Findings and Lessons Learned From Strengthening the Provision of Voluntary Long-Acting Reversible Contraceptives With Postabortion Care in Guinea

Anne Pfitzer; Yolande Hyjazi; Bethany Arnold; Jacqueline Aribot; Reeti D. Hobson; Tsigue G. Pleah; Shani Turke; Benita O’Colmain; Sharon Arscott-Mills

doi:10.9745/GHSP-D-18-00344

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Contraceptive methods typically used in Guinea. © Suzanne Austin/Jhpiego
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FIGURE 1
Location and Type of PAC Facilities in Guinea
Abbreviations: HF, health facility; PAC, postabortion care.
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FIGURE 2.
Contraceptive Method Mix Among Postabortion Clients Choosing a Method Prior to Discharge and Among All Women Ages 15–49 in Guinea Currently Using a Modern Method
Abbreviations: DHS, Demographic and Health Survey; DMPA, depot medroxyprogesterone acetate; IUD, intrauterine device; LAM, Lactational Amenorrhea Method; mCPR, modern contraceptive prevalence rate; PAC, postabortion care.
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A client in Guinea chooses to use implants for contraceptive protection. © 2012 Suzanne Austin/Jhpiego

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TABLE 1.

Evolution of the Postabortion Care Program in Guinea, 1998–2014

Phase and Years of Implementation	Cumulative No. of Health Facilities	Program Description	Donor	Types and Specific Names of Health Facilities
Introduction 1998–2001	12	Pilot in 2 national hospitals (1998 and 1999), followed by 10 additional sites in 2001, in Conakry and Upper Guinea. Activities included advocacy to stakeholders; development of PAC policies, standards, and protocols; site needs assessments; training in infection prevention, counseling skills, and family planning, and in abortion complication management using MVA; provision of initial stocks of equipment and supplies; transfer of learning visits to support organization of services, placement of contraceptives in PAC procedure room, and linkage to other reproductive health services and supportive supervision; site-level all-staff orientations about PAC, which often included engaging local officials and radios to inform them of the services. Policy: The MOPH first recognized the need for PAC, then led the development and finalization of the PAC policy, standards, and protocols. Subsequently, MOPH adopted the PAC implementation approach used in the first 12 health facilities as the standard for PAC introduction to be used in scale-up. All subsequent implementing partners were asked to follow the same approach.	USAID	National hospitals: Donka and Ignace Deen Regional hospitals: Faranah, Kankan Prefectural hospitals/municipal medical centers: Dabola, Dinguiraye, Mandiana, Siguiri, Kissidougou, Kouroussa, Kerouane Urban health center: Banan Koro
Early expansion 2002–2005	22	Activities included training of trainers, who then supported implementation of the same activities as above in order to integrate PAC in 10 new sites; community engagement meetings linked with initiation of PAC services at new sites.	USAID, UNFPA, unknown for selected health facility	Prefectural hospitals/municipal medical centers: Matam, Ratoma, Flamboyant, Minière, Forecariah, Pita, Boke, Boffa, Fria, Dubreka
Expansion 2006–2009	38	Policy: When the MOPH revised national reproductive health policies, standards, and protocols, PAC standards and protocols were incorporated into that document, which was finalized in 2006. Activities included those listed above in 16 new sites as well as supervision and refresher training for the 22 sites previously integrated. A 2008 regional PAC meeting in Saly, Senegal, and hosted by CEFOREP was the catalyst for additional PAC program consolidation, including: Fostering Change Virtual Leadership Program targeting 4 West African countries, including Guinea (2009–2010) Advocacy, tool development, and initial implementation in 5 Conakry health facilities of a quality improvement methodology of SBM-R²² Commercial vendor established and approved by MOPH to resupply MVA equipment	UNFPA and USAID	Regional hospitals: N’zérékoré, Kindia, Mamou, Labe Prefectural hospitals/municipal medical centers: Télimélé, Lelouma, Coleah, Beyla, Sinko, Gueckedou, Macenta, Lola, Yomou, Coyah Urban health center: Télimélé, Lelouma/Leysare
Support to existing sites 2010–2014	38	Activities included follow-up and supportive supervision of PAC activities in health facilities in Conakry and Upper and Forest Guinea, training of PAC service providers in LARCs, and rollout of SBM-R at 28 sites. Revision of community health worker educational materials regarding bleeding during pregnancy and postabortion family planning. 2013 regional meeting in Saly, Senegal, hosted by E2A, and evaluation visits of Fostering Change Program Countries.²³	USAID and UNFPA
Post-assessment 2014-present	48	Ebola virus epidemic-related disruptions to the health system. In recovery and reconstruction phase, training of providers and support to additional 10 sites, including 6 in prefectures not previously covered and in 4 urban health centers.	USAID	Prefectural hospitals/municipal medical centers: Dalaba, Tougué, Mali, Koubia, Gaoual, Koundara Urban health center: Dabola, Dubreka, Manquepas, Boffa

Abbreviations: CEFOREP, Centre Régional de Formation, de Recherche et de Plaidoyer en Santé de la Reproduction; E2A, Evidence to Action; LARCs, long-acting reversible contraceptives; MOPH, Ministry of Public Health; MVA, manual vacuum aspiration; PAC, postabortion care; SBM-R, Standards-Based Management and Recognition; UNFPA, United Nations Population Fund; USAID, United States Agency for International Development.
Notes: Guinea is geographically divided into 8 regions, 38 prefectures or municipalities (equivalent to a district), and 410 sub-prefectures. Each sub-prefecture has a health center (urban or rural). Prefectural hospitals have an average catchment population of 304,804, and regional hospitals cover 1,447,819 population. Users pay fixed amounts defined by the Ministry of Health for each type of service and facility, thus PAC service costs are fixed at 6000 francs (US$0.82) in health centers, 10,000 francs ($1.37) in prefectural or regional hospitals, and 15,000 francs ($2.05) in teaching hospitals. This price does not include contraceptive services, which incur a small additional fee. Donors supply the great majority of contraceptives offered through government health facilities in Guinea.

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TABLE 2.

Characteristics of Respondents by Facility Type, Provider Qualification, and Study Tools Administered

	Prefectures/Municipal Focal Points^a	Maternity In-Charges^b	PAC Providers	Total Facilities
Respondents^c by facility type
National hospitals	—	2	7	2
Regional hospitals	—	7	22	7
Prefectural hospitals	—	26	42	26
Urban or improved health centers	—	3	4	3
Total	—	38	75	38
Respondents by qualification
Obstetrician/ gynecologist	—	10	5	15
General practitioner	16	23	23	62
Nurse/laboratory technician^d	7	2	5	14
Midwife	3	—	23	26
Auxiliary nurse	4	3	18	25
Medical student	—	—	1	1
Total	30	38	75	143
Study tool administered^e	Questions on lists of facilities in their respective jurisdictions, whether facilities offered PAC, commodity availability, financing for activities, supervision reporting, and plans for expansion	Questions on staffing by cadre overall and for PAC services, staff training, hours and organization, recordkeeping, and supervision	Questions on types of services available, availability of supplies, attitudes and opinions about PAC and contraception; assessment of provider knowledge and skills in postabortion family planning counseling

Abbreviation: PAC, postabortion care.
↵^a Includes the head of the health office, the reproductive health focal point, and others who are responsible for more than one facility.
↵^b Includes medical officer in charge of maternity, head of PAC unit, and deputy/assistant maternity in-charge.
↵^c In addition to these subnational respondents, the study team interviewed 3 national stakeholders from the family health division.
↵^d Among PAC providers, 1 of the 5 nurses was a laboratory technician.
↵^e A separate facility assessment tool was also administered, which included an inventory of equipment and supplies and abstraction of service statistics from PAC registers.

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TABLE 3.

Number and Proportion of Health Facilities Offering Postabortion Care, by Level, Along With Parameters of Service Availability and Family Planning Integration, as Reported by Maternity In-Charge Respondents

Facility Type	Facilities in Country^a	Facilities With PAC Services^b	Facilities With PAC Services Available 24/7	Facilities With Any FP Services Provided in PAC Unit	Facilities With Both LARC Methods in PAC Unit^c	Facilities With Both LARC Methods in FP Unit
Facility Type	No.	No. (% of total health facilities)	No. (% of PAC health facilities)	No. (%)	No. (%)	No. (%)
National hospitals	3	2 (66.7)	2 (100.0)	2 (100.0)	2 (100.0)	2 (100.0)
Regional hospitals	7	7 (100.0)	7 (100.0)	7 (100.0)	6 (85.7)	7 (100.0)
Prefectural hospitals/municipal medical centers	34	26 (76.5)	26 (100.0)	26 (100.0)	25 (96.2)	26 (100.0)
Urban health centers	78	3 (3.8)	1 (33.0)	3 (100.0)	3 (100.0)	3 (100.0)
Rural health centers	334	0 (0.0)	—	—	—	—
Total	456	38 (8.3)	36 (94.7)	38 (100.0)	36 (94.7)	38 (100.0)

Abbreviations: FP, family planning; LARC, long-acting reversible contraceptive; PAC, postabortion care.
↵^a Based on Guinea National Health Management Information System.
↵^b One of the urban health centers (in the same town as a prefectural hospital) had PAC services in place in prior years but not during the whole of calendar year 2013, because of the lack of manual vacuum aspiration equipment.
↵^c The LARCs available in Guinea are Copper T380A intrauterine devices and Jadelle subdermal implants.

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TABLE 4.

PAC Caseload, Family Planning Counseling, and Family Planning Use, Health Facility Register Data, 2013

Region	PAC Cases	PAC Cases Counseled on Family Planning	PAC Clients Leaving the Facility With a Method	PAC/Family Planning Clients Who Chose a LARC Method
Region	No.	No. (% of PAC cases)	No. (% of counseled PAC clients)	No. (% of family planning acceptors)
Conakry	2,215	2,209 (99.7)	1,775 (80.1)	623 (35.1)
Kindia^a	471	360 (76.4)	231 (49.0)	44 (19.0)
Boke	148	141 (95.3)	84 (56.8)	5 (6.0)
Mamou	300	286 (95.3)	228 (76.0)	97 (42.5)
Labe	295	223 (75.6)	92 (31.2)	10 (10.9)
Faranah	205	199 (97.1)	133 (64.9)	19 (14.1)
Kankan	692	691 (99.9)	567 (81.9)	118 (20.8)
Nzérékoré	218	217 (99.5)	205 (94.0)	66 (32.2)
Total	4,544	4,326 (95.2)	3,315 (73.0)	982 (29.6)

Abbreviations: IUD, intrauterine device; LARC, long-acting reversible contraceptive; PAC, postabortion care.
↵^a Two health facilities in Kindia region, a health center and a prefectural hospital, did not have any service statistics data for 2013. The health center staff indicated that they referred all PAC cases to a nearby hospital (in same city).

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TABLE 5.

Health Systems Factors Influencing Effective FP/LARC Integration Within PAC

	Region
	Conakry	Kindia	Boke	Mamou	Labe	Faranah	Kankan	Nzérékoré	Total
Health systems factors
PAC health facilities (N)	7	6	3	2	3	4	6	7	38
No. of staff providing PAC services^a	119	30	23	15	14	19	34	22	276
Median	8	5.5	9	7.5	6	5	5.5	3	5
Range	1–39	1–8	5–9	3–12	1–7	4–5	2–10	0–5	1–39
Availability of trained personnel^b
PAC (Total)	128	43	54	38	31	33	49	40	416
Group-based PAC course	70	22	28	19	11	16	27	18	211
On the job	58	21	26	19	20	17	22	22	205
FP/LARCs
IUD	54	18	13	15	9	17	24	26	176
Implants (Jadelle)	23	16	12	15	9	12	16	17	120
Supervision tools incorporate PAC inclusive of FP
Internal or external supervision or both	7	5	3	2	3	4	6	7	37
Equipment and supplies available
IEC materials	6	5	1	2	3	4	5	6	32
Contraceptives in MVA room
Condoms	5	5	2	0	2	3	2	3	22
Pills (POP/COC)	5	5	3	1	2	4	5	6	31
DMPA	5	4	2	0	1	2	4	6	24
IUD	6	4	3	2	3	4	4	5	32
Implants	6	6	3	2	3	3	5	5	32
MVA equipment and supplies	3	0	1	0	0	0	0	3	7
Infection prevention supplies^c	4	1	1	0	3	0	3	7	19
No. (%) of health facilities with any stock-outs of contraceptives	1 (14)	2 (33)	2 (67)	0 (0)	2 (67)	2 (50)	4 (67)	4 (57)	17 (45)
No. (%) of health facilities with a complete set of minimum equipment and supplies	3 (43)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	2 (29)	5 (13)
HMIS functioning
No. (%) of health facilities that report PAC data^d	6 (86)	5 (83)	3 (100)	2 (100)	3 (100)	3 (75)	6 (100)	7 (100)	35 (92)

Abbreviations: COC, combined oral contraceptive; DMPA, depo-medroxyprogesterone acetate; FP, family planning; HMIS, health management information system; IEC, information, education, and communication; IUD, intrauterine device; LARC, long-acting reversible contraceptive; MVA, manual vacuum aspiration; PAC, postabortion care; POP, progestin-only pill.
Data sources include maternity in-charge responses and the facility assessments.
↵^a The investigators could not confirm the number of PAC providers in one health facility in N’zérékoré; thus providers are included from only 6 health facilities in that region.
↵^b We assume that maternity in-charges did not list the same providers as both trained through group-based and on-the-job PAC training.
↵^c Exhaustive list of 28 items that included access to water source, cleaning supplies, personal protective equipment, means to sterilize or high-level disinfect MVA equipment and instruments, containers, antiseptics, and disinfectants.
↵^d Two health facility maternity in-charges, one in Conakry and one in Kindia, did not report the PAC data they collected. One health facility in Faranah did not collect PAC data at all.