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Background: Most postpartum women in low- and middle-income countries want to delay or avoid future pregnancies but are not using modern contraception. One promising strategy for increasing the use of postpartum family planning (PPFP) is integration with maternal, newborn and child health (MNCH) services. However, there is limited evidence on effective service integration strategies. We examine facilitators of and barriers to effective PPFP integration in MNCH services in Kenya and India. Methods: We conducted a cross-sectional, mixed-method study in two counties in Kenya and two states in India. Data collection included surveying 215 MNCH clients and surveying or interviewing 82 health care providers and managers in 15 health facilities across the four sites. We analyzed data from each country separately. First, we analyzed quantitative data to assess the extent to which PPFP was integrated within MNCH services at each facility. Then we analyzed qualitative data and synthesized findings from both data sources to identify characteristics of well and poorly integrated facilities. Results: PPFP integration success varied by service delivery area, health facility, and country. Issues influencing the extent of integration included availability of physical space for PPFP services, health workforce composition and capacity, family planning commodities availability, duration and nature of support provided. Conclusions: Although integration level varied between health facilities, factors enabling and hindering PPFP integration were similar in India and Kenya. Better measures are needed to verify whether services are integrated as prescribed by national policies.
This paper presents findings from one component of a descriptive evaluation of PPFP service integration conducted in India (May–June 2014) and Kenya (June-July 2014). This borader cross-sectional, mixed-methods study 16 examined how PPFP services are provided in order to identify factors enabling and limiting integration of PPFP with MNCH services in different settings. We selected India and Kenya as study sites because of their long-running PPFP programs, which provided us a unique opportunity to evaluate provider and client experiences from different PPFP program models. The study was conducted in two of the 29 states in India (Jharkhand and Bihar), and two of the 47 counties in Kenya. (Embu and Siaya). PPFP integration programs began in five states in India in 2010 and provided support for introducing PPFP counseling during antenatal care (ANC) and reorganizing intrapartum and immediate postpartum care to offer postpartum intrauterine device (PPIUD) services immediately after birth. This integration of services built upon the rise in institutional deliveries following the Janani Suraksha Yojana (JSY) incentive scheme established in 2005. Jharkhand was among the first five states to initiate PPFP services. Hospital providers received both a 3-day training on clinical services for PPIUD as well as a 2-day training in PPFP counseling. Hospitals also received tools and job aids to support counseling, services and data management, and program staff offered supportive supervisions visits jointly with health authorities. Programs replicated the same approach as in Jharkhand in Bihar, India, starting in 2012, but added community outreach and messaging on birth spacing and PPFP during home visits through a 1-day training of Accredited Social Health Activists (ASHAs) and auxiliary nurse midwives on family planning methods and key PPFP messages. Subsequent to experiences in the first states, PPFP continued to expand across India. Furthermore, the government created a dedicated PPFP counselor position and opened an initial 1,300 posts. The 2013 reproductive, maternal, newborn and child and adolescent health (RMNCH+A) strategy incorporated PPFP to make services available across India, but renamed the counselors as RMNCH+A counselors. In Kenya, PPFP programs began on a small scale in Embu from 2006 to 2010 as part of a pilot study, and then through a Ministry of Health sanctioned training on integrated maternal and newborn and family planning training. This training consisted of an orientation on PPFP for providers in facilities with a high volume of deliveries, followed by a 5-day clinical training in PPIUD and infection prevention for nurse-midwives. Community health workers also received a 2-day orientation on PPFP. Program staff worked with county officials to offer supportive supervision and to identify PPFP “champions” to support postnatal care and PPFP. Meanwhile at national level, the 2009–2015 National Reproductive Health Strategy included the integration of family planning into other reproductive health services as a key approach for improving access to comprehensive reproductive health services. The National Family Planning Guidelines for Service Providers 2010 specifies the postpartum timing for initiating various contraceptive methods. In 2012, a program in Siaya, Kenya, used a multidisciplinary approach to demonstrate integration of family planning and maternal, infant, young child nutrition (FP/MIYCN) into antenatal, intrapartum, postnatal, and early childhood care services at facility- and community-levels. A baseline assessment informed this demonstration project and the development of materials, followed by capacity building of facility providers, community health volunteers on how to counsel on family planning and nutrition, integrate FP/MIYCN in all service delivery areas (maternity, maternal and child health/family planning, outpatient department) and manage program data. Bondo subcounty- (formally referred to as a district) was the only subcounty- out of six in Siaya where PPFP and nutrition services had been integrated thus through the time of the study. Unlike the other three locations, the Bondo facilities did not offer PPIUD as an option immediately after birth. At the sub-county hospital, FP/MIYCN training took place onsite for three days along with a one-day whole-site orientation, while health center providers underwent five days of training with clinical practice. In consultation with local health authorities, we purposively selected 15 health facilities in the two countries: six public health facilities from Bondo subcounty in Kenya and three facilities each from Embu county in Kenya, and Jharkhand and Bihar states in India. In India, the facilities were chosen based on health officials’ assessment of high performance, given the study objective to learn about what works to integrate PPFP. In Embu, Kenya, the health facilities were selected based on both performance and ease of access. There were six public facilities included in Bondo to capture all facility types participating in the nutrition and PPFP integration program. We published a separate manuscript on the family planning and nutrition integration experience from Bondo subcounty 17. Data collection methods in this study included a client flow analysis (Dataset 1, published elsewhere 18, 19); surveys of MNCH clients (Dataset 2) and providers (Dataset 3), and in-depth interviews with local authorities, facility management and health care providers. A convenience sampling approach was used for provider surveys and interviews. The number of participants at each facility was determined by the number of PPFP providers expected to be on duty, not a sample size/power calculation or content saturation. The study teams obtained letters of support from state- or county-level officials, alerted facilities ahead of arrival, then met with the person in charge for briefing and identification of providers available at the facility. Providers on duty on the day of interviews were approached for interviews or surveys. A study information sheet was posted at each facility and provided to in-charge and anyone else upon request. MNCH service provider and client surveys were conducted at all 15 health facilities. At each facility, the number of providers surveyed using the structured questionnaire varied between one and four depending on the number of clinical staff at a facility and types of services provided. We collected data on the proportion of consultations that include PPFP counseling as well as their perceptions on PPFP services they provided. With regard to clients, we surveyed a sample of pregnant women and mothers of children under age 2 years attending maternal or child health services to determine whether they received PPFP counseling during their visit on the day of the survey. For the client survey, the number of respondents sampled was designed to provide a study power of 80% to estimate ±10% with 95% confidence, in the estimation of the proportion of clients receiving integrated PPFP services. Clients responded to questions about wait time before consultation with a service provider, privacy during consultations (audio and visual), comfort discussing private/sensitive health matters, perceptions of service providers’ behavior towards them, and the availability of medications and FP commodities. Surveys were conducted using tablets loaded with CommCare software (CommCare v.2.11.0, Dimagi Inc.); it took 1–3 days to complete the surveys at each health facility. In India, service provider and client surveys were conducted in either Hindi or English depending on a respondent’s preference. In Kenya, all service provider surveys were conducted in English whereas client surveys were conducted in English, Swahili, or Luo, depending on the respondent’s preference. Surveys are available on Open Science Framework 20. Client flow analysis was conducted at two facilities in each Indian state and in three facilities in each county in Kenya; five facilities with low client loads were excluded. Client flow tools were modified from a tool used previously to assess integration of HIV and sexual and reproductive health services 21. On days of data collection, research assistants approached all women aged 18 years or older who were at the health facility seeking MNCH services (ANC, postnatal, well-, or sick-child care), screened those who were willing to participate and consented those who met study eligibility criteria. Those who were pregnant and/or had a child under 2 years old and consented to participate were asked to carry a client-flow form which was completed by service providers at various service delivery points during the visit. Women in active labor were excluded since we could not expect them to keep track of providers caring for them and the form during childbirth. The client-flow form allowed up to five healthcare workers to check off services provided on a standard list of possible services and note any referral recommendations. The client-flow forms were collected at the point where each client exited the health facility. Semi-structured, key informant interviews were conducted with local health authorities (district or sub-county officials), facility management and service providers to understand perceived benefits of PPFP integration, challenges in implementing integrated services, and the institutionalization of integrated services in the health system. In India, experienced qualitative interviewers from the International Institute of Health Management Research (IIHMR) conducted interviews. In Kenya, two independent consultants were hired and trained to conduct interviews. Key informants were selected on the basis of their involvement in supervising MNCH and PPFP services in the selected facilities. Each service provider was interviewed only once either as a facility health in-charge or about the PPFP services they provided. Providers were asked which service delivery unit they worked in (ANC, labor and delivery, postnatal care and/or child health). They were also asked to pick one of those units which they spend more time in and to answer subsequent questions about their work in that unit. At each site, qualitative researchers conducted interviews in a single day using structured interview guides designed specifically for each type of respondent: key informant, in-charge, or provider. Key informants and in-charges had to have a role in overseeing MNCH services in the facility including integration of PPFP. Service provider interviews were conducted in either Hindi or English in India, and solely in English in Kenya. Interviews lasted between 30 and 60 minutes and were conducted in private. While the study team discussed the concept of saturation with data collectors, they completed the number of interviews assigned, with no overlap between quantitative survey and qualitative interview respondents. All interviews were recorded, transcribed, and, if necessary, translated to English prior to analysis. A total of 215 MNCH clients and 39 health care providers were surveyed, and 10 key informants and 33 facility informants interviewed, across the four study sites ( Table 1). * Interviews excluded from analysis after facilities sorted by level of integration (see Table 2) Quantitative data analysis. Research assistants entered quantitative data from client and provider surveys into REDCap, version v6.0.1., a web-based software for data capture and management. Descriptive analysis was conducted using SPSS Statistics (version 22) and Stata (version 12). The investigators carried out frequency distributions and cross-tabulations and reported the outputs in percentages. No statistical testing was done. FP integration and qualitative data analysis. We analyzed qualitative data using a grounded theory approach. Interview scripts were read iteratively and open/conceptual codes generated. We conducted the FP integration analysis in three phases. The first phase comprised of four steps, as follows: Step 1: quantitative data from client surveys, health worker surveys, and client-flow analysis by facility were collated using Microsoft Excel. We excluded two facilities from Kenya where we did not collect client flow data because they had fewer than five client respondents per service area. Step 2: three research team members separately analyzed the collated client and provider survey data to generate independent assessments of the level of PPFP integration within maternal and child health services, to develop an approach similar to previous studies 22, 23. However, wide variation in levels of integration across service areas at many facilities, made it difficult to come to agreement about the overall level of integration in each facility. To address disagreements between the independent assessment of level of integration, we further disaggregated data by service area within each facility (ANC, Labor and Delivery, PNC, Child Health) and jointly analyzed the level of PPFP integration within each service area of each facility. In only two facilities were women having given birth in that visit interviewed. For each facility, analysis included the number of clients interviewed at the unit they initially sought care from (ANC, PNC or child health), and the percentage that indicated PPFP was discussed. Step 3: the number of providers surveyed, and their responses to the question as to how many among the last 10 clients seen in their ‘primary’ unit to whom they provided PPFP counseling or services (range 0–10). Step 4: client flow data were considered, specifically the number of clients who indicated that the purpose of the visit was ANC, labor and delivery, PNC or immunization/child health, as well as the number where the provider ticked having offered FP counseling or provision of a method. Box 1 provides further details about the specific survey used for this analysis and explains how the three researchers compiled the data for analysis. Clients Analysis of the client data explored the primary reason for the visit: “I’d like to ask you a few questions about your visit to this facility today. What was the primary reason for your visit?” Response options included: 1. Antenatal care, 2. Intrapartum/Labor room, 3. Postnatal/ Postpartum, 4. Child welfare/ Pediatrics, 5. Family planning, 6. Other, 98. Don’t know, 99. No response Later in the questionnaire, clients were asked: “Now I’d like to talk to you about the main reason for your visit today. During your visit to ( automatically populated with primary reason from question above), did you discuss family planning?” with yes/no response options. This was the question used to assess level of integration, after disaggregation of clients according to whether they primarily visited for ANC, PNC, child health or labor and delivery. Providers Providers often work in multiple service areas in a facility, but were asked to select one area (from a list of ANC, Intrapartum/Labor room, Postnatal/Postpartum care, Child welfare/Pediatrics) that would become the subject of subsequent questions. Later in the survey, providers were asked to quantify these responses with: “I would like to ask you a couple of questions about the last ten clients you have seen who were [pregnant / recently gave birth / or had given birth in the last two years]. Of those ten women, to how many did you either provide family planning counseling or a family planning method?” Client flow Data were stratified by the same primary reason for visit as above, and we captured a cell count of the number of clients visiting the facility for that reason during data collection as a denominator. Then the count of all clients whose form included a mention of FP counseling or FP services for each of the primary visit reasons strata were included in the numerator. Data compilation and review We created a spreadsheet with rows for each health facilities and columns for each type of service (ANC, PNC, child health, or labor and delivery). We first included a count of all data points for each (client, provider surveys, client flow data) as a denominator. Then, for each facility and type of service, we populated the number of clients reporting FP discussion, the number among last 10 clients seen that a provider reported offering FP counseling, and the clients whose forms included FP integration, as numerators. For providers, this resulted in a series of numbers from 0-10. The average of those numbers was used. For the other data, simple percentages were calculated. Similar to previous studies 22, 23, we used an ordinal scoring system to characterize the level of service integration, where 1 = low levels of integration (0-29% of MNCH client visits included PPFP and survey data suggested little integration), 2 = moderate levels of integration (30–59% of visits included PPFP and survey data suggested some integration), and 3 = high levels of integration (60–100% of visits included PPFP and survey data suggested integration). In cases where there was not concordance between client flow and interview data, we relied on the client flow data as a more robust source. Independent rankings were then reviewed by all three researchers, although at that point the analysis relied on scores so the discussion focused more on whether there was sufficient data to determine an integration level. We set a minimum of 5 clients responses. There was insufficient data to consistently analyze level of PPFP integration in PNC and child health services. We thus used the levels of integration in ANC to disaggregate health facilities with high and moderate levels of integration and grouped these as well integrated (shown in bold text in Table 2) and those with low-levels of integration we termed poorly integrated (shown in non-bold text in Table 2). The decision to group the middle tier of integration as “well integrated” was made on the assumption that this integration was unlikely to be by chance, but as a result of the program having some effect. KO03 and KO06 excluded because insufficient data for all units. Text indicates where on broad range of level of integration (30–100%). If there are two notations, it indicates differences in client flow and client survey data, where at least 5 clients were surveyed about that service area. Bold text indicates well-integrated care, non-bold indicates poorly integrated care. *Unlike the other service areas, integration of FP in antenatal care involves only FP information, counseling, possibly condoms and referrals. In other service areas, there should also be provision of a contraceptive method or intra-facility referral for provision. The second phase of analysis involved reviewing the semi-structured interview transcripts to identify factors enabling and limiting integration of PPFP services at each facility and coded the text using a combination of thematic and free-coding in ATLAS.ti 7.5 (Scientific Software Development GmbH, Berlin, Germany). We reviewed qualitative findings across sites to identify characteristics common to well-integrated facilities separately from those that were poorly integrated. In the third phase, we analyzed antenatal care client reports of privacy, interactions with staff, and waiting times to compare experiences at well-integrated and poorly integrated facilities by calculating percentages per site. We did not use the same approach for postnatal care or child health clients because of the small numbers of these respondents. To synthesize findings, we triangulated analyses described above, and examined trends in client, provider and management experiences at well-integrated and poorly integrated facilities in each study county, country, and overall. The study was approved by the Johns Hopkins School of Public Health institution review board (No 5517), IIHMR’s Institutional Review Board in India, and the Kenya Medical Research Institute (KEMRI) Ethical Review Committee in Kenya. All participants provided oral informed consent, in accordance with approved research protocols, in order to avoid collecting personal identifiers for study participants.
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