Effect of family planning interventions on couple years of protection in Malawi

Abstract Objective The primary objective was to assess the effect of family planning interventions at two health facilities in Malawi on couple years of protection (CYP). Methods A prospective quasi‐experimental design was used to compare CYP and uptake of long‐acting reversible contraception (LARC) between two intervention facilities (Area 25 Health Center and Kasungu District Hospital) and two nonintervention facilities (Mkanda Health Center and Dowa District Hospital). The interventions included community mobilization and demand generation for family planning, and training and mentoring of providers in LARC insertion. Monthly data were collected from 1 year prior to intervention implementation until 2 years thereafter. Results From the pre‐intervention year to the second post‐intervention year, CYP increased by 175.1% at Area 25, whereas it decreased by 33.8% at Mkanda. At Kasungu and Dowa, CYP increased by 90.7% and 64.4%, respectively. Uptake of LARC increased by 12.2% at Area 25 r, 6.2% at Kasungu, and 2.9% at Dowa, but decreased by 3.8% at Mkanda. Conclusions The interventions led to an increase in CYP and LARC uptake. Future family planning programs should sensitize communities about family planning and train providers to provide all contraceptives so that women can make informed decisions and use the contraceptive of their choice.

2012. This initiative has three program interventions: (1) community mobilization and training of local leaders in maternal health and family planning, (2) training of skilled community midwife assistants, and (3) the construction of maternity waiting homes. UNC Project-Malawi decided to integrate a package of family planning interventions into the three interventions from the Presidential Initiative on Safe Motherhood. The project's primary objective was to increase the couple years of protection (CYP) provided by contraceptive services at two health facilities where UNC Project-Malawi was constructing maternity waiting homes.
"Couple years of protection" is a commonly used family planning metric to monitor output and progress in the delivery of contraceptive services at the project level. 5,6 Secondary objectives included the introduction of immediate postpartum long-acting reversible contraception (LARC) and improvement of the facilities' contraceptive method mix.
The present quasi-experimental study was designed to compare the CYP provided at each of the two intervention health facilities with those provided at two matched nonintervention health facilities for the year before implementation of the family planning package and for the 2 years after the package was implemented.

| MATERIALS AND METHODS
In the present prospective study conducted in Malawi, a package of  The HPP also organized two "population weekends," one in the   For the analyses, graphs were created to compare trends in monthly family planning visits and monthly LARC uptake between each intervention site and its comparison site during the 3-year monitoring period.
Then, the absolute difference between each intervention facility and its comparison facility was calculated for each family planning parameter.
Finally, CYP were computed for each health facility for each intervention period and the percent change in CYP before and after the intervention was calculated. The calculation of CYP was based on formulas published previously. 6 The data collected for condoms and sterilization were not used in calculating CYP because of inconsistencies in recording this information among the four facilities. No statistical analysis was planned.

| RESULTS
The radio discussion panel was held on January 16, 2014, at the Lilongwe Teacher's College in Area 25 and recorded live on Zodiak Broadcasting Station, the largest radio station in Malawi (Table 1). It was attended by more than 100 people, and more than 400 people The column percentages were calculated by dividing the number of visits where the contraceptive was given by the total number of visits. The column percentages do not always add up to 100% because condom provision at visits was inconsistently recorded and was therefore excluded from this table.
At all health facilities except Mkanda Health Center, CYP increased between the pre-intervention year and the second post-intervention year (

| DISCUSSION
The present family planning interventions contributed to a greater increase in CYP at the two targeted sites when compared with their comparison sites. Much of the increase in CYP at the two intervention sites was attributable to an increased uptake of LARC, particularly implants, indicating that the contraceptive method mix at those sites was also improved. It is important to note that the demand generation activities did not focus on LARC use but on the importance of family planning use in general. Therefore, the increase in LARC uptake is likely attributable to the increased access to LARC offered by the providers at the intervention sites after the LARC training courses because many providers were not counseling about or offering LARC prior to the training because of their lack of skills to insert and remove these contraceptives.
F I G U R E 1 Proportion of family planning visits where a long-acting reversible contraceptive was inserted at the four health facilities during the three study periods. Error bars represent 95% confidence intervals. The column percentages were calculated by dividing the number of visits where the contraceptive was given by the total number of visits. The column percentages do not always add up to 100% because condom provision at visits was inconsistently recorded and was therefore excluded from this table.
The present interventions included community mobilization, which helped to increase the demand for family planning use. Uptake of family planning is often low because of misinformation regarding the adverse effects of contraceptives. 3,10,11 The open days provided correct information about family planning and involved the education of traditional leaders, who are custodians of culture and influence decision-making at both the community and the family level.
Other programs in Africa have also successfully involved traditional leaders in health campaigns, although none focused on family planning only. [12][13][14] In addition, local religious leaders were educated about the benefits of family planning. The religious leaders were generally supportive of undertaking the events in their communities, including learning about the benefits of family planning and disseminating this information to their congregations. A similar study in Jordan also worked with religious leaders and found that trained religious leaders were more effective in disseminating family planning messages compared with untrained counterparts. 15 Other interventions in Africa that have focused on involving religious leaders in family planning messaging have also found positive results. [16][17][18][19] Skilled healthcare providers are critical in family planning programs to meet the supply-side needs for family planning provision.
Inadequately trained staff could be a barrier to the provision of family planning, especially LARC. 20,21 Therefore, the present intervention included staff training and on-the-job mentoring after the courses to ensure the staff became competent. This strategy was also successfully adopted in Kenya and Senegal, where investigators have recommended that staff training and mentoring be included in family planning programs to increase the uptake of family planning, especially LARC. 22,23 Postpartum women are among those with a high unmet need for family planning. 24 Studies have shown that postpartum women want to avoid pregnancy in the next 24 months, but 70% of them are not using contraceptives. 24 Because the family planning data were collected from the government family planning registers and DHIS2, it was only possible to collect information that was recorded in them. There were some inconsistences in filling the registers at the health facilities. For example, data on the age and parity of the family planning patients were inconsistently collected, so this information could not be analyzed.
Also, finding a pure comparison facility for the intervention sites was a challenge because other organizations may have been implementing interventions in these sites that could have affected their family planning provision. However, we used the most similar comparison facilities that we could find. An additional limitation is that the radio discussion panel was broadcast nationally, and therefore the populations in the comparison communities were also exposed to this component. Given these limitations, it was not possible to examine causal relationships, and therefore the findings from the present analysis demonstrate changes before and after program intervention activities.
In conclusion, after implementation of a package of family planning interventions, the uptake of family planning, particularly LARC,

AUTHOR CONTRIBUTIONS
CL contributed to the data analysis and writing the manuscript. NK, BP, OM, NC, and JHT contributed to implementing the interventions, data collection, and revising the manuscript. ISS and KS contributed to data analysis and interpretation, and revising the manuscript. All authors read and approved the final manuscript.

ACKNOWLEDGMENTS
The present study was funded by the Bill and Melinda Gates Foundation (OPP#1090837).

CONFLICTS OF INTEREST
The authors have no conflicts of interest.
T A B L E 4 Couple years of protection at the four health facilities.

SUPPORTING INFORMATION
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