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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

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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 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. ...
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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.
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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.
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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.
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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.
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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.
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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.