Reducing Barriers to Postabortion Contraception: The Role of Expanding Coverage of Postabortion Care in Dar es Salaam, Tanzania.

BACKGROUND: In Tanzania, limited access to postabortion care (PAC) contributes to high rates of maternal mortality. To address the issue, Pathfinder International and the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) introduced and expanded coverage of PAC in 64 public health facilities in Dar es Salaam, Tanzania. METHODS: During a 30-month period, we implemented a multifaceted approach to introduce and expand PAC, including clinical training and mentorship for health care providers; service reorganization, equipment provision, and an expanded method mix offering; standardization of PAC reporting tools; and community engagement and referral. We assessed outcomes using PAC service statistics from 64 public health facilities in 4 districts of Dar es Salaam and health care provider mentorship data from 385 observed PAC visits. RESULTS: From January 2016 to June 2018, voluntary postabortion contraceptive uptake increased steadily. A total of 6,636 PAC clients, including 2,731 young people (ages 10-24), adopted a method post-procedure. Average semesterly client volume per facility increased from 27 to 52.4 manual vacuum aspiration clients and 17.6 to 43.9 postabortion contraceptors between the first and last periods. Overall postabortion contraceptive uptake was 80.6% (6,636/8,230), with a method mix of 58.3% implant, 18.9% intrauterine device, 13.7% pills, 8.6% injectables, and 0.5% permanent methods. Adults and young people had comparable method mix. Mentored providers showed improvements in service quality indicators. During the last period, 92% counseled the client on contraception, 93% considered the client's sexual and reproductive health intentions, 94% provided correct method information and supply, and 96% documented services on the client's family planning card. Different provider types (mid- and senior-level) performed comparably. CONCLUSIONS: Expanding PAC coverage to primary- and secondary-level facilities led to high uptake of voluntary contraception among postabortion clients. Key interventions included PAC clinical training and mentorship; service reorganization, equipment provision, and an expanded method mix offering; use of standardized PAC registers; and community engagement for awareness building and linkage to PAC.

Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study.

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15-49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57-0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued. Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.