Background
-
to identify, appraise and synthesize research evidence regarding the approaches or strategies to scaling up PPFP for improving coverage and sustainability.
-
to identify, appraise and synthesize research evidence on the barriers to and facilitators of scaling up of PPFP.
Methods
Criteria for considering studies for this review
Types of studies
Types of participants
Types of scaling up strategies
Types of outcome measures
Barriers to and facilitators (Factors that influence scaling up of PPFP)
Literature search
Sources
Search strategy
Management of search results
Data collection
Study selection
Data extraction
Quality assessment
Data synthesis
Appraisal of confidence in the review findings
Researchers’ reflexivity
Results
Study selection
Findings of the review
Characteristics of included studies
Author-Year
|
Country
|
Type of study
|
Design
|
Sample
|
Scaling up category
|
---|---|---|---|---|---|
Akman 2010 [55] | Turkey | Quantitative | RCT | 180 | Recipient of care |
Billings 2007 [49] | Bolivia, Mexico | Qualitative | IDI | 49 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
Cooper 2014 [47] | Bangladesh | Qualitative | IDI, FGD | 40 | Recipient of care |
deSilva 2021 [39] | Sri Lanka | Qualitative | IDI | 12 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
DeSisto 2019 [27] | USA | Qualitative | IDI | 41 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
Eluwa 2016 [41] | Nigeria | Quantitative | BA | 728 | Recipient of care |
Espey 2021 [45] | Rwanda | Quantitative | BA | 12,068 | Human resource, Recipient of care |
Ingabire 2018 [46] | Rwanda | Quantitative | BA | 9020 | Human resource, Recipient of care |
Karra 2019 [40] | Sri Lanka | Quantitative | stepped-wedge cluster RCT | 39,084 | Healthcare infrastructure, Human resource, Recipient of care |
Kestler 2006 [51] | Guatemala | Quantitative | BA | 13,928 | Healthcare infrastructure, Human resource, Recipient of care |
Koch 2022 [28] | United States | Quantitative | Retrospective Cohort | 6233 | Financing |
Lacy 2020 [29] | United States | Quantitative | QI | 2012 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
Nelson 2019 [53] | Liberia | Mixed methods | FGD, KII, CBA | 1066 | Policy and regulation, Human resource, Recipient of care |
Palm 2020 [30] | United States | Mixed methods | IDI, stepped wedge | 20 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
Pearson 2020 [35] | Tanzania | Quantitative | Stepped-wedge cluster RCT | 15,264 | Healthcare infrastructure, Human resource, Recipient of care |
Pleah 2016 [48] | Benin, Chad, Côte d’Ivoire, Niger, Senegal, Togo | Quantitative | BA | 15,000 | Human resource |
Pradhan 2019 [43] | Nepal | Quantitative | Stepped wedge RCT | 75,587 | Healthcare infrastructure, Human resource, Recipient of care |
Rasch 2005 [36] | Tanzania | Qualitative | cross-sectional | 1365 | Human resource, Recipient of care |
Saeed 2008 [54] | Pakistan | Quantitative | RCT | 600 | Recipient of care |
Sebastian 2012 [52] | India | Quantitative | RCT | 959 | Recipient of care |
Simmons 2013 [31] | USA | Quantitative | RCT | 50 | Financing, Recipient of care |
Sodje 2016 [42] | Nigeria | Quantitative | Prospective cohort | 1061 | Human resource, Recipient of care |
Stephens 2019 [37] | Tanzania | Quantitative | cross-sectional | 6636 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
Tang 2014 [32] | USA | Quantitative | RCT | 800 | Recipient of care |
Tran 2018 [50] | Burkina Faso, Democratic Republic of Congo | Qualitative | IDI, FGD | 213 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, Recipient of care |
Wilkinson 2019 [33] | United States | Quantitative | Retrospective Cohort | 1072 | Financing |
Wu 2020 [44] | Nepal | Mixed methods | BA | 953 | Recipient of care |
Yahner 2022 [38] | Bangladesh, Tanzania | Qualitative | IDI, FGD | 60 | Human resource, Recipient of care |
Zerden 2015 [34] | United States | Quantitative | RCT | 324 | Recipient of care |
Methodological quality
Strategies of scaling-up post pregnancy family planning
Component
|
Description
|
References
|
---|---|---|
Human resource | ||
Training/continuing education of Health care providers | Training for clinicians, support staff, and administrative staff through various modalities (e.g., small-group in-person training, one-on-one proctoring, virtual Webinar series) on topics including family planning; medical management of contraception; hands-on clinical skills (e.g., Long-Acting Reversible Contraception (LARC) insertion and removal); billing, coding, and reimbursement; and preventing coercion and bias | |
Ongoing technical assistance | Ongoing, targeted technical assistance to clinicians, support staff, and administrative staff through various modalities (e.g., coaching calls, in-clinic training specialists) on topics including hands-on clinical skills; purchasing, stocking, and billing for contraceptives; patient education materials; contraceptive access policies/procedures; contraceptive workflow; and data collection and reporting | |
Financing | ||
Provision of low- or no-cost contraception | Direct funding or stocking for participating health centers across delivery settings to offer contraceptive methods and services to eligible individuals at low or no cost | |
Grants for equipment/supplies | Direct funding to health care facilities to purchase contraceptive supplies and equipment, other clinic supplies, and supplies for personnel Providing reimbursement to facilities for administrative cost, technical, and logistic control | |
Health care facility level | ||
Package Service | Offering modern contraception as part of postnatal care (PNC) or post-abortion care (PAC) services Integration of PAC into existing health systems as a part of their regular service delivery FP and Immunization integration, intra-facility referrals between FP and vaccination | |
Improving access to technologies and equipment as manual vacuum aspiration (MVA), medications, pain Control and contraceptive methods Strengthening each hospital’s infrastructure for post-abortion care Instituting an abortion surveillance system and using it to increase provision of post-abortion care | ||
Quality improvement | Continuous quality improvement to identify barriers and potential strategies to address those barriers; ongoing measurement of aggregate, de-identified data on use of various contraceptives; provision of contraception services or person-centered counseling; and knowledge, skills, attitudes, or beliefs about contraception among providers | |
Recipients of care | ||
Awareness campaign | Digital media and marketing campaigns to increase awareness about the availability of reproductive health services and provide information and resources on reproductive health topics | |
Stakeholder engagement | Engagement in multi-stakeholder partnerships with public and private entities for effective implementation | |
Developing and distributing informational materials (Information education and communication (IEC) materials on PPFP, including leaflets and a video that played in the waiting room) Counseling sessions with postpartum women and group meetings with mothers-in-law, postpartum women, and men Fictional stories presented in leaflet and oral form within home visits and group discussion sessions Involving women in the promotions to improve understanding the importance of PPFP & postpartum intrauterine device (PPIUD) Reminder cards are given to women at each follow-up visit to remind them of the next visits. Cards would also contain a message to stress the health benefits of follow-up visits Counseling with more time allocated to specific topics Prenatal one to one counselling on postpartum contraception | ||
Policy and regulation | ||
Policy change | Overall public and private insurance coverage for contraception, such as LARC coverage and reimbursement and multiple months of dispensing; expanded ability of providers to prescribe and dispense contraception; ensured payment parity for providers; over-the-counter contraception without a prescription |
Effect of strategies for scaling up post pregnancy family planning
Main theme
|
Outcomes
|
Number of studies
|
Summarized review finding
|
GRADE-CERQual Assessment
|
---|---|---|---|---|
Point of care | Adoption, Coverage | 8 | Point of care strategies increase the use of post pregnancy contraceptive methods | Moderate confidence |
Financing | Adoption, Coverage | 2 | Financing strategies increase the use of post pregnancy contraceptive methods | Low confidence |
Human resources | Adoption, Coverage | 1 | Human resource strategies increase the use of post pregnancy contraceptive methods | Low confidence |
Main theme
|
Outcomes
|
Number of studies
|
Summarized review finding
|
GRADE-CERQual Assessment
|
---|---|---|---|---|
Healthcare infrastructure PLUS Policy and regulation PLUS Financing PLUS Human resource PLUS point of care | Adoption, Coverage | 7 | Healthcare infrastructure, Policy and regulation, Financing, Human resource, point of care: may increase the use of immediate postpartum long-acting reversible contraception | Moderate confidence |
Human resource PLUS point of care | Adoption, Coverage | 5 | Human resource, point of care: increase the use of post pregnancy contraceptive methods | Moderate confidence |
Healthcare infrastructure PLUS Human resources PLUS point of care | Adoption, Coverage | 4 | Healthcare infrastructure, Human resources, point of care: increase the use of post pregnancy contraceptive methods (Post abortion, Immediate PPIUD) | Moderate confidence |
Financing plus point of care | Adoption, Coverage | 1 | Financing plus point of care: may increase the use of post pregnancy contraceptive methods | Very Low confidence |
Policy and regulation PLUS Human resource PLUS point of care | Adoption, Coverage | 1 | Policy and regulation, Human resource, point of care: may increase the use of post pregnancy contraceptive methods | Very Low confidence |
Factors influencing scaling up of PPFP
Category
|
Factor
|
Reference
|
---|---|---|
People | Family involvement, accompaniment, and tradition | [38] |
Fear of judgment | [38] | |
Lack of interest | [45] | |
Knowledge regarding lactational amenorrhea and suitable contraceptive methods | [50] | |
Loyalty toward the religious doctrines in religious based hospitals in post abortion contraceptive counselling instead of applying national family planning guidelines | [36] | |
Male partner: | ||
Integration of men | [45] | |
Partner sharing in decision making | [47] | |
Myths and misinformation, Misconceptions about modern contraception | ||
Perceived quality of facility services | [38] | |
Factors related to postnatal care | ||
Prioritization by women of scheduled postpartum visits | [50] | |
Opportunities to encourage continuity of care, especially for PPFP | [38] | |
A contraception-dedicated six-week postpartum | [50] | |
Religious and traditional norms: | ||
Sexual abstinence for up to three to six months postpartum | [50] | |
Social pressure to closely space pregnancies | [38] | |
Traditional views on the consequences borne by closely spaced children and their mothers | [50] | |
Cultural and religious objections to family planning and lingering misconceptions | [48] | |
Service delivery | Access to facility services | [38] |
Factors related to counselling | ||
dedicated PPFP counseling materials | [50] | |
privacy within the health facility | [53] | |
time necessary to fully counsel women on all available and appropriate methods | [45] | |
Time required for One-to-one counseling | [55] | |
Limited availability of clinic days and scheduled visits dedicated to contraception | [50] | |
Extent of antenatal care (ANC) coverage | [48] | |
Medical products | Available equipment and supplies | [48] |
Availability of readily accessible methods and plans for stock-outs in health facilities | [50] | |
Financing | Challenges with Engaging private insurance companies | [27] |
Financial risk intolerance | [30] | |
LARC device cost/reimbursement | ||
Administrative infrastructure and financial flexibility | [30] | |
Out-of-pocket payment of contraceptives | [50] | |
Cost/Fund to buy or to purchase the instruments or LARC by health facilities | ||
Health information systems | Challenges in acquiring data use agreements between public health and medicaid | [27] |
Difficulty analyzing raw medicaid claims data | [27] | |
Long duration for resolving technical billing issues | [27] | |
Technical complexity of information technology system for claims processing | [27] | |
Pre-existing strong collaborations across agencies with respect to data | [27] | |
Leadership and Governance | Leadership stability | [30] |
Support from high-level leadership | [27] | |
Clinical champions | ||
Co-location of health department and financial agency and/or strong pre-existing working relationship between agencies | [27] | |
Connecting with rural birthing facilities | [27] | |
Translating what works across various contexts | [27] | |
Effect of political sensitivity around contraception on team’s ability to work on increasing LARC access | [27] | |
Political commitment to post abortion and postpartum FP programs | ||
Process changes for coders and pharmacy staff members | [27] | |
Health workforce | Ability to work with other teams in the learning community and share resources | [27] |
Continued support and guidance from trainers in informal follow-up visits and phone calls | [48] | |
Judgmental treatment from health providers | [38] | |
Inability to perform the procedure or Lack of knowledge/skills about all contraceptive methods | ||
Lack of live clinical insertions | [45] | |
Lack of supervision throughout practice insertion sessions | [45] | |
Pre-existing personal connections of team members | [27] | |
Shared culture and language facilitated the training, reduced miscommunication between teams, and built engagement and mutual support | [48] | |
Spill over: hearing about process from others in the learning community | [27] | |
Team members long and continuous involvement with immediate postpartum LARC initiative | [27] | |
Turnover in team members | [27] | |
Uncertainty about goal for immediate postpartum contraceptive use | [27] |