John Stanback

Contraceptive injections by community health workers in Uganda: a nonrandomized community trial

OBJECTIVEnTo compare the safety and quality of contraceptive injections by community-based health workers with those of clinic-based nurses in a rural African setting.nnnMETHODSnA nonrandomized community trial tested provision of injectable Depo Provera (DMPA) by community reproductive health workers and compared it with routine DPMA provision at health units in Nakasongola District, Uganda. The primary outcome measures were safety, acceptability and continuation rates.nnnFINDINGSnA total of 945 new DMPA users were recruited by community workers, clinic-based nurses and midwives. Researchers successfully followed 777 (82% follow-up): 449 community worker clients and 328 clinic-based clients. Ninety-five percent of community-worker clients were satisfied or highly satisfied with services, and 85% reported receiving information on side-effects. There were no serious injection site problems in either group. Similarly, there was no significant difference between continuation to second injection (88% among clients of community-based workers, 85% among clinic-going clients), nor were there significant differences in other measures of safety, acceptability and quality.nnnCONCLUSIONnCommunity-based distribution (CBD) of injectable contraceptives is now routine in some countries in Asia and Latin America, but is practically unknown in Africa, where arguably the need for this practice is greatest. This research reinforces experience from other regions suggesting that well-trained community health workers can safely provide contraceptive injections.

Community-based health workers can safely and effectively administer injectable contraceptives: conclusions from a technical consultation.

This commentary discusses conclusions from a technical consultation that examined community-based health workers (CHWs) and their ability to safely and effectively administer injectable contraceptives. It provides the positive outcomes that will result from CHWs administering injectable contraceptives and states that there is sufficient evidence to support expansion of CHWs providing progestin-only injectable contraceptives especially DMPA. Copyright

Validation of a job aid to rule out pregnancy among family planning clients in Nicaragua

In Latin America, one of the most common barriers to family planning access is denial of services to women who present at clinics in the absence of menses. Where pregnancy tests are unavailable, many providers fear that nonmenstruating women may be pregnant and, worrying about possible harm to the fetus, require the woman to await the onset of menses before initiating a contraceptive method. In 2005, during a randomized trial of oral contraceptive users in Nicaragua, we assessed a job aid endorsed by the World Health Organization to help providers exclude pregnancy among family planning clients. Among 263 new, nonmenstruating clients, the job aid ruled out pregnancy for 60% of the women. Only 1% of the women were pregnant, and no woman identified by the job aid as not pregnant was pregnant. Provider fears that nonmenstruating clients are pregnant are usually misplaced, while fears that hormonal methods can harm fetuses are exaggerated.

Reaching providers is not enough to increase IUD use: a factorial experiment of 'academic detailing' in Kenya.

Although the IUD is an extremely effective and low-cost contraceptive method, its use has declined sharply in Kenya in the past 20 years. A study tested the effectiveness of an outreach intervention to family planning providers and community-based distribution (CBD) agents in promoting use of the IUD in western Kenya. Forty-five public health clinics were randomized to receive the intervention for providers only, for CBD agents only, for both providers and CBD agents, or no detailing at all. The intervention is based on pharmaceutical companies detailing models and included education/motivation visits to providers and CBD programmes, as well as provision of educational and promotional materials. District health supervisors were given updates on contraceptives, including the IUD, and were trained in communication and message development prior to making their detailing visits. Detailing only modestly increased the provision of IUDs, and only when both providers and CBD agents were targeted. The two detailing visits do not appear sufficient to sustain the effect of the intervention or to address poor provider attitudes and lack of technical skills. The cost per 3.5 years of pregnancy protection was US

Excluding pregnancy among women initiating antiretroviral therapy: efficacy of a family planning job aid

49.57 for the detailing intervention including the cost of the IUD, compared with US

Sale and provision of injectable contraceptives in drug shops in developing countries: conclusions from a technical consultation

15.19 for the commodity costs of the current standard of care--provision of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). The effectiveness of provider-based activities is amplified when concurrent demand creation activities are carried out. However, the cost of the detailing in comparison to the small number of IUDs inserted indicates that this intervention is not cost-effective.

Randomized trial of "quick start" versus advance provision of oral contraceptive pills in Nicaragua.

BackgroundGuidelines for initiating ART recommend pregnancy testing, typically a urine test, as part of the basic laboratory package. The principal reason for this recommendation is that Efavirenz, a first-line antiretroviral medication, has the potential of causing birth defects when used in the first trimester of pregnancy and is therefore contraindicated for use by pregnant women. Unfortunately, in many African countries pregnancy tests are not routinely provided or available in ART clinics, and, when available outside clinics, are often not affordable for clients.Recently, the World Health Organization added a family planning job aid called the pregnancy checklist, developed by researchers at Family Health International, as a recommended tool for screening new ART clients to exclude pregnancy. Although the checklist has been validated for excluding pregnancy among family planning clients, there are no data on its efficacy among ART clients.This study was conducted to assess the clinical performance of a job aid to exclude pregnancy among HIV positive women initiating ART.MethodsNon-menstruating women eligible for ART were enrolled from 20 sites in four provinces in Zambia. The pregnancy checklist was administered followed by a urine pregnancy test as a reference standard. Sensitivity, specificity, and positive and negative predictive values were estimated.ResultsOf the 200 women for whom the checklist ruled out pregnancy, 198 were not pregnant, for an estimated negative predictive value of 99%. The sensitivity of the checklist was 90.0%, and specificity was 38.7%. Among the women, 416 out of 534 (77.9%) did not abstain from sex since their last menses. Only 72 out of the 534 women (13.4%) reported using reliable contraception. Among the 416 women who did not abstain, 376 (90.4%) did not use reliable contraception.ConclusionThe pregnancy checklist is effective for excluding pregnancy in many women initiating ART, but its moderate sensitivity and specificity precludes its use to completely replace pregnancy testing. Its use should be encouraged in low resource settings where pregnancy tests are unavailable or must be rationed. Family planning methods should be available and integrated into ART clinics.

Radical Common Sense: Community Provision of Injectable Contraception in Africa

In September 2013 a technical consultation held in Research Triangle Park NC USA concluded that in the developing world drug shops have the potential to play a much greater role in helping women and couples achieve their family planning intentions. Already an important source of health care products in many countries drug shops could expand access to a range of contraceptive methods particularly progestin-only injectable contraceptives. The group of 15 researchers and program experts found that sale of depot medroxyprogesterone acetate (DMPA) is common in drug shops in some countries and that training policy research and advocacy interventions should be prioritized by funders and the family planning community. (excerpt)

Improving adherence to family planning guidelines in Kenya: an experiment

The objective was to evaluate continuation rates and bleeding patterns in women starting combination oral contraceptives (OCs) using the quick start approach compared with advance provision in Nicaragua. We randomized 232 healthy women with regular menses not in the first 7 days of their cycles to begin 30 µg combination OCs by either quick start (n = 116) or advance provision (n = 116). The main end point was pill continuation through 6 months; secondary end points were bleeding patterns and 6-month pregnancy rates. The study was designed to have 85% power to detect a 20% difference in combined OC continuation and a 3-day difference in total bleeding/spotting days per trimester. Ninety-two percent of women completed the 6-month study. Kaplan-Meier pill continuation probabilities were high and similar in both groups (quick start 0.97 advance provision 0.98 log-rank P = .65). When analyzed by intent-to-treat the total number of bleeding/spotting days per trimester was also similar. However 10 women randomized to advance provision began combination OCs immediately and 9 women started combination OCs before their next period. When data were analyzed by treatment used we could not rule out a difference of more than 3 days in total bleeding/spotting days during the first trimester (quick start n = 127 mean = 12.3; advance provision n = 84 mean = 10.1). Bleeding/spotting days were similar in the second trimester. Other bleeding outcomes were similar regardless of analysis method. There were no differences in pregnancy rates. Quick Start is a reasonable method of combination OC initiation for developing countries with high continuation rates despite slightly more bleeding/spotting days initially. (authors)

Proposed clinical guidance for excluding pregnancy prior to contraceptive initiation

Sub-Saharan Africa lags far behind the rest of the world in the use of family planning. Myriad factors contribute to low contraceptive prevalence in the region, but clearly, existing demand is not being met, and governments, donors and non-governmental organizations (NGOs) have failed to ensure access to a range of contraceptive options for Africa’s people. Rural areas are particularly neglected: clinics are few and far between, and typically offer few family planning choices. This chapter describes a recent innovation in sub-Saharan Africa that began to diffuse when four determining factors came into play simultaneously: (1) high unmet need for contraception, (2) strong preference for injectable family planning methods, (3) a critical shortage of clinical health workers, and (4) the existence of under-utilized, community-based family planning programs. The result of the innovation was logical, but radical: the provision of the continent’s favorite contraceptive by its lowest level health workers.