Clinical training and trainee follow-up systems to improve access to long-acting reversible contraception in conflict settings
Authors: Ribka Amsalu, Maria Tsolka, Jean Bosco Muyisa, Felipe Rojas Lopez, Amy Cannon
Journal: The Lancet Global Health (2017)

BackgroundLong-acting contraceptive methods (LARC)—intra-uterine device (IUDs) and contraceptive implants—are highly effective in the prevention of unintended pregnancy. However, access to LARC is limited, especially in developing countries where access is dependent on availability of medical doctors and midwives. Pre-service training for nurses does not usually include counselling about LARC methods, or insertion and removal of IUDs and implants. We aimed to improve access and availability of LARC in North Kivu, Democratic Republic of the Congo, by implementing a clinical training programme for nurses who had clinical experience in the public health system. The programme was implemented in collaboration with the Ministry of Health. The purpose of the programme was to increase access to all modern contraceptive methods, including LARC, at health centre level and to improve nurses' clinical skills in family planning counselling and insertion and removal of IUDs and implants.MethodsFrom July, 2011, we delivered contraceptive commodities, installed data collection systems, and obtained approval to train nurses and midwives (mid-level health-care providers). Seventy-one nurses and midwives received competency-based clinical training for 3 weeks at a district hospital in Goma. The training curricula included counselling, practicum on anatomical models, and, finally, service provision to clients under observation and supervision by facilitators. Facilitators were mostly Congolese medical doctors who had received the 3-week clinical training and a certification on how to facilitate clinical trainings (trainers of training) at a centre managed by Marie Stopes Society in Kenya. Each health-care provider received trainee follow up, mentoring, and frequent supportive supervision by clinical supervisors throughout the implementation period. The programme was monitored via a monthly review of client data, supportive supervision reports, client exit interviews, and provider log books.FindingsFrom January, 2012, to December, 2013, the number of clients seeking modern contraceptive methods increased by 54% (from 8301 in 2012 to 12 830 in 2013). The percent change of clients seeking IUDs was 127% (from 440 to 999) and the number of clients who had contraceptive implants increased by 46% (from 5124 to 7499). Client exit interviews of 415 women at 23 clinics showed a satisfaction rate of 80–90%.InterpretationCompetency-based clinical training is feasible in a conflict setting such as the Democratic Republic of the Congo, and can be effective in improving provider skills and availability and use of LARC. Attention to the partnership with the Ministry of Health and establishment of clinical training centres at the start of the programme were crucial for success.FundingDonation from an anonymous private foundation that does not have commercial interests in the study topic. The donor did not participate in the design of the study, data analysis, or the interpretation of findings.