In 2017-2018, the study team worked closely with the Rwanda Ministry of Health (MOH) to
develop and pilot test a theory-based, multi-level intervention targeting postpartum
family planning (PPFP) supply and demand in 4 government health facilities in Kigali, the
capital. This innovative PPFP intervention was informed by clients, clinic providers,
champions, and Community Health Workers. Long-acting reversible contraceptives (LARC),
the intrauterine device (PPIUD) and implant, are fundamental to PPFP programs. LARCs are
highly effective and are the only reversible methods that may be safely used in early
postpartum period by breastfeeding women. During the pilot, LARC uptake among postpartum
women increased significantly (172% for PP implant, 2,687% for PPIUD), PPFP feasibility
and acceptability were high among providers and clients, and side-effects were rare.
The study team now proposes to use an implementation science framework to evaluate the
effectiveness of different PPFP demand creation strategies and test the hypothesis that
our PPFP intervention is adaptable to large-scale implementation, cost-effective, and
sustainable. In a Type 2 effectiveness-implementation hybrid study, we will evaluate
facility organizational readiness prior to implementing the PPFP intervention in a clinic
randomized trial in 10 high-volume health facilities in Kigali, Rwanda (Aim 1).
Adaptability and sustainability within government facilities is a critical aspect of the
proposal, and the MOH and other local stakeholders will be engaged from the outset. It is
expected that this project will deliver PPFP counseling to over 21,000 women/couples
during the project period. They will then evaluate the PPFP intervention effectiveness
and implementation processes using RE-AIM (Aim 2). The team hypothesizes that the PPFP
intervention will significantly increase the number of stakeholders engaged, PPFP
providers and promoters, couples/clients receiving information about PPFP (reach), and
LARC uptake (effectiveness) comparing intervention versus standard of care. It is
expected that PPFP client satisfaction will be high and side-effects will be rare. The
independent effectiveness of each demand creation strategy on LARC uptake will be
estimated. Assessment of measures of PPFP intervention adoption, implementation, and
maintenance at the patient-, provider- and stakeholder-level to assess PPFP intervention
sustainability will be completed by the study team. Finally, this project will evaluate
PPFP intervention cost-effectiveness and develop a national costed implementation plan to
guide Rwandan MOH decision-making for nationwide roll-out of PPFP services (Aim 3). This
trial hypothesizes that the PPFP intervention will be cost-saving relative to standard of
care.
This intervention represents an important contribution to the Rwanda Family Planning 2020
goals and the MOH are enthusiastic to see our successful pilot efforts expanded to a
larger number of facilities for greater and sustained impact. The new PPFP implementation
model is designed to be replicable and expandable to other countries in the region which
similarly have high unmet need for PPFP.