Increasing Family Planning Access in Kenya Through Engagement of Faith-Based Health Facilities, Religious Leaders, and Community Health Volunteers.

Health facilities managed by faith-based organizations (FBOs) are important providers of health care in Kenya but provide only a small proportion of family planning services in the country. From 2013 to 2017, the Christian Health Association of Kenya (CHAK) implemented a project with 6 FBO-managed health facilities to increase voluntary family planning services in western Kenya, in partnership with religious leaders and community health volunteers (CHVs). The project aimed to build capacity of FBO-managed health facilities, increase religious leaders' knowledge of family planning, mobilize communities, improve family planning access and referrals for services, and advocate for improved family planning commodity security from the public sector. Project impact was evaluated using facility-level service statistics, project records and reports, and feedback from religious leaders and CHVs who implemented the project. Facility service statistics showed large increases in family planning visits. Phase 1 (2013-2014) was implemented at 2 health facilities, where client visits for family planning increased sixfold (from 705 to 4,286 visits) with tenfold increases seen in client visits for pills, intrauterine devices, and implants. In Phase 2 (2015-2017), the project was expanded to an additional 4 health facilities and total client visits for family planning nearly doubled (from 7,925 to 14,832 visits). During Phase 2, new client visits for implants increased threefold, making implants the most popular family planning method. Religious leaders who implemented the project reported reaching nearly 700,000 people with family planning messages and referring more than 87,000 clients to health facilities for family planning services. The religious leaders expressed confidence in the effectiveness of the project and in their role in enhancing access to voluntary family planning. Health facilities, religious leaders, and CHVs also reported multiple challenges to implementation, including inconsistent supply of family planning commodities from county health departments. This project demonstrates the potential of FBO-managed facilities and faith leaders to increase family planning demand and service provision, as well as the importance of coordination with the public sector to ensure supply of commodities and support for FBO-managed facilities.

Postabortion Care: 20 Years of Strong Evidence on Emergency Treatment, Family Planning, and Other Programming Components.

Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30-70 percentage points within 1-3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria.

Advocacy for International Family Planning: What Terminology Works?

Advocating for international family planning while avoiding miscommunications with politically and religiously conservative policy makers and the public requires care and clarity with language. We find that terms such as "international family planning" are well received when the meaning is clearly explained, such as "enabling couples to determine the number and timing of pregnancies, including the voluntary use of methods for preventing pregnancy - not including abortion - harmonious with their beliefs and values". Family planning also helps reduce abortions - a powerful message for conservative policy makers and the public. We concur with Dyer et al. (2016) that the messenger is important; we find that many of the most effective advocates are religious leaders and faith-based health providers from the Global South. They know and validate the importance of family planning for improving family health and reducing abortions in their communities. "Healthy timing and spacing of pregnancy" is positive language for policy makers, especially when describing the health impact for women and children. Universal access to contraceptive services is emerging as vital for family health and also to help achieve the Sustainable Development Goals (UN 2015). Language on international family planning will evolve, and clarity of meaning will be foundational for effective advocacy.

Achieving success with family planning in rural Afghanistan.

PROBLEM: Afghan women have one of the world's highest lifetime risks of maternal death. Years of conflict have devastated the country's health infrastructure. Total fertility was one of the world's highest, contraceptive use was low and there were no Afghan models of success for family planning. APPROACH: We worked closely with communities, providing information about the safety and non-harmful side-effects of contraceptives and improving access to injectable contraceptives, pills and condoms. Regular interaction with community leaders, mullahs (religious leaders), clinicians, community health workers and couples led to culturally acceptable innovations. A positive view of birth spacing was created by the messages that contraceptive use is 300 times safer than pregnancy in Afghanistan and that the Quran (the holy book of Islam) promotes two years of breastfeeding. Community health workers initiated the use of injectable contraceptives for the first time. LOCAL SETTING: The non-for-profit organization, Management Sciences for Health, Afghan nongovernmental organizations and the Ministry of Public Health implemented the Accelerating Contraceptive Use project in three rural areas with different ethnic populations. RELEVANT CHANGES: The contraceptive prevalence rate increased by 24-27% in 8 months in the project areas. Men supported modern contraceptives once they understood contraceptive safety, effectiveness and non-harmful side-effects. Injectable contraceptives contributed most to increases in contraceptive use. LESSONS LEARNT: Community health workers can rapidly increase contraceptive use in rural areas when given responsibility and guidance. Project innovations were adopted as best practices for national scale-up.

Intraoperative extracorporeal irradiation for limb sparing in 13 dogs.

OBJECTIVE: To evaluate extracorporeal intraoperative radiation therapy (IORT) as a treatment method for limb and joint sparing in dogs with appendicular sarcomas in sites other than the distal aspect of the radius. STUDY DESIGN: Retrospective study. ANIMALS: Thirteen client-owned dogs. METHODS: The bone tumor database and medical records (1998-2002) were reviewed for dogs with primary appendicular bone tumors treated with IORT limb-sparing surgery and adjuvant chemotherapy. The segment of bone containing the tumor was isolated from adjacent soft tissue and an osteotomy performed distant to the tumor. The bone segment was exteriorized, irradiated (70 Gy single fraction), and then stabilized with internal fixation. Adjuvant chemotherapy was administered. Lameness was graded and local and distant tumor control was determined. Associations between intra- and postoperative variables with complications and Kaplan-Meier survival analysis for median disease-free interval and survival time were calculated. RESULTS: Limb function was good or excellent in 10 dogs (77%). Postoperative complications (9 dogs, 69%) included deep infection, fracture of the irradiated bone, and implant failure. Surgical failure was more likely if a single implant was used to stabilize the osteotomized bone and if deep infection developed postoperatively. In 3 dogs, tumors recurred locally within bone in the radiation field. The disease-free and overall success rates of extracorporeal IORT for limb and joint preservation were 46% and 54%, respectively. CONCLUSIONS: Extracorporeal IORT provides a novel alternative to traditional techniques for preservation of joint and limb function in dogs with primary appendicular sarcomas. A minimum of 2 implants and intramedullary bone cement should be used to stabilize the osteotomized bone to minimize postoperative complications. Extracorporeal IORT should be used with caution in dogs with tumors of the distal tibia because of a high complication rate. Dogs with tumors in areas of good soft-tissue coverage, such as the humerus and femur, may be good candidates for limb and joint-sparing surgery using extracorporeal IORT. CLINICAL RELEVANCE: Extracorporeal IORT is a surgical technique that can be used for limb and joint salvage in dogs with primary appendicular sarcomas in sites usually not amenable to traditional limb-sparing techniques.