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The effectiveness of community based distribution of injectable contraceptives using community health extension workers in Gombe State, Northern Nigeria

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This study reports on findings of a pilot of community-based distribution (CBD) of injectable contraceptives in two local government areas (LGAs) of Gombe State, Nigeria. From August 2009 to January 2010, the project enrolled, trained and equipped community health extension workers (CHEWs) to distribute condoms, oral and injectable contraceptives in communities. The project mobilized communities and stakeholders to promote Family Planning (FP) services in the selected communities. Using anonymised unlinked routine service data, the mean couple years of protection (CYP) achieved through CBD was compared to that achieved in FP clinics. The CBD mean CYP for injectables- depo medroxy-progesterone acetate (DMPA) and norethisterone enantate was higher (27.72 & 18.16 respectively) than the facility CYP (7.21 & 5.08 respectively) (p < 0.05) with no injection related complications. The CBD's mean CYP for all methods was also found to be four times higher (11.65) than that generated in health facilities (2.86) (p < 0.05). This suggests that the CBD of injectable contraceptives is feasible and effective, even in a setting like northern Nigeria that has sensitivities about FP.
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Effectiveness of CBD of Injectables in Nigeria
80
ORIGINAL RESEARCH ARTICLE
The effectiveness of Community Based Distribution of Injectable
Contraceptives using Community Health Extension Workers in
Gombe State, Northern Nigeria
1
FHI360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Nigeria;
3
Association for Reproductive and Family Health (ARFH);
4
Department of Family Medicine, Medical University of Southern Africa
*For correspondence: mabass@sidhas.org; Tel: 09-461555
Abstract
This study reports on findings of a pilot of community-based distribution (CBD) of injectable contraceptives in two local
government areas (LGAs) of Gombe State, Nigeria. From August 2009 to January 2010, the project enrolled, trained and
equipped community health extension workers (CHEWs) to distribute condoms, oral and injectable contraceptives in
communities. The project mobilized communities and stakeholders to promote Family Planning (FP) services in the selected
communities. Using anonymised unlinked routine service data, the mean couple years of protection (CYP) achieved through
CBD was compared to that achieved in FP clinics. The CBD mean CYP for injectables- depo medroxy-progesterone acetate
(DMPA) and norethisterone enantate was higher (27.72 & 18.16 respectively) than the facility CYP (7.21 & 5.08 respectively)
(p<0.05) with no injection related complications. The CBD’s mean CYP for all methods was also found to be four times higher
(11.65) than that generated in health facilities (2.86) (p<0.05). This suggests that the CBD of injectable contraceptives is feasible
and effective, even in a setting like northern Nigeria that has sensitivities about FP. (
Résumé
Cette étude porte sur les résultats d’un projet pilote de distribution à base communautaire (DBC) des contraceptifs injectables
dans deux Administrations Locales (AL) de l’Etat de Gombe, Nigeria. D’aout 2009 au janvier 2010, a inscrit, a formé et a équipé
des membres de personnel de santé communautaire (MPSC) pour distribuer des préservatifs, des contraceptifs oraux et des
injectables dans les communautés. Le projet a mobilisé les communautés et les parties prenantes pour promouvoir la
planification familiale (PF) dans les communautés choisies. , les L’utilisation des données de service de routine anonyme et non
corrélées, la moyenne de couple d’années de protection (CAP) obtenue par la CDB a été comparée à celle obtenue dans les
cliniques de PF. La DBC de CAP pour les produits injectables Depomedroxy-acétate de progestérone (DMPA) et l'énanthate de
noréthistérone était plus élevé (27,72 et 18,16 respectivement) que l'installation (7,21 et 5,08 respectivement) CYP (p <0,05),
sans des complications liées à l’injection. On a trouvé que la CAP moyenne de la DB pour toutes les méthodes a également était
quatre fois plus élevée (11,65) que celles générées dans les établissements de santé (2,86) (p <0,05). Ceci suggère que la DBC
des contraceptifs injectables est réalisable et efficace, même dans un milieu tel que le nord du Nigeria qui a des sensibilités de la
PF. (
Keywords: Community-based provision, contraceptives, injectable, PHC
Introduction
Access to modern methods of contraception
(female sterilisation, intrauterine device, hormonal
contraceptives and condoms) in least developed
countries is very limited. The global unmet need
for family planning (FP), estimated at 200 million
women in 2008, disproportionately affects women
in remote and underserved areas
1
. In sub-Saharan
Africa for example, about 63% of women are at
risk of unintended pregnancy and 25% of women
married or in a union have an unmet need for FP
2
.
Factors associated with this unmet need are varied,
ranging from the unavailability of services to
cultural or religious barriers, rural residence, and
lack of knowledge about family planning
3-4
. The
Effectiveness of CBD of Injectables in Nigeria
81
shortage of skilled health care workers and a weak
distribution chain for health commodities further
limits access to FP service.
In Nigeria, estimates of unmet need for FP
grew from 17% to 20% between 2003 and 2008
3
.
Despite the fact that 72% of Nigerian women
know of at least one contraceptive method, the
proportion of women of reproductive age who are
using (or whose partner is using) a contraceptive
method at any given time, known as the
contraceptive prevalence rate (CPR) for any
method was only 15% (and 10% for modern
methods), one of the lowest in Sub-Saharan
Africa. As a consequence, fertility rate remains
high in Nigeria with a total fertility rate (TFR) of
5.7 births per woman. About 11% of all
pregnancies are unintended (unwanted or
mistimed)
3
. Since FP can directly or indirectly
contribute to the achievement of all eight
Millennium Development Goals (MDGs),
addressing FP needs in Nigeria becomes even
more important
4-7
.
Although the use of modern contraception in
Nigeria remains low, CPR has increased modestly
over the last 18 years (from 4% in 1990 to 10% in
2008), mainly in the use of injectables (from 1% to
3%). DMPA (63%) and norethisterone enantate
(21%) are the most commonly used injectable
contraceptives
3
. For most women in rural areas,
oral contraceptive pills and injectable
contraceptives are the methods of choice for FP.
This is mostly because of their effectiveness and
ease of use, particularly for injectables due to the
fact that they can be used discreetly
8
.
Injectable contraception in Nigeria is provided
almost exclusively in health facilities; mostly
public sector hospitals (25.5%) and health centres
(21.0%)
3
. However, FP clinic utilization in Nigeria
is low with one in three women experiencing a
difficulty with transportation and distance to
health facility as a major barrier to accessing
health care
3
.
Community based distribution of
injectable contraceptives has been used
successfully in other countries to promote FP
uptake. In rural Afghanistan, within eight months
of introduction of a CBD to FP program,
contraception increased by 24 - 27%; with
injectables contributing the most to the increase
9
.
In a rural district of Uganda, contraceptive
prevalence increased by about 5% after a
community-based provision of DMPA was
introduced
10
. A study in Bangladesh demonstrated
a 25% decline in fertility rates in areas that utilized
the community-based provision of DMPA model
when compared with areas where the use of
DMPA was rare
8
.
Community based provision of
injectable was also found to increase contraceptive
uptake in rural Madagascar with 41% of clients
reported as being new FP users
11
. Despite evidence
elsewhere showing that CBD of injectable
contraceptives can be successfully implemented,
community based channels of provision of
injectable contraception remain largely unexplored
in Nigeria
12, 13
.
CHEWs are a low cadre of trained medical
professionals working in primary health care
(PHC) facilities and are also the main health
workforce in rural areas. The CHEW was
introduced into the Nigerian health care system in
the 1970s to alleviate shortages of medical
personnel at the PHC level particularly in the rural
areas
14
. CHEWs are expected to spend half of their
time in the communities, and the other half in their
assigned clinic. However, because of shortages of
higher cadre medical personnel in many rural parts
of the country, CHEWs spend most of their time in
the clinics with very little time for community
activities.
The United Nation Fund for Population
Activities (UNFPA) since 2003 has supported the
community reproductive health project in selected
LGAs in Nigeria, using trained community
volunteers, to distribute condoms and re-supply of
oral pills only. Little is known of the feasibility
and effectiveness of CBD for injectables in
Nigeria, particularly in the predominantly Moslem
northern states. Family Health International (FHI)
in collaboration with the Association for
Reproductive and Family Health (ARFH), the
Federal and the State Ministries of Health,
supported a project to use pre-existing CHEWs in
two LGAs in Gombe State, on CBD to injectable
contraceptives from October 2009 to February
2010. This paper describes the results of a
secondary analysis of routine data which
demonstrate the effectiveness of adding injectable
Effectiveness of CBD of Injectables in Nigeria
82
contraceptives to the mix of community-based
family planning methods provided in northern
Nigeria.
Methods
The study was conducted in northern Nigeria, a
region with the worst maternal and reproductive
health indicators. The maternal mortality rate
(MMR) in Gombe State is estimated at
1,002/100,000 live births, two times higher than
the national average
13
.
Gombe’s population was
estimated at 2,353,879 people in 2006, with two
dominant ethnic groups Hausa and Fulani.
Women of childbearing age account for 22% of
the population.
Gombe has 11 predominantly rural local
government areas (LGAs) and 554 health
facilities, 110 of which provide FP services.
Gombe State has an established CBD program
consisting of trained male and female community
volunteers who distribute condoms and provide
resupply of oral pills. The federal ministry did not
however approve of the provision of injectable
contraceptive by non-medical professionals based
on safety concerns. Five wards each, in Funakaye
and Yamaltu/Deba LGAs, were selected in
conjunction with stakeholders at the federal, state
and local government level as sites for the CBA
for injectable project. Since the purpose of the
project was to add injectables to the method mix
already available in the existing CBD for oral pills,
the selection of sites was based on five factors: (1)
an established community-based contraceptives
program for oral contraceptive, with linkages to
the health facilities; (2) an established
commodities logistics system; (3) a functioning
supervisory system with identified supervisors;
(4)scheduled and effected supervisory visits to
oversee community volunteers; and (5) an
informal data collection and data flow process.
The project trained 30 CHEWs employed by
government in the study sites to provide injectable
contraceptives in the community setting. Prior to
the intervention, the CHEWs provided health
services including FP services in PHCs within
selected LGAs and were not previously involved
in CBD of FP methods. In the preparatory phase,
FHI identified and engaged stakeholders at all
levels; federal, state and community. At the
community level, FP uptake was promoted
through community meetings and outreaches
where FP information was shared and
misconceptions on FP were clarified. Advocacy
visits to community gate keepers traditional
rulers, religious leaders, ward heads and opinion
leaders within the project communities paved way
for larger community gatherings to promote male
involvement and generate demand. CHEWs were
introduced to the communities they served during
community sensitization meetings. Clients were
able to identify the CHEWs and schedule
appointments with them by direct contact or via
phone calls. Clients either visited the CHEWs at
home or invited the CHEWs to their homes after
scheduling appointments. Social gatherings such
as weddings and naming ceremonies were also
used to reach clients.
Cultural sensitivities in this predominantly
Moslem community guided the selection criteria
of CHEWs, final selection was done by the local
authorities. All the 30 selected CHEWs were
female aged 28-40 years, and resident in the
community they served. The CHEWs were trained
for forty hours over five days as community-based
providers of FP counselling, and a mix of
contraceptives which included DMPA and
norethisterone enantate injectables. The training
involved both theory and practical sessions based
on an adapted curriculum from the Federal
Ministry of Health. It included modules on
reproductive anatomy and physiology,
contraceptive technology, counselling, client
screening using job aids and checklists, injection
techniques, infection control and waste disposal,
HIV, managing supplies, referrals, and data
collection. The CHEWs were expected to pass a
post training evaluation test, and also demonstrate
proficiency in administering injections. CHEWs
who met these criteria received a certificate of
participation; all 30 CHEWs met the criteria.
Safety was addressed by training the CHEWs on
universal safety precautions and providing sharps
Effectiveness of CBD of Injectables in Nigeria
83
disposal boxes which were incinerated at the
referral health facilities.
The 30 trained CHEWs were deployed in the
two LGAs (15 per LGA) to provide community
based FP services and link eligible clients through
referrals to health facilities for clinic-based
methods IUD, implant, and sterilization – or for
other medical conditions. Each CHEW received
job-aids, checklists, and a seed stock of
contraceptive commodities which was replenished
from state MOH stores using the user-fees charged
for the service. Clients were charged the
following; 80 Naira ($0.6) for DMPA and
norethisterone enantate injectables, 15 Naira ($0.1)
for a cycle of oral pills, 20 Naira ($0.13) for each
female condom and 1 Naira ($0.01) for a unit of
male condoms (at an exchange rate of 150 Naira to
1USD). The CHEWs kept records of each service
encounter using daily activity sheets (described
below). Seven CBA supervisors were selected
among officers-in-charge of PHC facilities in line
with the existing supervisory structure of the
health system. CHEWs were linked to the CBA
supervisor in the health facility located within the
community served. These facilities served as the
referral centres for clinic-based FP methods. At
the time of the intervention, there were five
facilities that provided FP services in each of the
two LGAs.
Data collection
The data on community-based activities used a
collection tool adapted from the Nigerian national
FP register by adding three columns that captured
information on i) clients who switched over from
clinic provision to community-based provision, ii)
reported complications, and iii) referrals. At each
encounter with a client in the community, the
CHEWs recorded client age, sex, and type of FP
commodity provided, and referrals on these daily
activity sheets. To monitor safety, during
encounters with revisit clients for injectables, the
CHEWS also recorded cases of injection abscesses
or very painful injections. Each supervisor collated
data monthly from the CHEWs she supervised and
filled in the monthly summary forms to aggregate
the community-based activities. The data on
facility-based uptake during the study period were
derived from the routine FP service statistics in the
public health facilities (primary and secondary
health facilities) located in the two pilot LGAs.
Prior to the intervention, the facility M&E system
was weak, no data capturing tools and lack of M&
E supervision. For this reason, pre-intervention
data is unavailable.
Analysis
The main measurement of outcome was the
couple-years of protection (CYP), which was
calculated by dividing the total uptake of each FP
commodity by the duration of the protection
provided, assuming an average of 10 acts per
month. The number of each commodity required
to make up one CYP are as follows: 120 units for
condoms; 4 doses of DMPA injectable; 6 doses of
Norethisterone enantate injectable; 15 cycles of
oral contraceptives. The CYP for each method was
summed for all methods to obtain a total CYP.
Data were analyzed using 10 (Stata Corp,
2007). Frequencies were calculated and cross-
tabulated to compare contraceptive uptake in the
community-based service to routine facility-based
provision of contraceptives. A paired test of
difference in means was used to compare mean
CYP (all FP methods) from facility-based
provision to mean CYP (all FP methods) from
community-based FP service provision. Further
analysis was done to compare the difference in the
mean CYP of facility-based provision to
community-based provision by each FP method.
Statistical significance for all tests was defined as
p<0.05.
Results
Health facilities in Gombe do not keep client level
data in the registers. The socio-demographic
characteristics of clients attending health facilities
were not available. A total of 2,363 clients
accessed the community-based FP service
(injectables, oral pills and condoms) in the two
LGAs during the study period (October 2009 to
February 2010). Funakaye reported 1,066 (45%)
acceptors, slightly less than Yamaltu/Deba’s 1,297
Effectiveness of CBD of Injectables in Nigeria
84
(55%). This translates to an average of 12 and 14
clients per CHEW per month for Funakaye and
Yamaltu/Deba LGA respectively. Only 82 (8%)
and 247 (19%) of the clients in Funakaye and
Yamaltu/Deba LGAs respectively were males. The
majority of FP clients reached in the two LGAs
were between the ages of 25 – 34 years (55%),
followed by the age group 15 – 24 years (25%),
and the 35 and 44 years age group (18%). The age
distribution was similar across the two LGAs.
(Table 1)
In total, 1,216 cycles of oral contraceptive pills,
1,076 doses of Norethisterone enantate and 1,022
doses of DMPA were dispensed through the
community-based system during the study period.
FP uptake in the health facility was found to be
lower, with a total of 289 cycles of oral pills, 306
doses of Norethisterone enantate, and 299 doses of
DMPA dispensed through facility based provision
(Table 2).
Table 3 shows the comparison of mean CYP
from CBA and facilities; the CBA yielded a
significantly higher mean CYP for all methods
(11.65) compared to facility-based service (2.86)
(<0.01). Mean CYP by each FP method for
facility and community-based services
respectively were: male condom 0.01 and 5.91
(<0.01), female condom 0.03 and 0.15 ( =0.06),
DMPA 7.21 and 25.72 ( <0.01), Norethisterone
enantate 5.08 and 18.16 ( <0.01) and oral pills
1.98 and 8.29 ( <0.01)
Table 4 shows the comparison of the mean
CYP in the two LGAs for each FP method
provided through CBA and facility-based
provision. Both LGAs recorded a significantly
higher CYP for all contraceptive methods except
the female condom from CBA compared to the
facility-based service. In Funakaye LGA, a mean
CYP of 11.32 from all contraceptive methods was
provided via CBA compared to 4.50 mean CYP
provided by the facility-based provision in the
corresponding wards ( <0.05). Similarly, in
Yamaltu/Deba LGA, a mean CYP of 11.97 was
provided by the CBA while the facility-based
provision yielded a mean CYP of 1.22 ( <0.01).
DMPA provided the highest contribution to the
total CYP in both facility-based and CBA in both
LGAs. However, the difference in mean CYP from
CBA and facility-based provision was found to be
more statistically significant in Yamaltu/Deba
(=0.029) than in Funakaye LGA ( =0.099).
Norethisterone enantate also had good uptake in
both LGAs through the CBA and Yamaltu/Deba
again had a more statistically significant mean
CYP difference ( =0.026) compared to Funakaye
(=0.047).
From a total of 2,363 clients served during the
observation period, 721 (30.5%) reported a switch
from using services in fixed facilities to enrolling
in the CBD project. The highest proportion of
clients who switched to CBD was recorded among
those using Norethisterone enantate (38.6%) and
DMPA (30.8%). (See table 5)
Table 1: Demographic Characteristics of CBA Acceptors by LGA, August 2009 to January 2010
Funakaye LGA (n=1066) Yamaltu/Deba LGA (n=1297)
n (%) n (%)
Sex
Male 82 (7.7) 247 (19.1) <0.01
Female 984 (92.3) 1050 (80.9)
*Age group (years)
15 – 24 255 (26.2) 308 (25.3) 0.357
25 – 34 545 (55.9) 653 (53.7)
35 – 44 164 (16.8) 235 (19.3)
> 45 11 (1.1) 19 (1.6)
Effectiveness of CBD of Injectables in Nigeria
85
Table 2: FP commodity uptake in LGA by type of commodity and service delivery from August 2009 to
January 2010
Table 3: Comparison of mean CYP achieved by type of FP methods between facility-based and CBA services,
August 2009 to January 2010
Mean CYP (C I), both LGAs combined
Facility Community
All methods 2.86 (1.37-4.34) 11.65 (8.54-14.75) <0.001
DMPA 7.21 (1.11-13.30) 25.72 (18.46-32.98) <0.001
Norethisterone enantate 5.08 (1.47-8.69) 18.16 (12.29-24.03) <0.001
Oral Pills 1.98 (0.34-3.61) 8.29 (5.95-10.62) <0.001
Male condom 0.01(-0.01-0.03) 5.91 (3.97-7.85) <0.001
Female condom 0.03 (-0.04-0.11) 0.15 (0.05-0.26) 0.060
Table 4: Comparison of mean CYP achieved from facility-based and CBA services by LGA, August 2009 to
January 2010
Funakaye LGA Yamaltu/Deba
Mean CYP (C I) Mean CYP (C I)
Facility Community Facility Community
All methods 4.50 (1.87-7.13) 11.32 (7.11-
15.53)
0.018 1.22 (-0.06-
2.50)
11.97 (7.09-
16.86)
<0.001
DMPA 11.06 (-1.02-
23.14)
23.58 (11.76-
35.40)
0.099 3.35 (-3.65-
10.35)
27.86 (13.73-
41.99)
0.029
Norethisterone
enantate
8.00 (2.12-13.88) 18.84 (10.57-
27.11)
0.047 2.16 (-2.41-
6.73)
17.48 (4.68-
30.28)
0.026
Oral Pills 3.36 (0.41-6.31) 9.50 (6.50-
12.50)
0.018 0.59 (-0.82-
1.10)
7.07 (2.34-
11.80)
0.028
Male condom 0.00 4.6 (1.53-
7.67)
0.014 0.02 (-0.03-
0.06)
7.22 (4.14-
10.30)
0.003
Female condom 0.07 (-0.12-0.25) 0.07 (-0.12-
0.16)
0.935 0.00 0.24 (0.03-0.45) 0.033
Funakaye LGA Yamaltu/Deba LGA
FP commodity
CBD Facility CBD Facility
n (%) n (%) n (%) n (%)
DMPA 465 (12%) 232 (30%) 557 (9%) 67 (37%)
Norethisterone enantate 551 (15%) 241 (32%) 525 (9%) 65 (36%)
Oral Pills 685 (18%) 250 (33%) 531 (9%) 39 (22%)
Male Condom 2,050 (54%) 0 (0%) 4,326 (71%) 10 (5%)
Female Condom 34 (1%) 40 (5%) 139 (2%) 0 (0%)
Total 3,785 (100%) 763 (100%) 6,078 (100%) 181 (100%)
Effectiveness of CBD of Injectables in Nigeria
86
Table 5: Reported switch in service utilization from fixed health facility to CBD during observation period
Method Total number of
clients
No. clients reported switch from
fixed facility to CBD
%
DMPA 689 212 30.8
Norethisterone enantate 713 275 38.6
Oral Pills 561 135 24.1
Condoms 400 99 24.8
Total 2363 721 30.5
Injection Safety
During the course of the study, no needle stick
injury or any other any injection related adverse
event such as injection abscess was reported.
Safety boxes were filled appropriately, and
disposed according to facility protocol.
Discussion
The CBA pilot project expanded access to FP in
rural northern Nigeria by complementing fixed
facility-based service provision with the flexible
and culture-sensitive approach of community-
based access. The mean CYP of all methods in this
CBA pilot project was 4 times higher than that
from facility-based provision, a significant
difference observed in the two LGAs. The ability
to promote FP depends on the use of effective and
innovative strategies to deliver these services to
rural populations
15
.
Policy in Nigeria limits the provision of
injectable contraception to health facilities. The
findings of this study suggest the provision of
injectables beyond health facilities to include
mobile community-based provision by trained low
cadre health workers is feasible and safe. For the
observed increase in CYP, the workload (12 to 14
clients per CHEW per month) remained
manageable. This is critical since CHEWs play an
important role in the operation of PHCs in Nigeria,
and are expected to share their time almost equally
between facility and community tasks. An increase
in community workload might have negative
impact on the facility workload.
It is important to note that the financial barrier
to access was not removed entirely in the pilot
project. The government prescribed fees for FP
methods was applicable. The only savings that
might have occurred was in client transportation
costs – clients did not incur transportation costs.
The removal of user fee will further increase the
uptake of FP in Nigeria. Factors other than cost
that may have played a role in increased uptake of
FP in the community, these may include
convenience injections do not have to be
administered during clinic hours which often times
conflict with domestic or commercial priorities of
women; relaxed setting of homes; professional
providers who were part of the communities and
could be trusted; endorsement by traditional rulers
and key gatekeepers as well as other demand
creation activities engaged in by the CBA project.
Mekonnen et al argue that awareness of the
community-based service amongst other factors
could predict the success of a community-based
family planning program
16
.
The findings are even more significant when
the location of the project, the predominantly
Moslem Northern Nigeria, is considered. FP is
perceived as ‘foreign’ and ‘western’ and
organisations promoting FP are frequently
regarded with suspicion and as such gaining access
to communities and developing trust has usually
been a challenge
17
. Hence the low CPR for modern
methods (3.5%), and injectables in particular
(0.9%).
3
Despite the socio-cultural and religious
barriers to FP access that characterize northern
Nigeria, the pilot project has demonstrated that it
is possible to (1) gain the support of traditional and
religious leaders, (2) increase use of contraceptives
through community-based service systems.
Women are expected to secure consent of male
partners before accessing FP services. This project
however found that although male acceptors were
in the minority (8% to 19%), male condom uptake
Effectiveness of CBD of Injectables in Nigeria
87
was relatively high, representing 54 and 71% of
total FP commodity units dispensed in Funakaye
and Yamaltu respectively. In Nigeria, motivating
men to attend FP clinics is difficult
18
. The findings
therefore suggest that despite the prevailing belief
and religious influences, it is possible to reach men
through community-based provision of FP
services.
The higher CYP of the CBA pilot corroborates
the high-unmet need for FP services in Nigeria,
where unmet need for contraception is 20% (15%
for spacing and 5% for limiting). The prevalence is
even higher among rural dwellers.
3
Our findings of
a significantly high CYP contribution by injectable
contraceptives support the evidence of high
injectable contraceptive use elsewhere when
community-based FP programs are introduced,
including in Muslim countries
8,9,10,11
.
A major limitation to this study is the absence
of a control; it is therefore not possible to exclude
the influence of confounders on the findings of our
study. The unavailability of pre-intervention
community or facility data further limits the study,
as we are unable to tell if the observed
improvement would be significant compared to the
pre-intervention period. The pilot was conducted
for a period of six months, we are unable to
demonstrate that our findings could be sustained; it
is possible that the FP uptake via CBD would
wane over time. Our study is also limited in
generalizability, as the pilot was carried out in
only five wards each in the two local governments.
Conclusion
Our study demonstrates the feasibility of
community-based provision of injectable
contraceptives in Nigeria using low cadre of health
workers. Facility-based provision of FP services
can be effectively and safely complemented with
community-based service. Policy guidelines to
address human resources at PHC level, monitoring
and supportive supervision of CHEWs and
commodities supply chain issues will need to be
addressed to allow for scale up of CBA in Nigeria
and optimal impact.
Acknowledgment
The community-based project received funding
from the Contraceptive and Reproductive Health
Technologies Research and Utilization (CRTU)
program, USAID-sponsored assistance agreement
(2005-2010) with Family Health International
through the Cooperative Agreement No. 620-A-
00-04-00122-00.
Contribution of Authors
Rabiatu Abdul-hadi, Moyosola Abass, Bolatito
Aiyenigba, Lolade Oseni, Christoph Hamelmann,
and Otto Chabikuli contributed to study
conception, design, analysis and interpretation of
data. Moyosola Abass, Bolatito Aiyenigba and
Lolade Oseni conducted the statistical tests.
Rabiatu Abdul-hadi, Moyosola Abass, Bolatito
Aiyenigba and Lolade Oseni wrote the drafts of
the publication. Mohammed Ibrahim, Solomon
Odafe, Oladapo A. Ladipo and Otto Chabikuli
contributed to the critical revision of the article
.
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... Due to lack of rigorous research data on the effectiveness and safety of provision of injectable contraceptives by both cadres of health workers, WHO's 2012 recommendations only recommend the provision of injectable contraceptives by LHWs and pharmacy workers in specific circumstances. In the present review, we found six studies reporting on the provision of injectable contraceptives by LHWs [18][19][20][21][22][23], none on the provision by pharmacy workers. Of the six studies, which report on task-sharing injectable contraceptives to LHWs, four were single-arm studies merely [19,20,21,23], one study reported on performance outcome of LHWs [22] (ability to adequately perform injections) and the last one compared community-based provision by LHWs to facility-based provision by a different cadres of health workers including LHWs [18]. ...
... In the present review, we found six studies reporting on the provision of injectable contraceptives by LHWs [18][19][20][21][22][23], none on the provision by pharmacy workers. Of the six studies, which report on task-sharing injectable contraceptives to LHWs, four were single-arm studies merely [19,20,21,23], one study reported on performance outcome of LHWs [22] (ability to adequately perform injections) and the last one compared community-based provision by LHWs to facility-based provision by a different cadres of health workers including LHWs [18]. These studies did not meet inclusion criteria for this review and could not further contribute to the evidence. ...
Article
Full-text available
Objective. This systematic review was conducted to provide up-to-date evidence on the safety and effectiveness of task sharing in the delivery of modern contraceptives. Study Design. The review followed the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. We searched Medline, Embase, Cochrane CENTRAL, and Google Scholar for peer-reviewed studies that reported on effectiveness and/or safety outcomes of task sharing of any modern contraceptive method. Only Cochrane Effective Practice of Organizations of Care (EPOC) study designs were eligible, and quality assessment of the evidence was performed using the Cochrane risk of bias (RoB) tools. Meta-analyses, where possible, were carried out using Stata, and certainty of the evidence for outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation tool (GRADE). Results. Six studies met the inclusion criteria: five reported on self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to administered by trained health providers; and one assessed tubal ligation performed by associate clinicians compared to advanced-level associate clinicians. Self-injection improved contraceptive continuation, with no increase in unintended pregnancy and no difference in side effects compared to provider administered. In tubal ligation, the rate of adverse events, time to complete procedure, and participant satisfaction were similar among associate clinicians and advanced clinicians. Conclusion. The evidence suggests that self-injection of DMPA-SC and tubal ligation performed by associate clinicians are safe and effective. These findings should be complemented with the evidence on the feasibility and acceptability of task sharing of these methods. The review protocol was registered with PROSPERO CRD42021283336.
... The study also revealed that clients of CHEWs were as satisfied with services as those who received care from other providers, such as nurses 37 . Other studies conducted in northern Nigeria also found that CHWs can effectively provide implants 38 and injectables 39 under supervision. Despite the positive outcomes of these studies, the deployment of CHWs as a strategy to improve contraceptive prevalence in Nigeria appears to be limited in scope. ...
... Family planning-related contact with CHWs was associated with more modern contraceptive use in the combined sample of six states, but this did not always reach statistical significance when examined by state. In Kano, Nasarawa and Taraba states, visits by CHWs were associated with increased probability of modern contraceptive use, a finding in keeping with the results of other studies from sub-Saharan Africa and Asia 12,16,38,39 . This relationship held true, even after adjusting for having visited a health facility where women received FP information in the 12-month period preceding the survey. ...
Article
Full-text available
This paper assessed the effect of visits by Community Health Workers (CHW) in the prior 12 months on modern contraceptive use at the time of the survey using a national sample of women residing in rural communities in Nigeria. Cross-sectional data from 5072 rural women ages 15-49 years interviewed in the PMA2020 Survey in 6 states in Nigeria in 2018 were used. Descriptive analysis and generalized linear models were conducted in Stata 15.1 and average marginal effects calculated. Overall prevalence of modern contraceptive use was 14.8% (95% CI: 12.7%, 17.3%), varying from 2.1% in Kano to 22.7% in Nasarawa. Ten percent of women reported that they were visited by a community health worker in the 12-month period preceding the survey, ranging from 2.9% in Kano to 14.6% in Nasarawa. Women visited by a CHW had 50% higher odds of reporting modern contraceptive use, and these visits raised the probability of modern contraceptive use by an average of 6.4 percentage points overall. Local governments in rural Nigeria should invest in training, deploying and supervising CHWs in the provision of modern contraception through home visits to women who may otherwise have limited access to improve use.
... In other contexts with low contraceptive prevalence, community-based provision of contraceptive services has proven effective at capturing and supporting new and existing FP users, delivering high volumes of contraceptives, and has contributed to increasing mCPR [15,16]. However, cross-sectional evaluations of these programs tend to focus on single client visits (particularly new users) and quantities of methods provided [17,18], and do not always consider the contraceptive trajectories of their clients after they received their method, be it from an individual provider or during a community-based event. Yet, for FP programs to successfully support women's contraceptive choices, they must not only contribute to contraceptive initiation but also foster long-term use of the woman's preferred method(s), and enable her to switch and stop contraception based on her preferences and life decisions [19,20]. ...
Article
Full-text available
While community-based interventions are a proven high-impact strategy to increase contraceptive uptake in low-income countries, their capacity to support women’s contraceptive choices (including continued use, switching and discontinuation) in the long run remains insufficiently discussed. This cohort study follows 883 women 3 and 6 months after they received a modern method during community campaigns organized in Kinshasa (D.R. Congo), to analyze their contraceptive trajectories and the factors associated with ever discontinuing contraceptive use in the first 6 months following a campaign. In the community-based distribution (CBD) model currently institutionalized in DRC, campaign clients are not provided with additional doses or support, besides baseline counseling, to (dis-)continue using the method they received, but must rely on Family Planning resources within the existing local health system. Almost a third (28.9%) of all women discontinued modern contraception during the study period, with much higher discontinuation rates for short-acting methods (38.7% for pills and up to 68.9% for DMPA-SC). Variables previously associated with high discontinuation (marital status, fertility intentions and side-effects) led to higher odds of “ever discontinuing”. However, these variables became non-significant when controlling for resupply issues. Women’s self-reported reasons for discontinuation confirmed the multivariate regression results. Detailed sub-analysis of resupply issues for pills, injectables and Cyclebeads pointed to the role of cost, unreliable campaign schedules and weak integration of community-based strategies into the formal health system. Extremely low rates of implants removal suggest similar access to FP services issues. The study highlights the need to identify CBD strategies best suited to support women’s choices and preferences towards successful contraceptive trajectories in fragile health systems.
... In larger urban centers CHEWs assist nurses and physicians; in rural health centers they work alone or with another CHEW or nurse. Although CHEWs are expected to spend half their time on community-based functions, in reality they spend most of their time in clinics due to shortages of higher cadre staff in many rural areas (Abdul-hadi et al. 2013;Kress, Su, and Wang 2016;Uzondo et al. 2015). ...
Article
Full-text available
Task sharing is a strategy with potential to increase access to effective modern contraceptive methods. This study examines whether community health extension workers (CHEWs) can insert contraceptive implants to the same safety and quality standards as nurse/midwives. We analyze data from 7,691 clients of CHEWs and nurse/midwives who participated in a noninferiority study conducted in Kaduna and Ondo States, Nigeria. Adverse events (AEs) following implant insertions were compared. On the day of insertion AEs were similar among CHEW and nurse/midwife clients—0.5 percent and 0.4 percent, adjusted odds ratio (aOR) 0.92 (95 percent CI 0.38–2.23)—but noninferiority could not be established. At follow‐up 6.6 percent of CHEW clients and 2.1 percent of nurse/midwife clients experienced AEs. There was strong evidence of effect modification by State. In the final adjusted model, odds of AEs for CHEW clients in Kaduna was 3.34 (95 percent CI 1.53–7.33) compared to nurse/midwife clients, and 0.72 (95 percent CI 0.19–2.72]) in Ondo. Noninferiority could not be established in either State. Implant expulsions were higher among CHEW clients (142/2987) compared to nurse/midwives (40/3517). Results show the feasibility of training CHEWs to deliver implants in remote rural settings but attention must be given to provider selection, training, supervision, and follow‐up to ensure safety and quality of provision.
... CBD may be particularly important for overcoming the confluence of these barriers in Northern Nigeria where private health providers are less prevalent 25,27 and sexual and gender norms more conservative 28 . Past studies in Nigeria and beyond have also found that, compared to facility-based service provision, CBD yields higher contraceptive uptake by reaching more marginalized populations [29][30][31][32][33] . ...
Article
Full-text available
Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (N public =235; N private =224) completed a phone survey from a convenience sample of 1,444 women (N public =912; N private =532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.
... Increasing contraceptive use has many demographic dividends, and unmet need denies women these beneits and violates their reproductive health rights. Studies have shown that several obstacles have hindered women access to FP services: unavailability of services, cultural and religious barriers, lack of knowledge and rural residence [99,100]. Additionally, weaknesses in the existing FP programmes coupled with the fact that in SSA FP programmes tended to ofer select methods (as a mater of convenience) or as a means of promoting the most efective and long-lasting methods [78]. ...
... The meeting concluded that community health workers could safely counsel and provide DMPA to clients, and sufficient evidence was available to support including CBD of DMPA in national family planning policies (Stanback, Spieler, Shah, Finger, and Expanding Access Technical Consultation 2010) (Table 1). Research conducted in Uganda, Nigeria, Madagascar, and Kenya has shown that CBD of injectable contraceptives is feasible, satisfactory, and a means of expanding access to contraceptives among hard-to-reach clients (Abdul-hadi et al. 2013;Hoke et al. 2012b;Krueger et al. 2011;Malarcher et al. 2011;Prata et al. 2011). ...
Article
Full-text available
Background Community-based distribution (CBD) of injectable contraceptives has increased access to family planning for millions of women in rural areas in resource-limited settings. Despite the evidence of the success of this contraceptive delivery method, many nations have yet to integrate CBD into their family planning policies. The aim of this paper to describe the process through which PATH spearheaded efforts to successfully advocate for policy change to authorize non-clinical personnel in Zambia to provide injectable contraceptives. Methods We describe a four-part framework for policy advocacy: (a) evidence building and technical assistance, (b) stakeholder engagement, (c) government engagement, and (d) knowledge dissemination. Results Advocacy for policy change to allow CBD of injectable contraceptives was long and iterative. Evidence to support advocacy efforts was built through a Zambian delegates’ study tour to Rwanda to witness Rwanda’s robust CBD program and a rapid assessment of Zambian pilot sites where non-clinical personnel were administering injectable contraceptives. Advocacy was led by PATH in partnership with key stakeholders from the Zambia Family Planning Technical Working Group (FPWTG), key government officials, and a special task force of stakeholders focused on advocating for CBD of injectable contraceptives. This task force used evidence from the study tour and rapid site assessment in national and international forums to demonstrate the beneficial effects of allowing non-clinical personnel to administer injectable contraceptives. The Zambian government authorized the policy change in 2016. Conclusion The policy advocacy efforts of PATH, FPWTG, and the special task force demonstrate the need for an ample evidence base and sustained engagement of government and stakeholder groups.
Preprint
Full-text available
While community-based interventions are a proven high-impact strategy to increase contraceptive uptake in low-income countries, their capacity to support sustained use of family planning remains insufficiently discussed. This cohort study follows 883 women 3 and 6 months after they received a modern method during community campaigns organized in Kinshasa (D.R. Congo), to analyze their contraceptive trajectories (continuation, switching, abandonment) and the factors associated with ever discontinuing contraceptive use in the first six months following a campaign. Contrary to most pilot studies, campaign clients were not provided with additional support, besides baseline counseling, to continue using the method they received, and could only rely on resources of the existing local health system. Almost a third (28.9%) of all women discontinued using modern contraception during the study period, with much higher discontinuation rates for short-acting methods (29.8% for pills and up to 64.0% for DMPA-SC). Variables previously associated with high discontinuation (marital status, fertility intentions and side-effects) led to higher OR for “ever discontinuing”. However, these variables became non-significant when controlling for resupply issues. Women’s self-reported reasons for discontinuation confirmed the multivariate regression results. Detailed sub-analysis of resupply issues for short-acting methods highlighted the role of cost, unreliable campaign schedules and weak integration of community-based strategies into the formal health system, which hinders their capacity to act as a gateway into long-term contraceptive use.
Article
Full-text available
Objective To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria. Design Scoping review. Data sources and eligibility criteria Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included. Data extraction and analysis The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed. Results A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively. Conclusion Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.
Article
Full-text available
Background: Beginning in 2015, subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was added to the contraceptive method mix in Nigeria, primarily through social marketing in the private sector and community-based distribution in the public sector. We compare user experiences in acquiring DMPA-SC across sectors during this national scale-up. Methods: From October 2017 to February 2018, 459 women (N public =235; N private =224) completed a phone survey from a convenience sample of 1,444 women (N public =912; N private =532) who obtained DMPA-SC from participating providers and agreed to be contacted. We examined the sociodemographic predictors of attending a public vs. private provider and analyzed differences in care-seeking across sectors (becoming aware of DMPA-SC, choosing a provider, choosing DMPA-SC, quality of care). Results: Respondents obtaining DMPA-SC from public providers were younger and less educated than those attending private providers. Both program respondents were comprised of similar percentages of new users of modern contraception (58.7-60.3%), although most respondents became aware of DMPA-SC through a friend/family member (43.1%) or a provider (41.5%). Relatively more public sector respondents also heard about DMPA-SC through community outreaches whereas relatively more private sector respondents became aware through media. Convenience was the most common reason for choosing a provider—43.8% among all respondents (higher among public sector respondents). Private sector respondents were also more likely to choose a past or usual provider. Having overall higher quality interactions were more likely among clients who attended private providers than public providers, but responses to individual quality item measures show specific areas of poor quality for providers in each sector. Conclusions: Training emphasizing technical thoroughness, sensitivity toward younger women, and client choice may help improve women’s experiences with obtaining DMPA-SC, ultimately contributing to accelerating demand for and uptake of DMPA-SC specifically and contraception in general.
Article
Objective: To assess opportunities and threats towards the continuity and success of Community-based reproductive health service programme in Northeast Ethiopia. Design: Community-based comparative cross sectional study. Setting: Two districts of Amhara region, Ethiopia, classified as strong and weak community based reproductive health programme areas. Subjects: Seven hundred Ninety two women aged 15-49 years residing in the selected districts of Amhara region. Community-based reproductive health workers, programmeme coordinators and field supervisors were used as informants of qualitative data collection. Main outcome measure: Current use of modern contraceptive methods. Results: Strong versus weak programme areas: knowledge about modern contraceptive method (MCM), was (90% and 86.8%), [OR (95% CI) = 2.87(1.68, 4.91)], ever use of MCM (61.1 % and 29.7%), [OR (95% CI) = 3.71(2.72, 5.07)] and current use of MCM (54.8% versus 19.7%), [OR (95% CI) =4.95(3.53, 6.95)]. Method interruption was significantly higher, 37.6% in weak than 10.9% in strongly performing programme area. Causes of defaulting in strong versus weak programme areas were: wanted more pregnancy (4% and 39.5%), fear of contraceptives\' side effects (16% and 31.6%) and lack of method of choice (20% and 2.6%). Type of religion, husband approval, awareness of service existence and client satisfaction remained to be the predictors of current use of MCM in multivariate analysis. Qualitative study findings were found coherent with the quantitative results. Conclusion: Type of religion, husband approval, client satisfaction and awareness of service existence were the predictors of modern contraceptive methods utilisation in the study population. East African Medical Journal Vol. 85 (3) 2008: pp. 138-144
Article
Context: While most developing countries have at least begun the transition from high to low fertility, the process has occurred at very different rates in various regions. The pattern of change in Sub-Saharan Africa differs from that of other regions, a factor that has implications for family planning programs there. Methods: Data from 108 Demographic and Health Surveys, World Fertility Surveys and Contraceptive Prevalence Surveys were assembled for 41 developing countries, covering the period extending from the mid-1970s to the late 1990s. Results: The percentage of women who want no more children has risen slowly but steadily in Sub-Saharan Africa since the 1970s, having reached a level of 20-40% in many countries by the late 1990s. Yet overall levels remain far below those seen in Asia and in North Africa, where the level of demand for limiting births clusters in the 40-60% range. The proportion of women wanting to stop childbearing is also high in Latin America, and shows more evidence of leveling off than in Asia. Unmet need for the means to limit births is increasing fairly uniformly for most Sub-Saharan African countries; in contrast, in Asia and North Africa and Latin America and the Caribbean, it is generally declining with the adoption of contraceptive use. While the evidence indicates that most women in Sub-Saharan Africa who practice contraception do so to space rather than to limit births, trend data suggest that the proportion of users practicing contraception to limit births has been increasing in recent years; in some countries, this proportion approaches half of all method use, and is higher than expected elsewhere. In contrast, there has been little change in this balance in Asia and North Africa and in Latin America and the Caribbean, with the great majority of users in both regions seeking to limit rather than space births. Conclusions: While demand for contraception is increasing throughout the developing world, most of the demand in Asia and North Africa and in Latin America is already being met, while much of the demand in Sub-Saharan Africa is not. In both Asia and Latin America, where contraceptive use is already high, providers need to gear their services toward helping clients to continue use and to improve the effectiveness of their contraceptive practice. In Sub-Saharan Africa, where use is low, programs must aim to encourage adoption of modern methods.
Article
To reduce a large unmet need for family planning in many developing countries, governments are increasingly looking to community health workers (CHWs) as an effective service delivery option for health care and as a feasible option to increase access to family planning services. This article synthesizes evidence on the feasibility, safety and effectiveness of community-based delivery of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). Manual and electronic search and systematic review of published and unpublished documents on delivery of contraceptive injectables by CHWs. Of 600 identified documents, 19 had adequate information on injectables, almost exclusively intramuscular DMPA, provided by CHWs. The data showed that appropriately trained CHW demonstrate competency in screening clients, providing DMPA injections safely and counseling on side effects, although counseling appears equally suboptimal in both clinic and community settings. Clients and CHWs report high rates of satisfaction with community-based provision of DMPA. Provision of DMPA in community-based programs using CHWs expanded access to underserved clients and led to increased uptake of family planning services. We conclude that DMPA can be provided safely by appropriately trained and supervised CHWs. The benefits of community-based provision of DMPA by CHWs outweigh any potential risks, and past experiences support increasing investments in and expansion of these programs.
Article
Injectable contraceptives are now the most popular contraceptive methods in sub-Saharan Africa. Injectables have not been an option for African women lacking convenient access to health facilities, however, since very few family planning programmes permit community-based distribution (CBD) of injectables by non-medically trained workers. Committed to reducing unmet contraceptive need among remote, rural populations, the Ministry of Health and Family Planning (MOHFP) of Madagascar sought evidence regarding the safety, effectiveness and acceptability of CBD of injectables. The MOHFP joined implementing partners in training 61 experienced CBD agents from 13 communities in provision of injectables. Management mechanisms for injectables were added to the CBD programme's pre-existing systems for record keeping, commodity management and supervision. After 7 months of service provision, an evaluation team reviewed service records and interviewed CBD workers and their supervisors and clients. CBD workers demonstrated competence in injection technique, counselling and management of clients' re-injection schedule. CBD of injectables appeared to increase contraceptive use, with 1662 women accepting injectables from a CBD worker. Of these, 41% were new family planning users. All CBD agents wished to continue providing this service, and most supervisors indicated the programme should continue. Nearly all clients interviewed said they intended to return to the CBD worker for re-injection and would recommend this service to a friend. This experience from Madagascar is among the first evidence from sub-Saharan Africa documenting the feasibility, effectiveness and acceptability of CBD services for injectable contraceptives. This evidence influenced national and global policy makers to recommend expansion of the practice. CBD of injectables is an example of effective task shifting of a clinical practice as a means of extending services to underserved populations without further burdening clinicians.
Article
Afghan women have one of the world's highest lifetime risks of maternal death. Years of conflict have devastated the country's health infrastructure. Total fertility was one of the world's highest, contraceptive use was low and there were no Afghan models of success for family planning. We worked closely with communities, providing information about the safety and non-harmful side-effects of contraceptives and improving access to injectable contraceptives, pills and condoms. Regular interaction with community leaders, mullahs (religious leaders), clinicians, community health workers and couples led to culturally acceptable innovations. A positive view of birth spacing was created by the messages that contraceptive use is 300 times safer than pregnancy in Afghanistan and that the Quran (the holy book of Islam) promotes two years of breastfeeding. Community health workers initiated the use of injectable contraceptives for the first time. The non-for-profit organization, Management Sciences for Health, Afghan nongovernmental organizations and the Ministry of Public Health implemented the Accelerating Contraceptive Use project in three rural areas with different ethnic populations. The contraceptive prevalence rate increased by 24-27% in 8 months in the project areas. Men supported modern contraceptives once they understood contraceptive safety, effectiveness and non-harmful side-effects. Injectable contraceptives contributed most to increases in contraceptive use. Community health workers can rapidly increase contraceptive use in rural areas when given responsibility and guidance. Project innovations were adopted as best practices for national scale-up.
Article
To assess opportunities and threats towards the continuity and success of Community based reproductive health service programme in Northeast Ethiopia. Community based comparative cross sectional study. Two districts of Amhara region, Ethiopia, classified as strong and weak community based reproductive health programme areas. Seven hundred and ninety two women aged 15-49 years residing in the selected districts of Amhara region. Community based reproductive health workers, programme coordinators and field supervisors were used as informants of qualitative data collection. Current use of modern contraceptive methods. Strong versus weak programme areas: knowledge about modern contraceptive method (MCM), was (90% and 86.8%), [OR (95% CI) = 2.87(1.68,4.91)], ever use of MCM (61.1% and 29.7%), [OR (95% CI) = 3.71(2.72, 5.07)] and current use of MCM (54.8% versus 19.7%), [OR (95% CI) = 4.95(3.53,6.95)]. Method interruption was significantly higher, 37.6% in weak than 10.9% in strongly performing programme area. Causes of defaulting in strong versus weak programme areas were: wanted more pregnancy (4% and 39.5%), fear of contraceptives' side effects (16% and 31.6%) and lack of method of choice (20% and 2.6%). Type of religion, husband approval, awareness of service existence and client satisfaction remained to be the predictors of current use of MCM in multivariate analysis. Qualitative study findings were found coherent with the quantitative results. Type of religion, husband approval, client satisfaction and awareness of service existence were the predictors of modern contraceptive methods utilisation in the study population.
Article
To compare the safety and quality of contraceptive injections by community-based health workers with those of clinic-based nurses in a rural African setting. A nonrandomized community trial tested provision of injectable Depo Provera (DMPA) by community reproductive health workers and compared it with routine DPMA provision at health units in Nakasongola District, Uganda. The primary outcome measures were safety, acceptability and continuation rates. A total of 945 new DMPA users were recruited by community workers, clinic-based nurses and midwives. Researchers successfully followed 777 (82% follow-up): 449 community worker clients and 328 clinic-based clients. Ninety-five percent of community-worker clients were "satisfied" or "highly satisfied" with services, and 85% reported receiving information on side-effects. There were no serious injection site problems in either group. Similarly, there was no significant difference between continuation to second injection (88% among clients of community-based workers, 85% among clinic-going clients), nor were there significant differences in other measures of safety, acceptability and quality. Community-based distribution (CBD) of injectable contraceptives is now routine in some countries in Asia and Latin America, but is practically unknown in Africa, where arguably the need for this practice is greatest. This research reinforces experience from other regions suggesting that well-trained community health workers can safely provide contraceptive injections.
Abuja: National Population Commission and ICF Macro
National Population Commission. Nigeria Demographic and Health Survey 2008. Abuja: National Population Commission and ICF Macro, 2009.
Abuja: Federal Ministry of Health
  • Fmoh National
  • Imnch Assessment
FMOH. National IMNCH Assessment. Abuja: Federal Ministry of Health, 2009.