Risk factors and knowledge associated with high unintended pregnancy rates and low family planning use among pregnant women in Papua New Guinea

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Study Justification:
The study aimed to address the high rates of unintended pregnancies and low utilization of family planning methods among pregnant women in Papua New Guinea (PNG). Unintended pregnancies have significant negative impacts on maternal and child health in resource-limited settings. However, there is a lack of data on pregnancy intention and family planning use in PNG, which hinders the development of effective public health strategies. This study aimed to fill this knowledge gap and provide evidence to inform interventions to improve family planning accessibility, uptake, and knowledge.
Highlights:
1. More than half (55%) of the pregnant women in the study reported their pregnancy as unintended.
2. Only 18% of the women reported ever using a modern family planning method, and knowledge of different methods was low.
3. Factors associated with unintended pregnancy included being single, separated, or divorced, having a higher level of education, and having multiple pregnancies.
4. Male partner involvement in antenatal care was associated with a reduced risk of unintended pregnancy.
5. Factors associated with modern family planning use included male partner involvement and having multiple pregnancies.
6. Family planning use varied by the healthcare facility attended by the women.
Recommendations:
1. Targeted interventions are urgently needed to improve family planning knowledge, access, and uptake among pregnant women in PNG.
2. Male partner involvement in antenatal care should be encouraged and promoted to reduce unintended pregnancies.
3. Strategies should be developed to address the barriers to accessing family planning services reported by women.
4. Healthcare facilities should be supported to provide comprehensive family planning services and information.
Key Role Players:
1. Policy-makers: They play a crucial role in developing and implementing policies that prioritize family planning and reproductive health in PNG.
2. Medical specialists: Their expertise is needed to provide guidance and support in the development and implementation of family planning interventions.
3. Healthcare workers: They are essential in delivering family planning services and providing information and counseling to pregnant women.
4. Research institutions: They can contribute by conducting further research to evaluate the effectiveness of interventions and monitor progress in improving family planning outcomes.
Cost Items for Planning Recommendations:
1. Training and capacity building for healthcare workers to provide comprehensive family planning services.
2. Development and dissemination of educational materials and resources on family planning.
3. Awareness campaigns to promote family planning and increase knowledge among the general population.
4. Strengthening healthcare facilities to ensure they have the necessary infrastructure and resources to provide family planning services.
5. Monitoring and evaluation activities to assess the impact of interventions and make necessary adjustments.
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on the specific context and implementation strategies.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study is based on a facility-based cross-sectional sample of 699 pregnant women in Papua New Guinea, which provides valuable insights into the prevalence and predictors of unintended pregnancy and modern family planning (FP) use. The study also includes analysis of cross-sectional baseline data from a larger prospective observational cohort study. However, the study design is limited to a specific region in Papua New Guinea, which may limit the generalizability of the findings. To improve the strength of the evidence, future studies could consider expanding the sample size and including a more diverse population from different regions of Papua New Guinea. Additionally, conducting a longitudinal study would provide more robust evidence on the long-term impact of interventions to improve FP knowledge, uptake, and access.

Unintended pregnancy is a major driver of poor maternal and child health in resource-limited settings. Data on pregnancy intention and use of family planning (FP) is scarce in Papua New Guinea (PNG), but are needed to inform public health strategies to improve FP accessibility and uptake. Data from a facility-based cross-sectional sample of 699 pregnant women assessed prevalence and predictors of unintended pregnancy and modern FP use among pregnant women in East New Britain Province, PNG. More than half (55%) the women reported their pregnancy as unintended. Few (18%) reported ever having used a modern FP method, and knowledge of different methods was low. Being single, separated or divorced (AOR 9.66; 95% CI 3.27–28.54), educated to a tertiary or vocational level (AOR 1.78 CI 1.15–2.73), and gravidity > 1 (AOR 1.43 for each additional pregnancy CI 1.29–1.59) were associated with unintended pregnancy; being accompanied by a male partner to ANC was associated with a reduced unintended pregnancy (0.46 CI 0.30–0.73). Factors associated with modern FP use included male partner involvement (AOR 2.26 CI 1.39–3.67) and gravidity > 1 (AOR 1.54 for each additional pregnancy CI 1.36–1.74). FP use also varied by the facility women attended. Findings highlight an urgent need for targeted interventions to improve FP knowledge, uptake and access, and male partner involvement, to reduce unintended pregnancies and their complications.

This study included analysis of cross-sectional baseline data from a larger prospective observational cohort study of pregnancy and childbirth undertaken in ENB Province, by a multi-partner research program led by the Burnet Institute with the PNG Institute of Medical Research, the ENB Provincial Health Office (now Provincial Health Authority) and the Kirby Institute of the University of New South Wales, Sydney. Input from relevant national and local stakeholders, including policy-makers, medical specialists, and healthcare workers at all levels, was sought during 2013 and 2014 to inform the design of the study. This paper reports on interview data relevant to FP collected at the enrolment contact point at the first ANC visit. ENB Province is located in the Islands Region of PNG. According to the 2011 census, ENB had a population of 328,369 and a population growth rate of 3.6% between 2000 and 201123. The province is predominantly rural, reflecting PNG’s national profile wherein 87% of the PNG population reside in rural areas24, with two small urban centres (populations estimated at close to 32,000 (Kokopo) and 5000 (Rabaul)23). Pregnant women of any gravidity attending their first ANC visit were recruited from five healthcare facilities located in three of the four districts in ENB (Gazelle, Kokopo and Rabaul) where 78% of the provincial population resides23. They comprise a mix of two government and three church-run facilities and are the busiest providers of reproductive health services in these adjoining districts, accounting for over 75% of antenatal services, based on information provided by the Provincial Health Office in 2014. Nonga General Hospital is the government referral hospital for the province, and is located near Rabaul township. The government-run Kerevat Rural Hospital is the most remotely located of the participating facilities and is administered by the Gazelle District Health Administration. Saint Mary’s Hospital Vunapope, and Napapar and Paparatava Health Centres are administered by Catholic Health Services, PNG, under the Gazelle District Health Administration. Vunapope is located in the town of Kokopo, the capital and largest urban centre in ENB, whereas Napapar and Paparatava are smaller, rural facilities. Women were enrolled between March 2015 and June 2017. A target sample size of 700 was set by the larger cohort study’s parameters needed to assess predictors of low birth weight. Recruitment aimed for a representative sample of pregnant women attending ANC who were selected randomly (by rolling dice) with spacing to ensure both early and late attendees were invited. Women had to meet the following eligibility criteria; (1) age of 16 years or older; (2) attending ANC for the first time for the current pregnancy; (3) residing within the catchment area of the healthcare facility; (4) intending to live in ENB for the subsequent 12 months; (5) agree to participate in the study. Written informed consent was obtained from all study participants. A questionnaire with a mix of closed and open-ended questions was drafted in English and translated into Tok Pisin language, the most widely spoken national language of PNG. It was administered using electronic handheld devices by research officers of PNG nationality, trained in clinical interview techniques, using a private location at each facility to ensure confidentiality. Outcome measures of pregnancy intention and FP use were adapted from standard FP items in the DHS women’s questionnaire25, and modified to the PNG context after pre-testing (including revision to include contraceptive methods currently available). Women could report their current pregnancy as either (1) mistimed (i.e., wanting to be pregnant later, but not at this time), (2) unwanted (i.e., not wanting to be pregnant at all) or (3) wanted; a pregnancy was considered unintended if it was mistimed or unwanted26. Women were asked if they had ever used FP, and if so, without prompting, were asked to recall all methods (modern and/or traditional) that they had ever used. Modern and traditional methods of FP were defined using World Health Organization classifications27 with modern methods comprising: oral contraceptive pills, implants, injectables (Depo Provera), female sterilisation, male sterilisation, intra-uterine devices, diaphragm, emergency contraception, male and female condoms. Exposure measures comprised of questions relating to socio-demographic characteristics, male partner involvement in ANC, pregnancy history, and knowledge of FP methods. Male partner involvement was assessed by asking women whether their husband/male partner was in attendance at ANC that day, and if not, whether he would have liked to attend. Questions relating to pregnancy history (pregnancy number and number of years since the previous pregnancy) included all previous pregnancies regardless of outcome. Similar to questions on FP use, without prompting, women were asked to recall all methods of FP of which they were aware. Open-ended questions asked women to give opinions on barriers to accessing FP services if they reported that access to FP was sometimes a problem, or if they were unsure if access was difficult. They were also asked to provide reasons for non-use of FP if they reported never having used any method of FP. Research officers selected from a list of standardised response options those that best matched the woman’s answer/s, with multiple response options allowed. If a participant’s response differed from the standardised list this was captured as a free-text entry. Bivariate and multivariable logistic regression explored correlates of unintended pregnancy and lifetime use of a modern method/s of FP. Variables of interest were chosen for multivariable analyses a priori and included healthcare facility of recruitment and variables cited in the literature to be associated with these outcomes of interest (marital status, indicators of socio-economic status and gravidity21,22,28) and variables hypothesised to have an association (male involvement in ANC and reporting difficulty accessing FP). Due to collinearity between participant educational level, male partner educational level, participant employment status, male partner employment status and monthly household expenditure, only participant educational level was included in the final multivariable model. Similarly, due to collinearity between age and gravidity, only gravidity was included in the final models. All analyses were performed using STATA version 13.0 (StataCorp, TX, USA). Approval for the study protocol was granted in PNG by the Papua New Institute of Medical Research’s Institutional Review Board (14.11), the National Department of Health Medical Research Advisory Committee (14.27), and in Australia by the Alfred Hospital Human Research Ethics Committee (348/18). Approval to conduct the study was obtained from the Provincial Executive Committee of the East New Britain Provincial Government, and the individual health centres involved. Key considerations were to ensure written informed consent using local language forms and detailed explanations, minimisation of discomfort during data collection, and assurance of confidentiality through use of non-identifiable study identifiers; there was separate, limited, controlled access to any identifying information required for follow-up. Independent contact points for complaints or adverse event reporting were publicised and maintained by the Burnet Institute and PNG Institute of Medical Research. All study participants provided written informed consent. All study procedures were performed in accordance with relevant guidelines and regulations.

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Innovation 1: Mobile Health (mHealth) Applications
Develop a mobile health (mHealth) application that provides information on family planning methods, pregnancy planning, and maternal health. The app can include educational materials, interactive tools, and reminders for ANC visits and contraceptive use. It can also provide a platform for women to ask questions and receive personalized guidance from healthcare providers.

Innovation 2: Community Health Workers
Train and deploy community health workers (CHWs) to provide education and counseling on family planning and maternal health in remote areas. CHWs can conduct home visits, organize community workshops, and provide support to pregnant women and their families. They can also distribute contraceptives and refer women to healthcare facilities for ANC services.

Innovation 3: Telemedicine Services
Establish telemedicine services to improve access to maternal health services in remote areas. Pregnant women can consult with healthcare providers through video calls or phone calls, reducing the need for travel and increasing access to medical advice and guidance. Telemedicine can also be used for FP counseling and prescription of contraceptives.

Innovation 4: Mobile Clinics
Set up mobile clinics that travel to remote communities to provide ANC services and family planning counseling. These clinics can be equipped with basic medical equipment and staffed by healthcare providers who can conduct check-ups, provide contraceptives, and offer counseling services. This will bring healthcare services closer to the communities, reducing barriers to access.

Innovation 5: Public-Private Partnerships
Establish partnerships between the government, private sector, and non-governmental organizations to improve access to maternal health services. Private sector companies can provide funding, resources, and expertise to support initiatives such as educational campaigns, training programs, and infrastructure development. This collaboration can help leverage resources and reach a wider population.

Innovation 6: Supply Chain Management
Improve supply chain management for contraceptives and maternal health commodities to ensure consistent availability in healthcare facilities. Implementing robust inventory management systems, forecasting demand, and strengthening distribution networks will help prevent stockouts and ensure that women have access to the contraceptives they need.

These innovations aim to address the barriers identified in the study and improve access to maternal health services and family planning in Papua New Guinea. It is important to tailor these innovations to the specific context and needs of the communities, taking into consideration cultural sensitivities and local infrastructure.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Targeted Interventions: Based on the findings of the study, there is an urgent need for targeted interventions to improve family planning (FP) knowledge, uptake, and access, as well as male partner involvement, to reduce unintended pregnancies and their complications. These interventions should focus on increasing awareness and knowledge of modern FP methods among pregnant women in Papua New Guinea (PNG).

2. Education and Awareness Campaigns: Develop and implement educational campaigns to increase awareness and knowledge of modern FP methods among pregnant women and their male partners. These campaigns can include community outreach programs, workshops, and information sessions in healthcare facilities, schools, and community centers.

3. Training for Healthcare Providers: Provide training for healthcare providers on modern FP methods and counseling techniques. This will ensure that healthcare providers have the necessary knowledge and skills to provide accurate information and guidance to pregnant women seeking FP services.

4. Integration of FP Services: Integrate FP services into antenatal care (ANC) visits to improve access and uptake. This can include offering FP counseling and services during ANC visits, ensuring that healthcare providers discuss FP options with pregnant women, and providing on-site access to modern FP methods.

5. Male Partner Involvement: Encourage and facilitate male partner involvement in ANC visits and FP decision-making. This can be done through educational campaigns targeting male partners, providing information and resources specifically for male partners, and creating a supportive environment in healthcare facilities that welcomes and encourages male involvement.

6. Collaboration and Partnerships: Foster collaboration and partnerships between government agencies, non-governmental organizations, healthcare providers, and community leaders to implement and sustain these interventions. This will ensure a coordinated and comprehensive approach to improving access to maternal health services and reducing unintended pregnancies.

It is important to note that these recommendations should be tailored to the specific context and needs of Papua New Guinea, taking into consideration cultural, social, and economic factors.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Baseline Data Collection: Collect baseline data on the current status of maternal health, unintended pregnancies, family planning knowledge, uptake, and access in Papua New Guinea (PNG). This can be done through surveys, interviews, and data analysis from healthcare facilities and relevant stakeholders.

2. Intervention Implementation: Implement the recommended interventions, including targeted educational campaigns, training for healthcare providers, integration of family planning services into antenatal care visits, and initiatives to encourage male partner involvement. These interventions should be implemented in selected healthcare facilities in PNG.

3. Data Collection during Intervention: Collect data during the intervention period to assess the impact of the implemented interventions. This can include surveys, interviews, and data analysis to measure changes in unintended pregnancies, family planning knowledge, uptake, and access among pregnant women in the selected healthcare facilities.

4. Data Analysis: Analyze the collected data to evaluate the effectiveness of the interventions. Compare the baseline data with the data collected during the intervention period to identify any improvements in maternal health outcomes, unintended pregnancies, family planning knowledge, uptake, and access.

5. Evaluation and Feedback: Evaluate the results of the data analysis and provide feedback to relevant stakeholders, including government agencies, non-governmental organizations, healthcare providers, and community leaders. Share the findings to inform future strategies and interventions aimed at improving access to maternal health in PNG.

6. Continuous Monitoring and Improvement: Continuously monitor the impact of the implemented interventions and make necessary adjustments based on the findings. This can include refining the interventions, expanding their reach to more healthcare facilities, and addressing any identified barriers or challenges.

By following this methodology, it will be possible to simulate the impact of the recommended interventions on improving access to maternal health in Papua New Guinea. The data collected and analyzed will provide valuable insights for policymakers and stakeholders to make informed decisions and develop effective strategies to address the identified issues.

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