Implementation of postpartum intrauterine device (PPIUD) services across 10 districts in Malawi

Background Malawi has a high maternal mortality and unmet need for family planning, which could be reduced by improving access to postpartum intrauterine device (PPIUD) insertion. Our objective is to describe the implementation of PPIUD services by 4 local organizations at 14 government health services across 10 districts in Malawi. Methods This program was a collaborative effort between the Malawi Ministry of Health’s Reproductive Health Directorate and 4 supporting organizations. Training, educational, and monitoring and evaluation materials for PPIUD insertion were developed between December 2013 and April 2014. Each organization was then responsible for PPIUD community sensitization, provider training, and tracking of PPIUD insertions (via PPIUD register books) at their targeted health facilities. Community sensitization activities included Open Day campaigns, which were organized by local leaders to sensitize their communities, and Population Weekends, which were organized by religious leaders to target their congregations. Results Community sensitization activities, provider trainings, and mentoring occurred from January 2014 to June 2015, and monitoring and evaluation continued until December 2016 at some sites. One national Radio Discussion Panel with religious leaders was broadcast, 20 Open Day campaigns and 2 Population Weekends were held, 429 providers were trained during 27 trainings, and 249 PPIUD insertions occurred. Conclusions PPIUD can be safely offered in Malawi. However, the biggest challenge with program implementation was with encouraging providers to take the extra time and effort to insert an IUD within 48 hours of delivery. In addition, frequent rotation of trained labour ward staff to other clinical areas hindered the program’s sustainability since new trainings had to be held whenever staff members were rotated. Further research should be done to determine the best strategies to motivate busy providers to insert PPIUD, and PPIUD should be integrated into both medical and nursing curriculums to reduce the number of postgraduate trainings required to sustain PPIUD services.

UNC implemented PPIUD at two facilities, whereas BLM, SSDI, and UNFPA each implemented it at 4 facilities (Figure 1). These 14 facilities were chosen by the RHD because of their high volume of deliveries and interest in expanding their FP services, and they were located in 10 different districts across Malawi (Figure 1). Each organization was responsible for implementing the PPIUD community sensitization, training, and monitoring and evaluation activities at their targeted facilities as no standardized guidelines for implementation existed. However, the organizations first worked together to produce the PPIUD training presentation, manual, checklist, counseling cases, provider information sheet, pre/post-test, course evaluation, and register. These materials were presented to the FP Sub-Committee for approval in January 2014, piloted during two trainings in February 2014, and finalized in April 2014 (Figure 2). Map of 10 PPIUD Implementation districts in Malawi Timeline of PPIUD Implementation activities Figure Abbreviations: PPIUD = postpartum intrauterine device; UNC = University of North Carolina Project-Malawi; SSDI = Support for Service Delivery Integration-Services; BLM = Banja La Mtsogolo; UNFPA = United Nations Population Fund The partners also worked with the Malawi Health Education Unit (HEU) to develop a PPIUD brochure and three posters in Chichewa, the most commonly-spoken language in Malawi. These materials were pilot-tested by the HEU in three districts across the country in March 2014 and finalized by the HEU the next month. The remaining activities were left to each partner to implement in their own manner. Community sensitization was generally done by first sensitizing the targeted communities’ traditional chiefs to the importance of postpartum FP and PPIUD since they play an important role in influencing their communities’ beliefs and practices. The partners then worked with the chiefs to establish FP Community Task Forces, comprised of key members of the targeted communities who could help to organize an Open Day for their community. Open Days were large community gatherings where multiple activities were utilized to promote FP, including songs, dramas, quiz games, and mobile vans that offered FP services on-site. They also included the use of FP Champions (former or current FP users, particularly IUD users), men who were supportive of FP, and local community health workers, to explain the benefits of FP and dispel its myths. To sensitize men to FP and PPIUD, SSDI organized soccer and bawo (a local board game) tournaments at their Open Days. UNC partnered with Family Planning Association of Malawi (FPAM, Malawi’s International Planned Parenthood affiliate) to organize its Open Days. Through a grant that only UNC received, it was also able to work with Health Policy Project (HPP, a 5-year USAID-funded project in Malawi) to sensitize religious leaders and their congregations to the benefits of FP. HPP had already been collaborating with the Malawi Ministry of Economic Planning and Development (MEPD) to train and sensitize the religious leaders of the main religious denominations in Malawi about the benefits of FP and the needs to increase its access. Multiple workshops with these religious leaders were held, during which each religious denomination developed strategies and brochures to promote family planning within their religion’s teachings. One strategy agreed upon by the various religious leaders was to organize a live radio discussion panel to promote the use of FP. The radio discussion panel was held on January 16, 2014 and was recorded live on Zodiak Radio Station, one of Malawi’s radio stations. The four panelists represented the Malawi Council of Churches and Evangelical Association of Malawi, the Episcopal Conference of Malawi, the Seventh Day Adventist Church in Malawi, and the Quadria Muslim Association of Malawi. This distribution of panelists was chosen because 69% of Malawians are Christian and 26% are Muslim, with 6% subscribing to another or no religion.11 The Panelists focused on highlighting the structures each denomination had in support of FP, clearing misconceptions on religion’s stance on FP, and focusing on FP as a key strategy to improve the health of women and children and slow down rapid population growth. The panel also served as an advertisement for Population Weekends, which were held in UNC’s two targeted districts. The Population Weekends were held in Kasungu District from 17 to 19 January, 2014, and in Area 25 from 31 January to 2 February, 2014. During the Population Weekends, the participating churches and mosques focused their weekend sermons, songs, bible studies, and youth group meetings on FP and gave out FP brochures designed by each of the three major religious denominations in Malawi (Protestant, Catholic, and Muslim). Each brochure focused on the benefits of FP and healthy birth spacing and quoted supporting verses from the Bible or Quran. Brochures were also produced on adolescent sexuality for use by youth groups. Immediately after the Population Weekends, FPAM held their Open Day campaigns in the same areas targeted by the Population Weekend. Provider training and mentoring in PPIUD insertion began in February, 2014, and included training in both post-placental IUD insertion (0–10 minutes after placental delivery) and immediate postpartum IUD insertion (10 minutes to 48 hours after placental delivery), as well as IUD removal and management of missing IUD strings. Trained providers included community midwives, nurse midwife technicians, registered nurse midwives, medical assistants, and clinical officers. Only clinical officers were trained in intracesarean IUD insertion since they were the only trained cadre allowed to perform cesarean sections. They were all trained in the classroom over two days using the Mama-U Postpartum Uterus Trainer (Laerdal Global Health, Stavanger, Norway). The trainers were then placed at the targeted health facility for the remaining three days whenever it was possible to send a trainer to the facility, so that the trainees could practice on actual patients with supervision. Each facility was given PPIUD instrument kits, including long placental Kelly forceps and a Mama-U Trainer. The initial trainers were 5 American gynecologists and one of the Malawian Master FP Trainers trained in Zambia. These 6 trainers then trained Malawian providers to become trainers. After each training, each trained provider was paired with a Malawian FP mentor. For mentoring, the mentors would meet with their mentees on a monthly basis to monitor any problems or successes they had with PPIUD, for up to 6 months after the training. Monitoring and evaluation was done through monthly visits to the facilities, during which the number of PPIUD insertions was collected through review of the facility’s PPIUD register book, in which all PPIUD insertions were recorded. Due to the end of one of the grant sources for this project, BLM and SSDI only monitored their sites until June, 2015, whereas UNC and UNFPA monitored their sites with other grant funding until December, 2016.

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• Dima Health