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Effect of Deploying Trained Community Based Reproductive Health Nurses (CORN) on Long-Acting Reversible Contraception (LARC) Use in Rural Ethiopia: A Cluster Randomized Community Trial: Effect of Deploying Trained Community Based Reproductive Health Nurses
Abstract and Figures
To investigate the effect of innovative means to distribute LARC on contraceptive use, we implemented a three arm, parallel groups, cluster randomized community trial design. The intervention consisted of placing trained community‐based reproductive health nurses (CORN) within health centers or health posts. The nurses provided counseling to encourage women to use LARC and distributed all contraceptive methods. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where the new service providers were deployed, health post or health center. We calculated difference‐in‐difference (DID) estimates to assess program impacts on LARC use. After nine months of intervention, the use of LARC methods increased significantly by 72.3 percent, while the use of short acting methods declined by 19.6 percent. The proportion of women using LARC methods increased by 45.9 percent and 45.7 percent in the health post and health center based intervention arms, respectively. Compared to the control group, the DID estimates indicate that the use of LARC methods increased by 11.3 and 12.3 percentage points in the health post and health center based intervention arms. Given the low use of LARC methods in similar settings, deployment of contextually trained nurses at the grassroots level could substantially increase utilization of these methods.
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... In 20 studies, the number of healthcare providers that received training in LARC (n = 4942) was reported, whereas eight studies did not report the number of providers that received training. 20 17,18,[20][21][22][23][24]27,29,32,35,37,[39][40][41][42]44 Our primary outcome of interest, end-use of LARC, was reported in all 28 included studies, and was measured as (1) change in uptake of LARC -including number of women choosing LARC to be their first method of contraception as well as women switching to LARC from a different method [18][19][20]24,25,[27][28][29][30][31][32][35][36][37][38][39][40][41][42][43][44] ; and (2) change in IUD uptake specifically -including postpartum intrauterine devices. 17,[21][22][23]26,33,34 No studies reported the number of unintended pregnancies at 12 months after initiating LARC use, and 15 studies reported the preferred LARC method among healthcare workers and women. ...
... In 20 studies, the number of healthcare providers that received training in LARC (n = 4942) was reported, whereas eight studies did not report the number of providers that received training. 20 17,18,[20][21][22][23][24]27,29,32,35,37,[39][40][41][42]44 Our primary outcome of interest, end-use of LARC, was reported in all 28 included studies, and was measured as (1) change in uptake of LARC -including number of women choosing LARC to be their first method of contraception as well as women switching to LARC from a different method [18][19][20]24,25,[27][28][29][30][31][32][35][36][37][38][39][40][41][42][43][44] ; and (2) change in IUD uptake specifically -including postpartum intrauterine devices. 17,[21][22][23]26,33,34 No studies reported the number of unintended pregnancies at 12 months after initiating LARC use, and 15 studies reported the preferred LARC method among healthcare workers and women. ...
... 17,[21][22][23]26,33,34 No studies reported the number of unintended pregnancies at 12 months after initiating LARC use, and 15 studies reported the preferred LARC method among healthcare workers and women. 19,20,25,[27][28][29][30][31][32]36,38,[40][41][42][43] Uptake of other contraceptives was measured in 19 studies, including use of SARC methods, 19,24,27,28,31,32,37,[39][40][41] overall users of family planning methods 18,25,30,[32][33][34][36][37][38]40,41,43,44 and users of oral contraceptives specifically. 27,28,30,31,41 Of the included studies, 89% found an increased uptake of LARC methods (n = 24 cohort + 1 randomized control trial/ 28), 17,19,21,[23][24][25][27][28][29][30][31][32][33][34][37][38][39][40][41][42]44 whereas 11% of the studies found a decreased or unchanged LARC uptake (n = 3/28) 20,26,35 after training of healthcare providers ( Table 1). ...
Introduction:
Unintended pregnancy, a major global health issue resulting in unsafe abortions and maternal deaths in low- and middle-income countries, could be significantly reduced through increased use of modern contraception, including long-acting reversible contraceptives (LARC). Training of healthcare providers to administer such contraceptives may improve uptake. We conducted a systematic review to collate the end-user uptake data following training of health care providers in low- and middle-income countries.
Material and methods:
We searched PubMed, Embase, the Global Health Library, and the Cochrane Library up to 23 May 2020. The review was restricted to low- and middle-income countries and focused on healthcare providers who had received training in LARC. Studies that reported contraceptive uptake among women, preference of LARC amongst health care workers and/or women, and unplanned pregnancies within 12 months of LARC initiation were included. All included studies underwent quality assessment using either the Cochrane's risk of bias tool or the Newcastle-Ottawa Scale. PROSPERO registration number CRD42020185291.
Results:
A total of 28 studies (end-users n= 6.112.544) were included (27 cohort studies and one randomised trial). 19 studies were set in Africa, 5 in Asia, one in Central America and 4 were multi-country studies. 28 studies reported LARC use among women, and 25 studies found an increase in uptake of LARC either by women using short acting methods switching to longer acting methods or by recruiting new users of LARC. The randomised controlled trial was assessed as high quality and reported positive findings, however there was great heterogeneity in the type of intervention and of how outcomes were measured amongst the other included studies. Further, the quality of these studies varied, although it should be noted that the poor quality studies reflected the trends of those of higher quality.
Conclusions:
Despite heterogeneity, current evidence indicates that training of healthcare providers in LARC may increase the uptake amongst women in low- and middle-income countries. More robust studies are warranted to inform policy.
... In recent years, U.S. adolescents and adults have had greater access to more highly effective contraceptive options, including long-acting reversible contraceptive (LARC) methods (e.g., intrauterine devices (IUDs), implants); this access has been attributed both to the implementation of the Affordable Care Act as well as to dedicated contraceptive programs and healthcare provider training (Comfort et al., 2021;El Ayadi et al., 2017;MacCallum-Bridges & Margerison, 2020). Accordingly, U.S. women report increased use of LARCs (Daniels et al., 2015;Finer et al., 2012;Kavanaugh et al., 2015;Mosher et al., 2016), similar to patterns observed in some other countries, such as Australia, the Netherlands, Sweden, and some parts of rural Ethiopia (Grzeskowiak et al., 2021;Hellstr€ om et al., 2019;Marra et al., 2020;Zerfu et al., 2018). Also according to NSFG data, the 12-month probability of contraceptive failure has declined from 14.9 in 1995 to 10.3 in 2010 (Sundaram et al., 2017). ...
Objectives:
To examine changes over time in event-level condom/contraceptive use and the association between past year penile-vaginal intercourse frequency and event-level condom/contraceptive use.
Methods:
Data were from the 2009 and 2018 National Survey of Sexual Health and Behavior, an online probability survey of U.S. adolescents and adults.
Results:
Use of condoms and highly effective hormonal contraceptives decreased while long-acting reversible contraceptive use increased from 2009 to 2018 among adults. Increased penile-vaginal intercourse frequency was associated with decreased use of most contraceptive methods but an increase in condom use for adolescents.
Conclusions:
Sexual frequency should be considered when assessing condom/contraceptive use.
... In Ethiopia, 44% of sites assessed indicated that LARC was available along with other options [30]. When availability was coupled with capacity building to nurse providers, method uptake among new users and method shift improved [31][32][33]. Method shift was well demonstrated in the present study where both capacity building and the availability of equipment and supplies were ensured. ...
Background: Modern family planning uptake in Ethiopia, primarily short-acting injectables, has increased after the engagement of community health extension workers (HEWs). The aim of this study was to investigate the effectiveness of using Level IV health extension workers to deliver long-acting reversible contraceptives (LARCs) at the community level.
Methods: A retrospective cohort study design was used to recruit 710 women who received LARC insertion services at pilot health posts within eight months before survey time. The interviewer administered a data collection tool to collect the required data through a house-to-house survey. The questionnaire had sections covering demographic and socioeconomic characteristics, reproductive history, use of family planning methods, knowledge about LARC methods (i.e., IUCD and Implanon), and service satisfaction. Descriptive statistics were used to analyze data. Chi-square test was used to identify the determinants of LARC use.
Results: Out of 702 LARC users included in the study, 92.7% received services from Level IV HEWs. The median age of clients was 30 years (IQR: 25–35), 92.7% were married, and 22.6% were new family planning users (75% Implanon users and 19.4% Jaddelle users). Of the aggregated variables, 67.38% had good knowledge of LARC, 92.28% had positive attitudes in availing services at health posts, and 92.76% was the satisfaction score of clients. New users tended to be young, Muslim, less likely to want more children, and more likely to decide on contraception on their own.
At eight months post insertion, LARC use was effective in preventing pregnancy (99.7%) with low removal (n = 36, 5.1%) and expulsion rates (n = 1, 0.1%). No infection was reported. The major reasons for removal were side effects and the desire to have children. Client knowledge, attitude, and satisfaction were found to be high.
In conclusion, trained Level IV HEWs provided LARCs safely and effectively at the health post level as an alternative service delivery outlet.
Purpose:
Appreciating user differences in contraceptive sources is essential for improving contraceptive access and safeguarding an equitable and sustainable future. Therefore, this study explored whether urban residence and individual wealth are associated with where women access contraception (e.g., government, private, or nongovernmental organization provider) and assessed whether these associations are modified by the income level in the respondents' country of residence.
Methods:
We analyzed the cross-sectional data of Demographic Health Surveys conducted between 2009 and 2020 in 25 countries. The final data set included 25,081 young women aged between 15 and 24 years who are using contraceptives. Multinomial logistic regression models were established to assess the associations of our outcome variable, namely, various contraceptive sources, with our main independent variables, namely, urban residence and wealth index. We also assessed the potential effect modification by country income level on the above associations.
Results:
We observed obvious urban-rural and rich-poor disparities in odds of using contraceptive sources. Generally, living in urban residences and being wealthy were positively associated with all sources of contraceptives. However, these associations were mostly modified by country income level. People living in urban residences utilized more private sources, especially in low-income (beta coefficient, B = 0.973) and upper-middle-income countries (B = 1.361). Young women in urban areas across all analyzed countries were also more likely to use contraceptives from other sources (B = 0.267). In addition, women from poor households were less likely to use private sources (B = -1.166) and other sources (B = -0.547).
Discussion:
Even though young women may prefer private sources of contraceptives due to their confidentiality and flexible hours, these sources carry more benefits for rich and urban young women than for poor and rural women. The differential accessibility and affordability may account for the observed urban-rural and rich-poor disparities in using contraceptive sources, respectively, and the income level of a country is likely to modify such disparities.
Objective
The objective of this study was to evaluate the role of public-sector family planning program impact scores and other country-level factors on LARC use among young women aged 15-24.
Study design
We conducted this research using a large population database covering several decades’ worth of multi-wave cross-sectional samples of the demographic health survey (DHS) and the World Bank website data. We carried out a multi-level analysis on data from 1990 to 2019 from 22 Sub-Saharan African countries, with 163,242 participants.
Results
We found LARC use was at 3.1% of all young women under study. Sierra Leone, 2019 survey had the highest LARC use at 21,961 per 100,000. A 10% increase in public-sector family planning program impact scores was positively associated with LARC use with odds ratio of 1.44, 95% CI, 1.43- 1.45). We also noted that a 1% increase in HIV prevalence was associated with a reduced odds ratio of LARC use at 0.75 (95% CI, 0.70-0.81).
Conclusions
Findings from this study provide empirical evidence highlighting the importance of country-level factors in influencing LARC use among young women in sub-Saharan Africa
Implications
For young women in Africa, policymakers need to increase their effort on national family planning programs especially in the public sector. Broader societal level interventions to improve LARC use are required. Specific interventions must address the complexities of HIV prevention and LARC use to benefit young women living in countries with a high HIV prevalence.
Poverty and Food insecurity are the greatest challenges facing Ethiopia today. This study was motivated by the belief that there are various bundles of factors that have contributed for the prevalence of poverty and food insecurity with particular reference to two Peasant Associations. I also examine the extent to which poverty and food insecurity are interrelated. The study found out that the majority of the respondents were dependent on cash crops, were poor and food insecure. Poverty and food insecurity are found to be the two sides of the same coin. Both natural and human factors were identified as causes of poverty and different coping and survival strategies were also pointed out.
Background:
Low coverage of Skilled Birth Attendance (SBA) is one of the major drivers of maternal mortality in many low- and middle-income countries (LMICs) including Ethiopia. We conducted a cluster-randomized controlled community trial to assess the effect of deploying trained community based nurses to rural communities on the uptake levels of SBA in Ethiopia.
Methods:
A three-arm, parallel groups, cluster-randomized community trial was conducted to assess the effect of deploying trained community based reproductive health nurses (CORN) on the uptake of SBA services. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where these new service providers were deployed, a health post (HP) or health center (HC). Baseline and end line surveys were conducted to document and measure the effects of the intervention. Program impacts on SBA coverage were calculated using difference-in-difference (DID) analysis.
Results:
After nine months of intervention, the coverage of SBA services increased significantly by 81.1% (from 24.61 to 44.59) in the HP based intervention arm, and by 122.9% (from 16.41 to 36.59) in the HC arm, respectively (p <0.01). Conversely, a small and non-significant (2%) decline in SBA coverage were observed in the control arm (P >0.05). The DID estimate indicated a net increase in SBA coverage of 21.32 and 20.52 percentage points (PP) across the HP and HC based intervention arms, respectively (p < 0.001).
Conclusions:
Deployment of trained reproductive health nurses to rural communities in Ethiopia significantly improved utilization of SBA services. Therefore; in similar low income settings where coverage of SBA services is very low, deployment of trained community based nurses to grassroots level could potentiate rapid service uptake. Additional cost-effectiveness and validation studies at various setups are required, before scale-up of the innovation, however.
Trial registration:
clinicaltrails.gov NCT02501252.
Background
Improving use of family planning services is key to improving maternal health in Africa, and provision of quality of care in family planning services is critical to support higher levels of contraceptive uptake. The objective of this systematic review was to synthesize the available evidence on factors determining the quality of care in family planning services in Africa.
Methods
Quantitative and qualitative studies undertaken in Africa, published in English, in grey and commercial literature, between 1990 and 2015 were considered. Methodological quality of included studies was assessed using standardized tools. Findings from the quantitative studies were summarized using narrative and tables. Client satisfaction was used to assess the quality of care in family planning services in the quantitative component of the review. Meta-aggregation was used to synthesize the qualitative study findings.
Results
From 4334 records, 11 studies (eight quantitative, three qualitative) met the review eligibility criteria. The review found that quality of care was influenced by client, provider and facility factors, and structural and process aspects of the facilities. Client's waiting time, provider competency, provision/prescription of injectable methods, maintaining privacy and confidentiality were the most commonly identified process factors. The quality of stock inventory was the most commonly identified structural factor. The quality of care was also
positively associated with privately-owned facilities. The qualitative synthesis revealed additional factors including access related factors such as pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers' behaviour.
Conclusion
There is limited evidence on factors determining quality of care in family planning services in Africa that shows quality of care is influenced by multiple factors. The evidence suggests that lowering access barriers and avoiding unnecessary pre-requisites for taking contraceptive methods are important to improve the quality of care in family planning services. Strategies to improve provider behavior and competency are important. Moreover, strategies that minimize client waiting time and ensure client confidentiality should be implemented to ensure quality of care in family planning services. However, no strong evidence based conclusions
and recommendations may be drawn from the evidence. Future studies are needed to identify the most important factors associated with quality of care in family planning services in a wider range of African countries.
Background
To broaden access to family planning in rural areas and improve contraceptive prevalence, Senegal, in the context of wide method choice, is promoting implants and the intrauterine device, currently used throughout the country by only 5.6% of women of reproductive age who are in union, primarily urban women.
Methods
The TutoratPlus performance improvement approach strengthens family planning clinical skills, particularly for long-acting reversible contraceptives (LARCs), through mentoring, task sharing, and community outreach. Following a 2013 baseline situation analysis, 290 participating facilities in 12 of Senegal's 14 regions developed action plans to address gaps identified in 3 areas: provider performance, equipment, and infrastructure. Between 2013 and 2014, 85 trained mentors coached, demonstrated skills, and observed 857 providers, including nurses, nonclinical family planning counselors, and community health workers (CHWs), in LARC service provision through two 5-day visits per facility at 21-day intervals. We used routine service delivery data and TutoratPlus mentoring data to assess changes in contraceptive use, including LARCs, 6 months before and 6 months after the mentoring intervention among 100 of the facilities with complete data.
Results
The baseline assessment of 290 facilities found that fewer than half (47%) had a provider who could offer at least 1 LARC method, and 64% to 69% lacked kits. Post-intervention, all 290 facilities were adequately equipped and clinically able to offer LARCs. Among the 552 clinical providers, the percentage with acceptable LARC performance (at least 80% of observation checklist items correct) doubled from 32% to 67% over the 2 mentoring visits. In the 100 facilities with available comparison data, the number of new LARC users rose from 1,552 to 2,879 in the 6 months pre- and post-intervention—an 86% increase.
Conclusion
Success of the TutoratPlus approach in Senegal is likely in part attributable to addressing facility-specific needs, using on-site mentoring to assess provider capacity, and achieving workplace enhancements through community engagement. Without CHW-initiated community outreach, LARC uptake might have been lower. Although task sharing requires institutionalization within national health systems, TutoratPlus demonstrates that provider skills can be improved, facilities can be better equipped, and demand can be promoted using existing government and community resources.
Background
Long-acting reversible contraceptives (LARCs) are safe and highly effective, and they have higher continuation rates than short-acting methods. Because only a small percentage of sexually active women in Kenya use LARCs, the Tupange project implemented a multifaceted approach to increase uptake of LARCs, particularly among the urban poor. The project included on-site mentoring, whole-site orientation, commodity security, quality improvement, and multiple demand-promotion and service-provision strategies, in the context of wide method choice. We report on activities in Nairobi between July 2011 and December 2014, the project implementation period.
Methods
We used a household longitudinal survey of women of reproductive age to measure changes in the contraceptive prevalence rate (CPR) and other family planning-related variables. At baseline in July 2010, 2,676 women were interviewed; about 50% were successfully tracked and interviewed at endline in December 2014. A baseline service delivery point (SDP) survey of 112 health facilities and 303 service providers was conducted in July 2011, and an endline SDP survey was conducted in December 2014 to measure facility-based interventions. The SDP baseline survey was conducted after the household survey, as facilities were selected based on where clients said they obtained services.
Results
The project led to significant increases in use of implants and intrauterine devices (IUDs). Uptake of implants increased by 6.5 percentage points, from 2.4% at baseline to 8.9% by endline, and uptake of IUDs increased by 2.1 percentage points, from 2.2% to 4.3%. By the endline survey, 37.7% of clients using pills and injectables at baseline had switched to LARCs. Contraceptive use among the poorest and poor wealth quintiles increased by 20.5 and 21.5 percentage points, respectively, from baseline to endline. Various myths and misconceptions reported about family planning methods declined significantly between baseline and endline.
Conclusion
Training, commodity security, multiple service delivery models, and demand promotion were the cornerstones of a successful approach to reach the urban poor in Nairobi with LARCs.
In conflict-affected states, vouchers have reduced barriers to reproductive health services and have enabled health programs to use targeted subsidies to increase uptake of specific health services. Vouchers can also be used to channel funds to public- and private-service providers and improve service quality. The Yamaan Foundation for Health and Social Development in Yemen and the Marie Stopes Society (MSS) in Pakistan—both working with Options Consultancy Services—have developed voucher programs that subsidize voluntary access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs) of family planning in their respective fragile countries. The programs focus on LARCs and PMs because these methods are particularly difficult for poor women to access due to their cost and to provider biases against offering them. Using estimates of expected voluntary uptake of LARCs and PMs for 2014 based on contraceptive prevalence rates, and comparing these with uptake of LARCs and PMs through the voucher programs, we show the substantial increase in service utilization that vouchers can enable by contributing to an expanded method choice. In the governorate of Lahj, Yemen, vouchers for family planning led to an estimated 38% increase in 2014 over the expected use of LARCs and PMs (720 vs. 521 expected). We applied the same approach in 13 districts of Punjab, Khyber Pakhtunkhwa (KPK), and Sindh provinces in Pakistan. Our calculations suggest that vouchers enabled 10 times more women than expected to choose LARCs and PMs in 2014 in those areas of Pakistan (73,639 vs. 6,455 expected). Voucher programs can promote and maintain access to family planning services where existing health systems are hampered. Vouchers are a flexible financing approach that enable expansion of contraceptive choice and the inclusion of the private sector in service delivery to the poor. They can keep financial resources flowing where the public sector is prevented from offering services, and ensure that alternative sources are available for reproductive health services such as family planning. Programs should consider using vouchers in fragile states to facilitate access to family planning services and support the countries’ health systems.
Objective
This article evaluates the use of modern contraceptives among poor women exposed to a family planning voucher program in Cambodia, with a particular focus on the uptake of long-acting reversible contraceptives (LARCs).
Methods
We used a quasi-experimental study design and data from before-and-after intervention cross-sectional household surveys (conducted in 2011 and 2013) in 9 voucher program districts in Kampong Thom, Kampot, and Prey Veng provinces, as well as 9 comparison districts in neighboring provinces, to evaluate changes in use of modern contraceptives and particularly LARCs in the 12 months preceding each survey. Survey participants in the analytical sample were currently married, non-pregnant women ages 18 to 45 years (N = 1,936 at baseline; N = 1,986 at endline). Difference-in-differences (DID) analyses were used to examine the impact of the family planning voucher.
Results
Modern contraceptive use increased in both intervention and control areas between baseline and endline: in intervention areas, from 22.4% to 31.6%, and in control areas, from 25.2% to 31.0%. LARC use also increased significantly between baseline and endline in both intervention (from 1.4% to 6.7%) and control (from 1.9% to 3.5%) areas, but the increase in LARC use was 3.7 percentage points greater in the intervention area than in the control area (P = .002), suggesting a positive and significant association of the voucher program with LARC use. The greatest increases occurred among the poorest and least educated women.
Conclusion
A family planning voucher program can increase access to and use of more effective long-acting methods among the poor by reducing financial and information barriers.
Background
The long acting and permanent contraceptive methods (LAPCMs) has not used unlike that of short-acting methods in Ethiopia. Ethiopia is the second most populous country in Sub Saharan Africa with a high total fertility rate, and high maternal and child mortality rates. This study summarized the evidence of practice and intention to use long acting and permanent family planning methods among women in Ethiopia using systemic review and meta-analysis.
Methods
A systematic review and meta-analysis of the published and unpublished observational studies were conducted. Original studies were identified using databases of Medline/Pubmed, and Google Scholar. Heterogeneity across studies was checked using Cochrane Q test statistic and I2test. The pooled proportion of intention to use and the practice of long acting and permanent contraceptive methods were computed using a/the random effect model.
Results
Based on the ten observational studies included in the meta-analysis, the pooled prevalence of intention to use long acting and permanent contraceptive methods among married women according to the random effect model was 42.98 % (95 % CI 32.53, 53.27 %). On the other hand, the pooled practice of long acting and permanent methods of contraceptive among the study participants was 16.64 % (95 % CI 12.4 to 20.87 %).
Conclusion
This meta-analysis revealed that women’s intention to use LAPCMs is generally good but their utilization is low. It is recommended, therefore, that LAPMCs must be made more readily available and accessible to women at the lower level of health service delivery who are in need of it.