Figures & Tables
Figures
- FIGURE 1.
Provider- and Client-Level Interventions for the PPIUD Initiative
Abbreviations: AGOTA, Association of Gynecologists and Obstetricians of Tanzania; FP, family planning; IUD, intrauterine device; ob/gyn, obstetrics/gynecology; PPFP, postpartum family planning; PPIUD, postpartum intrauterine device.
- FIGURE 2.
Visual Representation of the Implementation Outcomes Framework27
aInstitute of Medicine standards of care.
- FIGURE 3.
Ecological Framework Illustrating Factors That Influenced Implementation of the PPIUD Initiative in Tanzania
Abbreviations: PPFP, postpartum family planning; PPIUD, postpartum intrauterine device.
Tables
- TABLE 1.
Key Elements and Inputs Intended for Implementation of the PPIUD Initiative in 6 Countries
Elements and Inputs Description Training: “Train-the-trainer” model: Training cascaded from master trainers to existing eligible providers at selected health facilities Counseling:
Prenatal counseling on available family planning methods with an emphasis on PPFP using standard training methods (e.g., GATHER model)
Included information on the advantages of PPIUD
Open discussion about providers’ views of PPIUD to address any prejudices
Role play, case scenarios
Providers encouraged to use counseling aids (e.g., leaflets, posters, flipcharts, and videos)
PPIUD insertion and removal:
Theoretical (classroom-based) training and practical sessions using Mama-U postpartum uterus models
Refresher trainings offered as needed
Regular training of new staff rotating in
Equipment and supplies Mama-U models
Copper T IUDs
Long-handled 33 cm curved Kelly forceps
National coordination Implementation was coordinated through national professional societies or colleges to encourage local ownership
National societies set up steering groups for clinical and technical guidance
Structures established to facilitate implementation Dedicated project management team
Facility-level project coordinators
Data Safety Monitoring Committees
PPIUD counseling and insertion services delivered by trained providers Integrated within existing maternity services
Prenatal counseling on all available contraception methods with an emphasis on PPFP, and the advantages of PPIUD as a safe, effective, and reversible long-acting method
Consent forms provided during prenatal visits
Stickers placed on women’s case files to identify consenting women at delivery
Women who did not receive prenatal counseling could be counseled during early labor or the postnatal period to ensure insertion within 48 hours if PPIUD was desired
Monitoring and evaluation Data collection officers collected information on counseling, consent, PPIUD, and follow-up for women delivering in participating facilities
Abbreviations: GATHER, greet, ask, tell, help, explain, and return; IUD, intrauterine device; PPFP, postpartum family planning; PPIUD, postpartum intrauterine device.
Achievements Participating hospitals, n 6 Providers trained under the PPIUD Initiative, n 827 Women counseled on family planning and PPIUD, n 21,479 Counseled during antenatal care, % 57.0 Counseled only after admission for delivery, % 43.0 Deliveries during the PPIUD Initiative period, n 91,387 Women followed up for postpartum interview, n 80,194 Women who consented for PPIUD insertion, n 5,634 PPIUD insertions, n 3,095 Abbreviation: PPIUD, postpartum intrauterine device.
- TABLE 3.
Number and Percent Distribution of Women, by Background Characteristics and Interview Type
Interviews With Pregnant Women Interviews With Women Receiving PPIUD n (%) n (%) Geographical region Mbeya 3 (15) 9 (33) Arusha 6 (30) 5 (19) Dodoma 2 (10) 4 (15) Dar es Salaam 5 (25) 6 (22) Pwani 4 (20) 3 (11) Age, years <20 1 (5) 1 (4) 20–24 3 (15) 3 (11) 25–29 10 (50) 13 (48) 30–34 3 (15) 2 (7) 35–42 2 (10) 7 (26) Missing 1 (5) 1 (4) Education Some Primary 1 (5) 0 (0) Completed Primary 3 (15) 6 (22) Some Secondary 3 (15) 1 (4) Completed Secondary 10 (50) 15 (56) More than Secondary 2 (10) 4 (15) Missing 1 (5) 1 (4) Marital Status Married 15 (75) 21 (78) Single, not living together 2 (10) 3 (11) Single, living together 1 (5) 0 (0) Widowed 0 (0) 2 (7) Missing 2 (10) 1 (4) Occupation Unemployed 5 (25) 6 (22) Homemaker 1 (5) 0 (0) Business owner 5 (25) 9 (33) Teacher 2 (10) 4 (15) Other (e.g., nurse, secretary, salonist) 5 (25) 7 (26) Missing 2 (10) 1 (4) Religion Christian 15 (75) 20 (74) Muslim 3 (15) 6 (22) Missing 2 (10) 1 (4) Total No. of Children (alive or deceased) 0 6 (30) 0 (0) 1 8 (40) 11 (41) 2 2 (10) 7 (26) 3 or more 3 (15) 8 (30) Missing 1 (5) 1 (4) Abbreviation: PPIUD, postpartum intrauterine device.
Characteristic n (%) Geographical Region Mbeya 4 (27) Arusha 4 (27) Dodoma 2 (13) Dar es Salaam 2 (13) Pwani 3 (20) Gender Male 2 (13) Female 13 (87) Age 29–39 7 (47) 40–50 4 (27) >50 2 (13) Missing 2 (13) Profession Physician 3 (20) Nurse 12 (80) Length working in profession, years ≥5 5 (33) 6–15 4 (27) ≥16 3 (20) Missing 3 (20) Length providing family planning services, years ≥5 5 (33) 6–10 7 (47) ≥11 1 (7) Missing 2 (13) - TABLE 5.
Application of the Implementation Outcomes Framework to Assess Facilitators and Barriers to PPIUD Initiative Implementation in Tanzania
Outcome and Definition Facilitator Barrier Implementation Outcomes Acceptability: Perception among stakeholders that intervention is acceptable (e.g., satisfaction with PPIUD training content, complexity, comfort) High satisfaction with PPIUD training
Lack of providers trained on PPIUD insertion
Lack of support from local health authorities
Adoption: Initial implementation of PPFP counseling and PPIUD insertion; Intention to try Increased confidence following PPIUD training
Time constraints and inadequate staffing
Gaps in referral system between satellite clinics and hospitals
Fidelity: Delivered counseling as intended (e.g., reach, content, and target population) Individual counseling replaced by group counseling
Diminished provider motivation
Counseling rushed or skipped
Skewed or incomplete counseling
Penetration: Diffusion of PPIUD Initiative within intervention facilities and to other non-intervention sites Emphasis on PPIUD’s mechanism of pregnancy prevention during training
Objections from faith-based facilities
Expectation for remuneration among staff who did not receive initial training
Sustainability: Long-term maintenance and institutionalization of the PPIUD Initiative Support for population policies and family planning programs to achieve fertility reduction goals
Breakdown of supply chain and stock-outs
Service Outcomes Equity: Extent to which the PPIUD implementation is equally available/accessible to all intended beneficiaries Differential treatment by health care providers
Financial barriers to accessing hospitals
Lack of community-based PPFP counseling and services
Client Outcomes Client receptiveness/demand for services:
Client receptiveness to being counseled on PPFP and/or demand for receiving the PPIUD
Level of support from husband/partner
Shared intention among couples to space pregnancy for financial reasons
Community and gender norms related to birth spacing
Community diffusion of preference for PPIUD and peer recommendation
Women's trust in provider advice
Cost-free counseling and insertion services
Fear of insertion, concerns related to sexual experiences postinsertion, unexpected expulsion and experience of unanticipated side effects (results published elsewhere26).
Satisfaction with PPIUD services:
Client receptiveness to being counseled on PPFP and/or receiving PPIUD; Satisfaction with counseling and services
Delivery of counseling and services by female provider
Interpersonal aspects of care
Perceived provider incompetence
Abbreviations: PPIUD, postpartum intrauterine device; PPFP, postpartum family planning.
Supplemental material
- Supplement 1 -
Supplement 1
- Supplement 2 -
Supplement 2
- Supplement 1 -
