An Unmet Need
There are approximately 214 million women of reproductive age in low-income regions who want to avoid pregnancy but have no modern way to do so. To compound this problem, as soon as they give birth, their odds of an unintended pregnancy increase, presenting new challenges to her and her child.
Dr. Anita Makins, PPIUD Project Director at the International Federation of Gynecology and Obstetrics (FIGO) explains, “Globally, there are 214 million women with an unmet need for contraception. This signals a disconnect between a woman’s desire to plan her pregnancies and her ability to do so. Unmet need can lead to shorter birth-spacing, which has a negative impact on both maternal and newborn health, and can put additional economic strain on a family, perpetuating the poverty cycle.”
A New Approach
A reliable contraceptive method gives her control, and with it, the opportunity to look after her new family, both in terms of care for her newborn and economic productivity. Indeed, effective methods of contraception have been proven to improve maternal health and reduce maternal mortality.
This is why the International Federation of Gynecology and Obstetrics (FIGO) sought a way to provide affordable, long-acting, and reversible contraceptive methods to these millions of women around the world. When they settled on an intrauterine device (IUD), they then wanted to make it as effective as possible. They found that a particular method and set of tools – long, curved Kelly forceps – would reduce what was perceived to be a high expulsion rate.
FIGO Takes on the Problem
FIGO received funding for a research proposal to introduce the practice to six hospitals in Sri Lanka. After some initial success, this expanded to an additional 12 hospitals in Sri Lanka and six hospitals in each of five additional countries: Bangladesh, India, Kenya, Nepal, and Tanzania.
The goal was to “address the gap in the continuum of maternal health care and… to increas[e] the capacity of healthcare professionals to offer IUDs by training community midwives, health workers, doctors, and delivery unit staff.”
One key problem, however, was that IUDs did not necessarily have the best reputation. Whether their reason was religious, cultural, or even based on a poor prior experience, FIGO knew this was an obstacle they would need to tackle. Their answer was to tackle the bias at the provider level, engaging with healthcare providers to eliminate their bias through training and sensitization. They would also go on to raise awareness by counseling women on all aspects of postpartum family planning, reducing common misconceptions around IUD use. In some countries, this meant working with community health workers acting at the local level to educate the women who were delivering, as well as the wider community.
Using Mobile Data Collection
As part of the research proposal, FIGO hired data collection officers in each of the countries to collect data on every woman delivering in the participating hospitals. Using CommCare, they tracked counseling, consent, postpartum intrauterine devices (PPIUDs), and follow-up to assess the acceptability, cost-effectiveness, and outcomes of the effort.
Emily Tunnacliffe, PPIUD Project Manager from FIGO explained, “CommCare provided a unique platform in that they have a global presence, with hubs in some of our project countries. They were able to provide on-hand support and training where needed, giving our country teams ownership of data collection in their particular contexts.”
In an effort to track as many patients as possible, FIGO set up follow-ups for each of the registered cases at six weeks and six months, with an 18-months follow-up scheduled, including provider surveys, in-depth interviews, and hospital checklists.
After the first year, FIGO was able to track 75% of women delivering in the participating facilities, regardless of their PPIUD status.
With the data they collected on the patients’ knowledge of PPIUDs, consent, insertion, and complication rates, FIGO was able to convince a wider audience in each of the six countries that PPIUDs are a useful and effective method of postpartum contraception.
The data also reinforced this conclusion by providing clinicians with clearer ways to identify problems, train and support individual providers, and improve the insertion method – all to further increase maternal health, decrease maternal mortality rates, and popularize the PPIUD as a viable approach.
A Successful Project
FIGO’s PPIUD project certainly faced more challenges than those presented in this short summary, but in the end, they were able to provide women across Africa and South Asia with stability during a period of their lives that should be empowering, not debilitating.
In this instance, a mobile data collection platform was not used to reinforce protocols or implement trainings, and the clinicians, community midwives, health workers, doctors, and delivery unit staff were ultimately responsible for the success of the program. But the monitoring and evaluation done on the initiative provided both improvements to that process and proof for additional regions to help the hundreds of millions of women who could still benefit from an effective postpartum contraceptive, like PPIUD.
The International Federation of Gynecology and Obstetrics (FIGO) is committed to addressing the high maternal mortality rates in low‐resource countries and supporting women to make informed decisions about the contraceptive methods available.
For more information on FIGO’s PPIUD initiative and the source to much of the information referenced in this article, check out: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.12598