Abstract
Cameroon exhibits a high level of maternal mortality (roughly 600 per 100,000 live births), partially related to its high total fertility rate (roughly 4.6). Survey evidence furthermore suggests that a significant fraction of pregnancies is unwanted or considered mistimed by the mother, especially among females under the age of 20. Despite this, the rate of utilization of family planning (FP) is low: e.g. only 48% of sexually active unmarried women use any form of (modern) contraception, or MC, and even then, it is primarily condoms. The use of LARCs (long-acting reversible contraceptives, i.e. the IUD and the implant) is less than 1% according to the most recent Demographic Health Survey in 2011.
In this context, the Ministry of Health has convened a team of experts to develop a new curriculum to train health providers on family planning. Furthermore, the study team, in collaboration with local partners, has separately developed a tablet-based application or decision-support-tool to technologically augment this training during the one-on-one family planning counseling sessions. The “app” guides the nurse through the counseling protocol by asking the client a series of questions about her current circumstances, goals, and preferences. It then assists the health provider in recommending the most suitable method(s) for her based on her answers (and the latest clinical knowledge).
Meanwhile, multiple regions in the country have instituted a performance-based financing (PBF) system for the provision of health services. In the case of family planning, clinics are paid a fixed amount for each unit of modern contraception they administer on a quarterly basis. The higher these payments (or subsidies), the greater the incentives for facilities to build demand for FP, either via reduced prices or sensitization and community outreach. Prices may be a barrier especially for adolescents (defined here as ages 15-24), who may not be able to afford contraceptives themselves and may be reluctant to ask parents, partners, or husbands for money to purchase them.
The goal of this study is to evaluate the effectiveness of these interventions – i.e. training health providers on family planning; the introduction off the “app”; and varying payments for contraceptives to facilities – on take-up of modern contraceptive methods and, therefore, incidence of unwanted and mistimed pregnancy rates among adolescent females and young women. We will use a cluster-randomized controlled trial (RCT), clustered at the facility level, with a factorial design to assess the effectiveness of each intervention on its own as well as in combination with the others.
