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Background: Clients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods. Methods. We examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients. Results: Following the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects. Conclusions: The intervention failed to improve PMTCT clients’ knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally. © 2014 Hoke et al.; licensee BioMed Central Ltd.
We conducted a mixed-methods study to test an intervention for expanding contraceptive options for postpartum PMTCT clients. The study’s primary outcome, examined for both the IUD and female sterilization, was the proportion of postpartum PMTCT clients who a) were aware that the method is a safe and effective contraceptive option for HIV-positive women and b) knew where they could receive the method. An intervention was introduced within maternal/ child health services in five public sector health centers in low-income peri-urban sections of Cape Town, South Africa. Intervention effectiveness was assessed through pre- and post-intervention cross-sectional interviews conducted with two samples of postpartum women exiting the clinic after receiving health services. To examine intervention implementation, in-depth interviews were conducted with providers in intervention facilities. Additional process data were collected through detailed implementation documentation. Working in consultation with the district health management team, the investigators designed a multi-faceted intervention that was informed by formative research previously completed by the investigators in South African PMTCT facilities. The earlier research revealed knowledge gaps on the part of health service providers and clients about use of long-acting and permanent contraceptive methods by women living with HIV [22]. The tested intervention focused on reinforcement of counseling on postpartum family planning delivered to PMTCT clients in antenatal, delivery, and child health services. Providers were trained to include the IUD and female sterilization among the methods promoted to clients, and clinical services for providing these methods were reinforced. Key intervention elements included the following (see Table 1, Column 1 for details): Intervention elements as intended and related challenges during implementation • Provider training on reproductive health services for HIV-positive women • Training on IUD insertion and removal • Clinical supply management support • Strengthened referral system for female sterilization • On-the-job coaching and mentoring • IEC materials and job aids While the study team provided technical support for intervention implementation and oversight, the aim was to introduce an intervention package with potential for broad implementation within public sector services. Accordingly, intervention elements were incorporated into routine service delivery and depended on the systems and providers already in place in the participating public sector health facilities. Before intervention implementation and 6 months after it was fully in place, we interviewed a total of 1077 women exiting child health services (538 pre-intervention and 539 post-intervention), with approximately equal numbers of women at each time period who had and had not enrolled in PMTCT services during their most recent pregnancy. Eligible participants were adult women who reported having received antenatal care and were seeking child health services for their infants at the 5 participating facilities. Different samples of clients were interviewed at each time period, as opposed to following a cohort over the 9-month intervention period, given the additional eligibility criterion of participants being no more than 6 months post-partum. During the two data collection periods, each lasting about 2 months, study participants were recruited in the waiting areas of the facilities; all clients were screened for eligibility and administered informed consent until the sample size was attained. Research assistants administered a structured questionnaire in either English or Xhosa, according to the participant’s choice, to collect information on socio-demographic characteristics, contraceptive use, reproductive history, fertility intentions, exposure to family planning counseling, and knowledge about the IUD and sterilization. Interviews took approximately 40 minutes, and participants were not compensated for their time. This analysis focused on the PMTCT clients. Using Stata 10.0, we computed summary statistics separately for the pre-intervention and post-intervention samples, and then analyzed the difference between samples. Differences between samples were analyzed using rank sum test for continuous variables and chi-squared and Fisher’s exact test for categorical variables. The study was powered to assess whether at least 30% of PMTCT clients interviewed post-intervention had correct knowledge about the IUD and female sterilization, respectively, as captured by the primary outcome variables. Power estimates were based on post-intervention estimates instead of a change over time since it was assumed that clients in the pre-intervention sample would have negligible knowledge about those methods that were largely unavailable prior to the study. Approximately 8 months after intervention introduction, a research assistant conducted individual in-depth interviews with 16 providers who had participated in the study-sponsored trainings. Open-ended questions explored providers’ attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients, with particular focus on IUD and female sterilization services. Questions examined providers’ views on the safety and appropriateness of those methods for women living with HIV. Providers were further asked about any approaches they take in assessing clients’ fertility desires and tailoring family planning accordingly. Other questions explored factors facilitating and impeding providers’ ability to promote use of the IUD and female sterilization, considering health system resources, the supports introduced through the study intervention, and clients’ needs and priorities. Interviews, conducted in English, were digitally recorded and took approximately 60 minutes. Providers were not compensated for their time. One lead investigator and an analyst read the transcripts and developed a coding scheme shaped by the interview guide. An analyst coded and analyzed transcripts using QSR International’s NVivo 9. To complete thematic analysis, the analyst prepared memos to capture the divergence and convergence of ideas emerging from the text data. The lead investigator reviewed the memos and introduced modest refinements in consultation with the analyst. The research team documented intervention implementation using a tracking tool. This document consisted of an Excel worksheet, similar to Table 1, with columns to record the intervention components, first as described in the research protocol and then as actually implemented. Investigators used a third column to record observations on challenges and considerations for future replication. Investigators filled in the tracking tool on an ongoing basis by abstracting information from trip reports, training reports, and team email correspondence. The research was approved by the Health Science Faculty Human Research Ethics Committee of the University of Cape Town, the Western Cape Department of Health, and the Protection of Human Subjects Committee of FHI 360.
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