A Sustainable Way to Expand Access to LARCs

By Andrea Mooney, Communications and Knowledge Management Advisor, SIFPO2, PSI

With USAID assistance, PSI’s SIFPO2 project recently welcomed implementing partners, donors and family planning experts from around the world to a technical consultation in Washington, DC, to discuss how task sharing can increase access to voluntary long-acting reversible contraceptives (LARCs) and permanent methods of family planning. At the meeting, PSI’s network member in Guatemala (PASMO), presented the USAID-funded work described below.

In the rural Western Highlands of Guatemala, healthcare providers are few and far between. For many women there, accessing voluntary family planning methods can be a challenge. Often, women travel an hour each way to a health facility, and wait two to four hours to receive a service, making a simple doctor’s visit potentially six hours long. If they’re using a short-acting family planning method like oral contraceptive pills or injectables, these women might have to make the entire trip again every few months.

Most of the country’s health care providers in rural areas are not doctors or nurses, but auxiliary nurses with a more basic level of qualifications and one year of training. A public health center may have only two or three doctors working alongside four auxiliary nurses. This means that if someone needs a service that only one of the few doctors or nurses at a health center can provide, the wait is longer, the time spent with the provider might be shorter, and the experience asking questions and receiving answers can be limited.

The Guatemalan Ministry of Health allows auxiliary nurses to provide family planning counseling and short-acting methods, but not the more effective LARCs that include intrauterine devices (IUDs) and hormonal implants. LARCs can be safely used for several years at a time and be removed by a provider when the client wishes, allowing clients to make fewer trips to see a provider. PSI’s Guatemalan network member, PASMO asked: Why not make IUDs and implants more available by adding those services to auxiliary nurses’ scope of practice?

According to World Health Organization (WHO) recommendations, auxiliary nurses can safely and effectively provide hormonal implants under specific supervisory requirements. PASMO presented the WHO recommendations to the Ministry of Health and received permission to test whether auxiliary nurses in Guatemala’s rural public health centers could safely and effectively offer implants and IUDs.

With the government’s permission, PASMO worked with 69 of the 133 facilities in the rural Western Highlands to enable more than 300 auxiliary nurses to provide these services, in addition to the short-acting methods and counseling they offered previously. Nurses and doctors in the same facilities continued to offer a full range of methods, and remained responsible for LARC removals. This allowed task sharing for inserting LARCs with nurses, doctors and now auxiliary nurses, who had not performed that task before.

As the numbers of providers who could offer LARC services grew, so did the percentage of clients choosing them. From 2012 to 2014 across all task sharing intervention facilities, more than 6,000 women opted for IUDs and more than 8,000 women chose hormonal implants in the context of informed choice. PASMO and the Ministry of Health carefully monitored service quality.

“In addition to these results, we saw higher client satisfaction, and higher job satisfaction among auxiliary nurses,” says Dr. Leonel Gomez, Chief of Party for PSI’s SIFPO2 in Guatemala, and Gynecologist and Obstetrician at PSI/PASMO.

Auxiliary nurses appreciated that they could now offer women more options than the choice between a short-acting method or a long wait for a LARC method from a doctor or nurse.

As a result of these successes, Guatemala’s Ministry of Health agreed that the 2017 update to the national family planning guidelines may include voluntary LARC provision by auxiliary nurses. This step will ensure that task sharing in public health centers outlasts the project.

For more information on how task sharing can increase access to family planning, read about this technical consultation, held on July 14, 2016, which brought together family planning experts from around the world to discuss the past, present and future of task sharing. The meeting was hosted by PSI’s SIFPO2 Project through the LARC and Permanent Method Community of Practice.

Photo credit: Rita Villanueva