Society for Family Health/Zambia
PPIUD Training in Zambia
Background
In early February 2009, PSI’s affiliate in Zambia, Society for Family Health (SFH), trained 13 individuals in post-partum IUD insertion and related counseling techniques. The training was held at the University Teaching Hospital (UTH) in Lusaka, the country’s largest referral hospital. Two American doctors, Dr. Sarah Prager and Dr. Pratima Gupta, led the training based on the ACQUIRE/Engender Health curriculum. SFH staff presented sessions on infection prevention, counseling and recording client information. The five-day training included two days devoted to theory and three days devoted to practical experience (with pelvic models and, where possible, clients.) Participants included:
- 5 midwives employed by SFH (3 Reproductive Health Providers and 2 Managers with supervision responsibilities);
- 6 providers from the University Teaching Hospital (2 obstetricians, 2 midwives from the antenatal ward and 2 midwives from the labor ward); and
- 2 observers from the Health Systems Strengthening Project (HSSP) which has trained more than 200 national master trainers for long-term family planning methods in Zambia.
By the end of the five-day training, 11 providers had demonstrated competency on the pelvic model and 9 clients had been inserted. The training succeeded in de-mystifying the procedure and demonstrating, through practice, that PPIUD provision is typically straightforward and simple. This document aims to describe the steps SFH took to prepare for this training as well as thoughts about what could be done differently to ensure the successful integration of PPIUD services into reproductive health programming in other countries.
PPIUD Training Preparation
During the 5 months leading up to the training, SFH took the following steps to prepare for the PPIUD training:
- Discussed the merits and safety of PPIUD services with and received verbal endorsement of this strategy from high-level counterparts at the MOH and UTH. (September 2008)
- Searched, unsuccessfully, for a local or regional training partner and began lobbying PSI/W to identify international consultants who could lead the training. (October 2008)
- Met with JHPIEGO/Kenya in Nairobi to discuss their experience with PPIUD training. (October 2008) This meeting was very helpful in alerting us to some of the common mistakes associated with PPIUD trainings (including inadequate interest/support from providers and clients.)
- Identified UTH as ideal partner based on significant enthusiasm and support from the head of the OB/GYN department for PPIUD and the high volume of deliveries (up to 70 per day.) Initiated weekly meetings to jointly plan for the PPIUD training. (December 2008)
- With assistance from PSI/W, identified trainers and agreed on training date and particulars (e.g. ideal # and cadre of participants, necessary equipment, etc.) (December 2008)
- Began procurement process for essential equipment as well as non-essential supplies requested by UTH (waterproof aprons and mattress liners for the labor ward.) (December 2008)
- Developed an MOU with the UTH specifying relative responsibilities of SFH and UTH. (December-January: required multiple discussions with UTH)
- Met with administrators and managers of the labor wards at 3 health centres in Lusaka (where SFH providers were already offering interval IUD services) to explain PPIUD and solicit their support for the service. In every case, the fact that SFH providers had already demonstrated an ability to increase the facility’s uptake of interval IUD was a huge selling point. Small gifts of appreciation (branded tee-shirts, nurse aprons and chitenges) also helped. (January 2009)
- Conducted daily sensitization talks for women waiting for antenatal check-ups at UTH and 3 nearby health centres where SFH staff offer interval IUD and implant services. (3 weeks prior to and continued during the week of the training.) The main purpose of the sensitization talk was to highlight the unique benefits of the IUD. Common side effects were also discussed. After further counseling?, SFH asked interested women to sign consent form and identified more than 50 consenting clients before the training began. Although the national guidelines in Zambia do not require consent for any FP method other than sterilization, we were required to ask for consent in order to request client phone numbers, which may be used for follow-up purposes.
- Selected and notified training participants. (January 2009)
- Developed a consent form and a modified MIS form for use with PPIUD clients. (January 2009)
- Put up low-literacy signs (“post-delivery loop available here; ask your midwife for more information”) in labor and antenatal wards of UTH and participating health centres. (week the training began.)
Lessons
1. In cases where PPIUD is not being practiced (and/or is not integrated into national RH/FP service delivery guidelines and protocols), written support from the MOH may facilitate training and program outputs. While we signed an MOU with a government site (UTH) and informed counterparts at the MOH, written endorsement from the MOH (either through an MOU or a simple letter) would have been helpful. (Especially when training participants asked how we had the authority to train providers in a service not yet recognized by the MOH.)
2. Ideally, training participants should be of the same cadre and experience levels with respect to the IUD. We had a mixture of doctors and midwives which forced the trainers to teach to two audiences and affected the group dynamics (most of the midwives were unable or unwilling to debate with highly respected doctors.) Despite the fact that we specified in the MOU that UTH would send 5 midwives from the labor ward, 3 of their 6 participants did not match this criteria. It may be worth looking at strengthening the language in the MOU for this purpose. On the other hand, it may be unrealistic for a department head NOT to include doctors and favored midwives from other departments in a valued training.
3. Multiple practical sites (ideally relatively close to the main training site) may increase opportunities for supervised practice with clients. Because it is not ideal for more than 2-3 providers to observe a procedure, it helps to be able to divide trainees into smaller groups which can work simultaneously with different clients, depending on the number of trainers. By casting the net widely among multiple facilities, a program can increase the likelihood that trainees will receive supervised practical experience during the training. On the first day following the training (Monday 9 February), 8 PPIUD clients were seen at one of the participating health centres compared to only 1 PPIUD client seen at UTH.
4. Sensitization/counseling among antenatal clients is essential to generate demand for the service and should begin well in advance of the training. However, it is not sufficient and should be supplemented with counseling among women in the labor ward (who are not in active labor) as soon as trained providers are available to offer the service. Eight out of the nine consenting clients served during Zambia’s February 2009 training, were identified by counseling women registering for inductions or during early labor or post-delivery stages.
5. While training providers with previous IUD experience is ideal, it is not necessary. Based on our experience, this training could be conducted successfully among providers with no previous IUD experience as long as they had strong interpersonal skills, some FP experience and interest/commitment to long-lasting methods. As noted in lesson 2, it is helpful to have a group with a similar background, but programs could train a number of providers with no prior IUD experience in PPIUD (and later, follow-this up with supplemental interval training.) In other words, difficulty identifying a number of providers with prior IUD experience is not a reason in and of itself for not moving ahead with PPIUD training.
For more information regarding Zambia’s PPIUD experience, please contact Jully Chilambwe () in Zambia.
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