A COMPREHENSIVE INTERVENTION MODEL TO IMPROVE POST -PARTUM IUD SERVICES IN GOVERNMENT FACILITIES IN KIGALI, RWANDA DR. ROSINE INGABIRE ETIENNE KARITA, ROSINE INGABIRE, JULIEN NYOMBAYIRE, ALEXANDRA HOAGLAND, VANESSA DA COSTA, AMELIA MAZZEI, LISA HADDAD, RACHEL PARKER, ROBERTINE SINABAMENYE, JEANNINE MUKAMUYANGO, JULIE SMITH, VICTORIA UMUTONI, ELLEN. MORK, SUSAN ALLEN, KRISTIN WALL RWANDA ZAMBIA HIV RESEARCH GROUP
CONFLICTS OF INTEREST The co-authors have no conflicts of interest to declare.
BACKGROUND AND OBJECTIVE The copper intrauterine device (IUD) is one of the most safe, effective, and cost-effective contraceptive methods Can be used during post-partum periods irrespective of breastfeeding User-independent and improves birth spacing to reduce maternal-child mortality Remains highly underutilized throughout Africa Objective : To develop a multi-level intervention targeting supply, demand, and sustainability to increase uptake of the post- partum IUD (PPIUD) up to 6 weeks after delivery in Kigali, Rwanda
METHODS Government facilities : 2 high-volume hospitals and 2 health centers selected for promotions and service delivery PPIUD promotions : Formative work informed development of a PPIUD educational flipchart which is delivered: In-clinic (antenatal care (ANC), labor and delivery (L&D), or infant vaccination) In the community by community health workers L&D and family planning nurse PPIUD training: 2-day didactic counseling, insertion/removal, and follow-up training (led by National PPIUD Trainers) Mentored practicum certification process Reimbursements: for facilities, successful community promotions, providers for insertions, and client follow-up transportation
RESULTS Two hospitals (with one associated health center) and two health centers were selected From August 2017- APR 2019, we trained: 108 PPIUD promoters (clinic staff and CHWs) 45 PPIUD providers (29 midwives and 16 nurses) Group PPIUD promotions were followed by one-on-one promotions for those interested in family planning Only one-on-one promotions were recorded
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019 ) Among women promoted Muhima to who delivered Kacyiru Remera Kinyinya Hospital T otal (N = 13,512) Hospital HC HC and HC Promotions during: Antenatal care 21% 4% 52% 50% 29% L&D 25% 40% 17% 11% 24% Post-partum 50% 56% 12% 16% 37% Infant vaccination visit 4% 0% 20% 23% 10% N=13,512 women received PPIUD promotions who later delivered.
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019) Among women promoted Muhima to who delivered Kacyiru Remera Kinyinya Hospital T otal (N = 13,512) Hospital HC HC and HC Promotions during: Antenatal care 21% 4% 52% 50% 29% L&D 25% 40% 17% 11% 24% Post-partum 50% 56% 12% 16% 37% Infant vaccination visit 4% 0% 20% 23% 10% Most promotions occurred in the post-partum ward (37%) and ANC (29%)
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019 ) Among women promoted Muhima to who delivered Kacyiru Remera Kinyinya Hospital T otal (N = 13,512) Hospital HC HC and HC Promotions during: Antenatal care 21% 4% 52% 50% 29% L&D 25% 40% 17% 11% 24% Post-partum 50% 56% 12% 16% 37% Infant vaccination visit 4% 0% 20% 23% 10% Variability across facilities in terms of when promotions were delivered
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019 ) Among women promoted Muhima to who delivered Kacyiru Remera Kinyinya Hospital T otal (N = 13,512) Hospital HC HC and HC Promotions during: Antenatal care 21% 4% 52% 50% 29% L&D 25% 40% 17% 11% 24% Post-partum 50% 56% 12% 16% 37% Infant vaccination visit 4% 0% 20% 23% 10% Of the 13512 women, n=4175 had PPIUDs inserted (31% uptake). Hospitals had higher uptake.
PPIUD INSERTIONS OVER TIME BY FACILITY (N = 4175 TOTAL PPIUD INSERTIONS) PBF-Incentives and training of CHW promoters began 400 7 providers on 350 annual or maternity leave ↓ 300 Temporary stock PPIUD Insertions 250 out of IUD Trainings/ANC, L&D, and IV promotions 200 began ↓ 150 100 50 0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 17 17 17 17 17 17 17 17 17 17 17 18 18 18 18 18 18 18 18 18 18 18 18 19 19 19 19 Muhima Hospital Kacyiru Hospital Remera Kinyinya Overall and and Health Center Health Center PPIUD Health Center Health Center
PPIUD INSERTIONS OVER TIME BY FACILITY (N = 4175 TOTAL PPIUD INSERTIONS) 6-months before the 20-months after the pilot: pilot: 45 PPIUD providers o 2 PPIUD providers o 4175 PPIUDs inserted (208.75/month) o 46 PPIUDs inserted o (7.7/month) 400 350 300 2622.8% increase PPIUD Insertions 250 200 150 100 50 0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 17 17 17 17 17 17 17 17 17 17 17 18 18 18 18 18 18 18 18 18 18 18 18 19 19 19 19 Muhima Hospital Kacyiru Hospital Remera Kinyinya Overall and and Health Center Health Center PPIUD Health Center Health Center
PPIUD INSERTIONS OVER TIME BY INSERTION TIMING (N = 4175 TOTAL PPIUD INSERTIONS) 400 373 317 307 350 275 300 230 228 223 PPIUD Insertions 218 218 250 212 201 199 186 169 200 165 146 131 121 117 150 91 100 50 50 0 Aug Sep Oct 17 Nov Dec Jan 18 Feb Mar Apr 18 May Jun 18 Jul 18 Aug Sep Oct 18 Nov Dec Jan 19 Feb Mar Apr 19 17 17 17 17 18 18 18 18 18 18 18 19 19 Post-Placental 10 mins - 48 hrs 4 - 6 weeks Intra-cesarean Post-abortion Total o 60% inserted within 10 minutes of delivery of the placenta o 14% between 10 minutes and 48 hours after delivery o 15% intra-cesarean o 9% between 4 and 6 weeks after delivery o 2% post-abortion
PPIUD INSERTION OUTCOMES (AUG 2017- APR 2019) Muhima Women receiving a Kacyiru Remera Kinyinya Hospital T otal PPIUD insertion Hospital HC HC and HC (N = 4175) Mean Mean Mean Mean Mean Age 28.2 28.5 27.7 27.4 27.9 Parity 2 2.4 2.5 2 2.2 Provider: ease of insertion* 9.6 8.5 9.7 9.8 9.4 Patient: anxiety during insertion* 1 2 2.7 1.1 1.7 Patient: pain during 1.1 2.4 2.6 1.0 1.8 insertion* *From a score of 1-10
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019) Muhima Women attending PPIUD Kacyiru Remera Kinyinya Hospital T otal follow-up (N = 2525) Hospital HC HC and HC Expulsion 7% 4% 2% 4% 5% Infection 0.5% 0.2% 0% 0% 0.3% Failure 0% 0% 0% 0% 0% Removal 2% 2% 1.2% 1.1% 1.5% Patient PPIUD satisfaction 9.8 9.9 10.0 9.9 9.9 PPIUD (mean)* 60% of women with expulsions had an IUD reinserted; 11% had an implant inserted *From a score of 1-10
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019) Muhima Women attending PPIUD Kacyiru Remera Kinyinya Hospital T otal follow-up (N = 2525) Hospital HC HC and HC Expulsion 7% 4% 2% 4% 5% Infection 0.5% 0.2% 0% 0% 0.3% Failure 0% 0% 0% 0% 0% Removal 2% 2% 1.2% 1.1% 1.5% Patient PPIUD satisfaction 9.8 9.9 10.0 9.9 9.9 PPIUD (mean)* *From a score of 1-10
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019) Muhima Women attending PPIUD Kacyiru Remera Kinyinya Hospital T otal follow-up (N = 2525) Hospital HC HC and HC Expulsion 7% 4% 2% 4% 5% Infection 0.5% 0.2% 0% 0% 0.3% Failure 0% 0% 0% 0% 0% Removal 2% 2% 1.2% 1.1% 1.5% Patient PPIUD satisfaction 9.8 9.9 10.0 9.9 9.9 PPIUD (mean)* 31% of the N=12 removals were due to the male partner not liking the method *From a score of 1-10
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019) Muhima Women attending PPIUD Kacyiru Remera Kinyinya Hospital T otal follow-up (N = 2525) Hospital HC HC and HC Expulsion 7% 4% 2% 4% 5% Infection 0.5% 0.2% 0% 0% 0.3% Failure 0% 0% 0% 0% 0% Removal 2% 2% 1.2% 1.1% 1.5% Patient PPIUD satisfaction 9.8 9.9 10.0 9.9 9.9 PPIUD (mean)* *From a score of 1-10
LIMITATIONS Group promotions in busy ANC, L&D, and infant vaccination limited the number of women receiving subsequent one-on-one counseling to those interested in family planning. Hospitals received referrals of high-risk cases from non-participating clinics. Many of those PPIUD clients did not return to one of our selected health facilities for follow-up. By operating in 2 health centers, pregnant women interested in PPIUDs during ANC promotions are not guaranteed to return to the same facility for delivery. This results in not capturing a PPIUD insertion if done at a non-study site. Though it is not possible to rule out the effect of secular changes with a pre-post design, no other programs were taking place in the capital.
PROGRAM IMPLICATIONS Supply Demonstrated feasibility to train government staff to deliver consistent, quality PPIUD services that are adaptable with workloads. Staff turnover and leave was a challenge, and new and refresher trainings will be needed over longer timeframes. Demand Demand generated by both in-clinic counseling as well as by CHWs. In future studies, we will expand CHW and couple-focused promotions and conduct comparative effectiveness studies of promotional strategies.
Recommend
More recommend
