remains a serious problem in Tanzania. This study aimed to identify the barriers to the uptake of modern FP methods among female youth reached by the Chaguo la Maisha project in Temeke District, Tanzania. Study designQualitative study conducted in March 2017 involving 15 female youths aged 18–24 years. Main outcome measuresPurposive sampling was used to select study participants and sampling followed the principle of data saturation. The study participants were those who received contraceptive counseling from community health mobilizers and agreed to visit a nearby health facility for FP services but did not go for the services. A semi-structured interview guide, translated into Kiswahili language was used. Data were transcribed; analyzed following qualitative content analysis. Major categories and subcategories that hindered visitations were identified. ResultsThree categories and their subcategories were identified as hindering FP method uptake. (1) individual perception factors: (a) myths and misconceptions, (b) fear of side effects, (c) fear of the possibility of being pregnant at the time of FP counseling; (2) community perception factors: discouragement from an intimate partner and closest friends; and (3) health facility system factors: unavailability of the preferred method and absence of the trained personnel for the FP method. ConclusionsThe main barriers to FP uptake were myths and misconceptions, and fear of side effects. The intimate partner or closest friends were significant decision influencers on contraceptive use, implying that FP campaigns should focus beyond the individual level.

Level of male involvement in selected maternal health interventions involving nursing mothers in Benin City, Edo State, Nigeria

Nigeria contributes an estimated 19% of global pregnancy related mortalities. The involvement of men in maternal health interventions has immense implications for the uptake and thereby success of such interventions. This study assessed level of male involvement in selected maternal health interventions involving nursing mothers in Benin City, Edo State with a view to providing information to improve the implementation and success of these interventions. A descriptive facility based cross-sectional study design was carried out among two hundred and twenty nursing mothers attending selected immunization clinics in a health facility in Benin City, Edo State. Data were collected using pretested structured questionnaires and analyzed using IBM SPSS version 21.0 statistical software with statistical significance set at P<0.050. The mean (SD) age of male partners of nursing mothers studied was 38.1 (6.4) years. In relation to selected maternal interventions 205 (93.2%) registered for antenatal care (ANC), 159 (72.3%) attended postnatal care (PNC) while family planning uptake was 30 (13.6%). Furthermore, in relation to level of male involvement, 150 (68.2%) male partners paid for ANC registration, 143 (65.0%) accompanied spouse to delivery, 205 (93.2%) paid for delivery, 14 (8.8%) accompanied wife for PNC and 57 (34.5%) supported spouse uptake of family planning. The overall level of male involvement was good 113 (51.4%) among nursing mothers. This study identified that male involvement in selected maternal health interventions was good, in relation to male performance the highest being payment for delivery and least being postnatal care attendance. There is need to sustain and improve on the level of male involvement in relation to maternal health interventions to ensure better maternal and child health outcome in the study population.

Design and pilot testing of a church-based intervention to address interpersonal and intrapersonal barriers to uptake of family planning in rural Tanzania: a qualitative implementation study

BackgroundUse of family planning (FP) saves the lives of mothers and children, and contributes to better economic outcomes for households and empowerment for women. In Tanzania, the overall unmet need...

A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia

Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.

Factors associated with modern family planning use among women living with HIV who attended care and treatment clinics in Jigjiga town, Eastern Ethiopia.

Background:Family planning helps to reduce the number of high-risk births and prevent unplanned pregnancies and mother-to-child transmission of HIV. The main purpose of this study was to determine the usage of family planning and its associated factors among women living with HIV who attended care and treatment clinics.Methods:This was a health facility–based cross-sectional study conducted among 332 sexually active reproductive-age women living with HIV who visited care and treatment clinics from 15 April and 15 June 2017. We used a systematic sampling technique for sample selection. The data were collected using pretested and structured questionnaires through face-to-face interviews. Seriously ill women living with HIV who were unable to respond to the questionnaire and refused to participate were excluded from this study. Logistic regression was fitted, and an odds ratio with a 95% confidence interval with a p value less than 0.05 was used to identify factors associated with modern family planning use.Result:The study revealed that the overall use of the modern family planning method was 56.3%, and the most common method used was injectable (37.4%) followed by implants (28.9%). About 19% of the users reported dual contraceptive use. About 58% got family planning from antiretroviral therapy clinics. Almost all the women (97.6%) had heard of seven modern family planning methods. Desire to have another child was the most common (79.7%) reason for not using family planning. Women who attended primary/secondary education (adjusted odds ratio: 2.61; 95% confidence interval: 1.29–5.28], who had no future fertility desire (adjusted odds ratio: 2.94; 95% confidence interval: 1.51–5.73), who had discussed family planning with their husband (adjusted odds ratio: 2.06; 95% confidence interval: 1.04–4.10), and who were counseled by the antiretroviral therapy provider about family planning (adjusted odds ratio: 4.53; 95% confidence interval: 1.70–12.06) were more likely to use family planning methods than their counterparts.Conclusion:The results of this study revealed that the use of modern family planning was low. There is a high frequency of implant usage, fear of mother-to-child transmission as a motivator for family planning usage, and low dual method usage. Hence, improving women’s education, involving husbands, and consistent family planning counseling by antiretroviral therapy providers are promising strategies to improve the uptake of modern family planning by women living with HIV.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal

Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Reported evidence on the effectiveness of mass media interventions in increasing knowledge and use of family planning in low and middle-income countries: a systematic mixed methods review.

BackgroundAn estimated 200 million women and girls in low and middle-income countries (LMICs) wish to delay, space or avoid becoming pregnant, yet are not using contraceptives. This study seeks to investigate the effectiveness of mass media interventions for increasing knowledge and use of contraceptives, and to identify barriers to program implementation.MethodsUsing a mixed-methods systematic approach, we searched five electronic databases using pre-determined search strategies and hand-searching of articles of any study design published from 1994 to 2017 of mass media interventions for family planning education. Two reviewers independently applied clearly defined eligibility criteria to the search results, quality appraisal, data extraction from published reports, and data analysis (using meta-analysis and thematic analysis) following PRISMA guidelines.ResultsWe identified 59 eligible studies. Although the majority of studies suggest a positive association between media interventions and family planning outcomes, the pooled results are still consistent with possibly null intervention effects. The reported prevalence ratios (PR) for media interventions association with increased contraceptive knowledge range from 0.97 to 1.41, while the PRs for contraceptive use range from 0.54 to 3.23. The qualitative analysis indicates that there are barriers to contraceptive uptake at the level of individual knowledge (including demographic factors and preconceived notions), access (including issues relating to mobility and financing), and programming (including lack of participatory approaches).ConclusionsThere is a need for rigorous impact evaluation, including randomised controlled trials, of mass media interventions on knowledge and uptake of family planning in LMIC settings. Interventions should be better tailored to cultural and socio-demographic characteristics of the target populations, while access to resources should continue to remain a priority and be improved, where possible.

KNOWLEDGE, ATTITUDE, AND PRACTICE LEVEL OF FAMILY PLANNING SERVICE RECIPIENTS IN THE HEALTH DISTRICT OF PETALING, SELANGOR

Background: Family planning (FP) is important to ensure the wellbeing of mothers and children. There are various facilitators and barriers towards a successful FP program. In the health district of Petaling (PKD Petaling), the uptake of FP is not optimum. However, local data are scarce to pinpoint the reasons. This study aims to assess the knowledge, attitude, and practice (KAP) level among the potential FP recipients and its associated factors. Materials and Methods: A cross-sectional study using self-administered questionnaires was conducted at six health clinics in PKD Petaling from May-July 2017. Descriptive analysis with chi-square and logistic regression analysis were conducted to identify associated factors. Result: Majority of the 360 respondents were Malays (75.3%) and married (91.9%). The overall KAP was 80.3%, 71.9%, and 46.7%. OCP and condom were the two most recognised FP methods whereas OCP and Depo Provera were the most commonly used. Education level was associated with a good knowledge and positive attitude towards FP. The predictors of current FP usage included older age, having 4 or more children, good knowledge and attitude about FP. Conclusion: An effective FP programme require the identification and understanding of the various factors associated with the KAP level of FP to formulate appropriate improvement strategies. Based on the results, fear of side effects and husband’s opposition were the most prominent reasons for not using contraception. Dissemination of accurate information, inclusion of husband in FP decision-making, continuous staff training to improve the counselling effectiveness are needed to improve the uptake of FP in PKD Petaling. Keywords: Family planning, contraception, KAP, Malaysia, service recipient

Scaling Up a Strengthened Youth-Friendly Service Delivery Model to Include Long-Acting Reversible Contraceptives in Ethiopia: A Mixed Methods Retrospective Assessment.

Background: Donor funded projects are small scale and time limited, with gains that soon dissipate when donor funds end. This paper presents findings that sought to understand successes, challenges and barriers that influence the scaling up and sustainability of a tested, strengthened youth-friendly service (YFS) delivery model providing an expanded contraceptive method choice in one location – the YFS unit – with additional units in Amhara and Tigray, Ethiopia. Methods: This retrospective mixed methods study included interviews with key informants (KIs) (qualitative arm) and analysis of family planning (FP) uptake statistics extracted from the sampled health facilities (quantitative arm). A multistage convenience purposive sampling technique was adopted to randomly select 8 health facilities aligned with respective woredas, zones and regional health bureaus (RHBs). A semi-structured interview guide soliciting information on 6 scaling-up elements (stakeholder engagement, roles and responsibility, policy environment, financial resources, quality of voluntary FP services and data availability and use) guided the interviews. Fifty-six KI interviews were conducted with policy-makers, program managers, and clinic staff. Recurring themes were triangulated across administrative levels and implementing partners. Relevant FP data (acceptor status, age and method uptake) were extracted from the 8 sampled health facilities for a thirteen-month period. Qualitative findings triangulated with FP service statistics assessed the influence of the 6 scaling-up elements with trends in long-acting reversible contraceptive (LARC) uptake before and after training. Results: Our findings depict that respondents were knowledgeable and supportive of an expanded method mix. Statistically significant increases in long-acting contraceptive uptake were noted at 2 of the 8 health centers. Fidelity to the tested model was operationally constrained; respondents frequently mentioned trained staff absences and turnover as obstacles in offering quality FP services. Conclusion: Despite conducive policy environment, supportive stakeholders, favorable environment, and financial support for trainings, statistically significant increases in LARC uptake occurred at only 2 of the 8 health centers; indicating the influence of weak health systems, poor quality of voluntary FP services and a ceiling effect. Scale-up processes must consider potential bottlenecks of weak health systems and availability of financial resources by addressing these as crucial elements in any systematic scale-up framework.

Operationalizing Integrated Immunization and Family Planning Services in Rural Liberia: Lessons Learned From Evaluating Service Quality and Utilization.

Integration of family planning and immunization services provides an opportunity to meet women's need for postpartum family planning and infants' vaccination needs through client-centered care, while reducing financial and opportunity costs for families. The United States Agency for International Development's Maternal and Child Survival Program (MCSP) supported the Liberia Ministry of Health to scale up integrated family planning and immunization services as part of a broader service delivery and health systems recovery program after the Ebola epidemic. We conducted a mixed-methods program evaluation in 22 health facilities in Grand Bassa and Lofa counties. Family planning uptake and immunization dropout rates at project sites were compared to rates at 18 matched health facilities in the same counties. We conducted 34 focus group discussions with community members and 43 key informant interviews with health care providers and managers to explore quality of care and contextual factors affecting provision and use of integrated services including postpartum family planning. From November 2016 to July 2017, 1,066 women accepted referrals from immunization to family planning counseling (10% of all vaccinator-caregiver interactions); the majority of women who were referred (75%) accepted a family planning method the same day. Trends indicated slightly higher family planning uptake in intervention over nonintervention facilities, but differences were not statistically significant. Pentavalent vaccine dropout rates did not increase in intervention compared to nonintervention facilities indicating no negative impact on utilization of immunization services. Clients and providers expressed that the integrated services reduced costs and time for the clients, educated mothers about postpartum family planning, and ensured infants were completing their vaccinations. Providers expressed the need for increased human resources to meet the elevated demand for family planning counseling services and additional focus on community-level social and behavior change activities. Both groups emphasized that social stigma and norms about postpartum sexual abstinence prevented many women from seeking postpartum family planning services. Although scaling up integrated family planning-immunization services may be programmatically feasible and acceptable to clients and providers, the intervention's success and ability to understand and quantify impact are driven by the effect of contextual factors and fidelity to the intervention approach. Contextual factors need to be understood before implementation, measured during implementation, and addressed throughout implementation to maximize the approach's impact on service utilization and health outcomes.

A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda.

Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention. Methods: We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions. Results: The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled. Conclusions: A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.