What Have We Learned? Implementation of a Shared Learning Agenda and Access Strategy for the Hormonal Intrauterine Device.

In 2015, a global learning agenda for the hormonal intrauterine device (IUD) was developed with priority research questions regarding use of the method in low- and middle-income countries. In addition, members of the Hormonal IUD Access Group aligned on a strategy to expand access in the context of volunteerism and contraceptive method choice. This article synthesizes evidence generated since then and describes steps taken to address demand- and supply-side barriers to access. Findings demonstrated high continuation rates and satisfaction among hormonal IUD users that are comparable to other long-acting reversible contraceptives (LARCs). Across studies, a sizable number of users reported they would have chosen a short-acting method or no method at all if the hormonal IUD were not an option, which suggests that women did not see the hormonal IUD as interchangeable with other LARC options and thus it may fill an important niche in the market. With several countries now poised to scale up the method, resource mobilization will be key. On the demand side, investments in implementation research will be critical to understanding how best to launch and scale the method, while ensuring the sustainability of multiple quality-assured suppliers with affordable public-sector pricing will be necessary on the supply side.

Expanding Contraceptive Method Choice With a Hormonal Intrauterine System: Results From Mixed Methods Studies in Kenya and Zambia.

INTRODUCTION: Few women in low- and middle-income countries have access to the hormonal intrauterine system (IUS). Past research from a small number of facilities and the private sector suggest the IUS could be an important addition to the contraceptive method mix because it is the only long-acting method some women will adopt and users report high satisfaction and continuation. We aimed to determine whether these promising results were applicable in public facilities in Kenya and Zambia. METHODS: We used a mixed-methods approach with program monitoring data, interviews with women who received an IUS, and qualitative focus group discussions with providers. Data were collected in 2017-2019. RESULTS: Facilities in Kenya and Zambia reported 1,985 and 428 IUS insertions, respectively. If the IUS had not been available, 30% of adopters would have chosen a short-acting method. Women and providers gave diverse reasons for adopting the IUS, with the desire for fewer side effects being frequently mentioned in focus group discussions. Many IUS adopters first heard of the method on the day it was inserted (70% in Kenya, 47% in Zambia), yet providers reported that many women were unwilling to try a method they were just hearing about for the first time. Satisfaction and continuation were high: 86% of adopters in Kenya were still using the method 3-6 months after insertion and 78% were in Zambia (average 10 months post insertion). Providers also reported that most IUS adopters were satisfied; they rarely returned with complaints that could not be addressed with additional counseling. CONCLUSION: Expanding IUS access through the public sector shows promise to increase contraception use and continuation in low- and middle-income countries. Efforts to strengthen availability should consider demand and engage directly with various communities, including youth, around availability of a new long-acting option.

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya.

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women's tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services.

Characteristics of successful integrated family planning and maternal and child health services: Findings from a mixed-method, descriptive evaluation.

Background: Most postpartum women in low- and middle-income countries want to delay or avoid future pregnancies but are not using modern contraception. One promising strategy for increasing the use of postpartum family planning (PPFP) is integration with maternal, newborn and child health (MNCH) services. However, there is limited evidence on effective service integration strategies. We examine facilitators of and barriers to effective PPFP integration in MNCH services in Kenya and India.   Methods: We conducted a cross-sectional, mixed-method study in two counties in Kenya and two states in India. Data collection included surveying 215 MNCH clients and surveying or interviewing 82 health care providers and managers in 15 health facilities across the four sites. We analyzed data from each country separately. First, we analyzed quantitative data to assess the extent to which PPFP was integrated within MNCH services at each facility. Then we analyzed qualitative data and synthesized findings from both data sources to identify characteristics of well and poorly integrated facilities. Results: PPFP integration success varied by service delivery area, health facility, and country. Issues influencing the extent of integration included availability of physical space for PPFP services, health workforce composition and capacity, family planning commodities availability, duration and nature of support provided. Conclusions: Although integration level varied between health facilities, factors enabling and hindering PPFP integration were similar in India and Kenya. Better measures are needed to verify whether services are integrated as prescribed by national policies.

Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya.

BACKGROUND: Sub-Saharan Africa bears the greatest burden of cervical cancer. Human papillomavirus (HPV) vaccination programmes to prevent the disease will need to reach vulnerable girls who may not be able access health and screening services in the future. We conducted formative research on facilitators and barriers to HPV vaccination and potential acceptability of a future HPV vaccination programme amongst girls living in hard-to-reach populations in Kenya. METHODS: Stakeholder interviews with Ministry of Health staff explored barriers to and support for the uptake of HPV vaccination. A situation assessment was conducted to assess community services in Maasai nomadic pastoralist communities in Kajiado County and in Korogocho informal settlement in Nairobi city, followed by focus group discussions (n=14) and semi-structured interviews (n=28) with health workers, parents, youth, and community and religious leaders. These covered marriage, knowledge of cervical cancer and HPV, factors that might inhibit or support HPV vaccine uptake and intention to accept HPV vaccine if a programme was in place. RESULTS: Reported challenges to an HPV vaccination programme included school absenteeism and drop-out, early age of sex and marriage, lack of parental support, population mobility and distance from services. Despite little prior knowledge of cervical cancer and HPV, communities were interested in receiving HPV vaccination. Adequate social mobilisation and school-based vaccination, supplemented by out-reach activities, were considered important facilitating factors to achieve high coverage. There was some support for a campaign approach to vaccine delivery. CONCLUSIONS: Given the high level of support for a vaccine against cervical cancer and the experience of reaching pastoralist and slum-dwellers for other immunizations, implementing an HPV vaccine programme should be feasible in such hard-to-reach communities. This may require additional delivery strategies in addition to the standard school-based delivery, with vaccine offered at multiple venues, potentially through a campaign approach.

Using Young Mothers' Clubs to Improve Knowledge of Postpartum Hemorrhage and Family Planning in Informal Settlements in Nairobi, Kenya.

Women living in Nairobi's informal settlements face a higher risk of maternal death than those living elsewhere in the country, and have limited knowledge of actions they can take to improve their chances of survival during pregnancy and childbirth. As one strategy to reach this high risk group, Jhpiego has implemented young mothers' clubs (YMCs). These clubs comprise mothers aged 18-30 who come together on a weekly basis to share experiences and solutions to their challenges while receiving health education from health facility staff and community health workers (CHWs). The aim of this study was to assess whether the YMC strategy could be used to improve participants' knowledge of postpartum hemorrhage (PPH), positive behavior around childbirth, and family planning. Participants in nine YMCs (n = 193) across four informal settlements were interviewed to assess their knowledge of safe motherhood topics before and after a series of eight health education sessions. Data were analyzed with the McNemar test to determine significance of change in knowledge pre- and post-intervention. The largest improvements were observed in knowledge about what to include in a birth plan, with correct responses increasing from 32 to 73% (p < 0.001), 58-93% (p < 0.001), 36-66% (p < 0.001), 58-85% (p < 0.001), and 64-88% (p < 0.001) for identifying a birth companion, budget, skilled birth attendant, emergency supplies, and place of birth, respectively. Less substantial improvements were observed in knowledge of danger signs of PPH (up 10% from 77%, p = 0.003). Although knowledge of actions to take in the event of bleeding after delivery did significantly improve, final knowledge scores remained low--knowledge to urinate increased from 14 to 28% (p < 0.001) and to breastfeed from 12 to 24% (p = 0.005). Even though the vast majority of respondents (84%) knew before the intervention that a woman should space pregnancy by at least 2 years after delivery, there was an increase to 94% after the sessions (p = 0.008). Overall, participants demonstrated significant improvements in knowledge of safe motherhood and family planning topics, suggesting that the materials and methods used were generally effective for improving knowledge among this high risk group.

Prevalence of human papillomavirus in women with invasive cervical carcinoma by HIV status in Kenya and South Africa.

Data on the prevalence of human papillomavirus (HPV) types in cervical carcinoma in women with HIV are scarce but are essential to elucidate the influence of immunity on the carcinogenicity of different HPV types, and the potential impact of prophylactic HPV vaccines in populations with high HIV prevalence. We conducted a multicentre case-case study in Kenya and South Africa. During 2007-2009, frozen tissue biopsies from women with cervical carcinoma were tested for HPV DNA using GP5+/6+-PCR assay. One hundred and six HIV-positive (mean age 40.8 years) and 129 HIV-negative women (mean age 45.7) with squamous cell carcinoma were included. Among HIV-positive women, the mean CD4 count was 334 cells/µL and 48.1% were on combined antiretroviral therapy. HIV-positive women had many more multiple HPV infections (21.6% of HPV-positive carcinomas) compared with HIV-negative women (3.3%) (p < 0.001) and the proportion of multiple infections was inversely related to CD4 level. An excess of HPV18 of borderline statistical significance was found in HIV-positive compared with HIV-negative cases (Prevalence ratio (PR) = 1.9, 95% confidence interval (CI): 1.0-3.7, adjusted for study centre, age and multiplicity of infection). HPV16 and/or 18 prevalence combined, however, was similar in HIV-positive (66.7%) and HIV-negative cases (69.1%) (PR = 1.0, 95% CI: 0.9-1.2). No significant difference was found for other HPV types. Our data suggest that current prophylactic HPV vaccines against HPV16 and 18 may prevent similar proportions of cervical SCC in HIV-positive as in HIV-negative women provided that vaccine-related protection is sustained after HIV infection.