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Examining the Feasibility of Postpartum IUD Services in Rwanda

Theresa Hoke, PhD, MPH FHI 360

Study Goal and Objectives


Goal: Produce experience-based guidance regarding the feasibility of offering postpartum IUD insertion services in hospitals and health centers in Rwanda. Objectives 1.Examine the degree to which postpartum IUD service components are offered in accordance with performance standards; 2.Examine providers perspectives regarding the responsibility of offering postpartum IUD services; 3.Assess clients perspectives toward postpartum IUD services.

Intervention Components
Training: postpartum FP counseling Training: PPIUD insertion and removal Adjustments to ANC and maternity procedures Equipment and commodities Postpartum FP brochure Supportive supervision
3

Service Implementation Sites


Nyarugenge: Muhima Hospital -Training Center

Huye: Kabutare Hospital Rubona HC Kinyamakara HC Gakenke: Ruli Hospital Coko HC Rushashi HC Karongi: Kibuye Hospital Rubengera HC Kirambo HC Kirehe: Kirehe Hospital Kirehe HC Mulindi HC

Evaluation: Post-intervention Data Collection


Interviews with all ANC and maternity providers responsible for client counseling and actual insertion in participating sites Observation of client-provider interactions in ANC Observation of rotations in the participating maternities to assess provision of PPIUD services Interviews with women who are 3-5 months postpartum Compilation of service statistics

Results

Provider job knowledge: Issues covered by postpartum FP counseling score


Healthy timing and spacing of pregnancy Lactational amenorrhea method (LAM) Safe and effective FP methods for postpartum women Eligibility criteria for PPIUD

Recall of messages taught in training about advantages of the PPIUD as a contraceptive method

Median Postpartum FP Counseling Score

Median Score

Median Postpartum FP Counseling Scoreby Professional Designation

Median Score

Provider competence: Issues covered by PPIUD clinical score


Infection prevention Eligibility criteria for PPIUD Insertion procedures Timing of routine follow-up visits Normal side effects associated with IUD Issues indicating need for medical attention

Median PPIUD Clinical Score, by Training Status

Median Score

Median PPIUD Clinical Scoreby Professional Designation

Median Score

Observation of service delivery: Counseling on postpartum family planning during ANC


Message Healthy timing and spacing of pregnancy Following child birth, risk of pregnancy before menses return LAM criteria Difference between short-acting and long-acting FP methods IUD as a contraceptive option IUD can be inserted immediately following delivery Asks client about her choice of postpartum contraception Group Education N= 41 sessions 62% 83% 60% 52% 98% 86% Not observed Individual Counseling N= 335 sessions 36% 33% 26% 27% 62% 50% 93%

Observation of service delivery at the maternity: PPIUD service components


Service provision IUD commodities are available Sterilized insertion equipment is available Provider trained to do postpartum IUD is present or on call Observed shifts N= 180 99% 97% 82%

Provider asks woman in labor if she has chosen the postpartum IUD as her method
Individual counseling about postpartum IUD Group education on family planning delivered in post-labor ward

50%
36% 17%

Number of insertions by facility in first 10 months of services

insertions

[------------Health Centers----------]

[----Hospitals----]

Client Perspectives on PPIUD


Question posed to client Ever heard of the IUD? Of those. Knows a woman who has ever used the IUD During pregnancy, considered postpartum IUD insertion Clients N=277 51% N = 142 32% 8%

Conclusions
PPIUD services in public sector facilities in Rwanda are feasible. Service provision depends on individual providers. Knowledge gaps contribute to low PPIUD uptake. Successful scale-up will require attention to
Leadership commitment Provider motivation Demand generation.

Conclusions
PPIUD services in public sector facilities in Rwanda are feasible. Service provision depends on individual providers. Knowledge gaps contribute to low PPIUD uptake. Successful scale-up will require attention to
Leadership commitment Provider motivation Demand generation.