Menu
Menu
Menu
Menu
Background Programmes promoting the postpartum intrauterine device (PPIUD) have proliferated throughout South Asia and sub-Saharan Africa in recent years, with proponents touting this long-acting reversible contraceptive (LARC) method’s high efficacy and potential to meet contraceptive unmet need. While critiques of LARC-first programming abound in the Global North, there have been few studies of the impact of LARC-centric programmes on patient-centred outcomes in the Global South. Methods Here, we explore the impact of a PPIUD intervention at five Tanzanian hospitals and their surrounding satellite clinics on quality of contraceptive counselling and person-centred care using 20 qualitative in-depth interviews with pregnant women seeking antenatal care at one of those clinics. Using a modified version of the contraceptive counselling quality framework elaborated by Holt and colleagues, we blend deductive analysis with an inductive approach based on open coding and thematic analysis. Results Interpersonal aspects of relationship building during counselling were strong, but a mix of PPIUD intervention-related factors and structural issues rendered most other aspects of counselling quality low. The intervention led providers to emphasise the advantages of the IUD through biased counselling, and to de-emphasise the suitability of other contraceptive methods. Respondents reported being counselled only about the IUD and no other methods, while other respondents reported that other methods were mentioned but disparaged by providers in relation to the IUD. A lack of trained providers meant that most counselling took place in large groups, resulting in providers’ inability to conduct needs assessments or tailor information to women’s individual situations. Discussion As implemented, LARC-centric programmes like this PPIUD intervention may decrease access to person-centred contraceptive counselling and to accurate information about a broad range of contraceptive methods. A shift away from emphasising LARC methods to more comprehensive, person-centred contraceptive counselling is critical to promote contraceptive autonomy.
Patients and the public were not involved in the design, conduct, reporting or dissemination plans of our research. The research described here is part of a broader evaluation study of the six-country FIGO PPIUD initiative.20 In the words of the programme’s architects, The aim of the FIGO PPIUD initiative was to address the gap in the continuum of maternal health care and to provide for the postpartum contraceptive needs of women by increasing the capacity of healthcare professionals to offer PPIUDs by training community midwives, health workers, doctors, and delivery unit staff, as appropriate, in counselling and insertion of PPIUD.20 Contraception, including the IUD, is available free of charge in the Tanzanian public health system. Contraceptive counselling is routinely provided as a part of antenatal care, first as part of ‘health education’ delivered in group settings, followed by individual counselling. Although interval IUDs were already available as part of routine family planning service provision in Tanzania, the postpartum insertion of IUDs was not well-known or widely available at the onset of the intervention. The FIGO designers did not explicitly motivate this project as a single-method or LARC-first programme, but rather, cited the desire to address contraceptive unmet need and improve postpartum family planning options by adding PPIUD services to the existing contraceptive method offerings, thus expanding contraception choices.20 The initiative aimed to provide prenatal counselling on all aspects of contraception with a focus on postpartum family planning. Within the menu of methods of contraception, there was a special emphasis on the advantages of PPIUD as a safe, effective, and reversible long-acting method.20 The Association of Gynaecologists and Obstetricians of Tanzania (AGOTA, the Tanzanian FIGO affiliate) organised a series of trainings in six referral hospitals and in the surrounding satellite clinics that provide antenatal care and refer patients into the larger hospitals for delivery. The FIGO/AGOTA programme focused on training providers on cadre-appropriate skills and knowledge to support the implementation of PPIUD services. For doctors in the referral hospitals, this included technical training on postpartum insertion and removal of the copper IUD, while for nurses and midwives in satellite clinics, this included training to integrate PPIUD counselling into routine family planning counselling during antenatal, perinatal and postpartum care. The FIGO/AGOTA initiative employed a ‘training the trainer’ approach for both counselling and insertion training, identifying master trainers who then provided cascade training to other providers in their facilities. Trainers held sessions for counselling on ‘postpartum family planning inclusive of PPIUD’ for the staff of both referral hospitals and satellite clinics, aimed primarily at nurses and midwives. During these training sessions, ‘information on the advantages of PPIUD was presented and opportunities were given for prospective counsellors to openly state their views of the methods and address any prejudices’.20 After training, FIGO and AGOTA monitored providers’ work, including their rate of PPIUD insertion and any PPIUD-related complications to improve clinical quality of care. More information about the FIGO intervention can be found in de Caestecker et al.20 We launched a multi-site mixed-methods study (including a cluster-randomised trial) to evaluate this intervention in three countries: Nepal, Sri Lanka and Tanzania. The primary goals of this study were to examine the effect of the intervention on uptake, continuation and institutionalisation of PPIUD, and did not explicitly include any aims to assess person-centredness.48A detailed description of the cluster-randomised trial and evaluation is described by Canning et al.48 The qualitative portion of this study included in-depth interviews with women after their antenatal counselling, follow-up interviews with women 20 months postpartum, as well as interviews with providers who were trained by the PPIUD Project. Previous qualitative analyses from this study have focused on women’s reasons for PPIUD use/non-use,49 as well as provider and patient perspectives broadly on the programmatic implementation.28 Here, we focus specifically on perceptions of quality of care, with an emphasis on the impact of the PPIUD intervention on person-centred contraceptive counselling at the time of antenatal care. Management and Development for Health hired two Tanzanian women research assistants as independent consultants to conduct 20 in-depth interviews with pregnant women who had experienced at least two antenatal visits at one of the satellite clinics affiliated with the PPIUD intervention, but who had not yet given birth. Interviews took place between February and June 2017. The research assistants had extensive training and experience with qualitative interviewing prior to joining our study. Each had a bachelor’s degree in sociology and over 10 years experience conducting qualitative interviews for research studies. The study team conducted a training with these interviewers that included modules on the PPIUD intervention and postpartum family planning, research ethics, study protocols, non-directive and non-judgmental interviewing techniques, building rapport and active listening. These training modules included both didactic and interactive components. The interviewers had no prior relationship to study participants, and participants had no prior knowledge of any research team members. The research team translated the semistructured interview guide from English into Swahili, piloted them in that language, then made necessary changes to language, clarity and content. The interview guide focused on prior knowledge and use of contraception, experiences and perceptions of family planning counselling during maternity care, and postpartum contraceptive decision-making. The research assistants took a purposive sample of four women from five of the intervention sites (the sixth intervention site was not included in the evaluation due to a prexisting PPIUD intervention there). Since age and education are known to affect experiences of contraceptive counselling,50 the assistants attempted to recruit a diverse sample across these sociodemographic axes. Assistants approached women in clinic waiting rooms to invite them to participate in the study. If women agreed to be screened, they were assessed for the following four eligibility criteria: (1) currently residing in Tanzania; (2) between the ages of 18 and 49; (3) willing and able to provide informed consent and (4) received at least two antenatal visits at one of the satellite clinics affiliated with the PPIUD intervention, but had not yet given birth. If they were eligible and provided informed consent, one of the research assistants conducted an interview with them in a private area within the clinic. All respondents provided written informed consent to be interviewed and audio recorded. Women who could not sign their names but wanted to participate provided thumbprints to consent, in addition to the signature of a witness. We did not retain any names or identifiable information, and we assigned all participants a pseudonym for the purposes of analysis. Audio recordings were transcribed verbatim in Swahili, then translated into English. We show the background characteristics of the women interviewed in table 1. Respondent characteristics ANC, Antenatal Care; PPIUD, postpartum intrauterine device. The team analysing these data consisted of a multidisciplinary group of both Tanzanian and North American researchers. After an initial reading of the transcripts, we created a preliminary codebook, blending open coding (capturing codes emerging from the data) with a more concept-driven, deductive approach in which we coded for concepts defined by the Holt framework, including elements of relationship-building, needs assessment and decision-making support.51 After we generated the initial codebook, each interview was independently coded in Atlas.ti by at least two analysts. Our team discussed and incorporated codebook modifications throughout this process, before a final round of coding and analysis. We then applied thematic analysis to generate key themes and identify recurrent patterns related to quality of counselling and other emerging outcomes of interest.52 53 Prior to the final round of coding, we used our data to inform the creation of a modified version of the Holt framework (figure 1). Since our respondents were pregnant at the time of interview, their conversations with interviewers focused on their experience with the contraceptive counselling that was integrated into their antenatal care. They had not yet reached the stage in the contraceptive service provision process in which the final choice was made and method administered, which took place after delivery. As a result, these transcripts do not include data relevant to final method choice and follow-up, and so that pillar of the Holt framework, though important, is not included in our analysis. We show the modified version of the Holt framework, retaining all elements relevant to antenatal family planning counselling in figure 1. We present key themes that emerged related to quality of care, and person-centredness in family planning, and we map them onto the modified Holt framework, retaining key quotes for illustrative purposes. Modified Holt framework.
N/A
