Think | BIG: Shared View

Behavior Profile: USAID MCGL - Providers Offer Voluntary PAFP

	Health Goal	Health Goal: Reduce repeated unintended pregnancy
	Behavior	Service providers proactively offer comprehensive, compassionate, client-centered counseling and voluntary modern contraceptive services at the same time and location where women receive any postabortion care Percent of postabortion care clients counseled on modern contraception during PAC visit

Behavior Analysis			Strategy
BEHAVIOR AND STEPS What steps are needed to practice this behavior? Behavior Service providers proactively offer comprehensive, compassionate, client-centered counseling and voluntary modern contraceptive services at the same time and location where women receive any postabortion care Steps Maintain adequate contraceptive method mix, supplies, and equipment at point of care Sharpen FP and client-centered counseling knowledge and skills Treat all clients respectfully and with compassion, regardless of age, parity, or marital status Respect client privacy and confidentiality Strive to understand the client’s fertility desires from her perspective Conduct screening for gender-based violence if the client presents with signs of such, providing first-line support as needed Ask the client if she would like her male partner or companion to participate in her care and counseling session, or be informed about her condition, treatment, follow-up care, and FP method. If the client would like her male partner or companion to be involved, include the partner/person in FP counseling and ongoing consultation Counsel each client according to guidelines and the client’s situation Offer voluntary FP services to each client postabortion regardless of the type of evacuation procedure Refer to qualified provider if the method of choice is not available (e.g., due to level of service or being out of stock), offering a bridge method for interim use	FACTORS What factors may prevent or support practice of this behavior? Structural Accessibility: Providers cannot offer contraception at the same time and location that they provide emergency care because they lack adequate time due to competing priorities, including having many clients at one time Accessibility: Providers cannot offer contraception at the same time and location as emergency care because of a lack of dedicated space for counseling, especially when caseloads are high Service Experience: Providers can offer contraception at the same time and location as emergency care due to on-site availability of contraceptive supplies and equipment Service Experience: Providers do not offer contraception at the same time and location as emergency care because they are not held accountable for doing so Service Experience: Providers do not offer contraception at the same time and location as emergency care because of a lack of clear, active policy support (i.e., regulations, guidelines, performance indicators) for PAC, especially regarding adolescents Service Experience: Providers cannot offer contraception at the same time and location as emergency care because health systems and health facilities have not ensured that contraceptive services are available on maternity and emergency wards Social Norms: Providers do not offer contraception at the same time and location as emergency care because they work in a social and cultural context that is averse to PAC and to contraception in general, especially for unmarried adolescents Internal Attitudes and Beliefs: Providers offer contraception at the same time and location as emergency care because they believe providing contraceptive counseling and services to prevent repeat unwanted pregnancy is important and one of their key roles Attitudes and Beliefs: Providers do not counsel each client according to guidelines and the client's situation because they prefer certain methods for PAFP or particular types of clients (e.g., only condoms for adolescents, no LARCs if one child) Knowledge: Providers do not counsel each client according to guidelines and the client's situation because they lack knowledge about return to fertility and indications for contraceptive methods after surgical or medical evacuation, esp. for adolescents Knowledge: Providers do not counsel each client according to guidelines and the client's situation because they lack awareness of the link between SGBV, age of consent, and PAC for adolescent clients Skills: Providers do not offer contraception, especially to adolescents, at the same time and location as emergency care because they lack skills in providing contraception and adolescent-responsive care	SUPPORTING ACTORS AND ACTIONS Who must support the practice of this behavior, and what actions must they take? Institutional Policymakers: Develop and disseminate clear policies and guidelines to support the implementation of PAC Policymakers: Make the right and need for PAFP explicit for all medical providers AND the community at large and incorporate adequate PAC training for providers at all levels into pre-service, in-service and continuing professional training Policymakers: Authorize use of misoprostol for emergency medical management of complications of incomplete abortion Policymakers: Develop performance indicators to measure PAC delivery and quality Policymakers: Allocate budget for training providers in client-centered PAFP counseling, service provision and referral Managers: Section off or otherwise provide private space (aural and visual) for PAFP counseling where PAC is provided Managers: Add contraceptive counseling, uptake, and supplies to PAC record-keeping systems Managers: Organize/reorganize services and physical space (to improve client flow and engagement) Managers: Provide job aids to assist staff (medical eligibility criteria and other checklists, protocols, etc.) Managers: Collect analyze, and use data to assess method choice, etc. and address issues Managers: Implement quality improvement measures based on a PAC quality of care assessment Managers: Provide supportive supervision—including problem solving, constructive feedback, and positive feedback on what they are doing well—to PAC providers Logistics Personnel: Consistently procure adequate contraceptive supplies for the department providing PAC Supervisors: Ensure all staff receive comprehensive PAC training, including on how to reduce own biases and avoid judgement in service delivery Managers and Policymakers: Operationalize task-shifting to ensure adequate coverage (including optimizing roles of all levels of providers) Managers and District Health Officials: Participate in values clarification and other training to support providers Medical, Nursing, and Pharmacy Schools: Incorporate client-friendly PAC into pre-service training for all students	POSSIBLE PROGRAM STRATEGIES What strategies will best focus our efforts based on this analysis? Strategy requires Communication Support Enabling Environment Institutional Capacity Building: Collaborate with medical, nursing, and pharmacy schools (and the government agencies that regulate them) to integrate comprehensive adult- and adolescent-friendly PAC into educational curricula of nurses, midwives, pharmacists, and physicians Institutional Capacity Building: Design, test, and implement on-the-job PAC training and mentorship for all current and incoming maternal and reproductive health staff, appropriate to their service level Partnerships and Networks: Involve the private sector (e.g., pharmacies and private clinics and their associations) in providing comprehensive PAC Policies and Governance: Revise FP guidance for all levels of providers to include information on PAFP counseling and service provision. Policies and Governance: Draft, clarify, revise, and actively disseminate comprehensive PAC policies and guidelines—including the credentialing of mid-level health care providers, pharmacists, and pharmacies—for approval and dissemination Systems, Products and Services Infrastructure: Provide architectural design services, facility-based problem solving, and other needed support to add or section off space to create private counseling areas(s) Quality Improvement: Assist health facilities to apply job and client flow analysis tools to identify ways to reduce time and space pressures and ensure appropriate skill sets Quality Improvement: Integrate values clarification and attitude transformation (VCAT) and role playing related to adult- and adolescent-friendly PAFP into pre- and in-service training curricula for providers of emergency, maternal, and reproductive health care Quality Improvement: Conduct exit interviews to assess extent to which PAFP counseling and method provision is taking place and the quality of those services, including method choice Quality Improvement: Link (or provide technical assistance to link) PAC and FP data management systems Quality Improvement: Integrate at least one PAC indicator into country HMIS Quality Improvement: Develop provider training for client-centered comprehensive PAC Quality Improvement: Deploy trained field representatives to meet with providers monthly to address individual and structural barriers constraining PAFP Quality Improvement: Facilitate integration of contraceptive methods including LARCs within PAC into quality improvement and supervision tools and performance standards Quality Improvement: Work with managers to habituate asking at daily labor and delivery unit staff meetings for number of clients receiving PAFP or PPFP Demand and Use Advocacy: Advocate for expanding indicators used to monitor and assess PAC Advocacy: Advocate with policymakers, logistics managers, reproductive health departments, facility managers, district health teams, and others as needed to improve the onsite availability of modern contraceptive methods (including LARCs), related equipment, and space for counseling Advocacy: Train champions within and outside the MOH to advocate for comprehensive, adult- and adolescent-friendly PAC and to leverage donor resources Communication: Organize facilitated, short, multi-session workshops designed to give providers opportunities to reflect over time upon the rewards and burdens of providing PAC, including stigma (see https://sites.google.com/umich.edu/providershareworkshop/about) Collective Engagement: Organize community exploration of the reasons for and importance of PAFP, as well as the non-contraceptive benefits of some methods (e.g., lighter periods, reduced PMS, treatment of acne, decreased cancer risk) Skills Building: Conduct PAC training for providers, managers, and supervisors that adequately emphasizes adolescent-and adult-friendly counseling, comprehensive values clarification and attitude transformation exercises, data collection and use, and supplies management, and, particularly for adolescents, non-contraceptive benefits of certain methods (e.g., lighter periods, reduced PMS, treatment of acne, decreased cancer risk) Skills Building: Implement modularized onsite peer-learning approaches that emphasize continuous quality improvement vis-à-vis clinical guidelines, values clarification exercises, the practical realities of operationalizing quality, and choice during PAC Skills Building: Provide or support the MOH and facilities to provide long-term, need-based post-training support to providers

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