Institutionalizing postpartum family planning and postpartum intrauterine device services in Nepal: Role of training and mentorship

To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD).


| INTRODUCTION
Globally, 95% of women wish to avoid pregnancy in the first 24 months after childbirth; however, only around 40% will have used contraception in this period. 1,2 The unmet need for postpartum family planning (PPFP) is much higher in low-and middle-income countries (LMICs). In Nepal, unmet need for PPFP was 52% among women in the immediate postpartum period. 3 Postpartum intrauterine devices (PPIUDs) are an effective and affordable PPFP method that can reduce unmet need. 4 Health providers play a key role in addressing unmet need by providing quality and timely PPIUD services. 5,6 However, maintaining clinical standards is crucial and, as such, quality training and mentoring are necessary. 7,8 Since 2015, the Nepal Society of Obstetricians and Gynaecologists (NESOG) has been part of the International Federation of Gynecology and Obstetrics (FIGO) PPIUD initiative with efforts to institutionalize PPFP services in the immediate postpartum period in six referral hospitals across Nepal. PPIUD is the only long-acting, reversible PPFP method available for the immediate postpartum period in Nepal. The initiative is implemented in close coordination with the government line agencies. Its aim is to train in-service doctors and nurses working in maternity care in the implementing hospitals. It also trains preservice providers, such as nursing instructors, who teach nursing students practical skills in the selected hospitals.
Healthcare providers were trained via group-based training (GBT) or on-the-job training (OJT). Both modalities have similar curricula that focus on enhancing the learners' knowledge of all methods of PPFP and developing skills on providing PPIUD services.
GBT is similar to the concept of off-the-job classroom training. 9 GBT for this project was an intensive three days of training, where the learners had to dedicate their entire time to the course. Previous studies suggest that such training is more useful for enhancing knowledge. 10 The major advantage of this training modality is that a large amount of information can be delivered in less time.
OJT occurs in the work setting where the learners continue their daily job. OJT for this project was a 12-day, two hourly training, where the learners continued their daily responsibilities. OJT for PPFP/ PPIUD services is the first of its kind in Nepal, introduced by NESOG in coordination with government line agencies of Nepal. Previous research suggests that this training modality helps learners to better hone their skills. 9 Mentoring is defined as a process that helps staff, colleagues, or peers improve their work performance in a respectful manner. 11 In this initiative, mentoring forms part of both the OJT and the 3-day GBT. Mentors for this initiative were the doctors or nurses who had updated knowledge on the theories and were proficient in the skills.
Mentors worked with their mentees in smaller groups as well as on a one-to-one basis to improve their knowledge, skills, and attitudes.
Although the ultimate aim of the initiative is to improve PPIUD uptake among postpartum mothers, capacity building of health providers is also an important aspect. Feedback from learners on the different training modalities could provide important baseline information to evaluate the progress made toward achieving the initiative's ultimate goal, and to upscale training modalities that are more beneficial. Furthermore, it could help countries such as Nepal review their approaches and help countries with similar settings replicate good practices. Therefore, the aim of the present study was to explore the perceptions of key stakeholders of the PPFP/PPIUD initiative in Nepal on different modalities of training and mentoring activities.

| MATERIALS AND METHODS
This study followed the standard guidelines on qualitative research for data collection, analysis, and reporting the findings. 12 (Table 1).
Data analysis was done by content analysis manually by the research team, which included qualitative research experts. The categories identified from coding were grouped into different themes and subthemes. Anonymous original quotes that reflected real opinions from the respondents were chosen to give more insight.

| RESULTS
The results were structured around four major themes: usefulness of PPFP/PPIUD training, usefulness of mentoring, influence of training and mentoring on professional development, and recommendations for future training ( Table 2).

| New knowledge on PPFP/PPIUD
The majority of respondents taking part in FGDs mentioned that they had been taught about IUDs when they were students. However, they understood the concept of PPFP/PPIUD only after participating in PPFP/PPIUD training.
T A B L E 1 Characteristics of the study by type of institution and data collection.

| Group-based training versus on-the-job training
The majority of respondents suggested that they found OJT to be more effective than GBT. Many suggested that GBT was more intense and that only three days of training made it difficult to retain the knowledge. Many also mentioned that time is limited for practicing clinical skills during GBT. Some respondents further added that OJT provided more opportunities to improve their clinical skills and that the content delivered in each session was light and easy to remember.
We have conducted both GBT

PPFP/PPIUD-trainer, WRH
The trainers and focal persons from NHTC suggested that OJT is also more cost-effective because it is integrated into the trainees' daily job. However, they also indicated that GBT still needs to be continued intermittently to reach out to more health providers over a shorter duration.
We received GBT here in this institution which took place from morning to evening. But it was effective and not difficult to find three days for the training.

| Effect on professional growth
The majority of health providers suggested that the training had brought positive changes to their professional lives. Many said that the training had made them more responsible and motivated in their jobs. After the training, most felt more job satisfaction and described T A B L E 2 Themes and categories identified in the study.

| Recommendations for future training
Almost all the respondents strongly suggested that they wanted PPFP/PPIUD training to continue and would try their best to keep it sustainable. However, they had some recommendations for the government and the program implementers.

| Expansion of training to community and peripheral facilities
The majority of health providers pointed out that it is not only women, but many health providers from peripheral facilities, who are also not aware of PPFP/PPIUD services. Some highlighted that the preference for IUD has increased among rural women and to address their needs, more providers in the peripheries must be trained on PPFP/PPIUD services.

| Government commitment
Most of the health providers suggested that the government should commit to continue PPFP/PPIUD training and mentoring so that the facilities can also commit to sustain the activities. Mentors suggested that the mentoring program is already part of government family planning programs, but needs to be made regular so that mentoring activities can be conducted every six months for each facility.
We are committed to host the trainings in the hospital. But the government should maintain the momentum.

| Motivating factors
Many suggested that the implementers should consider additional strategies to motivate health providers to continue working on what they have learned.

The counselling rates and insertion rates tend to increase immediately after training and decline after some time. It
indicates something needs to be done to keep the health providers motivated. Some rewarding system could help.

| DISCUSSION
The results of the present study suggest that health providers perceived the training and mentoring for PPFP/PPIUD to be useful in Nepal. The majority of respondents identified OJT to be more effective than GBT. OJT for PPFP/PPIUD is the first of its kind and has been initiated and introduced by NESOG in Nepal. OJT in general focuses on "low dose" and "high frequency" pedagogy of learning. 14 There is growing evidence from many maternal and newborn health programs that this training approach improves knowledge retention and clinical behavior. 14 Moreover, OJT allows learning to be workplace based, which helps the learner avoid absenteeism from work.
It also allows time for the learner to familiarize themselves with their new skills before learning additional skills. 15 On the other hand, GBT focuses on the "high dose" and "low frequency" approach that has an increased risk for the learners to forget the content sooner. 16 However, this approach is still beneficial, in particular when learners are not in-service providers such as nursing instructors in this study. Although OJT can yield better results for improving skills, GBT is also known to have better knowledge outcomes. 9,10 Thus, GBT cannot be completely ruled out in circumstances that need to reach more people over a shorter time period.
In this study, mentoring helped the health providers improve their clinical acumen. The importance of mentors in clinical practice has gained prominence over the years. Mentoring is a process that helps learners improve their work performance in a respectful and nonrigid manner, treating them as peers or colleagues instead of a subordinate. 17 Health providers need to renew and update their skills continuously in the ever shifting and growing clinical world. Mentoring helps them learn and re-learn within the comfort of their work environment through one-to-one support and guidance. Moreover, mentoring is known to improve professional satisfaction, 17  Moreover, innovative strategies are needed to keep the health providers motivated. Lack of motivation and increased turnover of health providers have been key constraints of most health programs around the world. 21 The key motivational factors identified include financial incentives, career development, and management issues. 21 More efforts to acknowledge the challenges faced by the health providers and address each of the motivational factors to create a more supportive environment could also be the next steps to be considered by policymakers and the government.
This study provides baseline information indicating that more efforts are needed to explore sustaining the training and mentoring activities in this initiative. Although the findings suggest that OJT is a more popular training modality, this study does not conclude that such a modality would improve the ultimate outcome of the initiative.
Further follow-up studies are necessary to assess the long-term effect of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers. Meanwhile, the government line agencies need to carefully assess both modalities and implement both methods where appropriate.

| CONCLUSION
The training and mentoring activities embraced by the PPFP/PPIUD-Nepal team were perceived to be useful by participating health providers. In particular, OJT was the approach preferred by most health providers. However, further studies are necessary to explore the existing challenges and the long-term effect of OJT.

AUTHOR CONTRIBUTIONS
KT conceived the study and contributed to analysis and manuscript writing; RD contributed to study design, analysis, and writing the first draft of the manuscript and subsequent revisions. YBK was involved in finalizing the study tools, data collection, data analysis, and revision of the manuscript. SR, SV, SP, and ET were involved in manuscript revision.

ACKNOWLEDGMENTS
The authors would like to thank the FIGO team for their support and guidance and the NESOG team for their hard work and dedication to make this initiative grow. We would also like to acknowledge the efforts of all members of the PPFP/PPIUD national team for helping with the coordination of this study. We are obliged to all the facility coordinators and the participants of this study for their valuable time.

CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.