Abstract

Objective

To assess changes in the quality of care following the introduction of a new postnatal package.

Design

Using a pre-test, post test design to observe client–provider interactions with women 0–6 weeks postpartum.

Setting

Four health facilities in a rural district, eastern Kenya.

Participants

Health providers and postpartum women.

Intervention

Introduction of comprehensive postnatal package of care, with three targeted assessments within 48 h of birth, 1–2 weeks and 6 weeks, to providers working in maternity and maternal and child health clinics.

Main outcome measure

Improved quality of postnatal counselling.

Results

Increased mean scores for counselling on danger signs in the newborn (0.24–1.39) and infant feeding (1.33–2.19) were noted. The total quality of care index for the newborn increased overall but remained lower than desired (from 3.37 to 6.45 out of 11). Essential maternal care index improved (3.4–8.72 out of 23). More women accepted a family planning method at 6 weeks (35–63%).

Conclusions

The introduction of new comprehensive postnatal care package improved performance of providers in counselling in maternal and newborn complications, infant feeding and family planning. Additional studies looking at the postpartum family planning needs for women living with HIV would also be useful. However, providers would benefit from additional clinical skills for managing maternal and newborn complications during the critical period following childbirth.

Introduction

The postnatal period is neglected throughout Africa. The quality of care for those who seek services is often poor and many women and their infants are not encouraged to seek care until 6 weeks after delivery. Lack of a defined postnatal care package contributes to the discontinuity between maternal and child health programs [1].

Although there have been improvements in the quality of care during pregnancy and childbirth, there is limited uptake of early postnatal services for mother and newborn and acceptance and use of postpartum family planning methods in many countries. The greatest gap in the continuum of care occurs during the first crucial week after childbirth when both maternal and newborn deaths are most likely [2, 3]. In Africa alone at least 125 000 women and 870 000 newborns die in the first week after birth every year [4]. For many women in eastern and southern Africa, the postnatal period is a time of increased susceptibility to HIV and STIs [5, 6]. Although HIV infection in the mother will influence the baby's survival, practically all neonatal deaths in the first month of life are due to non-HIV causes (e.g. asphyxia, sepsis and prematurity), highlighting the need to address the quality of basic maternal and newborn care.

Evidence suggests that there are some ‘crucial’ moments when contact with the formal health system during the postpartum period by skilled attendants could be instrumental in identifying and responding to needs and complications after childbirth: the first few hours after birth (whether at home or in a health facility), between 3 and 7 days and at 6 weeks [7, 8]. Better understanding of complications such as haemorrhage in the early postpartum period, which is greater than 30% in Africa and Asia [9], has shown the importance of early and universal postpartum care [10].

The family planning needs of women during the first year postpartum are also not well addressed [11, 12]. In Kenya, 68% of women have an unmet need by 12 months [13, 14]. Postpartum women need information and services, provided at appropriate times, to address this unmet need. Providing a continuity of care from antenatal services, including prevention of mother-to-child transmission (PMTCT) of HIV, delivery and postpartum care can ensure that women's health and fertility intentions are more likely to be effectively met [15].

To improve the quality of postnatal care, the Ministry of Health (MOH) in Kenya increased both the recommended timing and content of postnatal services a women and her infant should receive to at least three assessments within the first 6 weeks after childbirth (within 48 h, 1–2 weeks and at 6 weeks. The study assessed whether the introduction of postnatal package of care contributes to improved counselling on essential maternal and newborn health and family planning.

Methods

Intervention description

The new Kenya comprehensive postnatal care package and job aid (checklist to aid providers) were developed by the Division of Reproductive Health (DRH), MOH, ACCESS-FP/Jhpiego and FRONTIERS/Population Council. These tools aim to increase provider awareness of the need to focus on providing the continuum of care from pregnancy to labour and childbirth and through to the postnatal period to ensure both mother and newborn survive. Table 1 summarizes the content of the postnatal care package which incorporates relevant maternal and newborn healthcare services in the postnatal period as well as postpartum family planning.

Table 1

Timing and content of the new postnatal-family planning package of care in Kenya

Timing of assessment or visit Services for the mother Services for the baby 
Assessment 1: pre-discharge (or within 48 h if delivered at home) Focused physical examination Exclusive breastfeeding 
 Counselling and support on: exclusive breastfeeding and lactational amenorrhoea method (LAM); healthy timing and spacing of pregnancies (HTSP) and family planning; maternal danger signs and management of complications. Essential newborn care 
 HIV and syphilis tests as indicated Newborn physical exam 
 Refer to HIV management units for follow up as indicated Newborn danger signs and management of complications 
 Appointment for next visit Nevirapine as indicated 
  Appointment for next visit 
Assessment 2: 2 weeks at MCH clinic Physical check Essential baby care 
 Maternal danger signs and management of complications Baby danger signs and management of complications 
 Counselling on: HTSP messages; return to sexual activity; return to fertility; LAM and family planning counselling and services Immunization 
 Appointment for next visit EBF 
  Physical examination 
  Appointment for next visit 
Assessment 3:6 weeks at MCH clinic Focused physical examination Essential baby care 
 Maternal danger signs and management of complications Danger signs and management of illnesses 
 LAM users—supportive counselling including transition Immunization 
 HTSP messages Physical examination 
 Return to fertility and sexual activity EBF 
 Family planning counselling and services (refer women for methods not available at Health Centres) Cotrimoxazole at 4 week as indicated 
 Dual method use Appointment for next visit 
 Return visit  
Timing of assessment or visit Services for the mother Services for the baby 
Assessment 1: pre-discharge (or within 48 h if delivered at home) Focused physical examination Exclusive breastfeeding 
 Counselling and support on: exclusive breastfeeding and lactational amenorrhoea method (LAM); healthy timing and spacing of pregnancies (HTSP) and family planning; maternal danger signs and management of complications. Essential newborn care 
 HIV and syphilis tests as indicated Newborn physical exam 
 Refer to HIV management units for follow up as indicated Newborn danger signs and management of complications 
 Appointment for next visit Nevirapine as indicated 
  Appointment for next visit 
Assessment 2: 2 weeks at MCH clinic Physical check Essential baby care 
 Maternal danger signs and management of complications Baby danger signs and management of complications 
 Counselling on: HTSP messages; return to sexual activity; return to fertility; LAM and family planning counselling and services Immunization 
 Appointment for next visit EBF 
  Physical examination 
  Appointment for next visit 
Assessment 3:6 weeks at MCH clinic Focused physical examination Essential baby care 
 Maternal danger signs and management of complications Danger signs and management of illnesses 
 LAM users—supportive counselling including transition Immunization 
 HTSP messages Physical examination 
 Return to fertility and sexual activity EBF 
 Family planning counselling and services (refer women for methods not available at Health Centres) Cotrimoxazole at 4 week as indicated 
 Dual method use Appointment for next visit 
 Return visit  

To introduce the postnatal care package, a 3 day training took place for staff and their supervisors from the maternal and child health clinics and maternity units from four health facilities in one district. Initially, 24 providers from the selected facilities were oriented in the postnatal care package, as well as in the use of a new postnatal register recently released by the MOH. Subsequently, the MOH requested a further 52 providers to be trained from other health facilities in the district. Regular supportive supervision visits were made to the four health facilities to assess knowledge, application of that knowledge and skills learned, and to resolve gaps identified during the visit.

Study design

A pre–post intervention cross-sectional design was used to assess any changes in the quality of counselling for postnatal care before (September 2006) and after (July 2007) the introduction of the new postnatal care package. The four health facilities in Embu district, Eastern Province, Kenya were purposefully selected according to specific criteria which included the provision of: focused antenatal care, PMTCT, family planning and counselling and support for infant feeding.

Direct observation of client–provider interactions were used to measure quality of postnatal care. The 48 h and 2 weeks consultations were not routine prior to the intervention and so none was observed pre-intervention. The 6-week routine consultations were observed both before and after the intervention. Observations of the cross-sectional client–provider interactions were carried out concurrently in maternity and maternal and child health/family planning units during the same time period with cross-sectional samples of women for each category at 48 h (post-intervention only: n = 29), 1–2 weeks (post-intervention only: n = 64) and 6 weeks (pre-intervention: n = 86 and post-intervention: n = 70). All women attending for postnatal services during the data collection period were approached and requested for permission to observe their consultation. Data collectors were qualified midwives from outside the study district, trained for 5 days and included role playing to internalize the data collection instruments. Supervisors checked all completed instruments for data quality and accuracy prior to data entry and analysis.

Data were entered using Epidata and exported to SPSS for analysis. The indicator/summary scores were obtained as the additive sum of items/variables representing specific aspects of postnatal care (e.g. essential newborn care and essential maternal care including return to fertility and family planning) observed during consultations with the clients. Distinct variables and indicator scores were tested using Wilcoxon–Mann–Witney test to determine the significance of differences between the pre- and post-intervention results at 6 weeks; this was after confirming that the normality assumption of the two-independent samples t-test failed. A P-value of less than or equal to 0.05 was used as the threshold for significance. This method was used to demonstrate overall improvements in quality of care rather than individual aspects of care.

Results

The quality of care was assessed on the basis of counselling for essential newborn and maternal health. Tables 2 and 3 outline the detail of the key indicators used for compiling the composite scores for newborn and maternal care, respectively.

Table 2

Provider interaction with mother on newborn care

Provider observed asking about newborn danger signs 48 h After delivery 2 Weeks after delivery 6 Weeks after delivery
 
 Post-intervention (n = 29) (%) Post-intervention (n = 64) (%) Pre-intervention (n = 86) (%) Post-intervention (n = 70) (%) Percentage point difference (%) P-valuea 
Difficulty breathing 38 45 17 41 +24 0.001** 
Poor or no feeding 79 58 20 23 +3 0.723 
Baby feels too hot or cold 62 44 19 47 +28 0.000** 
Provider counsels on 
 Breathing difficulty 45 41 39 +34 0.000** 
 Feeding difficulties 62 56 12 50 +38 0.000** 
 Temperature control 62 58 50 +42 0.000** 
 Advises on infant feeding 100 97 59 97 +38 0.000** 
 Re-emphasize exclusive breastfeeding 100 92 51 75 +24 0.006** 
 Encourage mother to discuss management 82 56 32 56 +24 0.003** 
Provider administers 
 Polio 100 36 68 94 +26 0.0003** 
 HBV/DPT — — 58 88 +30 0.0002** 
 BCG 100 38 11 08 0.6138 
Provider observed asking about newborn danger signs 48 h After delivery 2 Weeks after delivery 6 Weeks after delivery
 
 Post-intervention (n = 29) (%) Post-intervention (n = 64) (%) Pre-intervention (n = 86) (%) Post-intervention (n = 70) (%) Percentage point difference (%) P-valuea 
Difficulty breathing 38 45 17 41 +24 0.001** 
Poor or no feeding 79 58 20 23 +3 0.723 
Baby feels too hot or cold 62 44 19 47 +28 0.000** 
Provider counsels on 
 Breathing difficulty 45 41 39 +34 0.000** 
 Feeding difficulties 62 56 12 50 +38 0.000** 
 Temperature control 62 58 50 +42 0.000** 
 Advises on infant feeding 100 97 59 97 +38 0.000** 
 Re-emphasize exclusive breastfeeding 100 92 51 75 +24 0.006** 
 Encourage mother to discuss management 82 56 32 56 +24 0.003** 
Provider administers 
 Polio 100 36 68 94 +26 0.0003** 
 HBV/DPT — — 58 88 +30 0.0002** 
 BCG 100 38 11 08 0.6138 

aP-value is derived from a Wilcoxon–Mann–Whiney test.

**P < 0.01 between pre- and post-intervention at 6 weeks.

Table 3

Maternal indices in postnatal clinic

Maternal indices 48 h After delivery 2 Weeks after delivery 6 Weeks after delivery
 
Provider asks about Post-intervention (n = 29) (%) Post-intervention (n = 64) (%) Pre-intervention (n = 86) (%) Post-intervention (n = 70) (%) Percentage point difference P-valuea 
Bleeding since birth 76 61 39 +37 0.001** 
Colour/smell of vaginal discharge 93 72 17 41 +24 0.001** 
Condition of perineum 24 36 21 +21 0.000** 
Fever 38 33 20 +19 0.000** 
Provider carries out examination 
 Observe general appearance 97 92 42 70 +28 0.001** 
 Take temperature 79 49 49 +42 0.000** 
 Take pulse 34 24 32 +31 0.000** 
 Take blood pressure 100 83 34 75 +41 0.000** 
 Check eyelids and palms for pallor 41 67 35 52 +17 0.033* 
 Examine breasts/nipples 97 75 34 52 +18 0.022* 
 Palpate abdomen for uterine involution 100 75 35 52 +17 0.033* 
Provider counsels on 
 Return to sexual activity 69 50 16 45 +29 0.000** 
 Return to fertility 83 49 32 67 +35 0.000** 
 Family planning 86 83 12 40 +28 0.000** 
 Healthy timing and spacing of pregnancies 86 – 40 +33 0.000** 
 STI symptoms/signs – 13 02 07 +5 0.1369 
 Effects of STI/HIV in PP period – 17 06 15 +7 0.0643* 
 Presence of STI/HIV symptoms – 10 02 03 +1 0.8096 
 STI/HIV risk factors 21 14 07 18 +11 0.0405** 
 Any signs of STI/HIV risk factors 17 10 05 04 −1 0.9344 
 STI/HIV prevention 17 21 07 24 +17 0.0035** 
 Use of condoms 21 14 08 18 +10 0.0743* 
 Partner testing 79 37 13 26 +13 0.0451** 
Maternal indices 48 h After delivery 2 Weeks after delivery 6 Weeks after delivery
 
Provider asks about Post-intervention (n = 29) (%) Post-intervention (n = 64) (%) Pre-intervention (n = 86) (%) Post-intervention (n = 70) (%) Percentage point difference P-valuea 
Bleeding since birth 76 61 39 +37 0.001** 
Colour/smell of vaginal discharge 93 72 17 41 +24 0.001** 
Condition of perineum 24 36 21 +21 0.000** 
Fever 38 33 20 +19 0.000** 
Provider carries out examination 
 Observe general appearance 97 92 42 70 +28 0.001** 
 Take temperature 79 49 49 +42 0.000** 
 Take pulse 34 24 32 +31 0.000** 
 Take blood pressure 100 83 34 75 +41 0.000** 
 Check eyelids and palms for pallor 41 67 35 52 +17 0.033* 
 Examine breasts/nipples 97 75 34 52 +18 0.022* 
 Palpate abdomen for uterine involution 100 75 35 52 +17 0.033* 
Provider counsels on 
 Return to sexual activity 69 50 16 45 +29 0.000** 
 Return to fertility 83 49 32 67 +35 0.000** 
 Family planning 86 83 12 40 +28 0.000** 
 Healthy timing and spacing of pregnancies 86 – 40 +33 0.000** 
 STI symptoms/signs – 13 02 07 +5 0.1369 
 Effects of STI/HIV in PP period – 17 06 15 +7 0.0643* 
 Presence of STI/HIV symptoms – 10 02 03 +1 0.8096 
 STI/HIV risk factors 21 14 07 18 +11 0.0405** 
 Any signs of STI/HIV risk factors 17 10 05 04 −1 0.9344 
 STI/HIV prevention 17 21 07 24 +17 0.0035** 
 Use of condoms 21 14 08 18 +10 0.0743* 
 Partner testing 79 37 13 26 +13 0.0451** 

aP-value derived from a Wilcoxon–Mann–Whiney test.

*P < 0.05 between pre- and post-intervention at 6 weeks only.

**P < 0.01 between pre- and post-intervention at 6 weeks only.

Newborn care

The four key indicators making up essential newborn care include asking about danger signs in the newborn, counselling on danger signs in the newborn specific to the early postnatal period, immunizations received by infant and counselling on infant feeding (Table 2).

During the 48 h consultations, providers were more likely to ask mothers if their newborns had problems in feeding or if the baby felt too hot or too cold than at 2 or 6 weeks. At the 2 weeks consultation, around half of the providers asked about the three dangers signs. During the 6 weeks consultations although significant improvements were noted post-intervention, less than half of the providers asked if the infant had problems in breathing or had a fever or not. Mothers were most frequently counselled on feeding difficulties and temperature control within 48 h of birth and the 2 weeks consultation. Comparisons between the pre- and post-intervention groups at the 6 weeks consultation showed significant increases after the intervention for counselling on the three key indicators.

During all consultations on the postnatal ward, newborns were observed receiving Polio 0 vaccine and BCG, although fewer were observed receiving BCG and Polio at 2 weeks. These were mothers who had not delivered in a facility and were making their first visit following childbirth. After the intervention, providers at the 6 weeks consultation were much more likely to administer Polio 1 and HBV/DPT/Pentavalent.

In all consultations within 48 h, providers gave advice to mothers on infant feeding and frequently encouraged a discussion on how they were managing the feeding. In subsequent consultations, advice on breastfeeding and re-emphasis on exclusive breastfeeding remained high across the time period. Even though the overall scores almost doubled for the quality of newborn healthcare observed during the client–provider interactions at 6 weeks (Table 4), the post-intervention scores remained lower than desired.

Table 4

Comparison of mean summary quality of care scores for maternal and infant health observed during the 6 weeks consultations

Summary indices Pre-intervention (n = 86) Post-intervention (n = 70) 
 Mean score Mean score 
Maternal health 
 Asking about danger signs since childbirth (0–4)** 0.34 1.11 
 Physical examination conducted (0–7)** 1.88 3.79 
 Counselling on HIV/STIs* (0–8) 0.51 1.15 
 Family planning (0–4)** 0.53 1.7 
Total quality of care index for postpartum woman (0–23)** 3.26 8.27 
Infant health 
 Counselling on possible danger signs (0–3)** 0.24 1.39 
 Counselling on infant feeding (0–3)** 1.33 2.19 
 Immunizations received (0–2)** 1.25 1.76 
Total quality of care index for newborn (0–11)** 3.37 6.45 
Summary indices Pre-intervention (n = 86) Post-intervention (n = 70) 
 Mean score Mean score 
Maternal health 
 Asking about danger signs since childbirth (0–4)** 0.34 1.11 
 Physical examination conducted (0–7)** 1.88 3.79 
 Counselling on HIV/STIs* (0–8) 0.51 1.15 
 Family planning (0–4)** 0.53 1.7 
Total quality of care index for postpartum woman (0–23)** 3.26 8.27 
Infant health 
 Counselling on possible danger signs (0–3)** 0.24 1.39 
 Counselling on infant feeding (0–3)** 1.33 2.19 
 Immunizations received (0–2)** 1.25 1.76 
Total quality of care index for newborn (0–11)** 3.37 6.45 

Wilcoxon–Mann–Witney test used.

*P < 0.05 between pre- and post-intervention at 6 weeks.

**P < 0.01 between pre- and post-intervention at 6 weeks.

Maternal care

After the intervention providers were expected to ask postpartum women if they have experienced any problems since birth, and to counsel women on potential signs of complications. These included bleeding since birth, colour/smell of vaginal discharge, condition of perineum/caesarean section scar, signs of thrombophlebitis. For the majority of consultations within 48 h and 2 weeks of delivery, women were asked about any bleeding since birth, the colour and smell of their lochia, although few asked about the condition of the perineum or signs of thrombosis (Table 3).

Most providers were observed counselling or giving messages to the mother at 48 h on the possible danger signs: excessive bleeding, foul smelling vaginal discharge and poor healing of perineum. During the consultations on the postnatal ward, all women had their blood pressure taken, four-fifths their temperature taken, but only one-third had their pulse measured. All postpartum women were palpated for uterine involution and virtually all were given a full physical examination.

In less than one-fifth of the consultations within 48 h were risk factors on prevention of sexually transmitted infections including HIV and condom use discussed, although providers did discuss the importance of partners counselling and testing for HIV during most of the consultations. At the 2 weeks consultations, providers were not likely to counsel on sexually transmitted infections/HIV risks, but some improvements were observed following the intervention at the 6 weeks consultations (Table 3).

Among women counselled on family planning, two or more methods were discussed in three quarters of the 48 h consultations and in two-thirds of the 2 and 6 weeks consultations. The majority of women (n = 64) chose a family planning method (83%) during the 2 week consultation. There was a significant increase from 35% (n = 86) to 63% (n = 70) where women were observed choosing a family planning method at 6 weeks. After the intervention, the lower level of family planning uptake during the 6 week visit than the 2 week visit (63 vs. 84%) is probably because many women attending the 6 weeks consultation had already received a family planning method before leaving the health facility after birth or during the 2 weeks visit. At the 2 weeks consultations, only 16% of the women observed were not using any form of family planning. Two-thirds of those practicing family planning at 2 weeks were using the lactational amenorrhea method (LAM), although few (4%) used a condom as well as LAM. Other methods used at 2 weeks included implants (4%), vasectomy (2%) and condoms (4%).

Table 4 compares the mean summary of quality of care for mothers and infants observed at 6 weeks both before and after the intervention. Overall, the total quality of care score doubled. The improvements in all aspects of quality of care are highly encouraging, but given the poor level of care found during the pre-intervention assessments the composite score after the intervention still falls short of the level desired.

Discussion

This study sought to assess the quality of counselling following the introduction of an improved postnatal package that included postpartum family planning. The package incorporated essential maternal and newborn care in the first days after childbirth and at the same time provided opportunities to inform and provide appropriate family planning advice and methods (according to the breastfeeding status and time postpartum) at several points in time within 48 h, 1–2 weeks and at 6 weeks.

The comprehensive postnatal package was effective in improving the performance of most providers in the key component services of the postnatal care package, especially in terms of postpartum family planning. Significant improvements were noted in counselling for family planning and return to fertility at 6 weeks; an increase in the use of LAM immediately post-delivery and at 6 weeks; and use of the intra-uterine device at 6 weeks postpartum. The overall scores for quality of care remained relatively low but this was probably because the quality of care scores identified before the intervention was introduced were lower than had been anticipated. This conforms to study findings in Lesotho [15] and Swaziland [16]. Although all providers observed during this study provided services to postpartum women within their facilities, a number had not been trained in the formal Kenya family planning/reproductive health training program, indicating a nationwide gap that needs addressing. The weaker aspects of comprehensive postnatal care need increased attention. It is recommended that a strategy to roll out the package is implemented in line with the National Reproductive Health Policy (2007).

The void of comparable relevant data for programmes reveals the lack of systemic implementation of a postnatal package. Globally, there are no consistently measured indicators of effectiveness for postnatal care [4, 12]. Apart from measuring the number of births that take place at home, the postnatal indicators in demographic health surveys give no information on the content or quality of a postnatal care visit. There have been no major studies, such as the multi-country studies carried out for focused antenatal care or the use of magnesium sulphate for management of severe pre-eclampsia and eclampsia, to identify the optimum timing and delivery of integrated postnatal services that include all aspects of essential maternal and newborn care and family planning [4].

In Kenya, to raise the standard of care still further, the postnatal care training package would benefit from having a stronger clinical skills component for managing maternal and newborn complications. The process of expanding postnatal care availability will require further consultation with and inclusion of key actors, which provides the opportunity for engaging with the pre-service training institutions and professional bodies to ensure institutionalization and standardization of targeted postnatal care. Linkages with PMTCT services, community strategies, as well as using focused antenatal care as the platform for strengthening the continuum of care are essential next steps [17]. In fact, the second prong of PMTCT (prevention of unintended pregnancies) is often ignored; therefore this comprehensive package goes someway to address the family planning needs of postpartum women living with HIV. Nevertheless, additional studies looking at the postpartum family planning needs for women living with HIV would be useful.

When addressing the gaps in quality of postnatal service provision, it is important to strengthen community linkages to continue the momentum towards creating awareness about the new postnatal consultations and services; the need to co-opt critical actors, such as male partners and mothers in law, community leaders and health committees, community midwives, and community health workers [18] is also crucial.

Although the health facilities are typical of those found across Kenya, this study had some limitations. The contraceptive prevalence rate in Eastern Province is ∼51% (with use of modern methods at 38%), which is higher than the national rate of 39% (modern methods 32%) [13]. The client–provider observations of postnatal care–family planning services for 48 h were only recorded at the maternity unit for the post-intervention group. Observations of services for the 2, 6 weeks and 6 months visits included clients that delivered at home who might have different needs or characteristics to women who delivered at the hospital.

The introduction of new comprehensive postnatal care package improved performance of providers in counselling in maternal and newborn complications, infant feeding and family planning. However because this is a generally neglected area, providers would benefit from additional clinical skills for managing maternal and newborn complications during the critical period following childbirth.

Funding

This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement Number HRN-A-00-98-00012-00 and Subproject number 5800 53108. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Acknowledgements

The study would not have been possible without the support of the Annie Gatito and Mary Githitu of the Division of Reproductive Health, Ministry of Public Health and Sanitation. We also acknowledge all women who gave us their time for the study. Special thanks go to Ian Askew of Population Council and Cat McKaig and Holly Blanchard of ACCESS-FP for their thorough review of earlier drafts.

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