Implementation and evaluation of a large-scale postpartum family planning program in Rwanda

项目摘要 在2017 - 2018年，我们与卢旺达卫生部（MOH）密切合作，开发并试点测试了一种理论- 5.以产后计划生育供需为目标的多层次干预 首都基加利的政府医疗设施。这种创新的PPFP干预被称为"C4"，因为它 由客户，诊所提供者，冠军和社区卫生工作者告知。长效可逆 避孕药（LARC）、宫内节育器（PPIUD）和植入物是PPFP计划的基础。 LARC非常有效，是唯一可以安全用于产后早期的可逆方法 哺乳期妇女。在我们的试点期间，产后妇女的LARC摄取增加 值得注意的是（PP植入物为172%，PPIUD为2，687%），PPFP的可行性和可接受性较高， 供应商和客户，副作用很少。我们现在建议使用一个实现科学框架 评估不同PPFP需求创造战略的有效性，并检验C4是 适应大规模实施，具有成本效益和可持续性。在第2类有效性中- 实施混合研究，我们将在实施C4之前评估设施组织准备情况， 在卢旺达基加利的12个高容量卫生设施中进行的临床随机试验（目标1）。适应性和 政府设施的可持续性是我们提案的一个重要方面，卫生部和其他地方政府也在努力实现这一目标。 利益攸关方将从一开始就参与。我们预计将为超过21，000人提供C4 PPFP咨询服务 项目期间的妇女/夫妇。然后，我们将评估C4的有效性和实施情况 使用RE-AIM（目标2）进行处理。我们假设C4会显著增加 参与的利益攸关方、PPFP提供者和促进者、获得PPFP信息的夫妇/客户 （覆盖范围）和LARC吸收（有效性），比较干预与标准治疗。我们期待PPFP 客户满意度高，副作用少。每个需求的独立有效性 将估计LARC吸收的创建策略。我们评估C4采用、实施和 在患者、提供者和患者一级进行维护，以评估C4的可持续性。最后我们将 评估C4的成本效益，并制定一项国家成本实施计划，以指导卢旺达卫生部 在全国范围内推广公私伙伴关系筹资和伙伴关系服务的决策（目标3）。我们假设C4将节省成本 相对于护理标准。C4是对卢旺达2020年计划生育的重要贡献 我们的目标和卫生部都很高兴看到我们成功的试点工作扩大到更多的设施 更大和持续的影响。我们的PPFP实施模型设计为可复制和可扩展 该区域其他国家对私营部门筹资和伙伴关系方案的需求同样很高，但没有得到满足。

PROJECT SUMMARY In 2017-2018, we worked closely with the Rwanda Ministry of Health (MOH) to develop and pilot test a theory- based, multi-level intervention targeting postpartum family planning (PPFP) supply and demand in 5 government health facilities in Kigali, the capital. This innovative PPFP intervention is known as `C4' because it is informed by Clients, Clinic providers, Champions, and Community Health Workers. Long-acting reversible contraceptives (LARC), the intrauterine device (PPIUD) and implant, are fundamental to PPFP programs. LARCs are highly effective and are the only reversible methods that may be safely used in early postpartum period by breastfeeding women. During our pilot, LARC uptake among postpartum women increased significantly (172% for PP implant, 2,687% for PPIUD), PPFP feasibility and acceptability were high among providers and clients, and side-effects were rare. We now propose to use an implementation science framework to evaluate the effectiveness of different PPFP demand creation strategies and test the hypothesis that C4 is adaptable to large-scale implementation, cost-effective, and sustainable. In a Type 2 effectiveness- implementation hybrid study, we will evaluate facility organizational readiness prior to implementing C4 in a clinic randomized trial in 12 high-volume health facilities in Kigali, Rwanda (Aim 1). Adaptability and sustainability within government facilities is a critical aspect of our proposal, and the MOH and other local stakeholders will be engaged from the outset. We expect to deliver C4 PPFP counseling to over 21,000 women/couples during the project period. We will then evaluate C4 effectiveness and implementation processes using RE-AIM (Aim 2). We hypothesize that C4 will significantly increase the number of stakeholders engaged, PPFP providers and promoters, couples/clients receiving information about PPFP (reach), and LARC uptake (effectiveness) comparing intervention versus standard of care. We expect PPFP client satisfaction will be high and side-effects will be rare. The independent effectiveness of each demand creation strategy on LARC uptake will be estimated. We assess measures of C4 adoption, implementation, and maintenance at the patient-, provider- and stakeholder-level to assess C4 sustainability. Finally, we will evaluate C4 cost-effectiveness and develop a national costed implementation plan to guide Rwandan MOH decision-making for nationwide roll-out of PPFP services (Aim 3). We hypothesize that C4 will be cost-saving relative to standard of care. C4 represents an important contribution to the Rwanda Family Planning 2020 goals and the MOH are enthusiastic to see our successful pilot efforts expanded to a larger number of facilities for greater and sustained impact. Our PPFP implementation model is designed to be replicable and expandable to other countries in the region which similarly have high unmet need for PPFP.