This study examines the impact on family planning referral and follow-up of offering “Contraception Post Obstetric Event” (APEO-Anticoncepción Post Evento Obstétrico) combined with higher quality family planning services (a strengthened referral system and individual follow-up) to women aged 15-19 years or >35 years in the intervention area of Masaya, comparing the results with the control area of Rivas. Women in these age groups have an elevated risk in terms of their own morbidity and mortality as well as that of their newborn infants. However, In Nicaragua, women aged 15-19 years old or >35 years old continue to exhibit lower demand for family planning methods, especially those in rural areas and lower economic groups (ENDESA 2006/07). To examine the impact of the enhanced referral system and individual follow-up in Masaya compared to Rivas, this research study sought to 1) measure contraceptive use in women aged 15-19 years or >35 years in Masaya and Rivas who initially did not choose any method of contraception post-partum; 2) determine if higher quality of family planning services in Masaya increased the probability a women in these high-risk age cohorts would visit a health facility for contraceptives post-partum compared to Rivas, and 3) determine if higher quality of family planning services in Masaya was associated with a decreased inter-gestational period and/or a decrease in the number of high-risk pregnancies.
The results of this study were unexpected. Fewer women used their family planning referral for a follow up visit to their local health facility for contraceptives in the intervention area (Masaya) compared to the control area (Rivas). Interestingly, more women in Masaya reported visiting a health facility on their own without their referral than in Rivas. However, the overall contraceptive use rate in Rivas remained higher, even after including the women who returned on their own to procure contraceptives and were still using these contraceptives.
The results of the intervention point to two interesting conclusions. First, while the number of women that used their official family planning referral to return to their local health facility was well recorded, the number of women that returned without their official family planning referral and/or visited a pharmacy was not well recorded. The type and quality of family planning service received by women that returned without their official family planning referral and/or visited a pharmacy is unknown. These women may have not received the follow up and/or additional advice on the importance of contraceptive use and adherence. Secondly, while home visits to promote the use of contraceptives may have been made to women who did not visit a health facility following their obstetric event, these visits may not have been as systematic as initially planned.
The results of this study show that while reinforcing quality standards is important to achieve certain outcomes, such as family planning referrals and advice about family planning, the reasons why women choose to use contraceptives and their adherence to these contraceptive methods remain complex and involve many different aspects of individual behavior, the community and health system.
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