There's an App for That: Exploring the Market for Contraceptive Fertility Tracking Apps in the Philippines.

For generations, women have relied on fertility awareness methods to plan and prevent pregnancy, for over a decade, many have been aided by digital tools to do so. New contraceptive fertility tracking apps (CFTAs)-that are backed by clinical efficacy trials to support their effectiveness as contraception-have the potential to enhance method choice and offer users a unique contraceptive option, but there is little evidence to inform the decisions around expanding access, particularly in low-and middle-income countries. We conducted a mixed methods study with quantitative online surveys (n = 1600) and qualitative interviews (n = 36) to explore the potential appeal of and demand for a hypothetical CFTA in one such market, the Philippines. Interest in using a CFTA was high among our Internet-engaged, urban study population, with 83.9% "definitely" or "probably" interested in using it. Across demographic profiles, respondents perceived the appeal of the method as "natural" and "convenient." A majority were willing to pay for the method, though notably at a price (5.20 USD) below that of currently available CFTAs. We discuss various important factors to be considered before bringing a method like this to new markets, including the potential implications of equity constraints in reaching a wider market and the unexpected prevalence of other period-tracking apps not intended as contraception being used in this market that could complicate any future roll-out. These issues could be explored further with additional research.

Preference-aligned fertility management among married adolescent girls in Northern Nigeria: assessing a new measure of contraceptive autonomy.

INTRODUCTION: Universal access to sexual and reproductive healthcare-including family planning (FP)-is a global priority, yet there is no standard outcome measure to evaluate rights-based FP programme performance at the regional, national or global levels. METHODS: We collected a modified version of preference-aligned fertility management (PFM), a newly proposed rights-based FP outcome measure which we operationalised as concordance between an individual's desired and actual current contraceptive use. We also constructed a modified version (satisfaction-adjusted PFM) that reclassified current contraceptive users who wanted to use contraception but who were dissatisfied with their method as not having PFM. Our analysis used data collected 3.5 months after contraceptive method initiation within an ongoing prospective cohort of married adolescent girls aged 15-19 years in Northern Nigeria. We described and compared prevalence of contraceptive use and PFM in this population. RESULTS: Ninety-seven per cent (n=1020/1056) of respondents were practising PFM 3.5 months after initiating modern contraception, while 93% (n=986/1056) were practising satisfaction-adjusted PFM. Among participants not practising satisfaction-adjusted PFM (n=70), most were using contraception but did not want to be (n=30/70, 43%) or wanted to use contraception but were dissatisfied with their method (n=34/70, 49%), while the remaining 9% (n=6/70) wanted but were not currently using contraception. CONCLUSION: PFM captured meaningful discordance between contraceptive use desires and behaviours in this cohort of married Nigerian adolescent girls. Observed discordance in both directions provides actionable insights for intervention. PFM is a promising rights-focused FP outcome measure that warrants future field-testing in programmatic and population-based research.

Assessing acceptability and effectiveness of a pleasure-oriented sexual and reproductive health chatbot in Kenya: an exploratory mixed-methods study.

Integrating pleasure may be a successful strategy for reaching young people with sexual and reproductive health and rights (SRHR) interventions. However, sexual pleasure-related programming and research remains sparse. We aimed to assess chatbot acceptability and describe changes in SRHR attitudes and behaviours among Kenyan young adults engaging with a pleasure-oriented SRHR chatbot. We used an exploratory mixed-methods study design. Between November 2021 and January 2022, participants completed a self-administered online questionnaire before and after chatbot engagement. In-depth phone interviews were conducted among a select group of participants after their initial chatbot engagement. Quantitative data were analysed using paired analyses and interviews were analysed using thematic content analysis. Of 301 baseline participants, 38% (115/301) completed the endline survey, with no measured baseline differences between participants who did and did not complete the endline survey. In-depth interviews were conducted among 41 participants. We observed higher satisfaction at endline vs. baseline on reported ability to exercise sexual rights (P ≤ 0.01), confidence discussing contraception (P ≤ 0.02) and sexual feelings/needs (P ≤ 0.001) with their sexual partner(s). Qualitative interviews indicated that most participants valued the chatbot as a confidential and free-of-judgment source of trustworthy "on-demand" SRHR information. Participants reported improvements in sex-positive communication with partners and safer sex practices due to new learnings from the chatbot. We observed increases in SRHR empowerment among young Kenyans after engagement with the chatbot. Integrating sexual pleasure into traditional SRHR content delivered through digital tools is a promising strategy to advance positive SRHR attitudes and practices among youth.

Missed opportunity for self-injectable contraception awareness and adoption: Insights from client exit interviews in Uganda and Nigeria.

Objectives: To assess the extent to which self-injection contraceptive information and services are provided to women in Uganda and Nigeria. Study design: We conducted a descriptive information cascade analysis using data from a cross-sectional exit interviews with 492 family planning clients in Uganda and 720 in Nigeria. Results: More than a third of respondents in Uganda (31.2%) and Nigeria (40.5%) reported not receiving any information about the self-injection contraceptive during service provision. Only 45.6% clients who adopted self-injected DMPA-SC in Uganda and 1.7% in Nigeria were issued with additional doses to take home. Conclusion: The findings suggest that there are missed opportunities to provide women with information and services on DMPA-SC self-injection. Implication: A contraceptive counseling and services cascade can be a useful tool for identifying gaps in the quality and person-centeredness of family planning services, and ultimately improving the experience of clients.

Task shifting and community engagement as the keys to increasing access to modern contraception: Findings from mixed methods operational research in coastal Kenya.

RATIONALE: Kilifi County, Kenya, has a modern contraceptive prevalence of 44%, compared to the national prevalence of 61%. In 2018, the Government of Kenya and Population Services Kenya implemented a pilot project in Kilifi to improve contraceptive awareness and access. AIMS AND OBJECTIVES: The Riziki Demonstration Project task shifted contraceptive injectable and implant provision to community health extension workers (CHEWs) and supported community engagement led by community health volunteers (CHVs). This mixed methods evaluation examined the effect of Riziki on contraceptive service provision and identified drivers of the intervention's success in increasing public sector contraceptive uptake. METHOD: We obtained monthly contraceptive service provision data from DHIS2 for intervention and comparison facilities from June 2018 to July 2020. Controlled interrupted time series analyses were used to assess difference-in-differences effects on the levels and trends in service provision. Qualitative data included key informant interviews with health workers, community-based focus group discussions and contraceptive journey mapping. Topics included contraception-related shifts in the health system and social environment and changes to contraceptive accessibility and demand. RESULTS: We found positive difference-in-differences effects for levels of provision for implant (adj. ß = 7.4 per month, per facility, 95% confidence interval [CI]: 2.8-12.0) and all methods combined (adj. ß = 12.2, 95% CI: 3.0-21.3). The health system provided a legal framework and management support for the pilot. Community engagement by CHVs and CHEWs, including with men and religious leaders, bolstered supportive social norms by emphasizing birth spacing and family wellbeing. Awareness and supportive social norms were strengthened among women and their husbands through counselling that leveraged CHEW and CHV community embeddedness. CONCLUSION: Findings demonstrate the potential for task sharing combined with community engagement efforts to improve contraceptive awareness, knowledge and supply. Community engagement should include men, traditional leaders and other influencers to strengthen norms that position family planning in alignment with community values.

Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling.

INTRODUCTION: High-quality contraceptive counseling is critical for supporting full, free, and informed contraceptive decision-making. However, the quality of family planning counseling remains poor globally and is too often not tailored to the individual client. The Counseling for Choice (C4C) approach comprises provider tools and training to structure counseling to center clients' self-identified priorities and to provide relevant information and anticipatory side effects counseling. METHODS: Providers at 25 public and 20 private facilities in Malawi were trained in the C4C approach. Between October and December 2018, we enrolled women seeking contraceptive services in intervention facilities and in matched comparison clinics in a quasi-experimental study. We collected data immediately before and after contraceptive services were received. We used multilevel logistic regression to compare dimensions of women's counseling experience. RESULTS: Of 1,179 participants, women counseled by C4C-trained providers rated their providers higher on several quality dimensions, including enabling informed decision-making (11.1% of the comparison group rated their provider as excellent versus 34.4% in intervention), respectful care (35.0% comparison versus 51.3% intervention), and information given about side effects (38.1% comparison versus 72.5% intervention). CONCLUSION: In Malawi, C4C improved the quality of care that clients received and their client experience relative to standard counseling. Counseling approaches that center clients' priorities and provide enhanced anticipatory side effects counseling show promise in improving contraceptive counseling experiences and the quality of care that clients receive.

Demand Forecasting Approaches for New Contraceptive Technologies: A Landscape Review and Recommendations for Alignment.

INTRODUCTION: Market size estimations and demand forecasts use a variety of methodological approaches to inform decision-making around new (and lesser-used) contraceptive methods. For contraceptive products already available at scale in a market, historical procurement and consumption data can help to inform these forecasts. However, little published guidance is available on appropriate approaches to estimating contraceptive demand in the absence of historical data. METHODS: This landscape review aimed to describe the variety of approaches for modeling demand for new contraceptive methods, highlight opportunities for alignment around forecasting practices, and make recommendations to support more accurate forecasting and sound decision-making based on forecasts. We used the published scientific and gray literature to inform the development of a semistructured guide for key informant interviews. We conducted interviews with 29 experts representing a spectrum of interests in market size estimation and demand forecasting for new contraceptive methods (e.g., ministries of health, donors, manufacturers, technical assistance providers, and demand forecasting specialists). We coded notes from the interviews using thematic content analysis. RESULTS: The purposes of market size estimation and demand forecasting for new contraceptive methods vary widely, as do associated model inputs and outputs. Key informants revealed a need for more standardized language around market size estimation and demand forecasting and highlighted key recommendations: select models that are fit-for-purpose, clearly articulate assumptions and uncertainty in model outputs, consider a broad range of contraceptive options in a forecast to capture the complete contraceptive supply environment, and perform a reality check of results and refresh assumptions. CONCLUSION: We recommend following a simple decision pathway to ensure that forecasts are fit-for-purpose, with appropriate inputs, outputs, and assumptions clearly articulated. Common pitfalls around overestimating demand should be avoided. Incorporating best practices into forecasting exercises will ensure that models are useful for the stakeholders.

Trajectories of method dissatisfaction among Kenyan women using modern, reversible contraception: A prospective cohort study.

OBJECTIVES: Evidence on method dissatisfaction among current contraceptive users is sparse. Group-based trajectory modeling presents a novel approach to describing method dissatisfaction. STUDY DESIGN: In a cohort of Kenyan women using modern contraception, we identified group-based trajectories of method dissatisfaction over 24 weeks since clinic visit. RESULTS: Among 947 women, four trajectories were identified: consistent satisfaction (71%), increasing dissatisfaction (18%), decreasing dissatisfaction (8%), and consistent dissatisfaction (3%). DISCUSSION: Method dissatisfaction was common in a cohort of Kenyan women. Group-based trajectory models describe distinct and changing experiences of contraceptive use. Deeper understanding of trajectories of contraceptive experience may be useful for advancing person-centered family planning care that addresses users' changing preferences and challenges.

Differences in contraceptive prices between and within family planning outlets in urban and semiurban Nigeria: a prospective cohort study.

BACKGROUND: There is a lack of comprehensive evidence assessing variability and volatility in contraceptive prices. Improved understanding of contraceptive pricing, both between and within public and private service delivery points situated within complex, mixed health systems, may improve understanding of contraceptive access from the perspective of the consumer. OBJECTIVE: To describe variability and volatility in contraceptive method prices within localized urban and semiurban markets in Nigeria. STUDY DESIGN: We used product audit data from a complete census and longitudinal cohort of family planning vendors within 4 urban and semiurban study sites in Nigeria. Differences in outlet-level minimum prices by outlet type were assessed using generalized estimating equations. We presented descriptive summaries of within-outlet changes in minimum price over time. RESULTS: Among 672 family planning vendors, outlet-level minimum prices were significantly higher in private facilities/outlets than in public facilities. The outlet-level minimum price was $9.4 (95% confidence interval, $5.7-$13.2) higher for implants in private vs public facilities. We observed high availability of free contraceptive products in the public sector (79%-100%), moderate levels for specific contraceptive product types among community health workers and private facilities (28%-62% for male condoms), and low prevalence among private nonfacility outlets (0%-3%). Variability in contraceptive prices was high within private facilities and nonfacility outlets: standard deviations in the distribution of long-acting reversible contraceptive products ranged from $9.7 for implants to $13.1 for intrauterine devices in the private sector. Changes in minimum prices by contraceptive method type were common within the same outlets over time in the private sector. CONCLUSION: We observed high variability between and within contraceptive vendors in selected Nigerian family planning markets. Further research assessing the impact of price variability is critical for understanding contraceptive access and decision-making from the consumer's perspective.

Bias in product availability estimates from contraceptive outlet surveys: Evidence from the Consumer's Market for Family Planning (CM4FP) study.

Area-based sampling approaches designed to capture pharmacies, drug shops, and other non-facility service delivery outlets are critical for accurately measuring the contraceptive service environment in contexts of increasing de-medicalization of contraceptive commodities and services. Evidence from other disciplines has demonstrated area-based estimates may be biased if there is spatial heterogeneity in product distribution, but this bias has not yet been assessed in the context of contraceptive supply estimates. The Consumer's Marker for Family Planning (CM4FP) study conducted censuses and product audits of contraceptive outlets across 12 study sites and 2-3 rounds of quarterly data collection in Kenya, Nigeria, and Uganda. We assessed bias in estimates of contraceptive product availability by comparing estimates from simulations of area-based sampling approaches with census counts among all audited facilities for each study site and round of data collection. We found evidence of bias in estimates of contraceptive availability generated from simulated area-based sampling. Within specific study sites and rounds, we observed biased sampling estimates for several but not all contraceptive method types, with bias more likely to occur in sites with heterogeneity in both spatial distribution of outlets and product availability within outlets. In simulations varying size of enumeration areas (EA) and number of outlets sampled per EA, we demonstrated that the likelihood of substantial bias decreases as EA size decreases and as the number of outlets sampled per EA increases. Straightforward approaches such as increasing sample size per EA or applying statistical weights may be used to reduce area-based sampling bias, indicating a pragmatic way forward to improve estimates where design-based sampling is infeasible. Such approaches should be considered in development of improved methods for area-based estimates of contraceptive supply-side environments.

Use of a mobile app to capture supplemental health information during pregnancy: Implications for clinical research.

PURPOSE: Mobile applications ("apps") may be efficient tools for improving the quality of clinical research among pregnant women, but evidence is sparse. We assess the feasibility and generalizability of a mobile app for capturing supplemental data during pregnancy. METHODS: In 2017, we conducted a pilot study of the FDA MyStudies mobile app within a pregnant population identified through Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. We ascertained health conditions, medications, and substance use through app-based questionnaires. In a post-hoc analysis, we utilized electronic health records (EHR) to summarize sociodemographic and health characteristics of pilot participants and, for comparison, a pregnant population identified using similar methods. RESULTS: Six percent (64/1070) of contacted women enrolled in the pilot study. Nearly half (23/53) reported taking medication for headaches and one-fourth for constipation (13/53) and nausea (12/53) each. Few instances (2/92) of over-the-counter medication use were identified in electronic dispensing records. One-quarter to one-third of participants with depression and anxiety/panic, respectively, reported recently discontinuing medications for these conditions. Eighty-eight percent of pilot participants reported White race (95%CI: 81-95%), versus 67% of the comparison population (N = 2065). More pilot participants filled ≥1 prescription for antianxiety medication (22% [95%CI: 13-35%]) and antidepressants (19% [95%CI 10-31%]) pre-pregnancy than the comparison population (10 and 9%, respectively). CONCLUSIONS: Mobile apps may be a feasible tool for capturing health data not routinely available in EHR. Pregnant women willing to use a mobile app for research may differ from the general pregnant population, but confirmation is needed.

Incorporating Method Dissatisfaction into Unmet Need for Contraception: Implications for Measurement and Impact.

While unmet need for contraception is commonly used to assess programmatic needs, it inadequately captures the complexity of fertility and contraceptive preferences, including women's satisfaction with their contraceptive method. In their 2019 commentary, Sarah Rominski and Rob Stephenson propose reclassifying dissatisfied current users as having an unmet need for contraception. As revising the current definition based on their proposal would require significant investment to update survey and monitoring systems, understanding the potential impact on current estimates of unmet need is critical. We estimated the impact of this approach in a Kenyan cohort of modern contraceptive users. We found the prevalence of method dissatisfaction ranges from 6.6% (95% confidence interval [CI] 5.6-7.8%) to 18.9% (95% CI 17.1-20.9%); if applied nationally, this results in a large (approximately 25-70%) increase in Kenya's current estimate of unmet need for any contraception. Our findings suggest a large impact on unmet need estimates for equivalent populations. Overall, we advocate for better measurements of method satisfaction and acceptability, with metrics developed that are robust to socioeconomic gradients and validated in low- and middle-income settings to ensure women's contraceptive needs are captured equitably.

Bypassing high-quality maternity facilities: evidence from pregnant women in peri-urban Nairobi.

Utilization of high-quality maternal care is an important link along the pathway from increased facility-based delivery to improved maternal health outcomes, however women in Nairobi do not all deliver in the highest quality facilities available to them. We explored whether women living in peri-urban Nairobi who live nearby to high-quality facilities bypassed, or travelled farther than, their nearest high technical quality facility using survey data collected before and after delivery from women (n = 358) and from facility assessments (n = 59). We defined the nearest high technical quality facility as the nearest Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capable facility to each woman's neighbourhood. We compared women who delivered in their nearest CEmONC (n = 44) to women who bypassed their nearest CEmONC to deliver in a facility that was farther away (n = 200). Among bypassers, 131 (65.5%) women delivered in farther non-CEmONC facilities with lower technical quality and 69 (34.5%) delivered in farther CEmONCs with higher technical quality capacity compared to their nearby CEmONCs. Bypassers rated their delivery experience higher than non-bypassers. Women who bypassed to deliver in non-CEmONCs were less likely to have completed four antenatal care visits and to consider delivering in any CEmONC prior to delivery while women who bypassed to deliver in farther CEmONCs paid more for delivery and were more likely to report being able to access emergency funds compared to non-bypassers. Our findings suggest that women in peri-urban Nairobi bypassed their nearest CEmONC facilities in favour of delivering in facilities that provided better non-technical quality care. Bypassers with access to financial resources were also able to deliver in facilities with higher technical quality care. Policies that improve women's delivery experience and ensure that information about facility technical quality is widely distributed may be critical to increase the utilization of high-quality maternity facilities.

A risk scoring tool for predicting Kenyan women at high risk of contraceptive discontinuation.

OBJECTIVE: We developed and validated a pragmatic risk assessment tool for identifying contraceptive discontinuation among Kenyan women who do not desire pregnancy. STUDY DESIGN: Within a prospective cohort of contraceptive users, participants were randomly allocated to derivation (n = 558) and validation (n = 186) cohorts. Risk scores were developed by selecting the Cox proportional hazards model with the minimum Akaike information criterion. Predictive performance was evaluated using time-dependent receiver operating characteristic curves and area under the curve (AUC). RESULTS: The overall contraceptive discontinuation rate was 36.9 per 100 woman-years (95% confidence interval [CI] 30.3-44.9). The predictors of discontinuation selected for the risk score included use of a short-term method or copper intrauterine device (vs. injectable or implant), method continuation or switch (vs. initiation), < 9 years of completed education, not having a child aged < 6 months, and having no spouse or a spouse supportive of family planning (vs. having a spouse who has unsupportive or uncertain attitudes towards family planning). AUC at 24 weeks was 0.76 (95% CI 0.64-0.87) with 70.0% sensitivity and 78.6% specificity at the optimal cut point in the derivation cohort. Discontinuation was 3.8-fold higher among high- vs. low-risk women (95% CI 2.33-6.30). AUC was 0.68 (95% CI 0.47-0.90) in the validation cohort. A simplified score comprising routinely collected variables demonstrated similar performance (derivation-AUC: 0.73 [95% CI 0.60-0.85]; validation-AUC: 0.73 [95% CI 0.51-0.94]). Positive predictive value in the derivation cohort was 31.4% for the full and 28.1% for the simplified score. CONCLUSIONS: The risk scores demonstrated moderate predictive ability but identified large proportions of women as high risk. Future research is needed to improve sensitivity and specificity of a clinical tool to identify women at high risk for experiencing method-related challenges. IMPLICATIONS: Contraceptive discontinuation is a major driver of unmet contraceptive need globally. Few tools exist for identifying women who may benefit most from additional support in order to meet their contraceptive needs and preferences. This study developed and assessed the validity of a provider-focused risk prediction tool for contraceptive discontinuation among Kenyan women using modern contraception. High rates of early discontinuation observed in this study emphasize the necessity of investing in efforts to develop new contraceptive technologies and stronger delivery systems to better align with women's needs and preferences for voluntary family planning.

Utility of Short Message Service (SMS) for Remote Data Collection for HIV in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: Short message system (SMS) communication is widespread in low- and middle-income countries (LMICs), and may be a viable approach to address challenges with in-person data collection for HIV-related research and monitoring and evaluation. We reviewed the literature to characterize potential benefits and challenges with using SMS for remote data capture, including examples from HIV and sexual and reproductive health. RECENT FINDINGS: In our review, we found that studies that have used SMS to capture sensitive, self-reported data found this was an acceptable and feasible strategy, and may reduce social desirability bias of self-reported data; but studies are limited. Shared phones and privacy concerns have been described as challenges, but can be addressed with enhanced security features. Response rates to SMS surveys varied significantly by topic, population, and setting. SMS may improve generalizability and precision of health and behavior data for HIV in research and programs, but use in LMICs is limited. SMS systems should be carefully designed to overcome potential implementation hurdles.

The Utility of SMS to Report Male Partner HIV Self-testing Outcomes Among Women Seeking Reproductive Health Services in Kenya: Cohort Study.

BACKGROUND: Use of SMS for data collection is expanding, but coverage, bias, and logistical constraints are poorly described. OBJECTIVE: The aim of this study is to assess the use of SMS to capture clinical outcomes that occur at home and identify potential biases in reporting compared to in-person ascertainment. METHODS: In the PrEP Implementation in Young Women and Adolescents program, which integrated pre-exposure prophylaxis (PrEP) into antenatal care, postnatal care, and family planning facilities in Kisumu County, Kenya, HIV-negative women 14 years of age or older were offered oral HIV self-tests (HIVSTs) to take home to male partners. Women that brought a phone with a Safaricom SIM to the clinic were offered registration in an automated SMS system (mSurvey) to collect information on HIVST outcomes. Women were asked if they offered the test to their male partners, and asked about the test process and results. HIVST outcomes were collected via SMS (sent 2.5 weeks later), in-person (if women returned for a follow-up scheduled 1 month later), or using both methods (if women initiated PrEP, they also had scheduled follow-up visits). The SMS prompted women to reply at no charge. HIVST outcomes were compared between women with scheduled follow-up visits and those without (follow-up visits were only scheduled for women who initiated PrEP). HIVST outcomes were also compared between women reporting via SMS and in-person. RESULTS: Among 2123 women offered HIVSTs and mSurvey registration, 486 (23.89%) accepted HIVSTs, of whom 359 (73.87%) were eligible for mSurvey. Additionally, 76/170 (44.7%) women with scheduled follow-up visits and 146/189 (77.3%) without scheduled follow-up visits registered in mSurvey. Among the 76 women with scheduled follow-ups, 62 (82%) had HIVST outcomes collected: 19 (31%) in-person, 20 (32%) by SMS, and 23 (37%) using both methods. Among the 146 women without scheduled visits, 87 (59.6%) had HIVST outcomes collected: 3 (3%) in-person, 82 (94%) by SMS, and 2 (2%) using both methods. SMS increased the collection of HIVST outcomes substantially for women with scheduled follow-up visits (1.48-fold), and captured 82 additional reports from women without scheduled follow-up visits. Among 222 women with reported HIVST outcomes, frequencies of offering partners the HIVST (85/95, 89% in-person vs 96/102, 94% SMS; P=.31), partners using the HIVST (83/85, 98% vs 92/96, 96%; P=.50), women using HIVST with partners (82/83, 99% vs 91/92, 99%; P=.94), and seeing partner's HIVST results (82/83, 99% vs 89/92, 97%; P=.56) were similar between women reporting in-person only versus by SMS only. However, frequency of reports of experiencing harm or negative reactions from partners was more commonly reported in the SMS group (17/102, 16.7% vs 2/85, 2%; P=.003). Barriers to the SMS system registration included not having a Safaricom SIM or a functioning phone. CONCLUSIONS: Our results suggest that the use of SMS substantially improves completeness of outcome data, does not bias reporting of nonsensitive information, and may increase reporting of sensitive information. .

Accuracy of patient perceptions of maternity facility quality and the choice of providers in Nairobi, Kenya: a cohort study.

OBJECTIVES: This study aimed to assess the accuracy of pregnant women's perceptions of maternity facility quality and the association between perception accuracy and the quality of facility chosen for delivery. DESIGN: A cohort study. SETTING: Nairobi, Kenya. PARTICIPANTS: 180 women, surveyed during pregnancy and 2 to 4 weeks after delivery. PRIMARY OUTCOME MEASURES: Women were surveyed during pregnancy regarding their perceptions of the quality of all facilities they were considering during delivery and then, after delivery, about their ultimate facility choice. Perceptions of quality were based on perceived ability to handle emergencies and complications. Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency 'signal functions', skilled provider availability, medical equipment and drug stocks. 'Accurate perceptions' was a binary variable equal to one if a woman's ranking of facilities based on her quality perception equalled the index ranking. Ordinary least squares and logistic regressions were used to analyse associations between accurate perceptions and quality of the facility chosen for delivery. RESULTS: Assessed technical quality was modest, with an average index score of 0.65. 44% of women had accurate perceptions of quality ranking. Accurate perceptions were associated with a 0.069 higher delivery facility quality score (p=0.039; 95% CI: 0.004 to 0.135) and with a 14.5% point higher probability of delivering in a facility in the top quartile of the quality index (p=0.015; 95% CI: 0.029 to 0.260). CONCLUSIONS: Patient misperceptions of technical quality were associated with use of lower quality facilities. Larger studies could determine whether improving patient information about relative facility quality can encourage use of higher quality care.

Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya.

BACKGROUND: Short birth intervals are a major risk factor for poor maternal and newborn outcomes. Utilisation of modern contraceptive methods during the postpartum period can reduce risky birth intervals but contraceptive coverage during this critical period remains low. METHODS: We conducted a randomised controlled experiment to test whether vouchers for free contraception, provided with and without behavioural 'nudges', could increase modern contraceptive use in the postpartum period. 686 pregnant women attending antenatal care in two private maternity hospitals in Nairobi, Kenya, were enrolled in the study. The primary outcomes were the use of modern contraceptive methods at nearly 3 months and 6 months after expected delivery date (EDD). We tested the impact of a standard voucher that could be redeemed for free modern contraception, a deadline voucher that expired 2 months after delivery and both types of vouchers with and without a short message service (SMS) reminder, relative to a control group that received no voucher and no SMS reminder. RESULTS: By nearly 6 months after EDD, we find that the combination of the standard voucher with an SMS reminder increased the probability of reporting utilisation of a modern contraceptive method by 25 percentage points (pp) (95% CI 6 pp to 44 pp) compared with the control group. Estimated impacts in other treatment arms were not statistically significantly different from the control group. CONCLUSIONS: Reducing financial barriers to postpartum contraception alone may not be enough to encourage take-up. Programmes targeting the postpartum period should consider addressing behavioural barriers to take-up.

Providing support to pregnant women and new mothers through moderated WhatsApp groups: a feasibility study.

BACKGROUND: Group-based health services can improve maternal and newborn health outcomes. Group antenatal care and participatory learning and action cycles (PLA) with women's groups have been cited by the WHO as health systems interventions that can lead to improvements in adherence to care and health outcomes in pregnancy and the postpartum period. METHODS: We used a mixed-methods approach to assess the feasibility of a light touch group-based support intervention using the WhatsApp text-messaging platform. Pregnant women were enrolled at Jacaranda Health (JH), a maternity center in peri-urban Kiambu County, Kenya. Their phone numbers were added to WhatsApp groups consisting of participants with similar estimated due dates. The WhatsApp group administrator was a JH employee. Acceptability, demand, implementation, and practicality of this service were evaluated through in-depth interviews (IDIs), surveys, chart review, and analysis of group chats. Limited analysis of program efficacy (ANC visits, any PNC, and post-partum family planning uptake) was assessed by comparing participant data collected through chart review using a concurrent comparison of the general JH patient population. RESULTS: Fifty women (88%) of 57 eligible women who were approached to participate enrolled in the study. Five WhatsApp groups were created. A total of 983 messages were exchanged over 38 weeks. No harms or negative interactions were reported. Participants reported several benefits. Participants had differing expectations of the level of the group administrator's activity in the groups. ANC and PNC attendance were in line with the hospital's metrics for the rest of JH's patient population. Higher rates of postpartum long acting reversible contraception (LARC) uptake were observed among participants relative to the general patient population. CONCLUSIONS: A moderated mobile-based support group service for pregnant women and new mothers is safe and feasible. Additional research using experimental designs to strengthen evidence of the effectiveness of the support intervention is warranted.