Factors influencing uptake of contraceptive implants in the immediate postpartum period among HIV infected and uninfected women at two Kenyan District Hospitals

BMC Women's Health, Volume 15, No. 1, Year 2015

Interpretation

Background: Family planning is a cost effective strategy for prevention of mother to child transmission of HIV and reduction of maternal/infant morbidity and mortality. Contraceptive implants are a safe, effective, long term and reversible family planning method whose use remains low in Kenya. We therefore set out to determine and compare the uptake, and factors influencing uptake of immediate postpartum contraceptive implants among HIV infected and uninfected women at two hospitals in Kenya. Methods: This cross sectional study targeted postpartum mothers at two Kenyan district hospitals (one urban and one rural). All participants received general family planning and method specific (Implant) counseling followed by immediate insertion of contraceptive implants to those who consented. The data was analyzed by descriptive analysis, T-test, Chi square tests and logistic regression. Results: One hundred eighty-five participants were enrolled (91 HIV positive and 94 HIV negative) with a mean age of 26 years. HIV positive mothers were significantly older (27.5 years) than their HIV negative counterparts (24.5 years), P = 0.001. The two groups were comparable in education, employment, marital status and religious affiliation. Overall, the uptake of contraceptive implants in the immediate postpartum period was 50.3 % and higher among HIV negative than HIV positive participants (57 % vs. 43 %, P = 0.046). Multivariate analysis revealed that a negative HIV status (P = 0.017) and prior knowledge of contraceptive implants (P = 0.001) were independently associated with increased uptake of contraceptive implants. Conclusion: There was a high uptake of immediate postpartum contraceptive implants among both HIV infected and un-infected women; efforts therefore need to be made in promoting this method of family planning in Kenya and providing this method to women in the immediate postpartum period so as to utilize this critical opportunity to increase uptake and reduce the high unmet need for family planning. We conducted a cross sectional study targeting HIV infected and uninfected postpartum women admitted to the postnatal wards (PNW) of two Kenyan district hospitals, Naivasha District Hospital (a rural hospital) and Mbagathi District Hospital (an urban hospital) from the months of July to October 2012. Naivasha and Mbagathi district hospitals are public hospitals that provide both general and specialized care including regular FP service. A room within the postnatal units was used to provide FP counseling and insertion of implants to those who consented. Study participants were postpartum mothers in the postnatal wards of the two hospitals after delivery and before discharge. One HIV positive mother was recruited for every one HIV negative mother. The HIV status was obtained from the patients’ ANC card during admission into the postnatal wards and then confirmed from the patients’ hospital files. Those with unknown HIV status, were tested in the maternity unit and results documented in the patients’ files. The enrollment criteria included; consenting adult postpartum women with known HIV status, normotensive and with no known serious medical conditions such as active liver disease, deep venous thrombosis, migraine with aura, renal failure or breast cancer. Ethical approval was obtained from the Kenyatta National Hospital/University of Nairobi (KNH/UON) Ethics and Research committee. Consent was obtained in writing from all the study participants after adequate explanation for enrollment in this study. The study was conducted using an anonymous survey with no name identifying information provided in the questionnaire. All measures to maintain anonymity and confidentiality were strictly followed. Participant enrollment into the study was carried out by convenience sampling based the admission of patients in the PNW until the numbers of HIV positive and negative balanced. Pretesting of the questionnaire was done at the study sites using the same protocol and no revision was required. Trained research nurses administered the structured questionnaire and the information collected included; socio-demographic characteristics, parity, contraceptive knowledge and use, spouse approval of contraceptive use, future fertility intentions and knowledge and opinions about contraceptive implants. This was then followed by standardized contraceptive counseling about all available FP methods and specifically on the study method (implants). Those who further consented to insertion of contraceptive implants were inserted immediately after signing part B of the consent form and were encouraged to continue using barrier methods. A card that indicated the method given, date inserted and expiry date was given together with post insertion instructions on wound care. They were then advised to go to FP clinic of their choice for follow up. Those who did not consent to implant insertion were counseled on importance of FP use and referred to FP clinics of their choice for routine postpartum care (Fig. 1). Algorithm for enrolment of study participants Descriptive statistics were used to describe baseline maternal characteristics such as age, parity, education levels and FP knowledge. Mean and median was used for continuous variables and frequencies, and proportions were used for categorical variables. T-test was applied to compare means, while a two-sided chi-square test was used to compare proportions between the two groups. Fisher’s exact test was also utilized when at least one cell had a value of zero. Logistic regression was then applied to test the strength of association between demographic and reproductive variables and the primary outcome – uptake of contraceptive implants. The significant factors were then subjected to multivariate analysis to analyse for independent association. The data was entered into password protected Microsoft Access Database and subsequently transferred to SPSS statistical package for analysis. SPSS 16.0, Inc., 2007. One of the study limitations was selection bias, due to the non-probability sampling method but this was mitigated by the large sample size.

AI Digest

Study Justification:

– Family planning is an important strategy for preventing mother-to-child transmission of HIV and reducing maternal and infant morbidity and mortality.
– Contraceptive implants are a safe, effective, long-term, and reversible family planning method.
– The use of contraceptive implants remains low in Kenya.
– This study aimed to determine and compare the uptake and factors influencing the uptake of immediate postpartum contraceptive implants among HIV-infected and uninfected women in Kenya.

Highlights:

– The study enrolled 185 participants, with 91 HIV-positive and 94 HIV-negative women.
– The overall uptake of contraceptive implants in the immediate postpartum period was 50.3%.
– The uptake was higher among HIV-negative participants (57%) compared to HIV-positive participants (43%).
– Factors independently associated with increased uptake of contraceptive implants were a negative HIV status and prior knowledge of contraceptive implants.
– The study suggests that efforts should be made to promote immediate postpartum contraceptive implants in Kenya to increase uptake and reduce the high unmet need for family planning.

Recommendations:

– Promote immediate postpartum contraceptive implants as a family planning method in Kenya.
– Provide access to immediate postpartum contraceptive implants for women in the postnatal period.
– Increase awareness and knowledge about contraceptive implants among women of reproductive age.
– Strengthen family planning counseling services to include information about contraceptive implants.
– Train healthcare providers on the insertion and removal of contraceptive implants.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of family planning programs.
– Healthcare Providers: Responsible for counseling, insertion, and removal of contraceptive implants.
– Community Health Workers: Responsible for raising awareness and providing information about contraceptive implants.
– Non-Governmental Organizations: Responsible for supporting and implementing family planning programs.
– Research Institutions: Responsible for conducting further research and evaluation of family planning interventions.

Cost Items for Planning Recommendations:

– Training: Budget for training healthcare providers on the insertion and removal of contraceptive implants.
– Supplies and Equipment: Budget for purchasing contraceptive implants, insertion kits, and other necessary supplies.
– Awareness Campaigns: Budget for developing and implementing campaigns to raise awareness about contraceptive implants.
– Monitoring and Evaluation: Budget for monitoring and evaluating the implementation and impact of the recommendations.
– Program Management: Budget for coordinating and managing the implementation of the recommendations.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is fairly strong, but there are some areas for improvement. The study design is described, including the target population, data collection methods, and statistical analysis. The results are presented, including the uptake of contraceptive implants and factors associated with uptake. However, the abstract could be improved by providing more specific details about the sample size, the methods used for data analysis, and any limitations of the study. Additionally, it would be helpful to include information about the implications of the findings and any recommendations for future research or practice.

Abstract

We conducted a cross sectional study targeting HIV infected and uninfected postpartum women admitted to the postnatal wards (PNW) of two Kenyan district hospitals, Naivasha District Hospital (a rural hospital) and Mbagathi District Hospital (an urban hospital) from the months of July to October 2012. Naivasha and Mbagathi district hospitals are public hospitals that provide both general and specialized care including regular FP service. A room within the postnatal units was used to provide FP counseling and insertion of implants to those who consented. Study participants were postpartum mothers in the postnatal wards of the two hospitals after delivery and before discharge. One HIV positive mother was recruited for every one HIV negative mother. The HIV status was obtained from the patients’ ANC card during admission into the postnatal wards and then confirmed from the patients’ hospital files. Those with unknown HIV status, were tested in the maternity unit and results documented in the patients’ files. The enrollment criteria included; consenting adult postpartum women with known HIV status, normotensive and with no known serious medical conditions such as active liver disease, deep venous thrombosis, migraine with aura, renal failure or breast cancer. Ethical approval was obtained from the Kenyatta National Hospital/University of Nairobi (KNH/UON) Ethics and Research committee. Consent was obtained in writing from all the study participants after adequate explanation for enrollment in this study. The study was conducted using an anonymous survey with no name identifying information provided in the questionnaire. All measures to maintain anonymity and confidentiality were strictly followed. Participant enrollment into the study was carried out by convenience sampling based the admission of patients in the PNW until the numbers of HIV positive and negative balanced. Pretesting of the questionnaire was done at the study sites using the same protocol and no revision was required. Trained research nurses administered the structured questionnaire and the information collected included; socio-demographic characteristics, parity, contraceptive knowledge and use, spouse approval of contraceptive use, future fertility intentions and knowledge and opinions about contraceptive implants. This was then followed by standardized contraceptive counseling about all available FP methods and specifically on the study method (implants). Those who further consented to insertion of contraceptive implants were inserted immediately after signing part B of the consent form and were encouraged to continue using barrier methods. A card that indicated the method given, date inserted and expiry date was given together with post insertion instructions on wound care. They were then advised to go to FP clinic of their choice for follow up. Those who did not consent to implant insertion were counseled on importance of FP use and referred to FP clinics of their choice for routine postpartum care (Fig. 1). Algorithm for enrolment of study participants Descriptive statistics were used to describe baseline maternal characteristics such as age, parity, education levels and FP knowledge. Mean and median was used for continuous variables and frequencies, and proportions were used for categorical variables. T-test was applied to compare means, while a two-sided chi-square test was used to compare proportions between the two groups. Fisher’s exact test was also utilized when at least one cell had a value of zero. Logistic regression was then applied to test the strength of association between demographic and reproductive variables and the primary outcome – uptake of contraceptive implants. The significant factors were then subjected to multivariate analysis to analyse for independent association. The data was entered into password protected Microsoft Access Database and subsequently transferred to SPSS statistical package for analysis. SPSS 16.0, Inc., 2007. One of the study limitations was selection bias, due to the non-probability sampling method but this was mitigated by the large sample size.

Materials

N/A

Innovations

Based on the provided description, here are some potential innovations that could improve access to maternal health:

1. Mobile clinics: Implementing mobile clinics that travel to rural areas and provide maternal health services, including family planning counseling and contraceptive implant insertion. This would help reach women who may not have easy access to healthcare facilities.

2. Community health workers: Training and deploying community health workers who can provide education and counseling on family planning methods, including contraceptive implants, within their communities. This would help increase awareness and knowledge about available options.

3. Integration of services: Integrating family planning services, including contraceptive implant insertion, within existing maternal health programs and facilities. This would ensure that women have access to these services during their postpartum period.

4. Task-shifting: Training and empowering nurses and midwives to provide contraceptive implant insertion services. This would help alleviate the burden on doctors and increase the availability of trained providers.

5. Telemedicine: Utilizing telemedicine technology to provide remote counseling and consultation for women who may not be able to physically access healthcare facilities. This would help overcome geographical barriers and increase access to information and services.

6. Public-private partnerships: Collaborating with private healthcare providers to increase the availability of contraceptive implant insertion services. This could involve subsidizing costs or providing training and support to private clinics.

7. Peer education programs: Implementing peer education programs where women who have already received contraceptive implants share their experiences and knowledge with other women in their communities. This would help reduce stigma and increase acceptance of the method.

8. Targeted outreach campaigns: Conducting targeted outreach campaigns to raise awareness about the benefits and availability of contraceptive implants, specifically targeting HIV-infected women. This would help address any misconceptions or concerns related to HIV status and contraception.

These are just a few potential innovations that could be considered to improve access to maternal health, specifically in relation to contraceptive implant uptake among HIV-infected and uninfected women in Kenya. It is important to assess the feasibility, acceptability, and effectiveness of these innovations through further research and pilot programs.

AI Innovations Description

The recommendation to improve access to maternal health based on the study is to promote and provide immediate postpartum contraceptive implants to both HIV infected and uninfected women in Kenya. The study found that there was a high uptake of contraceptive implants in the immediate postpartum period among both HIV infected and uninfected women. Factors that were independently associated with increased uptake of contraceptive implants included a negative HIV status and prior knowledge of contraceptive implants.

To implement this recommendation, efforts should be made to raise awareness about contraceptive implants among women in Kenya, particularly during the antenatal period. This can be done through educational campaigns, antenatal care visits, and community outreach programs. Healthcare providers should also receive training on counseling women about contraceptive options, including the benefits and safety of immediate postpartum contraceptive implants. Additionally, healthcare facilities should ensure that contraceptive implants are readily available and accessible to women in the immediate postpartum period. This may involve training healthcare providers on insertion and removal techniques, as well as ensuring a reliable supply of contraceptive implants. By promoting and providing immediate postpartum contraceptive implants, the unmet need for family planning can be reduced, leading to improved maternal and infant health outcomes.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Increase awareness and education: Implement comprehensive awareness campaigns to educate women and their families about the importance of maternal health and the available services. This can include community outreach programs, workshops, and informational materials.

2. Strengthen healthcare infrastructure: Improve the availability and quality of healthcare facilities, especially in rural areas. This can involve building new clinics, upgrading existing facilities, and ensuring that they are adequately staffed and equipped to provide maternal health services.

3. Enhance training for healthcare providers: Provide specialized training for healthcare providers, including doctors, nurses, and midwives, to improve their knowledge and skills in maternal health care. This can include training on safe delivery practices, emergency obstetric care, and postpartum care.

4. Improve access to contraceptives: Increase the availability and accessibility of contraceptive methods, including contraceptive implants, by ensuring a reliable supply chain and distribution system. This can involve working with pharmaceutical companies, NGOs, and government agencies to ensure that contraceptives are affordable and readily available.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that can measure the impact of the recommendations, such as the number of women accessing maternal health services, the uptake of contraceptive methods, and the reduction in maternal and infant morbidity and mortality rates.

2. Collect baseline data: Gather data on the current state of maternal health access, including the number of women accessing services, the availability of healthcare facilities, and the utilization of contraceptive methods. This can be done through surveys, interviews, and analysis of existing data.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the indicators. This can be done using statistical software or specialized simulation tools.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. This can involve adjusting different variables, such as the coverage of awareness campaigns or the availability of healthcare facilities, to see how they affect the indicators.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. This can involve comparing different scenarios and identifying the most effective strategies.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This can help ensure the accuracy and reliability of the simulations.

7. Communicate findings and make recommendations: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and NGOs. Use the results to make recommendations for implementing the identified strategies and improving access to maternal health.

Author

Dima Health

Statistics:

Citations: 14

Identifiers:

DOI: 10.1186/s12905-015-0222-1

Research Areas:

Cancer, Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants

Study Countries:

Kenya

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female