LARC provision and uptake, especially for the IUD, is low at rural health centers despite the availability of LARC methods and LARC insertion trainings for rural providers in some areas(24). Needs assessment findings emphasized the need for: 1) LARC equipment, 2) LARC insertion trainings for nurses with opportunities to practice these skills regularly, 3) LARC promotions in the clinic and by CHW involving male partners when possible, 4) Family planning integration with other services including HIV, and 5) funding partners.
Equipment. Several health centers needed functional gynecological exam tables and lamps for viewing the cervix, designated for family planning department use only, in order to scale-up IUD provision. On-site access to adequately sized and functional sterilization devices, along with a sufficient power supply and backup power to run them, are essential components.
LARC training. The proportion of nurses in each health center who actively insert LARC methods was low (17% IUD, 45% implant). All nurses should be trained/re-trained in family planning service provision, including IUD and implant insertion and removal. Nurses often informally train each other on implant insertion and quickly become confident with this relatively straightforward procedure. In contrast, IUD insertions require more technical skill and confidence is quickly lost if these skills are not maintained through regular practice. These findings are similar to a 2014 rapid assessment of Zambian family planning clinics which found that, after LARC training, the proportion of nurses who were inserting Jadelle was much higher (96%) than IUDs (30%)(25). A study in South Africa and Zimbabwe found that provider misconceptions about the IUD persisted after training (for example, <5% reported that IUDs were appropriate for women with or at high risk for HIV), but that clinicians and nurses, especially in rural area, were eager to be trained/retrained on the IUD(26).
CHW promotions. Improving LARC – especially IUD – services must be accompanied by increases in demand so that providers are able to practice and maintain their skills. Rural health centers have robust networks of CHW who are able to reach those in the community who may not be attending the health center, including OCP and Depo-Provera users(27). We found that no CHW were formally trained to promote LARC methods and only three health centers reported that CHW were doing so. The effectiveness of CHW in promoting (C)FPC and LARC services has been demonstrated in Kigali(22, 23) as well as across 14 countries in a Marie Stopes International implementation of LARC services(28), and is likely to be transferrable to the rural context in Rwanda.
All associated CHW should be trained in promotion of (C)FPC and LARC to dispel myths which are common in rural areas(8, 9). As CHW are often trusted individuals who are close to the community and hold some influence(29), they are well-positioned to lead these promotional efforts. Additionally, as CHW visit homes they are able to increase male involvement in family planning decisions, a critical component of successful LARC promotion in other studies(8, 14). Focus groups conducted in Rwandan CHWs indicated that challenges to delivery of health care services included overwhelming workload, insufficient trainings, and poor supervision. CHW are not civil servants and their remuneration depends on a co-operative system with various sources of revenue. CHW reported that while money was an important incentive, they were also motivated by community value and respect(29).
In-clinic promotions. (C)FPC and LARC promotion can take place in the health center as well as through CHW in the community; opportunities for in-clinic promotions exist within infant vaccination, HIV testing, outpatient and antiretroviral treatment services. Rwanda is the only country in Africa to have offer CVCT as nationwide standard of care at the first antenatal visit (30). Health centers may be able to leverage the presence of male partners at CVCT services by offering add-on (C)FPC in the same session. Studies in Rwanda and Zambia have shown that knowledge of LARC methods is poor among men(31), and that fertility-goal based family planning provided to couples when access to LARC is ensured increases uptake of both IUDs and implants(22, 32, 33). More recently, post-partum IUD (PPIUD) insertion has been feasible and acceptable in Kigali(34, 35). Promotions for PPIUD would ideally take place prior to labor and involve male partners. PPIUD was not addressed during this needs assessment but if services were made available, this LARC option could also be discussed during (C)FPC at the first antenatal visit. Half of participating health centers had access to a functional TV and a media player of some kind. This can be leveraged to develop and deliver recorded education about LARC suitable for illiterate clients, as well as visual illustrations of LARC insertions(36).
HIV/family planning integration. Integrating family planning and HIV services has been a major goal of international stakeholders(37, 38) to reduce unintended pregnancy and perinatal HIV transmission(39). Integrating family planning (including LARC) and HIV services is a health policy priority in Rwanda(40, 41). However, current policies have not yet resulted in integration nor nationwide promotion of LARC methods(40, 41). Data from a recent qualitative study of interviews with key Rwandan policymakers and stakeholders indicated that the best way to integrate HIV and family planning services was through development of integrated training materials, data collection tools, and advocacy and policy guidance(42).
Partners and funders. The health centers had limited financial support for family planning and few non-governmental partnerships. Further advocacy with stakeholders is critical.
Maintaining adequate stocks of LARC methods and related insertion supplies is necessary for increased LARC provision but is not sufficient without the presence of functional sterilization equipment and a reliable power supply. The choice of disposable versus non-disposable implant insertion kits should be matched to the health center’s capacity for reliable and timely equipment sterilization. Disposable insertion kits are convenient but comparatively expensive and wasteful when compared with reusable insertion equipment. Many health centers already have stocks of reusable specula and scalpels that can be used with the proper sterilization equipment. Strategies to enhance nurses’ skill at inserting IUDs are needed including overcoming misconceptions that may persist after training as well as ongoing supervision and feedback regarding IUD insertion. Additional training of rural CHW will be required, and a key barrier is the high existing workload of CHW. Use of educational tapes/DVDs in health center waiting rooms may be an effective way to promote family planning services including LARC methods. Funding partnerships to support the purchase of dedicated, functional, durable family planning equipment; the installation of reliable backup power sources adequate to provide electricity for sterilization machines; the development and implementation of skills-based LARC insertion trainings and promotional materials for health centers; and training and compensation for CHW LARC promoters are urgently needed.
Future research will need to identify funding partnerships to support resource capacity for LARC provision (including equipment, provider trainings and follow-up supervision, and community awareness). Studies are needed to adapt existing materials developed for (C)FPC training and promotion in Kigali for the rural context.
This study is a comprehensive rural government health center needs assessment related to LARC services in Rwanda. Limitations include possible social desirability bias leading respondents to understate their need. Alternately, a desire to maximize the likelihood of future support could have had led to an overstatement of need. With these possible sources of bias in mind, health center staff comments regarding capacity for LARC insertion were triangulated with monthly LARC provision data from health center logbooks to validate qualitative data on capacity gaps. Similarly, responses about available materials, equipment, and infrastructure were paired with structured observations in each facility to confirm staff accounts whenever possible. These data were mutually validating.