Scaling Up Immediate Postpartum Family Planning Services in Rwanda

The initiative aims to provide a wide range of contraceptive methods to women in the immediate postpartum period, in line with the World Health Organization's (WHO) Medical Eligibility Criteria for Contraceptive Use. The PPFP package in Rwanda is comprehensive, beginning in the antenatal period with counseling at facility- and community-based antenatal care (ANC) visits. The package includes strategies for offering family planning (FP) at various points of contact with the woman and her child up to 12 months postpartum. Strong emphasis is placed on the immediate postpartum period, with the goal of reaching as many women as early as possible. The rollout and expansion of PPFP services started in 2016 with building the capacity of healthcare providers at MCSP-supported health facilities, equipping facilities with FP kits, and expanding PPFP coverage to all facilities in the MCSP-supported districts. In Phase I, MCSP introduced PPFP services in four districts (Musanze, Rwamagana, Kamonyi, and Ngoma). At the start of Phase II in 2017, the program expanded support for PPFP to six more districts (Nyabihu, Nyaruguru, Gatsibo, Huye, Nyamagabe, and Nyagatare). A national trainer demonstrates insertion of an intrauterine contraceptive device. A stakeholders' workshop was conducted in December 2016 to share lessons learned from Phase I districts and to plan for expansion to the additional six districts. Participants developed recommendations that guided PPFP implementation in the Phase II MCSP districts and led to improvements in the Phase I districts. The immediate PPFP intervention strategy has three key components: 1) improve counseling during pregnancy, so that a woman's choice can be recorded and verified at delivery; 2) improve providers' skills in providing a wide range of PPFP methods to suit women's individual preferences; and 3) undertake quality improvement efforts through mentorship. Competency-based training updates providers on the latest version of the WHO MEC, which expanded the number of PPFP methods that can be initiated prior to women's discharge from the maternity ward. During 2016-2017, MCSP trained 308 providers on PPFP counseling and 320 providers (including 12 national trainers) on PPFP clinical skills. The integrated strategies of competency-based training for counseling and technical skills, followed by mentorship and quality improvement activities, improved the providers' knowledge and skills. In turn, there has been a rise in rates of PPFP counseling and immediate PPFP uptake in MCSP-supported facilities where providers were trained to offer a full range of PPFP methods. Provision of PPFP counseling to pregnant women in the facilities across MCSP-supported districts increased from 78% in October-December 2016 to 93% by the same quarter of 2017. Before the intervention, PPFP uptake prior to discharge was not routinely measured. Since implementation began in January 2016, there has been a marked increase in PPFP uptake before discharge, from less than 1% at the start of the implementation period to 45% by October-December 2017. Among women discharged with an FP method, a rising proportion are selecting long-acting and permanent methods. The most popular methods used are implants, followed by progesterone-only pills. To increase demand for PPFP, information on the benefits of healthy timing and spacing of pregnancy should be shared with communities. Actions must be taken at the household, community, and facility levels to maximize the likelihood that couples are aware of all their FP options.