Effectiveness of task-sharing in providing comprehensive long-acting reversible contraceptives through Level IV health extension workers in rural Ethiopia


 Background: Modern family planning uptake in Ethiopia, primarily short-acting injectables, has increased after the engagement of community health extension workers (HEWs). The aim of this study was to investigate the effectiveness of using Level IV health extension workers to deliver long-acting reversible contraceptives (LARCs) at the community level. Methods: A retrospective cohort study design was used to recruit 710 women who received LARC insertion services at pilot health posts within eight months before survey time. The interviewer administered a data collection tool to collect the required data through a house-to-house survey. The questionnaire had sections covering demographic and socioeconomic characteristics, reproductive history, use of family planning methods, knowledge about LARC methods (i.e., IUCD and Implanon), and service satisfaction. Descriptive statistics were used to analyze data. Chi-square test was used to identify the determinants of LARC use. Results: Out of 702 LARC users included in the study, 92.7% received services from Level IV HEWs. The median age of clients was 30 years (IQR: 25–35), 92.7% were married, and 22.6% were new family planning users (75% Implanon users and 19.4% Jaddelle users). Of the aggregated variables, 67.38% had good knowledge of LARC, 92.28% had positive attitudes in availing services at health posts, and 92.76% was the satisfaction score of clients. New users tended to be young, Muslim, less likely to want more children, and more likely to decide on contraception on their own. At eight months post insertion, LARC use was effective in preventing pregnancy (99.7%) with low removal (n = 36, 5.1%) and expulsion rates (n = 1, 0.1%). No infection was reported. The major reasons for removal were side effects and the desire to have children. Client knowledge, attitude, and satisfaction were found to be high. In conclusion, trained Level IV HEWs provided LARCs safely and effectively at the health post level as an alternative service delivery outlet.


Introduction
With a population that just crossed the 100 million mark, a total fertility rate of 4.6, and a contraceptive prevalence rate of 36%, Ethiopia is the second most populous country in Africa. The population is expected to reach 138 million in the coming 10 years [1].
Although there have been remarkable improvements in the uptake of family planning services in Ethiopia, the urban-rural disparity and the skewed method mix call for more innovative approaches [2]. In a facility survey done by Performance Monitoring and Accountability 2020 (PMA2020), 84% of health posts provide three family planning methods, while 88% of health centers and 95% of hospitals provide ve or more [3].
In the past 15 years, the most preferred family planning method in Ethiopia was the injectable (Depo-Provera), and its uptake has increased by more than tenfold in the same period [2]. A review of the four rounds of PMA2020 showed that instances of the injectable family planning method remained high at 64.5% although its share has declined from 74.1% in 2011. During the same period, the percentage of Implanon use increased from 16.3-24.2%. Of all the family planning methods, the line share of intrauterine contraceptive devices (IUCDs) remained extremely low at 2% [3][4][5][6].
Utilization of long-acting reversible contraceptives (LARCs) was increasing at an extremely low rate until 2016 when it reached 7.9% primarily because of the involvement of health extension workers (HEWs) in this service, who administered one million implants [7]. Meanwhile, data from the Ethiopian Demographic Health Survey (EDHS) in 2016 showed that injectable family planning methods account for around 64%, used by married women, and permanent methods remain at close-to-zero status [2]. The trends in the use of modern family planning methods as evidenced by the EDHS report from 2000 to 2016 increased from 6% in 2000 to 36% in 2016, and injectable contraception accounts for two-thirds of the increase followed by implants only at around one-third [8,9].
The government of Ethiopia has implemented family planning (FP) as a strategy to improve maternal and child health and bring about overall development [10]. Accordingly, programs are being implemented to increase access to and demand for quality FP services through the expansion of the contraceptive method emphasizing long-acting methods at lower-level service delivery points [11]. As part of this strategy, the Federal Ministry of Health (FMOH) is implementing Implanon and IUCD scale-up initiatives in the country [12]. The aim is to expand voluntary access to long-acting FP methods at the lowest level of health service post; therefore, increasing the method choices available to remote and rural communities is important to improve maternal and child health.
Using the Health Extension Program (HEP) as a platform, the government began expanding FP options in 2009 with subdermal insertions of Implanon by HEWs at health posts [8]. It has now started an initiative to bring LARCs closer to remote and rural communities by training Level IV HEWs (L4HEWs) on the insertion and removal of IUCDs and performing implants at the health post level [13]. This is an additional task-shifting to HEWs, which is in line with the World Health Organization's (WHO) task-shifting recommendations and guidelines for auxiliary nurses for IUCD insertion and removal [14]. In the WHO's task-shifting recommendations, while allowing consideration of task-shifting for IUCD insertion, it requires rigorous research to supplement weak existing evidence [14]. Thus, the FMOH introduced the task-shifting program as a pilot study in 66 health posts. The primary aim of the pilot program was to effectively and safely examine the service provision of LARCs, speci cally Implanon and IUCDs, at health posts by L4HEWs as task-sharing. Therefore, the study was done to evaluate the pilot program by examining the user-level effectiveness of the LARC service provision by L4HEWs at health posts.

Study area and period
Administratively, Ethiopia is divided into nine federal regional states and two chartered cities. There are ve agrarian, two pastoralists, two emerging regions, and two chartered cities [15]. Each regional state is divided into zones, and each zone is divided into districts or Woreda. The lowest government budgetary and administrative structure is the Woreda although each Woreda is divided into several administrative structures called Kebele.
Access to adequate healthcare is particularly challenging in all nonurban settings. The healthcare delivery system in Ethiopia is organized in a three-tier system. The primary level in rural settings includes health posts linked with health centers and a primary hospital. In the urban setting, the health center is the primary entry point into the health system. As more than 80% of the Ethiopian population resides in the rural part of the country, health posts are the primary entry points of this population, and they are located at the geographic center of each Kebele. One health post is expected to serve a total population of 5,000, although this may vary based on the settings [16].
Health posts are expected to provide primarily preventive services focused on maternal and child health services, hygiene and sanitation, and communicable disease prevention [16]. All health posts have at least two HEWs who are trained for one, two, or three years and certi ed as Level I, Level II, or Level III, respectively. L4HEWs, introduced in 2016, are trained for one more year after graduating as Level III HEWs and serving for at least two years.
The provision of LARCs was initiated in selected health posts with at least one L4HEW in four agrarian regions at the end of 2016. These regions are Tigrai, Amhara, Southern Nations Nationalities and Peoples Region (SNNPR), and Oromia. During the survey, there were 66 health posts (20 in Tigrai,19 in SNNPR,14 in Amhara, and 13 in Oromia) that started providing LARCs. Out of these, 52 health posts were included in this study. Data were collected from April 12 to May 5, 2017.
Study design, population, and sample size This study was done using a retrospective cohort study design. Sample size was determined using discontinuation as a binary outcome with an assumption of 16% discontinuation of LARCs in one year, 3% margin of error, 95% con dence interval, 2% design effect, and 10% non-response. Accordingly, the sample size of 710 women study subjects recruited from each health post was determined using the "probability proportional to size" approach using the reported number of women who received LARCs as a measure of size. All women who received LARC insertion services at the pilot health post within eight months before the survey were eligible for the study. The list of users extracted from the registers of the target health post was used as a sampling frame.

Data collection instrument
Taking the EDHS 2016 questionnaire as a starting point [17], the instrument was developed with potential outcomes, user satisfaction, and knowledge about family planning methods and their side effects. This questionnaire has seven sections covering demographic and socioeconomic characteristics, reproductive history, use of family planning methods, knowledge about LARC methods (i.e., IUCD and implants), and service satisfaction. After inversely coding negatively assessed questions, ve aggregated variables were generated from the collected data, which includes wealth index and knowledge about IUCDs (six items) and implants (seven items), with "yes" or "no" responses in which those who scored above the median were considered as having good knowledge; clients' satisfaction with the service, assessed by seven items on a Likert scale in which those who scored above the median were considered as satis ed with the service provision; and attitudes about LARCs, measured by six statements on a ve-point Likert scale in which those who scored above the median were considered as having positive attitudes while those scored less than the median were considered as having negative attitudes toward the service. Furthermore, for the reliability test, a Cronbach's alpha coe cient of 0.70 and above was accepted.
Data collection and quality assurance A total of sixteen nurses and four supervisors (four teams of ve, one team per region for the four regions, each team with four data collectors and one supervisor) were used for eld data collection. All were trained for three days on the data collection tool. Following a line-by-line review of the tool, mock interviews with each other and a one-day eld pretesting were prepared as part of the training. The tool was re ned following its pretest, and feedback was also given to the data collectors on issues that required further clari cations. Completeness of the questionnaires, timing, and logical errors were followed by the supervisors. Missing data were completed immediately by revisiting the household. Double data entry was done on 10% of the completed data to check for entry-related errors.

Data management and statistical analysis
The data were coded and entered into a template using Microsoft O ce Access 2013 for Windows. The cleaned dataset was then exported to STATA version 14 for analysis. The electronic data was then examined for incompleteness, inconsistency, and unexpected responses by running frequencies and cross-tabulations of selected variables. Descriptive analysis of each variable was used for preliminary examination of ndings. Frequency and percentage were used to describe various characteristics of the study participants. Demographics and reproductive history were taken as independent variables while access to modern family planning only at the health posts, decision-making on the use of family planning (self vs. jointly with husband or partner), and LARC users were primary outcome variables. Chisquare was used to assess associations between being a LARC user and different characteristics. Pvalues below 5% were used as statistical signi cance.

Background characteristics
Majority of the respondents were within the age range of 20-34, and only 2.7% were under 20 years old, 92.7% were currently married, 61.0% were literate, 75.0% have literate partners (Table 1).

Risk factors of LARC use
Among the clients, 15.4% received family planning methods different from their original preference. The main reasons for this discrepancy were provider's recommendations (15.2%) and client's revision of preference after being counseled by providers (75.2%). Majority of those who have revised their preferences after receiving counseling were Christians, literates, housewives, those who were using other family planning methods, new family planning users, and those who did not plan their last pregnancy. New LARC users who were given services by L4HEWs tended to be young, lived in urban areas, slightly more Muslim by religion, less likely to want more children, more likely to decide on contraception on their own, and have access to modern family planning that is less dependent on health posts and L4HEWs (Table 2).  months of receiving the service. The four leading reasons for removal of LARC were the desire to have children (13, 36.1%), headache (9, 25%), arm pain (7, 19.4%), and fatigue (4, 11.1%).

Discussion
LARCs administered by HEWs in the current study were effective in preventing pregnancy with low removal and low expulsion, which is comparable with previous studies where the service was provided in health centers [18,19]. Level of discontinuation varied depending on the duration of follow-up, which for IUCD was 19.9% in a 10-year retrospective study in a university hospital in Nigeria [20], while it was 4.5% in a ve-year retrospective study in the same country [21]. For implants, it reached as high as 24% in a retrospective study done in the United States [22] and even higher in Nigeria [19]. The most common reason for discontinuation of use in the current study was the desire to become pregnant, followed by menopause or side effects. When the reason for discontinuation was side effects, the rate of discontinuation was higher in the rst year, and when the reason was the desire to become pregnant, it slightly increased with the length of follow-up [20,21,23]. In our study, side effects accounted for most of the reasons for discontinuation. The maximum length of follow-up in the current study is eight months, and more discontinuation is likely for fertility reasons if the follow-up of the study participants was continued beyond this period.
Contraceptive prevalence has signi cantly improved in Ethiopia in the past decade [2,24]. This change is partly attributed to the work of the health extension program through the delivery of health education, which is likely to have increased contraception awareness and the demand for LARCs [8, [25][26][27]. The nding of the current study is in line with these. The availability of health posts in short distances for the community staffed with HEWs improved access by reducing cost and time for the provision of LARCs and at times were the only outlets to access modern family planning. This is a signi cant nding of tasksharing because more quali ed HEWs may further increase access through direct service delivery instead of just activities to raise awareness.
In the current study, new LARC acceptors were more likely to be empowered to decide on contraception use, and access to modern family planning is less dependent on health posts and L4HEWs. In such areas where there are alternative service providers, it may be cost-effective to engage empowered clients and relocate these resources to areas where alternative outlets are limited [28,29].
Method mix in Ethiopia is improving slowly [2]. Injectable contraception slightly declined from 80% in 2011 to 70% in 2016 [8,24]. Such skewed distribution of method use may be a re ection of availability and readiness of the health sector to provide other options [29]. In this study, from the facility performance report, mixed LARC methods increased by threefold over an eight-month period.
A study that assessed factors affecting LARC use in Nigeria, Ethiopia, and the Democratic Republic of Congo identi ed the lack of equipment, private room, and products as a cause for the limited provision of that option in the studied countries. In Ethiopia, 44% of sites assessed indicated that LARC was available along with other options [30]. When availability was coupled with capacity building to nurse providers, method uptake among new users and method shift improved [31][32][33]. Method shift was well demonstrated in the present study where both capacity building and the availability of equipment and supplies were ensured.
L4HEWs played a role in method choice mostly by giving information during counseling and direct recommendations in a small proportion of cases [34,35]. Signi cantly more clients are empowered to decide on what type of LARC to use on their own or at least to discuss it with their partners. This is the general trend where informed and empowered clients who know about LARCs and would like to space births tend to prefer them [25,36]. Other studies in rural areas have indicated that established gender norms make it impossible for a married woman to make decisions in fertility and family planning methods [37]. It is therefore important to keep addressing these issues whenever they are identi ed as challenges.
Most LARC users were satis ed with the method they were using although they experienced minor side effects. The low level of side effects in general and the extremely low level of severe side effects leading to discontinuation in the current study is in agreement with many previous studies [38 -42]. Side effects are often an important reason to discontinue treatment [43,44], and since patients who experienced them may develop negative attitudes toward these methods, it is important for providers to counsel clients on the major side effects and how they could be handled if they occur.
One of the strengths of this study is it assessed LARC delivery through L4HEWs in a setting where there are few studies or reports that document service delivery by L4HEWs. Its ndings have a clear potential to serve as an evidence base to better implement task-sharing activities in Ethiopia. One of the limitations arises from its design. A retrospective cohort study design is open for recall bias in some of the data, which were collected by interviewing the respondents. Also, only a limited number of relevant variables could be examined compared to what could be done if the data were collected prospectively. However, the cohort nature of the design allows for a discussion of causal associations between exposure and outcome variables.

Conclusion
This study indicated that trained L4HEWs can serve as an alternative service delivery outlet at the health post level. Task-shifting from facility-based to community-based delivery of LARCs may be possible.