Vouchers increase early contraceptive uptake in women living with HIV
Vouchers can play a role in empowering more women to take up early contraceptive services after pregnancy.
A family planning voucher scheme increased the odds of women living with HIV starting a contraceptive soon after they gave birth in rural Uganda, while also reducing the number of weeks it took to access services.
In this randomised control trial evaluating the effect of a family planning voucher compared to the standard of care, women were 9.2 times more likely to take up a contraceptive within eight weeks of giving birth in the intervention arm.
The results provide important evidence that a voucher scheme, embedded within the context of a comprehensive family planning package, can increase early postpartum contraceptive uptake and continued use of contraceptives, in a setting where users are faced with financial, knowledge, and structural barriers to contraceptive services.
Family planning helps to prevent unwanted pregnancies and promotes longer birth intervals; these are key for eliminating perinatal transmission of HIV, and promoting maternal and child health. Previous studies in Uganda have estimated that up to 90% of women living with HIV want to delay or avoid pregnancy in the year after they give birth, and over 40% in the two years after birth. But the number of unwanted pregnancy remains high in this group.
Between October 2016 and May 2017, 320 postpartum women living with HIV were randomised to either a voucher scheme or control arm following delivery at Mbarara Regional Referral Hospital (MRRH), a publicly funded teaching hospital serving 10 districts with a population of over five million people.
The intervention comprised of immediate enhanced postpartum counselling on the five family planning methods available at MRRH, which included both long and short-acting modern contraceptive methods (condoms, injectables, contraceptive pills, copper IUDs, and contraceptive implant).
Women were also counselled on all these available methods taking into account their family size, medical eligibility for the different contraceptive methods, dual contraception, when to start contraception, how to use the contraceptives, potential side effects and benefits/effectiveness, and where the different family planning methods can be accessed.
They were then provided with vouchers as an incentive to seek/demand services. Vouchers invited the women to an appointment at a clinic of their choice to access family planning within three months and outlined the benefits and side effects of each contraceptive method.
Women in the control group were not given a voucher but were offered routine family planning counselling at discharge as defined by the Uganda clinical guidelines. Both groups were invited to start any available family planning method prior to discharge; these methods are offered for free under the Ugandan health system. The choice and place of family planning was entirely up to the participants.
By eight weeks postpartum, 91% of the women in the voucher arm had started family planning compared to 52% in the standard of care arm. Contraceptive use rates continued to increase between eight and 20 weeks postpartum and remained consistently significantly higher among the intervention group.
Additionally, the amount of time without using a contraceptive after birth was reduced to 5.9 weeks for those in the voucher arm compared to 9.3 weeks in the control. Around 10% of the women did not access any contraceptives.
At six months, the type of family planning method used was not different between the two groups. Most women (50%) chose injectables, and 52% of this group were in the intervention arm versus 48% in the control arm. The proportion of women using implants was 20%, with less than10% in each arm selecting condoms, oral contraception, and IUDs.
The study found that the intervention facilitated early contraceptive uptake and continuation through improved counselling, continuous information transfer and education, and appropriate referral to centres where these services are freely offered.