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Improving postpregnancy contraceptive method choice and long-acting reversible contraception provision in Botswana: a quality improvement pilot
  1. G Justus Hofmeyr1,2,
  2. Rebecca Jane Ryan3,
  3. Aamirah Mussa3,4,
  4. Bame Bame3,
  5. Sifelani Malima5,
  6. Thabo Moloi2,
  7. Rebecca Luckett3,6,
  8. Ndiwo B Memo6,
  9. Badani Moreri-Ntshabele2,6,
  10. Mercy Nkuba Nassali2,6,
  11. Modimowame Jamieson2,6,
  12. Kyungu M Kime2,6,
  13. Chelsea Morroni3,7
  1. 1 Effective Care Research Unit (ECRU), University of the Witwatersrand Johannesburg, Johannesburg, South Africa
  2. 2 Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
  3. 3 Botswana Sexual and Reproductive Health Initiative, Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
  4. 4 Usher Institute, University of Edinburgh, Edinburgh, UK
  5. 5 Department of Health Services Management, Ministry of Health and Wellness, Gaborone, Botswana
  6. 6 Department of Obstetrics and Gynaecology, Princess Marina Hospital, Gaborone, Botswana
  7. 7 MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Rebecca Jane Ryan, Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; rebeccajaneryan90{at}

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Key messages

  • Improving postpartum contraception provision, particularly long-acting reversible methods of contraception, in low-resource, high HIV-prevalence settings such as Botswana will reduce unintended pregnancy and associated adverse consequences.

  • Adaptation of postpregnancy intrauterine device (IUD) insertion techniques for a low-resource setting alongside sustained supervision and mentorship until competence is achieved increases uptake of postpregnancy IUD.

  • Training all departmental healthcare providers in contraceptive counselling and method provision increases the uptake of postpartum long-acting reversible contraception methods and prevents a missed opportunity for contraception initiation.

Why was change needed?

The most impactful and cost-effective strategy to reduce maternal and perinatal mortality is to enable women to avoid unintended pregnancy. Provision of immediate postpartum contraception, promoted by the WHO, can avert more than 30% of maternal deaths and 10% of child mortality.1–3 In Botswana, the maternal mortality ratio is 166.3 deaths per 100 000 live births, unsafe abortion is consistently in the top three contributors to maternal mortality, over 40% of pregnancies are unintended, and the adolescent birth rate is 44.7 per 1000 women4–6; multiple indicators which demonstrate high unmet need for contraception. Preventing unintended pregnancy in women living with HIV confers additional benefits in terms of optimising healthy pregnancies and reducing vertical HIV transmission.7 Long-acting reversible contraception (LARC), that is, the copper intrauterine device (IUD), the hormonal intrauterine system (IUS) and the progestogen-only implant, are recommended by the WHO as the most effective contraceptive methods.8 Despite this, LARC use was negligible in the most recent Botswana Demographic Survey9 conducted in 2017, with contraceptive prevalence predominantly comprised of condom use.

Initiation of IUDs immediately postpartum is limited in many countries outside of specific implementation programmes.10 Techniques unique to postdelivery, intracaesarean section (C-section) or postevacuation IUD insertion differ from those used for interval IUD insertion and, therefore, require specific provider training, which is not widely available …

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  • GJH and RJR are joint first authors.

  • Contributors GJH, MNN, BM-N, CM, AM, RJR and SM contributed to conception and design of the study. GJH, CM, AM, RJR and BB were involved in implementation of the intervention. SM contributed to procurement and GJH, TM, RL, NBM, BM-N, MNN, MJ and KMM contributed to mentorship in post-pregnancy IUD insertion. RJR and AM performed the statistical analysis. GJH and RJR wrote the first draft of the manuscript as joint first authors and AM, CM, MNN, TM, MJ, KMK, NBM and RL contributed to subsequent drafts. All authors participated in the study and have read and approved the manuscript.

  • Funding The study was supported by the Canada Fund for Local Initiatives (CFLI), grant number IB_LBP-#11897513-CFLI.

  • Disclaimer The funding source had no role in the design and conduct of the study, data collection, analysis, reporting, or decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.