Exploring Barriers: How to Overcome Roadblocks Impeding the Provision of Postabortion Care to Young People in Togo.

BACKGROUND: Family planning counseling and provision of a variety of contraceptive methods during postabortion care (PAC) can increase voluntary contraceptive use and prevent unintended pregnancies, helping to reduce maternal morbidity and mortality. Youth in Togo, however, face many barriers to accessing contraceptives during PAC including provider bias, parental consent policies, stigma, and pressure on young people to have children. This article describes the lessons learned from follow-up with providers who were trained on PAC to build their willingness and skills in offering youth-friendly PAC. METHODS: With assistance from the Evidence to Action (E2A) Project, Togo's Division for Maternal and Infant Health and Family Planning (DSMI/PF) systematically applied IntraHealth International's Optimizing Performance and Quality (OPQ) approach to improve the quality of PAC at 5 health facilities from 2014 to 2016. OPQ identified gaps and helped establish solutions to shortcomings that hinder youth's access to contraceptive choice during PAC. To address these shortcomings, staff trained providers to improve their knowledge, attitudes, and skills with regard to (1) medical eligibility criteria for contraceptive use to remove age as justification for denying contraceptives; (2) AFPAC to increase the ability to consider gender-based violence and to encourage client-focused and age-sensitive counseling; and (3) monitoring through disaggregation of data by age, method, and parity for data-driven planning and delivery of AFPAC. RESULTS: Providers reported improved attitudes and empathy toward young PAC clients, efforts to screen for exposure to sexual and gender-based violence, and willingness to explore reproductive health needs and assist clients in choosing contraceptive methods. Previously, no youth PAC clients chose contraceptives during PAC or returned to the facility for routine follow-up. After providers received OPQ training, they treated 775 PAC clients in 5 health facilities between June and December 2016; 351 were ages 14-24, of whom 142 (40.5%) chose a modern contraceptive. The most common method selected by youth was oral contraceptive pills (44%), followed by implants (41%) and injectables (15%). Of the 142 youth PAC clients who chose a method, 86 (58.5%) returned for the 7-day follow-up. CONCLUSIONS: Training providers to offer AFPAC along with the application of OPQ to improve the quality of PAC increases voluntary contraceptive uptake, including implants, among youth who make up a substantial portion of all PAC clients. Incorporating AFPAC in family planning/reproductive health policies, norms, protocols, and PAC training, as Togo's DSMI/PF did, is an important element to ensuring institutionalization of the practice.

Adaptation of the Training Resource Package to Strengthen Preservice Family Planning Training for Nurses and Midwives in Tanzania and Uganda.

BACKGROUND: Tanzania and Uganda have high total fertility and maternal mortality rates, and low contraceptive prevalence rates. High-quality preservice family planning education for nurses and midwives can improve the quality of sexual and reproductive health care, thereby improving health outcomes. DESCRIPTION OF INTERVENTION: In 2015, we worked with relevant stakeholders in Tanzania and Uganda through a series of surveys, assessments, and workshops to adapt modules of the Training Resource Package for Family Planning (TRP), an evidence-based global resource, to improve the quality of preservice family planning education for nurses and midwives. With support, a wide range of stakeholders, including policy makers, program managers, educators from nursing and midwifery training institutions, and representatives from professional associations, identified relevant TRP modules and adapted them to each country's context to inform and develop their own lesson plans in accordance with national policies, guidelines, and standardized preservice education templates. LESSONS LEARNED: Important lessons from the adaptation process include the following: (1) engage relevant ministries of health and education, professional associations, and regulatory councils at each step of the process to increase the acceptability and utility of the TRP; (2) use a context-specific process for adaptation of the TRP, as not one process will fit the needs of all countries; and (3) include nursing and midwifery educators in the adaptation process to create an established pool of trainers who can then cascade the TRP to other educators in their respective schools. Overall, participants in both countries expressed challenges with incorporating competency-based teaching methods into their curricula because they were unfamiliar with such approaches themselves and with reducing the extensive TRP content to fit within the time constraints for preservice education. CONCLUSION: Adaptation of an evidence-based global family planning training resource in Tanzania and Uganda resulted in substantive changes to the curricula of the reproductive health preservice course unit that will support nurses and midwives to provide quality, rights-based family planning services.

A Formative Assessment of Nurses' Leadership Role in Zambia's Community Health System.

BACKGROUND: Despite its achievements in decreasing HIV prevalence and under-five mortality, Zambia still faces high maternal and neonatal mortality, particularly in the rural and remote areas where almost 60% of the population resides. After significant investments in developing its community health system, the Zambian Ministry of Health was interested to understand how to leverage the role of nurses to sustain achievements made and further improve the quality of care in rural communities. The Ministry joined research partners in an assessment into the role and leadership capacity of nurses heading rural health facilities. METHODS: A seven-member research team conducted 30 in-depth interviews and 10 focus group discussions in four provinces with four categories of respondents: national decision-makers, provincial and district managers, rural facility staff and community respondents (neighborhood health committee members and volunteers). An initial scoping visit and literature review informed the development of specific interview guides for each category of respondent. After audio-recording and transcription, research team members identified and reached consensus on key themes, and presented and validated the findings at a national stakeholder workshop. RESULTS: Zambia's front-line health teams are a complex mixture of professional facility staff, community providers, community-based volunteers and neighborhood health committees. Nurses and nurse-midwives head over half the rural facilities in Zambia, where they are expected to lead the delivery of safe, high-quality care with staff and volunteers who often operate beyond their level of training. Nurses and midwives who are assigned to head rural facilities are not adequately prepared or recognized for the leadership responsibilities they are expected to fulfill. CONCLUSIONS: This paper highlights opportunities to support rural facility heads in effectively leading front-line health teams to deliver primary healthcare to rural communities. Front-line teams require a leader to coordinate and motivate seamless and sustainable quality services that are accessible to all. Zambia has the potential to support integrated, responsive quality care and advance toward universal health coverage if nurses are adequately prepared and recognized with job descriptions that reflect their responsibilities and opportunities for career advancement.

Improving the Quality of Postabortion Care Services in Togo Increased Uptake of Contraception.

High-quality postabortion care (PAC) services that include family planning counseling and a full range of contraceptives at point of treatment for abortion complications have great potential to break the cycle of repeat unintended pregnancies and demand for abortions. We describe the first application of a systematic approach to quality improvement of PAC services in a West African country. This approach-IntraHealth International's Optimizing Performance and Quality (OPQ) approach-was applied at 5 health care facilities in Togo starting in November 2014. A baseline assessment identified the following needs: reorganizing services to ensure that contraceptives are provided at point of treatment for abortion complications, before PAC clients are discharged; improving provider competencies in family planning services, including in providing long-acting reversible contraceptive implants and intrauterine devices; ensuring that contraceptive methods are available to all PAC clients free of charge; standardizing PAC registers and enhancing data collection and reporting systems; enhancing internal supervision systems at facilities and teamwork among PAC providers; and engaging PAC providers in community talks. Solutions devised and applied at the facilities during OPQ resulted in significant increases in contraceptive counseling and uptake among PAC clients: During the 5-month baseline period, 31% of PAC clients were counseled, while during the 13-month intervention period, 91% were counseled. Of all PAC clients counseled during the baseline period, 37% accepted a contraceptive, compared with 60% of those counseled during the intervention period. Oral contraceptive pills remained the most popular method during both periods, yet uptake of implants increased significantly during the intervention period-from 4% to 27% of those accepting contraceptives. This result demonstrates that the solutions applied maintained method choice while expanding access to underused long-acting reversible contraceptives. OPQ shows great potential for sustainability and scale in Togo and for application in similar contexts where the health system struggles to offer safe, high-quality, accessible PAC services.