Strengthening healthcare providers’ capacity for intra-uterine device and contraceptive implant services in humanitarian and fragile settings: a case study from Nepal

Alison Greer, Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women's 5Refugee Commission, 15 West 37th Street, New York, NY 10018, USA

Anushka Kalyanpur, CARE, 151 Ellis St NE, Atlanta, Georgia 30303, USA

Nguyen Toan Tran, Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women's 5Refugee Commission, 15 West 37th Street, New York, NY 10018, USA; Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW 2007, Australia; Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206 Genève, Switzerland

Abstract
Background – Access to modern family planning methods, including long-acting and reversible contraceptives (LARCs), to prevent unplanned pregnancy is critical to avert maternal deaths in humanitarian and fragile settings, where clinicians often have limited LARC competencies. This paper explores the perspectives and recommendations of providers and trainers involved in piloting the Clinical Outreach Refresher Training for Sexual and Reproductive Health module (S-CORT) on LARCs in Nepal.Methods – Qualitative data from end-of-training evaluations, which were self-filled by 15 trainees, a focus group discussion involving 11 of them, and written feedback from five co-trainers were transcribed, coded, and thematically analyzed. Results were intersected with those from pilots held in Bangladesh and the Democratic Republic of Congo.Results – Results suggest that the module could increase participants’ counseling and clinical skills, help anchor readiness for family planning and LARC provision before humanitarian emergencies, and reinforce informed consent, service privacy and confidentiality, and access for underserved populations, including adolescents. Recommendations for improvement included the advanced provision of the learning resources for self-study to promote blended learning and avail more clinical practice time.Conclusions – When the lack of skilled human resources is a barrier to LARC services in humanitarian and fragile settings, the S-CORT strategy could offer a rapid hands-on refresher training opportunity for clinicians requiring knowledge and skills update. Such a capacity-development approach could be valuable not only for emergency response but also in contexts prioritizing disaster preparedness planning.

Keywords
Long-acting and reversible contraceptives, contraceptive implants, intra-uterine devices, capacity strengthening, refresher training, human resources for health, humanitarian settings, preparedness, sexual and reproductive health and rights

Cite this paper
Kamille Gardner, Shabana Zaeem, Jagadishwor Ghimire, AKM Anisuzzaman, Bergson Kakule Syaivuya, Alison Greer, Anushka Kalyanpur, Nguyen Toan Tran, Strengthening healthcare providers’ capacity for intra-uterine device and contraceptive implant services in humanitarian and fragile settings: a case study from Nepal , SCIREA Journal of Health. Volume 6, Issue 2, April 2022 | PP. 28-43. 10.54647/pmh33204

References

[ 1 ]	Guttmacher Institute: Adding It Up - Investing in Sexual and Reproductive Health in Low- and Middle-Income Countries. Fact Sheet. July 2020. Available at: https://www.guttmacher.org/sites/default/files/factsheet/adding-it-up-investing-in-sexual-reproductive-health.pdf. Accessed on 17 Dec 2020. .
[ 2 ]	Sully E, Biddlecom A, Darroch J, Ashford L, Lince-Deroche N, Riley T: Adding It Up: Investing in Sexual and Reproductive Health, 2020. New York, NY: Guttmacher Institute.
[ 3 ]	Ganatra B, Gerdts C, Rossier C, Johnson Jr BR, Tunçalp Ö, Assifi A, Sedgh G, Singh S, Bankole A, Popinchalk A: Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet 2017, 390(10110):2372-2381.
[ 4 ]	Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L: Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health 2014, 2(6):e323-e333.
[ 5 ]	McGinn T, Bhabha J, Garfield R, Johnson K, Luchsinger G, Oddy L, Onyango MA, Shetir S, Searle L: Shelter from the storm: a transformative agenda for women and girls in a crisis-prone world. Columbia: United Nations Population Fund 2015.
[ 6 ]	Krause S, Williams H, Onyango MA, Sami S, Doedens W, Giga N, Stone E, Tomczyk B: Reproductive health services for Syrian refugees in Zaatri camp and Irbid City, Hashemite Kingdom of Jordan: an evaluation of the minimum initial services package. Conflict and health 2015, 9(1):S4.
[ 7 ]	Casey SE, Chynoweth SK, Cornier N, Gallagher MC, Wheeler EE: Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies. Conflict and health 2015, 9(1):S3.
[ 8 ]	Casey SE, Cannon A, Mushagalusa Balikubirhi B, Muyisa J-B, Amsalu R, Tsolka M: Twelve-month contraceptive continuation among women initiating short-and long-acting reversible contraceptives in North Kivu, Democratic Republic of the Congo. PloS one 2017, 12(9):e0182744.
[ 9 ]	Singh NS, Aryasinghe S, Smith J, Khosla R, Say L, Blanchet K: A long way to go: a systematic review to assess the utilisation of sexual and reproductive health services during humanitarian crises. BMJ Glob Health 2018, 3(2):e000682.
[ 10 ]	Gallagher M, Morris C, Aldogani M, Eldred C, Shire AH, Monaghan E, Ashraf S, Meyers J, Amsalu R: Postabortion Care in Humanitarian Emergencies: Improving Treatment and Reducing Recurrence. Global Health: Science and Practice 2019, 7(Supplement 2):S231-S246.
[ 11 ]	Tanabe M, Schaus K, Rastogi S, Krause SK, Patel P: Tracking humanitarian funding for reproductive health: a systematic analysis of health and protection proposals from 2002-2013. Conflict and health 2015, 9(S1):S2.
[ 12 ]	Blanchet K, Sistenich V, Ramesh A, Frison S, Warren E, Hossain M, Knight A, Lewis C, Smith J, Woodward A: An evidence review of research on health interventions in humanitarian crises. London: London School of Hygiene & Tropical Medicine 2013.
[ 13 ]	Sphere Project: Sexual and reproductive health in Sphere Handbook - Humanitarian charter and minimum standards in humanitarian response. Geneva: Sphere Project; 2018. https://handbook.spherestandards.org/en/sphere/#ch009_004.
[ 14 ]	Inter-Agency Working Group on Reproductive Health in Crises (IAWG): Minimum Initial Service Package (MISP). In: Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings. Edited by IAWG. New York; 2018. https://iawgfieldmanual.com/manual/misp: 17-67.
[ 15 ]	Foster AM, Evans DP, Garcia M, Knaster S, Krause S, McGinn T, Rich S, Shah M, Tappis H, Wheeler E: The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards. Reproductive Health Matters 2017, 25(51):18-24.
[ 16 ]	Women's Refugee Commission: A Clear Case for Need and Demand: Accessing Contraceptive Services for Rohingya Women and Girls in Cox’s Bazar - Case Study. New York; June 2019. https://www.womensrefugeecommission.org/research-resources/contraceptive-service-delivery-in-the-refugee-camps-of-cox-s-bazar-bangladesh/. Accessed 29 Dec 2020
[ 17 ]	Women's Refugee Commission: Gap between Supply and Demand for Contraceptive Services in Northeast Nigeria - Case Study. New York; 2020. https://www.womensrefugeecommission.org/research-resources/contraceptive-services-gap-nigeria/. Accessed 29 Dec 2020.
[ 18 ]	Women's Refugee Commission: Opportunities and Challenges for Contraceptive Service Delivery in Cyclone Idai-Affected Areas of Mozambique - Case Study. New York; 2020. https://www.womensrefugeecommission.org/research-resources/opportunities-challenges-for-contraceptive-service-delivery-in-cyclone-idai-affected-areas-mozambique/. Accessed 29 Dec 2020.
[ 19 ]	Tran NT, Harker K, Yameogo WME, Kouanda S, Millogo T, Menna ED, Lohani JR, Maharjan O, Beda SJ, Odinga EA: Clinical outreach refresher trainings in crisis settings (S-CORT): clinical management of sexual violence survivors and manual vacuum aspiration in Burkina Faso, Nepal, and South Sudan. Reproductive health matters 2017, 25(51):103-113.
[ 20 ]	Giri S, Risnes K, Uleberg O, Rogne T, Shrestha SK, Nygaard ØP, Koju R, Solligård E: Impact of 2015 earthquakes on a local hospital in Nepal: A prospective hospital-based study. PloS one 2018, 13(2):e0192076.
[ 21 ]	Uprety M, Dugar S, Gautam D, Budimir M, Parajuli B, Kharbuja R: The Genesis of August 2017 Nepal Floods. AGUFM 2017, 2017:NH51D-05.
[ 22 ]	World Health Organization: Maternal mortality: Levels and trends 2000-2017; Estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2017. https://www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/.
[ 23 ]	Prakash D, Pandey J, Bietsch K: Unmet Need for Family Planning and Fertility in Nepal: Levels, Trends, and Determinants. DHS Further Analysis Reports No. 119. Rockville, Maryland, USA: ICF; 2019. https://dhsprogram.com/pubs/pdf/FA119/FA119.pdf. Accessed Jan 2020.
[ 24 ]	Ministry of Health of Nepal: Nepal Health Facility Suvery 2015. Kathmandu, Nepal; 2017. https://dhsprogram.com/pubs/pdf/spa24/spa24.pdf. Accessed 11 Jan 2021.
[ 25 ]	USAID, World Health Organisation, United Nations Population Fund: Training Resource Package for Family Planning; https://www.fptraining.org; 2021.
[ 26 ]	World Health Organization, USAID: Family planning: a global handbook for providers. https://www.fphandbook.org/. 2018.
[ 27 ]	Maternal Child Survival Program: Providing Long-Acting Reversible Contraception (LARC) Learning Resource Package (Modular/Facility-Based). In.: MCSP Washington, DC; 2017. Available at: https://www.mcsprogram.org/resource/providing-long-acting-reversible-contraception-larc-learning-resource-package/. Accessed on 16 June 2022.
[ 28 ]	Population Council: Balanced Counseling Strategy Plus Trainer’s Guide Third Edition, part of The Balanced Counseling Strategy Plus: A Toolkit for Family Planning Service Providers Working in High STI/HIV Prevalence Settings. Third Edition. Washington, DC; 2015. Available at: https://www.popcouncil.org/uploads/pdfs/2015RH_BCS-Plus_TrainersGuide_en.pdf. Accessed on 16 June 2022.
[ 29 ]	Royse D, Thyer BA, Padgett DK: Program evaluation: An introduction: Cengage Learning; 2009.
[ 30 ]	Tran NT, Greer A, Dah T, Malilo B, Kakule B, Morisho TF, Asifiwe DK, Musa H, Simon J, Meyers J: Strengthening healthcare providers’ capacity for safe abortion and post-abortion care services in humanitarian settings: lessons learned from the clinical outreach refresher training model (S-CORT) in Uganda, Nigeria, and the Democratic Republic of Congo. 2020.
[ 31 ]	Sharma DC: Nepal earthquake exposes gaps in disaster preparedness. The Lancet 2015, 385(9980):1819-1820.
[ 32 ]	Chaudhary P, Vallese G, Thapa M, Alvarez VB, Pradhan LM, Bajracharya K, Sekine K, Adhikari S, Samuel R, Goyet S: Humanitarian response to reproductive and sexual health needs in a disaster: the Nepal earthquake 2015 case study. Reproductive Health Matters 2017, 25(51):25-39.
[ 33 ]	Myers A, Sami S, Onyango MA, Karki H, Anggraini R, Krause S: Facilitators and barriers in implementing the Minimum Initial Services Package (MISP) for reproductive health in Nepal post-earthquake. Conflict and health 2018, 12(1):1-9.
[ 34 ]	International Telecommunication Union: Yearbook of Statistics - Telecommunication/ICT Indicators - 2009-2018. In., 2019 edn. Geneva: ITU; 2019.