Promoting long-acting reversible contraception among post-abortion clients with a provider-comparison intervention: a cluster randomized controlled trial in Nepal

Abstract

Background: Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients.

Methods: The intervention used prominently displayed monthly posters comparing the health clinic's previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention's impact on LARC uptake while controlling for client- and clinic-level characteristics.

Results: The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers' counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved.

Conclusion: We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

Keywords: Behavioral science; Long-acting reversible contraception (LARC); Peer-comparison; Post-abortion care; Provider behavior change.

Fig. 1

Intervention Poster in Use at an SPN clinic (Low Performing Center): 2016. Translation - Top section: Your Centre’s PAFP LARC Uptake Performance (%) for August. Middle section: Center 1 (names redacted for anonymity)- 29%, Center 2–26%, Center 3–20%, Your Center − 15%. Bottom section: PAFP Uptake at your Center is LOWER than that of other centers like yours. What can you do to improve your PAFP uptake for next month? Remember: It’s a woman’s right to choose whether to use family planning

Fig. 2

Updated Intervention Poster (example of High Performing Center): 2017. Translation - Top section: Your LARC Uptake for Safe Abortion (SA) in the month of July. Middle section: Your Center (names redacted for anonymity)- 45%, Center 1–34%, Center 2–18%, Center 3–16%. Bottom section: (Navy and green) Your LARC uptake for SA is HIGH compared to other similar centers. (Grey) Please continue to be an example to other centers. (Grey and blue) Please remember: To use or not use contraception is the right of the woman

Table 1

Stepped-wedge Experimental Schedule

Fig. 3

Long-term LARC uptake rate. Note Fig. 3 shows aggregate LARC uptake among post-abortion clients for study participating clinics during the pre-experimental period (January to May 2016), experimental period (July 2016 to January 2017), and post-experimental period (February 2017 to December 2017)