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Karen Weidert,1 Koffi B Tekou,2 Ndola Prata1 1Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, Berkeley, CA, USA; 2Centre d’Evaluation et de Suivi du Groupe de Recherche et d’Appui en Santé et Education de la Population, Lomé, TogoCorrespondence: Ndola PrataSchool of Public Health, University of California at Berkeley, 6142 Berkeley Way West, Berkeley, CA 94720-6390, USATel +1510643-4284Email ndola@berkeley.eduContext: Provision of high-quality contraceptive counseling and services is essential to ensure family planning (FP) programs are rights-based and voluntary. Togo’s modern contraceptive use has steadily increased with almost a quarter of the method mix attributed to long-acting reversible contraceptives (LARC). The purpose of this study is to assess the quality of LARC provision in Togo.Methods: Data for this study were collected in 2016 as part of a larger research study conducted in Lomé, Togo to assess the effectiveness of the ongoing FP service delivery model. Quality of FP service was assessed in terms of program capacity and program performance. Program capacity was measured with five individual variables and program performance was measured with the Method Information Index (MII). Descriptive statistics and mixed effects models were used to assess likelihood of LARC uptake.Results: Of the 669 clients included in the study, 19.4% received a LARC method. Multivariable results show that LARC uptake is significantly associated with supervisory visit at the facility in the last three months (program capacity indicator) (OR 1.44; 95%CI 1.48– 2.39) and is twice as likely for those with a positive MII score, even after controlling for provider and client characteristics (OR 2.1; 95%CI 1.61– 2.51).Conclusion: This study identified supervisory visits and comprehensive contraceptive counseling as the key quality factors positively associated with uptake of LARC. Continued focus on quality of care and provider–client information exchange is necessary to ensure women’s FP needs are met.Keywords: LARC, Togo, method information index, FP services, quality

Elizabeth Pleasants,1 Tekou B Koffi,2 Karen Weidert,1 Sandra I McCoy,1 Ndola Prata1 1School of Public Health, University of California at Berkeley, Berkeley, CA, USA; 2Cabinet De Recherche Et D’évaluation (CERA), Lomé, TogoCorrespondence: Ndola PrataSchool of Public Health, University of California at Berkeley, 2121 Berkeley Way West, #6142, Berkeley, CA 94720, USATel +1 510-642-6915Email Ndola@berkeley.eduBackground: Despite improvements in contraception availability, women face persistent barriers that compromise reproductive autonomy and informed choice. Provider bias is one way in which access to contraception can be restricted within clinical encounters and has been established as common in sub-Saharan Africa. This analysis assessed the prevalence of provider restrictions and the potential impact on women’s method uptake in Lomé, Togo.Methods: This sub-analysis used survey data from provider and client interviews collected to assess the impacts of the Agir pour la Planification Familiale (AgirPF) program in Togo. The relationships between provider restrictiveness and women’s receipt of their desired method of contraception were modelled using mixed effects logistic regressions looking at all women and among subgroups hypothesized to be at potentially higher risk of bias.Results: Around 84% of providers reported a restriction in contraceptive provision for the five contraceptive methods explored (pill, male condom, injectable, IUD, and implant). Around 53% of providers reported restricting at least four of the five methods based on age, parity, partner consent, or marital status. Among all women, there were no significant associations between provider restrictiveness and women’s receipt of desired method, including among those who desired long-acting methods. In adjusted modeling, marital status was a covariate significantly associated with desired method, with married women more likely to receive their desired method than unmarried women (aOR 2.73, 95% CI 1.45–5.13).Conclusion: Provider reports of high levels of restrictions in this population are concerning and should be further explored, especially its effects on unmarried women. However, restrictions reported by providers in this study did not appear to statistically significantly influence contraceptive method received.Keywords: provider bias, provider restrictions, contraception, Togo

Natalie Morris, Ndola Prata Bixby Center for Population, Health and Sustainability, School of Public Health, University of California, Berkeley, CA, USA Background: Women in sub-Saharan Africa often use abortion as a method of limiting their fertility and spacing births. However, it is not well understood whether having an abortion influences contraceptive behavior. The goal of this study was to examine associations between abortion history and use of a modern contraceptive method among women in Luanda, Angola. Materials and methods: We analyzed data on 1,176 women aged 15–49 years from a 2012 cross-sectional study conducted in Luanda, Angola, which aimed to obtain general information on sexual and reproductive health indicators. The outcome and exposure were based on participant reports of past induced abortions and current use of a modern method. We used a modified Poisson regression with robust standard errors to estimate the relative risks of using a modern contraceptive method, given history of induced abortion. Results: Among all respondents, 736 (62.6%) reported using a modern contraceptive method. The clear majority of the respondents (73.21%), regardless of abortion history, were using either no method, a traditional method, or condoms. Long-acting reversible contraceptive use was very low across all respondents (2.73%). The most common family planning method reported by women with a history of abortion was condoms (32.76%). Regression analysis demonstrated that women who had a history of abortion were 1.23 times more likely to use a modern contraceptive method as compared to those who never had an abortion (relative risk: 1.23; 95% CI: 1.10–1.36), after adjusting for potential confounders. Postregression estimations of predicted probabilities demonstrated that women with a history of abortion had an 80% probability of using a modern method (95% CI: 0.76–0.84), while those who never had an abortion had a 60% probability of using a modern method (95% CI: 0.59–0.61). Conclusion: History of induced abortion was associated with use of a modern contraceptive method in our study population. The most common contraceptive used by women with a history of induced abortion was condoms, indicating that despite adoption of a modern method, many women are still at risk for an unintended pregnancy. Further research is needed to understand the causal factors underlying women’s postabortion contraceptive choices. Keywords: Angola, abortion, contraception, reproductive health

Ndola Prata, Karen Weidert Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, Berkeley, CA, USA Background: A myriad of interventions exist to treat postpartum hemorrhage (PPH), ranging from uterotonics and hemostatics to surgical and aortic compression devices. Nonetheless, PPH remains the leading cause of maternal mortality worldwide. The purpose of this article is to review the available evidence on the efficacy of misoprostol for the treatment of primary PPH and discuss implications for health care planning. Data and methods: Using PubMed, Web of Science, and GoogleScholar, we reviewed the literature on randomized controlled trials of interventions to treat PPH with misoprostol and non-randomized field trials with controls. We discuss the current knowledge and implications for health care planning, especially in resource-poor settings. Results: The treatment of PPH with 800 µg of misoprostol is equivalent to 40 IU of intravenous oxytocin in women who have received oxytocin for the prevention of PPH. The same dose might be an option for the treatment of PPH in women who did not receive oxytocin for the prevention of PPH and do not have access to oxytocin for treatment. Adding misoprostol to standard uterotonics has no additional benefits to women being treated for PPH, but the beneficial adjunctive role of misoprostol to conventional uterotonics is important in reducing intra- and postoperative hemorrhage during cesarean section. Conclusion: Misoprostol is an effective uterotonic agent in the treatment of PPH. Clinical guidelines and treatment protocols should be updated to reflect the current knowledge on the efficacy of misoprostol for the treatment of PPH with 800 µg sublingually. Keywords: PPH treatment, uterotonics, low-resource settings, cesarean section, retained placenta

Cassandra Blazer, Ndola Prata Bixby Center for Population, Health, and Sustainability, School of Public Health, University of California, Berkeley, CA, USA Abstract: We reviewed existing evidence of the efficacy of postpartum family planning interventions targeting women in the 12 months postpartum period in low- and middle-income countries. We searched for studies from January 1, 2004 to September 19, 2015, using the US Preventive Services Task Force recommendations to assess evidence quality. Our search resulted in 26 studies: 11 based in sub-Saharan Africa, six in the Middle East and North Africa, and nine in Asia. Twenty of the included studies assessed health facility-based interventions. Three were focused on community interventions, two had community and facility components, and one was a workplace program. Overall quality of the evidence was moderate, including evidence for counseling interventions. Male partner involvement, integration with other service delivery platforms, such as prevention of mother-to-child transmission of HIV and immunization, and innovative product delivery programs may increase knowledge and use during the postpartum period. Community-based and workplace strategies need a much stronger base of evidence to prompt recommendations. Keywords: postpartum period, family planning, birth spacing, interventions, systematic review, contraception, less developed countries

Ndola Prata,1 Suzanne Bell,1 Karen Weidert,1 Benjamin Nieto-Andrade,2 Adelaide Carvalho,3 Isilda Neves3 1Bixby Center for Population, Health and Sustainability, School of Public Health, University of California at Berkeley, Berkeley, CA, USA; 2Population Services International Angola, 3National Directorate of Public Health, Ministry of Health, Luanda, Angola Background: The objective of this study is to identify factors associated with current modern contraceptive use among Angolan women. By differentiating according to age groups (15–24 and 25–49 years), this study aimed to help family planning program planners better tailor interventions to improve utilization of modern contraception.Methods: A household survey was used to collect data from 1,545 women of reproductive age living in Luanda Province, Angola. Data on sociodemographic characteristics, reproductive behavior and intentions, contraceptive knowledge and use, and attitudes and beliefs regarding contraception and abortion were collected. The analyses were stratified based on age: 15–24 years (youth) and 25–49 years (adult). Multivariate logistic regression models were built for each age group, adding different subsets of variables in groups to see how relationships changed across the models.Results: Common factors associated with modern contraceptive use among all ages include education level, perceived contraceptive accessibility, contraceptive knowledge, communication with partner about family planning in last year, and self-efficacy. Exposure to family planning information in the media in the last few months, perceived partner approval of family planning, and marital status were all positively associated with current modern contraceptive use among women aged 15–24 years. Meanwhile, receiving information about family planning from a pharmacy in the last year was uniquely associated with current modern contraceptive use among women aged 25–49 years.Conclusion: Young women in Luanda, Angola seem to have a unique set of factors affecting their contraceptive use. These findings highlight the need for family planning programs to cater services and messages toward specific age groups. Keywords: contraceptive uptake, contraceptive access, contraceptive self-efficacy, partner communication

Ndola Prata, Suzanne Bell, Karen Weidert Bixby Center for Population, Health and Sustainability, School of Public Health, University of California (Berkeley), Berkeley, CA, USA Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death in low-income countries and is the primary cause of approximately one-quarter of global maternal deaths. The purpose of this paper is to provide a review of PPH prevention interventions, with a particular focus on misoprostol, and the challenges and opportunities that preventing PPH in low-resource settings presents. Methods: Using PubMed, we conducted a review of the literature on the randomized controlled trials of interventions to prevent PPH. We then searched PubMed and Google Scholar for nonrandomized field trials of interventions to prevent PPH. We limited our review to interventions that are discussed in the current World Health Organization (WHO) recommendations for PPH prevention and present evidence regarding the use of these interventions. We focused our review on nondrug PPH prevention interventions compared with no intervention and uterotonics versus placebo; this review does not decipher the relative effectiveness of uterotonic drugs. We describe challenges to and opportunities for scaling up PPH prevention interventions. Results: Active management of the third stage of labor is considered the “gold standard” strategy for reducing the incidence of PPH. It combines nondrug interventions (controlled cord traction and cord clamping) with the administration of an uterotonic drug, the preferred uterotonic being oxytocin. Unfortunately, oxytocin has limited application in resource-poor countries, due to its heat instability and required administration by a skilled provider. New heat-stable drugs and drug formulations are currently in development that may improve the prevention of PPH; however, misoprostol is a viable option for provision at home by a lay health care worker or the woman herself, in the interim. Conclusion: As the main cause of maternal mortality worldwide, PPH prevention interventions need to be prioritized. Increased access to prophylactic uterotonics, regardless of where deliveries occur, should be the primary means of reducing the burden of this complication. Keywords: PPH prevention, uterotonics, AMTSL, misoprostol, oxytocin