Counseling at all contacts for postpartum contraceptive use: Can paper-based tools help community health workers improve continuity of care? A qualitative study from Ethiopia

Background: Globally, there has been a resurgence of interest in postpartum family planning (PPFP) to advance reproductive health outcomes. Few programs have systematically utilized all contacts a woman and her baby have with the health system, from pregnancy through the first year postpartum, to promote PPFP. Nested into a larger study covering two districts, this study assessed the use, acceptability, and feasibility of tools for tracking women’s decision-making and use of PPFP in the community health system in Oromia region, Ethiopia. Community-level tracking tools included a modified Integrated Maternal and Child Health (IMCH) card with new PPFP content, and a newly developed tool for pregnant and postpartum women for use by Women Development Armies (WDAs). Proper completion of the tools was monitored during supervision visits. Methods: In-depth interviews and focus group discussions were conducted with health officials, health extension workers, and volunteers. A total of 34 audio-files were transcribed and translated into English, double-coded using MAXQDA, and analyzed using a thematic approach. Results: The results describe how HEWs used the modified IMCH card to track women’s decision making through the continuum of care, to assess pregnancy risk and to strengthen client-provider interaction. Supervision data demonstrated how well HEWs completed the modified IMCH card. The WDA tool was intended to promote PPFP and encourage multiple contacts with facilities from pregnancy to extended postpartum period. HEWs have reservations about the engagement of WDAs and their use of the WDA tool. Conclusions: To conclude, the IMCH card improves counseling practices through the continuum of care and is acceptable and feasible to apply. Some elements have been incorporated into a revised national tool and can serve as example for other low-income countries with similar community health systems. Further study is warranted to determine how to engage WDAs in promoting PPFP.

The testing of new and modified tools for PPFP is part of a larger quasi-experimental study exploring how to maximize all contacts a woman has with the health system during pregnancy, childbirth, and the first year postpartum (ClinicalTrials.gov registration number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT03585361″,”term_id”:”NCT03585361″}}NCT03585361, posted July 13, 2018). The study was conducted in Hetosa and Lode Hetosa districts in Arsi Zone, Oromia Region. In each district, one primary health care unit (PHCU) – a health center with five satellite health posts – was randomly assigned to an intervention arm or comparison arm. Since multiple health posts report to the same health center, randomizing individual health posts would risk contamination. Women were enrolled in their 2 nd and 3 rd trimester of pregnancy in February–March 2017. Study staff obtained consent and conducted enrollment interviews to collect demographic information, birth history, contraceptive knowledge, contraceptive use prior to pregnancy, and intention to use contraception after birth. Women were re-interviewed in May 2018 to collect endline information on contacts with the health system during and after pregnancy, information received on family planning, use of contraception since delivery, and infant feeding and immunization. The result revealed that postpartum women in the intervention arm were more likely to adopt contraception compared to women in the comparison arm ( Sitrin et al., 2020). After one year of intervention, the study team interviewed health officials, HEWs, and WDAs for their experiences and perspectives on the acceptability and feasibility of PPFP tracking tools and prompts. This qualitative assessment was done in both intervention and comparison clusters. The study districts were selected because of the absence of other large-scale FP programs. We aimed to study the perspectives of all stakeholders who had experiences with the PPFP tracking tools and prompts. The purposive sample for qualitative in-depth interviews (IDIs) included two zonal and four district health officials; four heads of primary health care units, and 23 HEWs from 18 health posts (10 intervention and 8 comparison; 18 interviews total as HEWs were interviewed jointly in health posts where two were available). In addition, we held six focus group discussions (FGDs) with 70 WDAs. No participant selected for IDIs or FGDs declined to participate. Sample size aimed to achieve saturation of themes. Additionally, up to five IMCH cards were pulled at each health post during supervision visits, conducted during implementation, to check for correct completion of the tool. A total of 180 IMCH cards were reviewed. A conceptual framework describing women’s decision-making and contraceptive use over the continuum of care guided the study design. This framework describes opportunities for two cadres of community health workers (CHWs), HEWs and WDAs, to influence women’s postpartum contraceptive use during service contacts at multiple levels of the health system ( Figure 1). This manuscript focuses on the analysis of HEW and WDA contacts with women and the tools used at the community health system level. Interventions to strengthen PPFP counseling, provision, and documentation were implemented at all health centers in the study districts, including comparison PHCUs. Because the study was designed to assess the additional benefit of strengthening PPFP through the health extension program, only the intervention arm received the community intervention. The community intervention had three components: 1) training and supervision of HEWs on PPFP with a refresher on implant insertion, 2) giving HEWs and WDAs tools to track women’s PPFP preferences and pregnancy risk, and 3) having HEWs orient WDAs on PPFP messages and the WDA tool. The detail imputes for each study arm are outlined elsewhere ( Sitrin et al., 2020). The project made small modifications to the existing IMCH card to allow documentation of counseling, method preferences, and PPFP uptake at every contact during pregnancy and within one year after birth. The content of the IMCH card included PPFP counseling, method choice, and method adoption at each contact. The modified version of the IMCH card is available as Extended data; Mossie et al., 2019). In addition, prompts were added to ask women about return of menses, breastfeeding status, and complementary feeding at each growth monitoring visit to assess their return to fecundity and pregnancy risk. The FMOH provided approval to test the modified tools. We conducted regular visits to intervention health posts using a supervision tool (available as Extended data; Mossie et al., 2019) to gather observations on use of tools, capture responses to questions posed to HEWs, and extract PPFP data. The WDA tool contained pictures of various contraceptive methods to help WDAs educate women on available options. It included boxes to check off a woman’s choice of PPFP method prior to delivery, along with boxes after birth to check breastfeeding status, use of FP, sexual activity, and if menses returned. The tool aimed to prompt WDAs to refer postpartum women to health posts if at risk of unintended pregnancy. The WDA tool is available as Extended data; Mossie et al., 2019). We created semi-structured interview and FGD guides with questions on experiences of health care workers, HEWs, and WDA on their roles and responsibilities around PPFP and their use of PPFP tracking tools. The tools were prepared in English, translated into local language (Amharic and Afan Oromo), then back-translated. The interview guides were pilot tested in an area outside the study area with similar policy and cultural context. Qualitative data were collected in May 2018. All FGD and in-depth interviews were audio-recorded and hand-written notes were kept after written informed consent was obtained from all participants. The FGDs lasted about 120 minutes and the IDIs were a maximum of 60 minutes long. The data collection was conducted by four research assistants. All research assistants had a postgraduate degree in public health and had received training for five days prior to the start of data collection. Supervisors oversaw field data collection. Research assistants who had participated in the data collection transcribed audio data in the original languages, Amharic and Afan Oromo. Two study members reviewed a sample of transcripts while listening to the audio data to confirm that there was congruence between the transcripts and audio data. The authors were public health and family planning program specialists and evaluators with experience in qualitative data analysis methods in health. Several authors, including the lead, are Ethiopian and two authors are from Oromia region and included men and women. After transcription, transcripts were translated to English for coding. The study team developed initial codes based on the content of the transcripts and the study tools. The team then coded selected transcripts during a qualitative data coding workshop and adjusted the codes. The final codebook with definitions was uploaded to a qualitative data analysis software (MAXQDA 2018; Taguette is an open-access alternative) (Supplement 1). Each transcript was coded by two separate coders sequentially. After the second coding, coders discussed any discrepancies or disagreements to reach consensus on what codes should apply to various segments. After transcripts were coded, the team analyzed the data using the ‘One Sheet of Paper’ technique ( Ziebland & McPherson, 2006). We reviewed segments for selected codes (including all related to tracking tools), sometimes grouped by type of respondent or study arm. We then summarized the various issues expressed on a single sheet of paper, including participant identifiers and links to specific coded segments (quotes), and developed written summaries for each code. Finally, we convened an analysis workshop, during which the investigators and analysis team reviewed each summary for similarity and outliers in views and opinions of study participants and identified emerging themes. Box 1 depicts the list of themes identified using the ‘One Sheet of Paper’ technique. The modified IMCH card 1. Usefulness of the IMCH Card 2. Completeness of the IMCH card 3. Acceptability and feasibility of the IMCH card The WDA tool 1. Usefulness of the IMCH card 2. Acceptability and feasibility of the WDA tool To support validity, preliminary findings were presented to select study participants – HEWs, health care workers, and health officials – to check that the results and interpretations agreed with their views and opinions The study was approved by the JHSPH-IRB (IRB No: 7143). A support letter was obtained from the Ethiopian Ministry of Health to conduct the study. Oral consent was sought and received from all study participants. We did not seek written consent because of some participant’s low literacy level, concern about collecting paperwork with identifying information and the minimal risk associated with the study. Every participant received a copy of the consent form in their preferred language.

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