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Global Health: Science and Practice

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Original Articles
Open Access

Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

Susan Duvall, Sarah Thurston, Michelle Weinberger, Olivia Nuccio and Nomi Fuchs-Montgomery
Global Health: Science and Practice February 2014, 2(1):72-92; https://doi.org/10.9745/GHSP-D-13-00116
Susan Duvall
aGlobal Health Consultant, Seattle, WA, USA
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  • For correspondence: nomi.fuchs-montgomery@mariestopes.org
Sarah Thurston
bGlobal Health Consultant, New York, NY, USA
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Michelle Weinberger
cMarie Stopes International, Washington, DC, USA
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Olivia Nuccio
dMarie Stopes International, London, UK
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Nomi Fuchs-Montgomery
cMarie Stopes International, Washington, DC, USA
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Figures & Tables

Figures

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  • Figure1
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    In Nigeria, a family planning client has her contraceptive implant inserted by Marie Stopes International (MSI) providers. Provision of implants by MSI increased more than 10-fold in Nigeria between 2009 and 2012.

  • FIGURE 1.
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    FIGURE 1.

    Number of Women Using an Implant Provided by Marie Stopes Uganda Versus Other Providers,a 2001, 2006, and 2011

    a “Other providers” includes all private-sector organizations offering implants, other than Marie Stopes Uganda, and all public-sector providers, including Ministry of Health facilities.

    Data for Marie Stopes Uganda users are from Marie Stopes International (MSI) service statistics and are modeled using MSI's Impact 2 model. These estimated user numbers include women who received an implant supplied by MSI that year as well as women who received implant services from MSI in past years who are modeled to still be protected by the implant. Data for implants provided by other providers are from 2001, 2006, and 2011 Uganda Demographic and Health Surveys and 2010 UN Population Prospects.

  • FIGURE 2.
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    FIGURE 2.

    Number of LAPMs Provided by MSI in sub-Saharan Africa, by Method, 2000–2012

    Abbreviations: LAPMs, long-acting and permanent methods; MSI, Marie Stopes International.

    Data from MSI service statistics.

  • FIGURE 3.
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    FIGURE 3.

    Method Mix Among Modern Method Users, Marie Stopes International (MSI) Users Versus the General Population, in African Countries Where MSI Operates, 2012

    Data for MSI users are from MSI service statistics, with user numbers modeled using MSI's Impact 2 model. As explained in the footnote to Figure 1, LAPM users include those who received their method in prior years who continue to be protected. Because sterilization protects women for a longer duration than IUDs and implants, previous sterilization clients remain in the total “user” number for more years (until aging out at 49, based on median age of sterilization). Data for the general population are from Demographic and Health Surveys for those sub-Saharan African countries where MSI operates.8 For MSI user numbers, short-acting methods exclude condoms to avoid the risk of overestimating condom use because of user wastage and dual protection.

  • FIGURE 4.
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    FIGURE 4.

    Proportion of Implants Delivered by MSI in sub-Saharan Africa, by Service Delivery Channel, 2012

    Abbreviations: MSI, Marie Stopes International.

    a “Other” includes community-based distribution, community health workers, and miscellaneous providers.

    Data from MSI service statistics. Data do not include 1,898 implants delivered through social marketing in Mali.

  • FIGURE 5.
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    FIGURE 5.

    Most Influential Source of Information Affecting Decision to Choose MSI Services Among sub-Saharan African Clientsa Across All Service Delivery Channels,b 2012 (N = 6,225)

    Abbreviations: CBD, community-based distribution; MSI, Marie Stopes International.

    a Data from exit interviews in 11 sub-Saharan African countries, from August 2012 through December 2012.

    b Results were weighted by region and delivery channel where appropriate. When weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed.

  • FIGURE 6.
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    FIGURE 6.

    Most Important Reason for Choosing Services From Marie Stopes International Among sub-Saharan African Clientsa Across All Service Delivery Channels,b 2012 (N =  6,225)

    a Data from exit interviews in 11 sub-Saharan African countries, from August 2012 through December 2012.

    b Results were weighted by region and delivery channel where appropriate. When weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed.

  • Figure8
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    In Zambia, Marie Stopes International clients examine contraceptive implants during a group counseling session about the variety of family planning methods from which women can choose.

Tables

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    TABLE 1. Number of Implants Provided by MSI in Selected sub-Saharan African Countries,a 2008–2012
    MSI Country Program20082009201020112012% Growth (2011–12)
    Burkina FasoN/A2,4407,8357,08614,386103%
    Ethiopia14,28631,95345,73768,34788,20629%
    Ghana2,6025,5493,11714,43323,16260%
    Kenya6,65243,33069,65172,477117,10662%
    Madagascar6,20617,53526,89934,17565,22991%
    Malawi1,7191,3692,59521,69184,389289%
    Mali303,29510,58817,64933,01987%
    NigeriaN/A1,1845,9446,38812,749100%
    SenegalN/AN/AN/A5356,6001,134%
    Sierra LeoneN/A8,38721,79229,25737,67229%
    South SudanN/AN/AN/A1531,138644%
    Tanzania25,45728,15724,46536,70564,75276%
    Uganda13,73029,87542,49881,544143,76276%
    Zambia6393,0374,7244,4579,900122%
    Zimbabwe8,72016,16624,86240,10752,25930%
    TOTAL80,041192,277290,707435,004754,32973%
    • Abbreviations: MSI, Marie Stopes International; N/A, not available (because the MSI country program had not yet begun providing implants).

    • ↵a Data from MSI's service delivery statistics for MSI country programs in sub-Saharan Africa that were active in implant service delivery in 2012. Data from Sudan and Swaziland recorded in 2010 and 2011 are not included because these country programs were closed in 2012. (The 2 countries contribute an additional 864 implants in 2010 and 486 in 2011.)

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    TABLE 2. Summary of MSI Country Programs Active in Implant Service Delivery in sub-Saharan Africa, 2012
    MSI Country ProgramMonth/Year Program OpenedNo. of FP Clients (all channels)No. of Implants ProvidedNo. of Mobile Outreach TeamsNo. of ClinicsNo. of Social FranchiseesMonth/Year Social Franchising Started
    Burkina Faso07/200924,51714,38641N/AN/A
    Ethiopia09/1990206,72388,206103144310/2008
    Ghana10/200639,79823,1626510603/2008
    Kenya03/1986229,836117,106152527904/2004
    Madagascar06/1992147,66165,229461412711/2009
    Malawi09/1987229,31084,38939315406/2008
    Mali11/200845,78733,019733406/2012
    Nigeria04/200916,44612,749515109/2012
    Senegal11/20119,9896,600311010/2012
    Sierra Leone03/1988127,14837,672131210012/2008
    South Sudan08/20111,7781,13822N/AN/A
    Tanzania09/1990149,25264,7522612N/AN/A
    Uganda07/1993260,466143,762241541906/2012
    Zambia06/200818,2619,90073707/2012
    Zimbabwe04/1988146,68052,259996108/2012
    • Abbreviations: FP, family planning; MSI, Marie Stopes International; N/A, not applicable.

    • Data from MSI service statistics. Number of FP clients were estimated from MSI service statistics, in which each service for a long-acting and permanent method is equal to 1 client and each year's supply of short-acting methods is equal to 1 client.

    • View popup
    TABLE 3. Demand-Generation Activities to Educate Clients About Family Planning and MSI Services, by Channel
    Mobile Outreach ServicesSocial FranchisingClinics
    Delivery of high-quality services to enable word-of-mouth referralsDelivery of high-quality services to enable word-of-mouth referralsDelivery of high-quality services to enable word-of-mouth referrals
    Educational outreach by community health workers (CHWs) or other community agents about importance of family planning and different methods through:
    • Door-to-door mobilization

    • Group information sessions

    • Educational/promotional communication and media

    Educational outreach about family planning and long-acting and reversible contraceptives (LARCs), including implants, as well as about BlueStar family planning services through:
    • CHWs and other community agents

    • Print or radio advertisements

    Educational outreach about family planning and MSI services through:
    • Kiosks at regular markets and popular events

    • Radio show appearances by MSI clinic staff

    • Flyers and promotional materials available at locations frequented by young women, such as markets, universities, and beauty salons

    Designated day for team visit, making it a noteworthy and anticipated community eventSpecial discount days on LARC services
    Local media advertisements about voluntary family planning and LARCs, including implantsPromotion of BlueStar brand, as an overall sign of quality service deliveryTraining for all clinic staff including receptionists and support staff to ensure client-friendly, non-judgmental environment
    Where appropriate, referrals from other MSI service delivery channelsReferrals from:
    • Other non-MSI services at franchisee

    • Other MSI service delivery channels, where appropriate

    Where appropriate, referrals from other MSI service delivery channels
    Announcement of upcoming mobile team visit via:
    • Town crier

    • Radio

    • CHWs or other community agents

    • View popup
    TABLE 4. Implant Discontinuation Rates Among Clients Receiving Implants From MSI in Ethiopia, Sierra Leone, and Uganda, 2010
    Duration of UseDiscontinuation Rate
    EthiopiaaSierra LeoneaUgandab
    (N = 562)(N = 433)(N = 470)
    3 months0.4%0.7%2.7%
    6 months0.7%3.0%N/A
    8 months5.7%6.2%N/A
    • Abbreviations: MSI, Marie Stopes International; N/A, not applicable.

    • ↵a Data from Ethiopia and Sierra Leone were collected in April 2010 during retrospective follow-up studies on women who received implants in 2009 at mobile outreach sites.19

    • ↵b Data from Uganda were collected in a prospective cohort study among women receiving implants, IUDs, or tubal ligations between February and April 2010 at mobile outreach sites.41

    • View popup
    TABLE 5. Key Components of Mobile Outreach and Implications for Scale Up, Replication, and Sustainability
    Mobile Outreach ComponentImplications for:
    Scale UpReplicationSustainability
    Free or highly subsidized servicesHelps facilitate rapid expansion, since poor and rural clients have highest unmet needRequires adequate financing mechanisms to subsidize costsRequires continued investment and greater role of country governments, through contract arrangements and other innovations
    Teams of dedicated providersCan encourage expansion in areas of high demand by filling service gaps at existing public and private clinics, particularly with high-quality services that can be monitored more easily with such providersRequires trained staff whocan be deployed to remote areasGreater emphasis on integrated service delivery models may generate hybrid models. As public-sector capacity develops, dedicated providers may shift their role to a support function.
    Public-private partnershipsMust be in place for channel to operate properly, and therefore, for service delivery expansion to occurRequires collaborative relationships with public sector and robust referral systemsPossible to sustain over the long term, although dynamics may change with the private sector mentoring public-sector providers who assume a larger role in service delivery (presuming the supply of competent public providers increases)
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Global Health: Science and Practice: 2 (1)
Global Health: Science and Practice
Vol. 2, No. 1
February 01, 2014
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Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International
Susan Duvall, Sarah Thurston, Michelle Weinberger, Olivia Nuccio, Nomi Fuchs-Montgomery
Global Health: Science and Practice Feb 2014, 2 (1) 72-92; DOI: 10.9745/GHSP-D-13-00116

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Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International
Susan Duvall, Sarah Thurston, Michelle Weinberger, Olivia Nuccio, Nomi Fuchs-Montgomery
Global Health: Science and Practice Feb 2014, 2 (1) 72-92; DOI: 10.9745/GHSP-D-13-00116
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  • Article
    • Abstract
    • INTRODUCTION
    • MSI HELPS TO EXPAND ACCESS TO IMPLANTS
    • MSI SERVICE DELIVERY CHANNELS
    • QUALITY ASSURANCE MEASURES
    • INFRASTRUCTURE AND IMPLEMENTATION STRATEGIES REQUIRED FOR SCALE UP
    • IMPLICATIONS OF MSI'S SERVICE DELIVERY APPROACH
    • Acknowledgments
    • Appendix. Quality Assurance Measures and Monitored Service Delivery Components by Marie Stopes International (MSI)
    • Footnotes
    • Notes
    • REFERENCES
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  • Comments
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  • Liftoff: The Blossoming of Contraceptive Implant Use in Africa
  • Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda
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  • Accessible Contraceptive Implant Removal Services: An Essential Element of Quality Service Delivery and Scale-Up
  • Rapid Contraceptive Uptake and Changing Method Mix With High Use of Long-Acting Reversible Contraceptives in Crisis-Affected Populations in Chad and the Democratic Republic of the Congo
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  • Is Household Wealth Associated With Use of Long-Acting Reversible and Permanent Methods of Contraception? A Multi-Country Analysis
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  • Stunning Popularity of LARCs With Good Access and Quality: A Major Opportunity to Meet Family Planning Needs
  • A better future for injectable contraception?
  • Using behavior change communication to lead a comprehensive family planning program: the Nigerian Urban Reproductive Health Initiative
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