ACCIONES DE LA INSULINA SOBRE EL EJE GONADOTROPO

A total of 475 couples from the intervention group attended either or both of intervention Components B and C. During the counselling session, they were asked whether they had a non- binding preference for a specific contraceptive method that they wished to adopt after birth. The majority expressed a preference for a particular method. This was recorded in their hand-held health booklets for future reference. Whether or not they expressed a preference, and if so for which method, was also reported on the study documentation form compiled by health workers for each session they conducted.

The breakdown of preference by method is illustrated in Table 22. The first line shows the preferred method for the 376 couples who attended Component B, showing that about two thirds chose a method, the most popular being by far the implant (34%), with less than 10% choosing the injectable, the pill, the IUD or another method (in decreasing order of preference). The second line illustrates the preferred method for the 329 couples who attended component C. The proportion who chose a method was higher, at nearly 80%, and the order of preference of methods chosen was the same.

Given that many couples attended both sessions, and some attended one but not the other, I compiled a summary indicator of contraceptive choice made during both or either session for all 475. If the couple had attended Component C (whether or not they had attended B), the choice made at this time was retained, given that it was made closest to the time when the method would be commenced. If they had not attended C, the choice made during B was retained. Overall, just over a quarter did not express any contraceptive preference at either session. The order of preference for methods chosen remained the same in the summary indicator. I used this indicator to compare the preference expressed during the intervention sessions with

contraceptive use at 8 months (see Subchapter 9.4.17).

Among the 226 couples who attended both Components, most responded in the same way on both occasions, but there was a change for 82 (36%) of them. Among those who changed their mind between the two sessions, the majority (65%) changed from having not expressed a preference during B, to specifying a preferred method during C.

Table 22: Contraceptive method preference expressed during Components B & C Preferred contraceptive method: n [%]

Implant Injectable Pill IUD Other Preference

not expressed TOTAL Comp. B 127 [33.8] 36 [9.6] 33 [8.8] 29 [7.7] 12 [3.2] 137 [37.1] 376 [100] Comp. C 124 [37.7] 63 [19.2] 41 [12.5] 27 [8.2] 8 [2.4] 66 [20.1] 329 [100] Summary preference 170 [35.8] 75 [15.8] 55 [11.6] 37 [7.8] 15 [3.2] 123 [25.9] 475 [100]

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8.4.

Discussion

8.4.1. Overall adherence levels

As discussed in the Subchapter 733.3.4, men’s participation in facility-based activities is usually easy to achieve in high income settings, whether these be offered during pregnancy (Maycock et al., 2013, Wolfberg et al., 2004) or after birth (Abbass-Dick et al., 2014, Pisacane et al., 2005). Similarly, in middle-income settings where it is usual for male partners to accompany their wives to ANC, educational interventions during pregnancy have achieved over 80% coverage (Mullany et al., 2007, Varkey et al., 2004). However, only a quarter of men participated in the sessions offered in the main other facility-based study conducted in Sub Saharan Africa which focused exclusively on MNH/PPFP (Kunene et al., 2004). The literature on male partner

involvement in PMTCT confirms that male partner attendance at facilities during pregnancy can be hard to achieve in this region. Trials of different invitation approaches have generally shown response levels below 50% (Ditekemena et al., 2011, Nyondo et al., 2015).

There are several features which may have enabled us to achieve an unusually high level of adherence for an urban, Sub-Saharan African context. On the one hand, I tried to incorporate and closely adhere to the results of the formative research at the design stage, thus producing an intervention that was acceptable. On the other hand, we mobilised a certain amount of financial resources and staff time for the purpose of maximising attendance. This included the double invitation strategy of telephone calls as well as written letters. Importantly, health workers were compensated for the extra work that the study entailed, based on the number of men and couples attending. This may have motivated them to put more effort into the invitation process. It is not clear from some of the other studies whether staff were compensated, and if so, in which way compensation was calculated. It is also possible that giving men a small financial contribution for travel expenses at the end of the first session (A) may have encouraged them to return again for the second (B). It is also not clear whether the lack of focus on HIV/AIDS both in our invitation and in the content of our sessions may have had an impact on attendance (see Subchapter 3.3.5).

Co-habitation was a pre-requisite for enrolment in this study, which may have meant that couples had a closer and more committed relationship, in which the man might have been more willingly become involved in the woman’s health care. In comparison, most participants in Kunene’s study didn’t co-habit but had a “regular visiting relationship” (Kunene et al., 2004). Adherence may also have been high because our study took place in an urban area, in which health centres are easily accessible to most families. On the other hand, I was told by health workers that because the study was running between March and June, several men were busy planting in the fields (on family plots within the city) and were therefore not available to attend.

144 Attendance may have been even higher had the intervention been implemented at another time of year.

8.4.2. Attendance at individual components and predictors of adherence

As for the difference in attendance between components A, B and C, it may be somewhat surprising that there was a drop between A and B, given that there was a greater degree of flexibility for negotiating the couple counselling appointment, including during evenings and weekends, whereas the timing of the group session could not be altered to suit individual needs. The failure of some A participants to return for B might be explained by fatigue, unwillingness to return a second time, dissatisfaction with A, or difficulty for both spouses to arrange to go together. It is possible that both the format and the order in which these components were offered influenced uptake. Another factor to consider is that whereas the invitation for A was in effect delivered through the combined effort of the RA (giving the letter) and the health worker (making the phone call), the invitation to B and C entirely depended on the health workers’ personal motivation to follow the established procedures, and on the organisation of work within the PHC.

Component C was the least well attended, given the level of referral hospital deliveries despite the fact that women were considered fit for PHC delivery at the time of enrolment. The study did not have the resources to train health workers at the referral hospitals. Had this been possible a higher attendance at C might have been seen, and all women could have been

included, regardless of obstetric risk. As mentioned, the difference between health centres in the proportion giving birth at referral facilities was probably due to geography, however reputation could also have played a role. A minor contribution to the drop in attendance between A and C could also be due to the fact that the majority of deliveries happened during the rainy season, when men who were farmers (8-10%) would have been particularly busy working in the fields.

I explored baseline factors and other characteristics that were potentially associated with high adherence. The PHC where the woman was recruited was confirmed as a significant factor affecting attendance, even when adjusting for place of birth. This suggests that internal differences between the PHCs may have influenced levels of uptake, including organisational structure, leadership, and commitment to the project (see qualitative evaluation findings, Subchapter 10.5). In polygamous marriages, men may have felt less invested in the health care of each wife, or held more traditional attitudes, leading to a reluctance to participate. On the other hand, couples who had used contraception in the past might have had prior contact with the health system and more familiarity with services, or been more open-minded towards biomedical advice, leading to a higher willingness to engage in the project.

145 It is interesting to observe the lack of association of certain plausible factors, such as education, with adherence. For certain potential predictors, it is possible that I may not have been able to detect the effect due to the small numbers in some categories, for example in the case of the woman’s participation in decision-making. At the same time, it is possible that other unobserved differences between study participants, which may or may not have been clustered at PHC level, affected levels of receptivity or interest in participating.

8.4.3. Contraceptive choices

The contraceptive preferences expressed by participants in Components B and C reflect the methods which are locally available in the city of Bobo-Dioulasso (Daniele, 2014), however there are some differences between the proportions choosing each method in this sample, compared to the distribution of contraceptives actually used by women in Burkina Faso cities, according to DHS data (INSD, 2012). Specifically, implants are the most chosen method here, whereas injectables and the pill were more commonly used than implants in the last DHS. This is supported by reports of a sharp increase in interest in implants in recent years in Sub-Saharan Africa (Duvall et al., 2014). Furthermore, the IUD is more likely to be chosen than condoms in this sample, whereas in the DHS condoms are more used. It is important to note that women’s expressed preference may not correspond to the methods they actually end up using, because of other factors such as availability. However, these data may point to an encouraging increase in the popularity of these long-term and highly effective methods. It is not clear whether the presence of the male partner at the time of the choice, in this study, influenced the type of methods chosen.

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