Post written by Margaret Gaw, Stanback Fellow, FHI 360.
Last year, I had the notable opportunity to sit down with four healthcare providers who work with patients to provide excellent contraceptive care in their respective countries. Listening to their experiences is vital to the aims of the CTI Exchange's series, Beginning With the End in Mind, because the ‘on-the-ground’ specifics of delivering contraceptives to the people who need them directly relate to acceptability, affordability, accessibility, and equity in contraceptive technology innovation.
Typically, contraceptives make their way into the hands of users either through a healthcare provider or through self-care. Thus, provider-side barriers and facilitators are key factors in the introduction and implementation of contraceptive products and services in complex health systems. Barriers could include negative provider attitudes, stock-outs of methods, lack of policies regarding family planning provision in schools, and distance to adequate health facilities. On the other hand, governmental expansion of contraceptive services and investment, effective contraceptive counseling, integration of health services, and availability of staff and supplies all enable introduction and uptake of contraceptives at the health system level. Health financing and policies in Sub-Saharan Africa play major roles in provider-side barriers and enablers to family planning in broader health systems (1).
Given the importance of provider perspectives and behaviors, how can researchers and stakeholders involved in the earlier processes of contraceptive R&D and innovation truly listen to providers themselves? In this blog, we turn toward doctors and nurse-midwives who have their fingers on the pulse of provider perspectives in countries where the need for family planning services and products is a major priority. We hear about their typical day-to-day life as a provider of family planning services and their insights on attributes of contraceptive methods that are beneficial or pose barriers to their patient populations. We welcome you to listen to these provider voices as invaluable in the effort to develop effective and desirable contraceptive methods.
Jully Chilambwe, Family Planning Technical Advisor at Jhpiego, Lusaka Zambia
Ms. Chilambwe is a technical advisor who works with the Ministry of Health within the district and province facilities in maternal, newborn and child health and family planning. She also works with the Advocacy and Accountability Collaborative (working with 30 civil society organizations across 10 provinces to address maternal newborn child health, adolescent health, nutrition, and to develop new policies, tools, and guidelines). She provides group counseling on all available family planning methods as well as one-on-one counseling and refers clients for any services they are unable to provide (i.e., STI and HIV testing, cervical cancer screening, etc.)
Benefits of current methods
Availability, effectiveness, few side effects
Discreet and easy use
Self-administered
Barriers to contraceptives
Misconceptions about infertility and cancer
Partner opposition
Stock outs (especially during COVID-19)
Provider bias (attitudes and lack of information and skill in providers)
Overwhelmed staff and competing priorities for providers
Potential solutions in contraceptive R&D
Improve provider training that includes addressing harmful attitudes and provider bias
Develop mentorship to sharpen knowledge and skills
Promote safe motherhood action groups in communities, community-based distributors, community health workers, and peer educators who can help with access to methods
Identify “gatekeepers” (i.e., community and religious leaders) and empower with knowledge related to family planning especially healthy timing and spacing
Develop acceptability research that takes into account socio-cultural and religious perspectives
Dr. Carolina Sales Vieira Macedo, OB/GYN and Associate Professor and Head of Contraception Division at University of San Paulo, Brazil
Dr. Macedo specializes in reproductive medicine with a focus on family planning, lectures and supervises medical students, and coordinates outpatient clinics at the university hospital, among other responsibilities. In a typical 5-hour shift, she may deliver family planning services to 50-80 patients, and she leads the training center in counseling, insertion and follow-up for LARCs country-wide (having trained 500+ healthcare providers).
Benefits of current methods
Varies depending on age, socioeconomic status, access to abortion, relationship and frequency of sex, health status, and need for non-contraceptive benefits
Free of charge (especially for LARCs)
Effectiveness, long duration, and low requirement for maintenance
Safety
Non-contraceptive benefits (such as reduced bleeding, reduced dysmenorrhea, and reduced need for menstrual products as around 25% of adolescents do not have access to menstrual health supplies)
Barriers to contraceptives
Cost/limit in the methods available for free (i.e., implant and hormonal IUD)
Misconceptions among users and healthcare providers
Lack of providers trained in LARC counseling, insertion, removal, and managing adverse effects like cramping
Lack of postpartum contraception services
Organizational barriers such as unnecessary testing required before access and infrequent same-day insertion
Potential solutions in contraceptive R&D
Develop more accessible counseling tools and provider trainings
Improve predictability of adverse events like unfavorable bleeding patterns
Reduce pain of insertion and ensure less expulsion of the IUD
Reduce amount of bleeding caused by some methods like the copper IUD
Develop better methods for understanding/researching acceptability across different contexts and measuring different domains (i.e., related to bleeding patterns) as well as standardized classifications/definitions of bleeding patterns (i.e., currently prolonged bleeding defined as 14+ days but that does not match everyday life and users’ experiences; spotting defined differently across organizations and across studies)
Dr. Anthony Adindu Nwala, Practice Area Lead for Reproductive Health and Family Planning at the Society for Family Health in Abuja, Nigeria
Dr. Nwala oversees 5 service delivery projects for reproductive health and family planning and works closely with the federal ministry of health, implementing partners, and heads of health facilities to ensure effective delivery of contraceptives.
Benefits of current methods
Privacy of injectables and implants
Popularity and relative affordability of implants
Barriers to contraceptives
Spousal rejection and inability to negotiate
Financial and cultural barriers such as religious influence to have many children
Misconceptions about contraceptive side effects
Potential solutions in contraceptive R&D
Develop more trainings on counseling methods
Advocate for in-country funding for family planning
Focus on male methods
Dr. Marsden Solomon, Family Planning Manager for Afya Uzazi, Nairobi Kenya
Dr. Solomon supervises family planning project staff who are providing technical support to county governments, health departments, and FP providers and ensures compliance to policies and laws (i.e. ensuring high-quality counseling and informed consent) in contraceptive delivery.
Benefits of current methods
Methods according to national method mix – including DMPA, oral contraceptive pills, implants
Discreet, long-acting, reversible methods
Non-contraceptive benefits of hormonal IUDs to help with heavy or irregular bleeding
Barriers to contraceptives
Human resource shortage including the absence or inadequacy of healthcare workers especially for implants and IUDs
Equipment shortage for providing services
Misconceptions at the community level of bleeding changes
Socio-cultural element of wanting many children
Potential solutions in contraceptive R&D
Counseling, including on contraceptive-included menstrual changes
Training materials (i.e., models) for community engagement and appropriate messaging to reduce myths and misconception
Advocacy to engage with government officials and community leaders and school health programs
Acceptability research that takes into account socio-cultural and religious perspectives
Have thoughts on this topic or the Beginning with the End in Mind series overall? Post your ideas on Twitter and LinkedIn, tag @ctiexchange, and use the hashtag #NextGenFP.
1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984360/