SLIDE 1 A COMPREHENSIVE INTERVENTION MODEL TO IMPROVE POST
GOVERNMENT FACILITIES IN KIGALI, RWANDA
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
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CONFLICTS OF INTEREST The co-authors have no conflicts of interest to declare.
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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
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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
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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
SLIDE 7 Among women promoted to who delivered (N = 13,512) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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)
SLIDE 8 Among women promoted to who delivered (N = 13,512) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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%
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019)
Most promotions occurred in the post-partum ward (37%) and ANC (29%)
SLIDE 9 Among women promoted to who delivered (N = 13,512) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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%
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019)
Variability across facilities in terms of when promotions were delivered
SLIDE 10 Among women promoted to who delivered (N = 13,512) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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%
PPIUD DEMAND CREATION AND SERVICE DELIVERY OUTCOMES (AUG 2017- APR 2019)
Of the 13512 women, n=4175 had PPIUDs inserted (31% uptake). Hospitals had higher uptake.
SLIDE 11 PPIUD INSERTIONS OVER TIME BY FACILITY (N = 4175 TOTAL PPIUD INSERTIONS)
50 100 150 200 250 300 350 400 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19
PPIUD Insertions
Muhima Hospital and Health Center Kacyiru Hospital and Health Center Remera Health Center Kinyinya Health Center Overall PPIUD
Trainings/ANC, L&D, and IV promotions began ↓ PBF-Incentives and training of CHW promoters began 7 providers on annual or maternity leave ↓ Temporary stock
SLIDE 12 PPIUD INSERTIONS OVER TIME BY FACILITY (N = 4175 TOTAL PPIUD INSERTIONS)
50 100 150 200 250 300 350 400 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19
PPIUD Insertions
Muhima Hospital and Health Center Kacyiru Hospital and Health Center Remera Health Center Kinyinya Health Center Overall PPIUD
6-months before the pilot:
- 2 PPIUD providers
- 46 PPIUDs inserted
(7.7/month)
20-months after the pilot:
- 45 PPIUD providers
- 4175 PPIUDs inserted (208.75/month)
2622.8% increase
SLIDE 13 PPIUD INSERTIONS OVER TIME BY INSERTION TIMING (N = 4175 TOTAL PPIUD INSERTIONS)
50 165 186 218 218 169 201 373 317 307 212 275 230 228 223 199 117 91 131 121 146
50 100 150 200 250 300 350 400 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19
PPIUD Insertions
Post-Placental 10 mins - 48 hrs 4 - 6 weeks Intra-cesarean Post-abortion Total
- 60% inserted within 10 minutes of delivery of the placenta
- 14% between 10 minutes and 48 hours after delivery
- 15% intra-cesarean
- 9% between 4 and 6 weeks after delivery
- 2% post-abortion
SLIDE 14 PPIUD INSERTION OUTCOMES (AUG 2017- APR 2019)
Women receiving a PPIUD insertion (N = 4175) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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 insertion* 1.1 2.4 2.6 1.0 1.8 *From a score of 1-10
SLIDE 15 PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019)
Women attending PPIUD follow-up (N = 2525) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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 PPIUD (mean)* 9.8 9.9 10.0 9.9 9.9 *From a score of 1-10 60% of women with expulsions had an IUD reinserted; 11% had an implant inserted
SLIDE 16 Women attending PPIUD follow-up (N = 2525) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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 PPIUD (mean)* 9.8 9.9 10.0 9.9 9.9
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019)
*From a score of 1-10
SLIDE 17 Women attending PPIUD follow-up (N = 2525) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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 PPIUD (mean)* 9.8 9.9 10.0 9.9 9.9
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019)
*From a score of 1-10 31% of the N=12 removals were due to the male partner not liking the method
SLIDE 18 Women attending PPIUD follow-up (N = 2525) Muhima Hospital and HC Kacyiru Hospital Remera HC Kinyinya HC T
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 PPIUD (mean)* 9.8 9.9 10.0 9.9 9.9
PPIUD FOLLOW-UP OUTCOMES (AUG 2017- APR 2019)
*From a score of 1-10
SLIDE 19 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.
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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.
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PROGRAM IMPLICATIONS
Service quality
Providers and users were highly satisfied with the services. Removals, expulsions, and infections were uncommon. Ongoing M&E is necessary to monitor these outcomes.
Reimbursements
PBF-type incentives appeared to increase uptake of PPIUDs. In current PBF structure, providers receive a flat rate for all methods provided
to new users, including the IUD (which takes more time and skill).
This could create a disincentive to providing IUDs. We are currently exploring stakeholder and policymaker perceptions of
restructuring reimbursements based on the skill and time it takes to provide a method.
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CONCLUSIONS
This successful, comprehensive intervention combining
demand creation and skilled supply has the potential to make a significant impact on PPIUD uptake in Rwanda.
We are planning to expand the service to other hospitals
and health centers in Kigali which could become training centers for other facilities.
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FUNDING AND PUBLICATION
Grant information: This work was supported by the Bill & Melinda Gates
Foundation [OPP1160661]. Additional support came from the Emory University Research Council Grant [URCGA16872456], Emory Global Field Experience Award, the Emory Center for AIDS Research [P30 AI050409], the National Institutes of Health [NIAID R01 AI51231; NIAID R01 AI64060; NIAID R37 AI51231], Centers for Disease Control and Prevention [CDC GH15-1616; 5NU2GGH001443], Emory AITRP Fogarty [5D43TW001042], and the International AIDS Vaccine Initiative (IAVI) [SOW2166] with the support of the United States Agency for International Development (USAID). The contents of this manuscript are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government.
Strong collaboration and support from our Ministry of Health as well as facility
directors.
Publication: Ingabire R, Nyombayire J, Hoagland A et al. Evaluation of a multi-level intervention to improve post-partum intrauterine device services in Rwanda [version 1]. Gates Open Res 2018, 2:38 (doi: 10.12688/gatesopenres.12854.1)
