The week of Thanksgiving, 2015, was warm and dry in Botswana as the season turned toward full winter that is, full summer, here in the Southern Hemisphere). I am fortunate to have this time for fieldwork experience with the Botswana-UPenn Partnership, the Fellowship in Family Planning, and the Penn Master of Public Health program, immersed in women’s health care in Gaborone, the country’s capitol city under the mentorship of Dr. Chelsea Morroni.
Maternal and child health, particularly cervical cancer prevention and pregnancy planning, has been a key issue here. Botswana has been strongly affected by the HIV/AIDS epidemic, with 23% of the adult population infected, including 30.4% of reproductive-age women. Human Papilloma Virus (HPV) co-infection has made cervical cancer the leading cancer among women. The Cervical Cancer Prevention Program (CCP), established by Dr. Doreen Ramogola-Masire at Princess Marina Hospital, provides excision of precancerous lesions of the cervix for women referred from one of several cervical cancer screening clinic sites in Gaborone. The Women’s Health Clinic at PMH provided care to over 1300 reproductive age women in 2014, only 10% of whom were using a World Health Organization (WHO) tier 2 or 3 (moderately effective) contraceptive method, and CCP is a well-established and widely accepted part of preventative health care in Botswana.
In fact, unintended pregnancy is estimated at 44-50% of all pregnancies in Botswana, even though the Ministry of Health provides free family planning services. A significant barrier is that family planning services are not available in many gynecology clinics, including the CCP sites; women must visit a specific FP clinic for contraception. Visits to both clinics cannot be done the same day, due to scheduling conflicts. Women who lack access to education or are from rural areas have borne the brunt of the burden of unmet contraceptive need in Botswana: although they have been able to receive care through the CCP, making the long journey to Gaborone on a separate day to obtain family planning has limited contraceptive access and service utilization.
My visit is focused on the initial steps for integration of cervical cancer prevention and family planning services. During my stay, I am working with key stakeholders who lead the CCP clinics, provide expert family planning consultation to the Ministry of Health, and direct the inpatient and outpatient OB/GYN services at Princess Marina Hospital. I am training the CCP staff on contraceptive counseling and intrauterine device (IUD) and contraceptive implant insertions, based upon the WHO’s Decision-Making Tool for Family Planning Clients and Providers.
This work will form the foundation of an upcoming clinical intervention and implementation study. The study will assess the acceptability and feasibility of incorporating family planning services into CCP care, and will measure the effectiveness of the contraceptive counseling, plus on-site IUD and implantS availability, on uptake of highly effective contraceptive methods for women seeking cervical cancer prevention who wish to delay pregnancy.
The “IUD at CCP” program will help fill the gap in contraceptive access in Botswana, by focusing on the importance dual method use (condoms for HIV prevention plus a highly effective contraceptive method for women not seeking pregnancy) at the time of cervical cancer screening. This will bring services to a setting that is convenient for the women with the highest need. Provider training in contraceptive counseling, and clinical training in IUD insertion techniques, as begun with this work, lays the groundwork for this program. A long-term, comprehensive implementation strategy including ongoing community education and garnering of public buy-in, with continuing provider trainings in shared-decision making and IUD and implant insertion techniques, will be needed for the continuing growth and success of this program.
It is my hope that I, and future public health practitioners and physicians, will be able to visit the warm, welcoming city of Gaborone in coming years, to participate the growth and witness the success of the IUD at CCP program.
Written by Elizabeth Gurney, MD, 2nd year Family Planning Fellow at the University of Pennsylvania