“Every method seems to have its problems”- Perspectives on side effects of hormonal contraceptives in Morogoro Region, Tanzania

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Study Justification:
– The study aims to understand the perspectives of postpartum women, their partners, community leaders, and health providers in Tanzania regarding the side effects of hormonal contraceptives.
– This information is important because side effects are a significant barrier to the sustained use of contraceptives, particularly in the postpartum period.
– By understanding these perspectives, appropriate counseling and dialogue on contraceptive side effects can be developed to address the concerns outlined by women, their partners, communities, and service providers.
Study Highlights:
– Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births.
– However, side effects were consistently cited as a reason for women and their partners to forgo family planning altogether, discontinue methods, switch methods, or use methods in an intermittent and ineffective manner.
– Side effects mentioned included excessive menstrual bleeding, missed menses, weight gain, and fatigue.
– Concerns were also expressed that contraceptives could induce sterility in women or harm breastfeeding children via contamination of breast milk.
– Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn’s health in the first months of life.
Study Recommendations:
– To meet Tanzania’s national target of increasing contraceptive use from 34% to 60% by 2015, appropriate counseling and dialogue on contraceptive side effects are needed.
– These counseling and dialogue sessions should address the pressing concerns outlined by women, their partners, communities, and service providers.
– The recommendations include providing accurate information about side effects, addressing misconceptions about contraceptive-induced sterility and harm to breastfeeding children, and addressing concerns about the impact of family planning on newborn health.
Key Role Players:
– Postpartum women
– Partners of postpartum women
– Community leaders (including religious and opinion leaders)
– Community health workers
– Facility-based providers
Cost Items for Planning Recommendations:
– Training and capacity building for health providers on counseling and addressing contraceptive side effects
– Development and dissemination of educational materials on contraceptive side effects
– Community engagement activities to address misconceptions and concerns
– Monitoring and evaluation of the implementation of counseling and dialogue sessions
– Research and data collection to assess the impact of the recommendations on contraceptive use and side effect perceptions

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on qualitative interviews conducted with a diverse range of respondents. The researchers used thematic analysis to analyze the data, which adds rigor to the study. The findings highlight the significant impact of side effects on contraceptive use in Tanzania. To improve the evidence, the study could benefit from a larger sample size and a more diverse range of participants, including women from urban areas and different socioeconomic backgrounds.

Background: Family planning has been shown to be an effective intervention for promoting maternal, newborn and child health. Despite family planning’s multiple benefits, women’s experiences of – or concerns related to – side effects present a formidable barrier to the sustained use of contraceptives, particularly in the postpartum period. This paper presents perspectives of postpartum, rural, Tanzanian women, their partners, public opinion leaders and community and health facility providers related to side effects associated with contraceptive use. Methods: Qualitative interviews were conducted with postpartum women (n = 34), their partners (n = 23), community leaders (n = 12) and health providers based in both facilities (n = 12) and communities (n = 19) across Morogoro Region, Tanzania. Following data collection, digitally recorded data were transcribed, translated and coded using thematic analysis. Results: Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births. However, side effects were consistently cited as a reason that women and their partners choose to forgo family planning altogether, discontinue methods, switch methods or use methods in an intermittent (and ineffective) manner. Respondents detailed side effects including excessive menstrual bleeding, missed menses, weight gain and fatigue. Women, their partners and community leaders also described concerns that contraceptives could induce sterility in women, or harm breastfeeding children via contamination of breast milk. Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn’s health in the first months of life. Conclusions: To meet Tanzania’s national target of increasing contraceptive use from 34 to 60 % by 2015, appropriate counseling and dialogue on contraceptive side effects that speaks to pressing concerns outlined by women, their partners, communities and service providers are needed.

The study design was informed by rapid ethnographic approaches developed as part of applied qualitative research for health [18–20]. Rapid ethnographic approaches, or “quick ethnography,” represents an adaptation of traditional (long term) anthropological inquiry with an aim to reduce the duration of time for fieldwork in order to provide timely insights to program planners, evaluators and stakeholders [21]. Similar to traditional ethnography, rapid ethnography subscribes to the constructivist worldview, which posits that knowledge is socially constructed [22, 23]. Because the goal of this research was to inform a program that promotes community-facility linkages, and aims to understand access to and opinions of facility-based maternal health services, the research team conducted in-depth interviews (IDIs) across a variety of respondents: postpartum women, their partners, community leaders (including religious and opinion leaders), community health workers (CHWs) and facility-based providers. These interviews explored several aspects of reproductive health including knowledge and use of FP, barriers to accessing and consistently using FP, and sources of influence that shape women’s perceptions and decisions related to FP. Sampling among the community-based respondent groups was stratified by communities living near (<3 km) and far (3–10 km) from health facilities. This was done across 16 villages in the catchment areas of 8 government health centers (8 villages near, and 8 villages far from a health center) in four districts of the region (Morogoro, Mvomero, Kilosa1 and Ulanga District Council). Stratification was done with an intention of exploring nuances in utilization of maternal, neonatal and child health services across districts and by distance to facilities. Facility-based providers helped the research team identify distant villages by discussing with the research team communities that were situated within their catchment area but were known to seldom interact with the formal health system. Once in communities, the data collection team presented themselves to village leaders (this sometimes included CHWs) and asked to be introduced to any woman known to have delivered in the preceding 14 months who may be available for an interview in the coming days. The 14-month time period was chosen as it reduced recall bias, but allowed enough time for women to reinitiate FP. Although couples were prioritized for IDIs, roughly two-thirds of all male partners were not available to participate. Prior FP use was not a criterion for participation, although nearly all postpartum women had prior experience using FP. Interviewed leaders included religious leaders, as well as members of an elected village board and/or village health committee. These individuals also assisted the research team in identifying CHWs. Leaders and CHWs were interviewed irrespective of gender, age, education level or length of service. Leaders and CHWs helped data collectors identify women and their partners. In addition, data collectors canvassed the village and invited eligible mothers and fathers to participate. A second phase of data collection included IDIs with facility-based providers. In total, 100 IDIs were conducted (88 community-based interviews and 12 facility-based provider interviews) (See Table 1). Demographic characteristics of postpartum women, their partners, community leaders and health providers aWomen who have delivered a child within the preceding 14 months bPartners of postpartum women interviewed cIncludes politicians, Muslim clerics and Christian ministers dIncludes Clinical Officers, Assistant Clinical Officers and Assistant Medical Officers with the ability to prescribe drugs eIncludes Enrolled Nurses, Registered Nurses, Nurse Midwives and Nursing Officers who do not prescribe drugs Interviews were carried out by six Tanzanian data collectors (three male, three female) with masters-level training in social sciences or public health and with previous experience in qualitative data collection. All data collectors were native Kiswahili speakers and they conducted all interviews in Kiswahili. The team was accompanied by a researcher from Johns Hopkins University (SAM) who conducted training and supervised field work with the team. The study team received one week of training, which included pilot testing. Data collection took place between July and September 2011. Upon entering a community, researchers sought guidance from members of village health committees to identify participants fulfilling the study criteria: women who gave birth in the 14 months preceding the study, their partners, public opinion leaders (including religious leaders), and community health workers (CHWs). Consenting participants were interviewed in a setting of their choosing—often their homes or surrounding environs—and IDIs typically lasted 60–90 minutes. In the event that an interview was compromised by the presence of a curious onlooker, the interviewer politely explained the purpose of the interview (“to learn about maternal health”) and requested that the onlooker leave. In two cases, a research manager (SAM) approached especially curious onlookers and engaged them in a separate, informal conversation that was not within the vicinity of the IDI. This approach was effective in maintaining privacy during IDIs. IDIs focused on knowledge, attitudes and experiences related to careseeking and counseling during the most-recent pregnancy and birth. At the outset of data collection, the research team did not intend to explicitly investigate opinions of and experiences with family planning. However the theme of contraception (coupled with concerns about side effects) emerged in the earliest interviews, and was probed more explicitly as data collection progressed. Following each day’s interviews, the field supervisor led debriefing sessions to triangulate findings, strengthen probing among data collectors, identify a need for follow-up interviews and develop themes for a codebook. All interviews were digitally recorded and transcribed by the same data collectors who carried out the interviews. Each transcript was quality controlled by bilingual researchers (JJC and IHM) and coded. Codes were first developed during data collection and later refined via open coding of a representative sample of transcripts. A codebook was developed collaboratively by the data collection team with lead researchers, and codes were applied to all transcripts using ATLAS.ti, a data management tool [24]. Coded texts were then translated into English, coded by the lead author with validation checks by SAM and PJW. In-country debriefings with regional and national stakeholders who included representatives from spheres of academia (Muhimbili University), policy (the MOHSW) and maternal health programming (Jhpiego) further informed the co-authors’ understanding of contextual realities related to contraception, which informed the presentation of this data. Ethical clearances were obtained from the Institutional Research Boards of Johns Hopkins Bloomberg School of Public Health in Baltimore, USA and Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania and informed consent was provided by all research participants.

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

1. Improved counseling and education: Develop comprehensive counseling programs that address the concerns and side effects associated with contraceptive use. This could include providing accurate information about side effects, addressing misconceptions, and offering support and guidance to women and their partners.

2. Community engagement: Engage community leaders, religious leaders, and opinion leaders to promote family planning and address concerns related to side effects. This could involve community meetings, workshops, and awareness campaigns to increase knowledge and understanding of contraceptive methods.

3. Training for healthcare providers: Provide training for healthcare providers on effective counseling techniques, addressing side effects, and promoting family planning. This could help providers better understand and address the concerns of women and their partners, and provide appropriate support and guidance.

4. Access to a variety of contraceptive methods: Ensure that a range of contraceptive methods are available and accessible to women, including options that have fewer side effects. This could involve expanding the range of contraceptive methods offered in health facilities and ensuring consistent availability of supplies.

5. Postpartum support: Develop targeted support programs for women in the postpartum period, addressing their specific concerns and needs related to family planning. This could include providing information and support during antenatal and postnatal care visits, as well as through community-based programs.

6. Integration of maternal health services: Integrate family planning services with other maternal health services, such as antenatal care and postnatal care. This could help ensure that women have access to comprehensive care and support throughout the continuum of pregnancy and childbirth.

7. Mobile health (mHealth) interventions: Utilize mobile technology to provide information, reminders, and support for family planning. This could include text message reminders for contraceptive use, mobile apps with information on side effects and contraceptive options, and telemedicine services for counseling and support.

These are just a few potential innovations that could be considered to improve access to maternal health. It is important to tailor interventions to the specific context and needs of the population, and to involve key stakeholders in the design and implementation of these innovations.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health would be to prioritize appropriate counseling and dialogue on contraceptive side effects. This recommendation is based on the findings that side effects of hormonal contraceptives are consistently cited as a reason for women and their partners to forgo family planning altogether, discontinue methods, switch methods, or use methods in an intermittent and ineffective manner.

To address this barrier, it is important to provide accurate information and address the concerns outlined by women, their partners, communities, and service providers. This can be achieved through comprehensive counseling sessions that address the potential side effects of contraceptives, including excessive menstrual bleeding, missed menses, weight gain, fatigue, and concerns about sterility or harm to breastfeeding children.

By addressing these concerns and providing accurate information, women and their partners can make informed decisions about contraceptive use, leading to increased access to maternal health services and improved maternal and child health outcomes.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Develop comprehensive and culturally sensitive educational campaigns to address misconceptions and concerns related to side effects of hormonal contraceptives. This can be done through community outreach programs, media campaigns, and partnerships with local leaders and healthcare providers.

2. Improve counseling services: Train healthcare providers to provide accurate and non-judgmental counseling on contraceptive methods, including addressing concerns about side effects. This can help women make informed decisions about their reproductive health and increase their confidence in using contraceptives.

3. Expand contraceptive options: Offer a wider range of contraceptive methods to meet the diverse needs and preferences of women. This can include non-hormonal methods, long-acting reversible contraceptives (such as intrauterine devices), and natural family planning methods. Providing more options can help women find a method that suits them best and reduces the likelihood of experiencing side effects.

4. Strengthen postpartum care: Integrate family planning services into postpartum care to ensure that women have access to contraceptives immediately after giving birth. This can include providing counseling, offering a range of contraceptive methods, and addressing concerns about side effects.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather data on the current access to maternal health services, contraceptive use, and the prevalence of concerns related to side effects. This can be done through surveys, interviews, and analysis of existing data.

2. Define indicators: Identify specific indicators that will be used to measure the impact of the recommendations. This can include indicators such as contraceptive prevalence rate, contraceptive discontinuation rate, and knowledge about contraceptive side effects.

3. Develop a simulation model: Create a simulation model that incorporates the baseline data and the potential impact of the recommendations. This model should take into account factors such as population demographics, healthcare infrastructure, and cultural norms.

4. Run simulations: Use the simulation model to project the potential impact of the recommendations over a specified time period. This can involve running multiple scenarios to assess the effects of different combinations of recommendations.

5. Analyze results: Analyze the simulation results to determine the potential improvements in access to maternal health services and contraceptive use. This can include assessing changes in the indicators defined in step 2.

6. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This will help ensure the accuracy and reliability of the simulations.

7. Communicate findings: Present the findings of the simulation study to relevant stakeholders, including policymakers, healthcare providers, and community leaders. This can help inform decision-making and guide the implementation of interventions to improve access to maternal health.

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