Suchergebnisse

Background: Long-acting reversible contraception (LARC) is highly effective at preventing pregnancy. However, in sub-Saharan Africa, LARC education for clients is relatively limited and providers are often not skilled in their insertion. Before 2009, only 1% of family planning clients in Rwanda received an LARC. Materials and Methods: We trained Rwandan government clinic nurses to promote, insert, and remove copper intrauterine devices (IUDs) and hormonal implants. Training started in two large urban clinics, and those nurses trained three successive waves of clinic nurses. Initial LARC promotions were clinic based, but in 2015 included community-based promotions in eight clinics. We compare IUD and implant insertions by year and clinic and discuss implementation successes/obstacles. Results: From 2009 to 2016, 222 nurses from 21 government clinics were LARC trained. The nurses performed 36,588 LARC insertions (19% IUD, 81% implant). LARC insertions increased over time, peaking at 8,897 in 2013. However, in 2014, the number dropped to 4,018 after closure of one large clinic, funding discontinuation, and supply stock-outs. With new funding in 2015, insertions increased reaching 8,218 in 2016. Catholic and non-Catholic and rural and urban clinics performed similarly, whereas clinics affiliated with community-based promotions performed better (p > 0.05). Between 2012 and 2014, 13% of family planning initiators chose the implant and 4% the IUD. Conclusions: LARC supply–demand services increased the proportion of family planning initiators choosing LARC to 17%. Challenges included inconsistent funding, irregular supplies, and staff turnover. Rural and Catholic clinics performed as well as urban and non-Catholic clinics. Concerted efforts to improve IUD uptake are needed.

BACKGROUND: Few family planning programs in Africa base demand creation and service delivery on theoretical models. Motivational interviewing (MI) is a counseling modality that facilitates reflection on the benefits and disadvantages of a health outcome to encourage behavior change. OBJECTIVES: We evaluate a couples-focused joint family planning and HIV counseling intervention using motivational interviewing (MI) to enhance uptake of long acting reversible contraception (LARC, Paragard copper intra-uterine device (IUD) or Jadelle hormonal implant) among Rwandan couples. STUDY DESIGN: In this experimental study, couples receiving care at eight government health clinics in Kigali, the capital city, were referred from a parent study of couples that did not want more children or wanted to wait at least two years for their next pregnancy. LARC methods were offered on site following joint HIV testing and family planning counseling. At the first follow-up visit one month after enrollment in the parent study, couples who had not yet chosen a LARC method were interviewed separately using MI, then brought together and again offered LARC. RESULTS: Following MI, 78/229 (34%) couples requested a LARC method (68 implant and 10 IUD). LARC uptake after MI was associated with the woman being Catholic (vs. Protestant/Muslim/Other, aOR 2.87, 95% C.I. 1.19-6.96, p=0.019) or having an income (vs. no income aOR 2.54, 95% C.I. 1.12-5.73, p=0.025); the couple having previously discussed LARC (aOR 8.38, 95% C.I. 2.54-27.59, p=0.0005); either partner believing that unplanned pregnancy was likely with their current method (aOR 6.67, 95% C.I. 2.77-16.11, p<0.0001) or that they might forget to take or make an appointment for their current method (aOR 4.04, 95% C.I. 1.32-12.34, p=0.014). Neither partner mentioning that condoms also prevent HIV/sexually transmitted infection (STI) was associated with LARC uptake (aOR 2.86, 95% C.I. 1.17-7.03, p=0.022), as was the woman citing long-term duration of action of the implant as an advantage (aOR ...

BACKGROUND: When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS: In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS: Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS: Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and ...