Emmanuel Philipo's presentation at the 2013 International Family Planning Conference in Addis Ababa-Ethiopia, November 13th, 2013. Adverse events, client satisfaction and method discontinuation following outreach delivery of long-acting and permanent family planning methods in rural Tanzania.
This presentation is made possible by the support from the American People through the United States Agency for International Development (USAID). The contents are the responsibility of MSI and do not necessary reflect the views of USAID or the United States Government SLIDE 1 Adverse events, client satisfaction and method discontinuation following outreach delivery of long-acting and permanent family planning methods in rural Tanzania Authors: Innocent Augustino 1 , Emmanuel Phillipo 1 , Heidi Brown 1 , Cristin Gordon-Maclean 2 1. Marie Stopes Tanzania 2. Marie Stopes International Presenter: Emmanuel Philipo 2013 International Family Planning Conference Addis Ababa-Ethiopia-November 13 th , 2013
Transcript
This presentation is made possible by the support from the American People through the United States Agency for International Development (USAID). The contents are the responsibility of MSI
and do not necessary reflect the views of USAID or the United States Government
SLIDE 1
Adverse events, client satisfaction and method discontinuation following outreach delivery of long-acting and permanent family planning methods in rural Tanzania
1. Marie Stopes Tanzania 2. Marie Stopes International
Presenter: Emmanuel Philipo2013 International Family Planning Conference
Addis Ababa-Ethiopia-November 13th, 2013
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Outline
Background and Objectives of the Study
Methodology
Findings Complications
Discontinuation
Satisfaction
Conclusions and Recommendations
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Maternal mortality ratio (MMR) – 454/100,000
Contraceptive prevalence rate (CPR) (15-49) –
Contraceptive prevalence rate (CPR) in rural areas - 25%
Total fertility rate nationally - 5.4
Total fertility rate rural - 6.1
MDG 5 targets for 2015: MMR 133/100,000 & CPR 60%
Background - Tanzania
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Background Marie Stopes Tanzania (MST) delivers free integrated FP (long-acting and
permanent methods) and VCT services through 26 outreach teams Coverage: All (n=127) districts in Tanzania mainland and Zanzibar. MST has reached 190,000 FP clients through outreach in 2012 95%+ of outreach services are provided at rural government facilities
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Objectives of the Study
To assess incidence associated with provision of BTLs, IUDs, and implants
To assess outreach clients’ health seeking behaviours after experiencing complications and upon deciding for IUD & implant removal
To document the discontinuation rates for IUDs & implants
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Methodology Design: Longitudinal cohort study - quantitative data collection
Baseline (March 2012); 15 day follow-up (March - April 2012);
90 day follow-up (June 2012); One year follow-up (February 2013)
Sample size: 451 women who received FP services (BTLs, IUDs, and implants) from MST’s mobile outreach clinics
Study areas: Two outreach teams (Musoma and Mabibo) in 2 districts– 14 dispensaries in Geita district – 14 dispensaries in Lushoto district
Recruitment: Study participants were voluntarily enrolled at MST outreach service delivery points after receiving the services; written informed consent
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Study Design and OutcomesOne year: March 2012 to February 2013
Day 1: Recruitment Recorded: Method taken, immediate complications, acceptability & satisfaction level prior to discharge
Day 15:Follow-up for BTL, IUD & implants
Measure: Complications associated with each method, health seeking behaviors, satisfaction, & resumption to normal activities/work. Also collection of removal data
Day 90:Follow-up for IUD & implants
Measure: Discontinuation of IUD/implants, details of who removed IUD/implant & details on reasons for removal
One Year:Follow-up for IUD & implants
Measure: Discontinuation of IUD/implants, details of who removed IUD/implant & details on reasons for removal
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Cohort and Retention
Day 1 (Recruitment)
Day 15 (FU – BTL, IUD &
Implants)
Day 90 (FU - IUD & implants)
451 enrolled (BTL=107; IUD=74; implants=270)
434 (96%) (BTL=106; IUD=70; implants=258)
300 (91%) (IUD=57; implants = 243)
278 (93%) (IUD=50; implants=228)
One year (FU - IUD & Implants)
BTL=1IUD=4
Implant=12
IUD=13 Implants=15
IUD=7 Implants=15
Loss to follow-up
Cohort
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Measurement of Complications Minor / no complications: Discomfort that requires minimal (e.g.
pain killers) or no medical intervention at all.
– Example - mild pain around the insertion area or prolonged menses
Severe complications: Any case that requires medical intervention from a medical personnel beyond recommendation to just rest or use common pain killers.
– Example - the client experiences constant/progressive severe pain around the insertion area or perforation of organ after procedure.
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Findings – cohort characteristicsAge: 59% were aged 25-39; 22% < 25 years; 19% were 40+
Marital status: 89% were married
Number of children: The majority of implant (77%) clients have <5 children,
as compared to IUD (57%)and BTL (27%) clients
Most BTL (56%) clients had 6 – 9 children
Very few IUCD (4%) and implant (4%) clients have more than above 10 children
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Findings - complications 15 days follow up
‘No FP users experienced severe complication’.
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Complication Prevalence Minor complications(n=53) reported by clients on the 15 days follow up
BTL: Mild pain around the wound
IUD: Discomfort during procedure Slight lower back pain Vaginal spot bleeding Prolonged menses
IMPLANTS: Discomfort at the insertion site following the procedure
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Care-seeking for complicationsDay 1: Recruitment
During post counseling 94% of the respondents were well informed on where to seek care when complications would arise within 15 days post procedures.
15 days follow-up
All minor complications reported in day 15 were attended at nearby rural government health facilities
Thus, none of the women received referrals to higher health facilities for further interventions.
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Findings - recovery 15 days follow-up:
92% reported to resume their normal work activities after the procedure (BTL- 80%, IUD -99% & Implants- 99%)
On the average,BTL clients took longer (6 days) to resume normal activities, as compared to IUD (1 day) & implant (2 days)
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Findings - discontinuation rates
15 days follow-up: No IUDs or implants
removed
90 days follow-up: 3 implants removed
Figure 1: Reasons for Implants removal at 90 days follow up (n=3)
Wanted to be pregnant,
(n=2)
Pregnant before
insertion(n=1)
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Findings - discontinuation rates
Figure 2: Reasons for removal (n=11)
One year follow-up: 11 implants removed
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Findings - client satisfaction The majority were very satisfied with the FP services provided
by MST outreach after the procedures 15 day follow-up: 99%
90 day follow-up: 99%
1 Year follow-up: 99%
80% would recommend MST outreach FP services to other people
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Conclusions Mobile outreach services offer safe & satisfactory access to LAPM in
hard-to-reach rural areas
Most LAPM clients do not experience any complications or report only minor adverse side effects such as; Discomfort during procedure, slight lower back pain, vaginal spot bleeding,
prolonged menses, mild pain around the wound, and discomfort at the insertion site following the procedure.
A few LAPM clients’ complaints could be attributed to lack of effective counseling leading to clients being unsure of what they should expect; Vaginal spot bleeding for IUD & mild pain around the wound for implants
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Recommendations
Build clinical capacity of Local Government Authority providers around removals/discontinuation of the long acting & permanent methods
Improve surgical performance of procedures to reduce chances of complications & counseling skills on managing possible adverse events.
Review & strengthen screening for eligibility of long term & permanent methods
Monitor discontinuation rates & their related reasons
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