Fistula and Conflict: Reproductive Health in East Democratic Republic of Congo
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by Dr. Nerys Benfield Obstetrician-Gynecologist and Clinical Fellow in Family Planning Bixby Center for Global Reproductive Health, UCSF May 19, 2011
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Fistula and Conflict: Reproductive Health in East Democratic Republic of Congo
- 1. Conflict, Fistula, and Family Planning Eastern Democratic Republic of Congo Nerys Benfield MD University of California, San Francisco
- 2. Objectives • Reproductive health in crisis situations. • Genital fistula - etiology, obstructed labor injury complex, social impact, and methods of treatment and prevention. • Unmet need for family planning in the fistula population.
- 3. Democratic Republic of Congo •Population: 71 million •Per capita GDP 2nd lowest in the world - $171 1877-1960: Belgian royal protectorate then colony •Infamous for atrocities and exploitation in extraction of resources like rubber 1971-97: Zaire • Mobutu authoritarian regime 12th largest country by geographic area in the world
- 4. Eastern DRC - “Africa’s World War” 1996-Present • Directly involved DRC, Rwanda, Burundi, Uganda, Zimbabwe, Namibia, Angola • Estimated 5.4 million conflict-associated deaths in DRC alone • More than 3 million displaced persons Coghlan B Mortality in the DRC. IRC
- 5. History of DRC Conflict 1994: Rwandan genocide 1997: Overthrow of dictatorship of Mobutu Sese Seko Alliance of eastern rebel leader Laurent Kabila with Burundian and Rwandan armies 1998: Alliance falls apart → lawless state with multiple armed groups Land and resource scramble Failed peace accords 1999 2002 2008
- 6. Complex Humanitarian Emergency In DRC: •>150,000 in refugee camps •>2 million internally displaced • 70-80% of refugees are women and children •Social disruption •Armed conflict •Population displacement •Collapse of public health infrastructure •Food shortages UNHCR Global Report DRC 2009 Al Gasseer J Midwif Women Health 2004
- 7. Reproductive Health in Complex Humanitarian Emergencies Waiting for USAID food distribution Fertility rates can increase or decrease McGinn HPN paper 45 2004 •Replace lost children •No access to contraception and safe abortion •Malnutrition •Destruction of family unit •Economic challenges
- 8. • Obstetrical complications • Hemorrhage, infection • Obstructed labor, fistula MMR in Afghanistan 8x MMR of all neighbors Maternal + Neonatal →22% of camp deaths in Pakistan • Unsafe abortion • Little available evidence Burma – 1 in 3 have induced abortion Camps in SSA – increased complications from abortion Maternal Mortality increases
- 9. Gender-based Violence increases • Perpetrators outside the home • Percentage of women raped during conflict • Rwanda 39% >500,000 women and girls • Burundi 25% • East Timor 24% • Kosovo 26% → Decreased to 1% after the conflict
- 10. Reproductive Health in DRC • Healthy life expectancy for women is 39yrs • Estimated Fertility Rate = 6.7/woman • Maternal Mortality Rate = 990/100K – improved from 1837/100K in 2001 • ↑poor pregnancy outcomes with ↑conflict activity
- 11. Sexual Violence in DRC • Total number of women affected is unknown – >40,000 reported rapes by 2004 • Epidemic of Rape - Used as a “weapon of war” to destabilize and intimidate communities - Culture of impunity
- 12. My Research Contraceptive and fertility desires and the impact of contraception counseling in genital fistula patients in Eastern DRC Conflict Large fistula burden Sexual Violence No Healthcare Access to Family Planning Traumatic birth experience
- 13. Research Question • Will the lost years of childbearing and societal acceptance spur women with fistula to desire more children or will the history of serious health sequelae from reproduction lead patients to want to delay further pregnancies. • Are women who would like to defer or limit future childbearing willing to use contraception?
- 14. • 2008: Needs assessment – N=78 – Interviews on history, birth experience, contraceptive and fertility desires • 2010: Contraceptive counseling program and assessment – N=61 – Changes in contraceptive knowledge and use
- 15. Security and Safety Active Conflict Zone • Secure Housing and Transportation – Provided by Congolese NGO HEAL Africa • No travel at night without armed personnel • No travel to rural areas without official permission and appropriate personnel • General Awareness is critical Our night-time armed guard
- 16. Goma Volcano Nyiragongo Massive eruption 2002 - destroyed much of the city - left 120,000 homeless Un- affected area of town
- 17. Genital Fistula • Approximately 3 million women worldwide are suffering from fistula at this time • Occurrence worldwide is 1-2/1000 deliveries • In Africa the incidence of genital fistula is 30,000-130,000 per year. • Clear indicator of health care disparities Wall LL. Lancet 2006
- 18. History of Fistula 2000BC - EGYPT “Incontinence of urine in an irksome place." 1000AD - PERSIA "In cases which women are married too young, and in patients who have weak bladders, the physician should instruct the patient in prevention of pregnancy. In these patients the fetus may cause a tear in the bladder that results in incontinence of urine. The condition is incurable and remains so until death.” 1840s - USA Dr J Marion Sims – early surgical techniques
- 19. Etiology of Fistula Obstructed labor The compression of fetal head against sacrum and symphysis cuts off blood supply leading to pressure necrosis Largest series of women with fistula (N=16380) - 94.4% due to obstructed labor Muleta M, Acta Obstet Gynecol 2010 DRC 2008: 71% obstructed labor, 20% trauma, 9% surgery
- 20. Trauma – Rape and sexual assault – Direct genital trauma DRC 2008: 20% caused by sexual assault DRC 2010: 0% Iatrogenic/surgical – Hysterectomy and cesarean section DRC 2008 - “The soldiers stole me and took me as a wife. I got pregnant. When I had trouble with my labor they cut my baby out with a machete in the forest” Etiology of Fistula
- 21. Risk Factors for Obstructed Labor 1. Pelvis too small – Young age at pregnancy • Large series from Ethiopia and Nigeria >50% had become pregnant before age of 18 • DRC 2008: 63% were pregnant before 18 – Malnutrition 2. Fetus too big – Male fetus – 77% of fistula Moerman ML Am J Obstet Gynecol 1982 Vangeenderhuysen D. Int J Gyncol Obstet 2001. Meyer L. Am J Obstet Gynecol 2007
- 22. Risk Factors for Obstetric Fistula - Average labor - 2-4 days DRC 2008: 25% labored 4-7 days DRC 2010: 60% >5 hours walk from nearest hospital “Since it was my first, they said it is normal for this to take a long time. When they realized it wasn’t going as planned, they tried to find a car but couldn’t. So I went on a donkey cart. The trip took a whole night.” • Lack of Access to Obstetrical Care
- 23. How does conflict affect direct fistula risk factors Conflict ↓ Access to Obstetrical Care ↑ Sexual Violence ↓ Surgical capacity and knowledge Fistula causes Obstructed labor Trauma Iatrogenic
- 24. Genital Fistula Complex • Urological injury • Gynecological injury • Gastrointestinal injury • Musculoskeletal injury • Neurological injury • Dermatological injury • Fetal injury – demise >90%
- 25. Genital Fistula Complex - cont’d • Social injury Social isolation Divorce Worsening poverty Malnutrition Depression and suicide Premature death Goh JT BJOG 2005 112:1328 Browning A Int J Gynecol Obstet Aug 31 2007 Nigeria: 74% were divorced or separated Ethiopia and Bangladesh: 40% had considered suicide DRC 2008: 56% rejected by their community
- 26. Genital Fistula Classification Site Type 1: Distal edge of fistula > 3.5 cm from external urinary meatus Type 2: Distal edge of fistula 2.5 to 3.5 cm from external urinary meatus Type 3: Distal edge of fistula 1.5 to < 2.5 cm from external urinary meatus Type 4: Distal edge of fistula < 1.5 cm from urinary meatus Size (a) Size < 1.5 cm (b) Size 1.5–3 cm (c) Size > 3 cm Scarring (i) No or mild fibrosis around fistula/vagina and/or vaginal length > 6 cm capacity, normal capacity (ii) Moderate or severe fibrosis around fistula/vagina and/or reduced vaginal length and/or capacity (iii) Special consideration, e.g. post-radiation, circumferential fistula, ureteric involvement, The Goh Classification is the most commonly used system.
- 27. Fistula Treatment • Conservative – For recent VVF<1cm Bladder drainage up to 4 weeks Spontaneous healing in 12-80% • Surgical Surgical closure 2-3 layer repair Post-surgical treatment includes bladder drainage for 2-3wks, nothing in vagina for 3 months.
- 28. Fistula Treatment Ethiopia: (N=77) 97% of complex fistulas closed successfully Nigeria: (N=899) 92% successful closure Failure associated with large size, UVJ involvement, scarring Roennenburg ML Am J Obstet Gynecol 2006 195:1748 Surgical closure is generally very successful.
- 29. Fistula Treatment • Bulbocavernosus Flap • Ureteral reimplantation or ileal conduit • Neo-urethra from bladder or labial tissue • Sub-urethral sling Complicated and large fistulas can require more complex surgical techniques Eilber, KS J of urology 2003 Browning A. Int J Obstet Gyencol 2006
- 30. Challenges after Surgical Repair • Post-operative incontinence • Social isolation – Social reintegration – Income-generating skills – Counseling • Fistula recurrence – vaginal delivery after repair → 11% recurrence Murray C. BJOG 2002 Carey MP Am J Obstet Gynecol 2002 MacDonald P Int J Obstet Gynecol 2007
- 31. Fistula Prevention • Avoid Pregnancy Access to Family Planning DRC 2008: 22% fistula- causing pregnancies were undesired Improve the status of women International Women’s Day at HEAL Africa • Safe Delivery Access to Obstetrical Care
- 32. Prevention in Conflict Settings Reproductive Health is often neglected in complex emergencies 1995 - Minimum Initial Service Package for Reproductive Health (MISP) – Set of reproductive health priority actions meant to save lives in an emergency setting – Focus on GBV, HIV, and Safe Delivery – EC and condoms are the only FP methods in acute phase
- 34. Prevention in Conflict Settings Challenges to MISP implementation • Views of governments and aid agencies “We are a catholic agency, conservative. … We don’t need to have reproductive health as a priority because we’ve so many other things to do.” • Multiple priorities • Lack of collaboration • Limited resources • Logisitic difficulties Hakamies N Repro Health Matters 2008
- 35. Heal Africa Congolese NGO • 300 bed hospital • Community education and training programs 1300 fistula repair surgeries since 2004 Hospital Grounds
- 36. Women with Fistula Demographics: (2010) • Age: • 31 [range 16-46] • At time of fistula – 19 [range 12-40] • Access to hospital: • Median distance of 67.75km • 59.3% of women walked >5 hrs [range 10m-3d walking] • Fistula Etiology: – 93% obstructed labor, 7% surgical • Fistula Outcomes: 88% fetal/neonatal demise (71% of women had no live children) 59% divorce or social isolation • Sexual Violence Rate decreased from 70% (2008) to 39% (2010)
- 37. Birth Experience • Birth was experienced as traumatic: DRC 2008: – 67% rated their last birth experience as “terrifying” – 69% afraid they were going to be seriously hurt or die during their last birth DRC 2010: – 96.5% afraid they would be seriously hurt or die during the fistula-causing labor and delivery “I survived only by the grace of God”.
- 38. Post-Repair Intentions DRC 2008: • 47% wanted to wait at least 1 yr • 14% did not want any more children DRC 2010: • 64% wanted to wait at least 1 yr • 18% did not want any more children Reasons for waiting: – 62% time to recover – 15% fear
- 39. Knowledge of contraception was limited DRC 2008: • Only 2 women had ever used contraception • Only 17 had ever heard of contraception DRC 2010: • No woman had ever used contraception • 52.4% had heard of contraception / medicine to prevent or delay pregnancy • Only 24.6% knew any specific methods Condoms, OCPs, Injection
- 40. Contraceptive Intentions • Intent to use contraception was high DRC 2008: • 89% would consider using contraception • Those who had been afraid they were going to die during their last birth were 3.8 times more likely to intend to use or consider using contraception. (p=0.049)
- 41. Contraceptive Counseling • Group contraception counseling Patient demonstrating cycle beads •Slightly modified from post-partum contraceptive counseling sessions •Groups of 10 to 30 women •Twice monthly Available contraceptives: Rhythm beads/fertility awareness method, condoms, combined and progestin-only pills, progestin injection, contraceptive implant(Jadelle),non-hormonal IUD Provided free of charge by UNFPA
- 42. Post-Counseling Contraceptive Knowledge Changes in Contraceptive Knowledge • After counseling: • Only 1 woman could not describe birth control • Average number of methods recalled = 5.2 • Proportion who knew ≥5 methods : 2%→94% Knowledge of modern birth control Knowledge of any specific methods ≥1 question correct for >50% of methods Pre- counseling 52.4% 24.6% 40% Post- counseling 97% 97% 84%
- 43. Post-Counseling Contraceptive Knowledge “I would like to know about these medicines because if you conceive the first time you could die, the second time too… but if you have these medicines to prevent that then you could help someone, save their life.”
- 44. Contraceptive Uptake • Amongst women discharged over the subsequent 3 months – 20% of study participants (5/25) and 3 additional women with fistula left with a modern contraceptive method
- 45. Future Directions • Study expansion currently underway to Panzi Hospital in Bukavu, South Kivu • Presenting findings to UNFPA and funder agencies to advocate for FP access • Working to develop regional systems for continued contraceptive access Onward to Bukavu
- 46. Research Development • New research committee and IRB at HEAL Africa • Clinical research training • Development and supervision of independent research projects - – Portable ultrasound use, prematurity outcomes, C/S DDI, delay in antenatal care,
- 47. Conclusions • Complex emergencies and conflict lead to destruction of the health care system and increased sexual violence which greatly affect women’s lives. • Genital fistula occurs when access to family planning and obstetrical care is limited. • Women with fistula are interested in reproductive control and birth spacing, and will use modern methods if made available.
Notas del editor
- Most populous francophone country in the world Lowest GDP is Burundi – from IMF From World Health stats 2006, although DRC data from 2004 Heart of Darkness Mobutu also became infamous for inequality and exploitation
- Also called First 1996-1997 and Second Congo Wars 1998-present Majority of deaths from preventable causes associated with decimated health and sanitation infrastructure and malnutrition. DRC has it’s own UN mission – MONUC who continue to be present for peacekeeping efforts with over 20K troops Data from UNHCR Most recent large-scale armed conflict - August 2010
- Large-scale conflict began with the horror of the Rwandan genocide in 1994 coupled with disintegration of the regime of Mobutu Sese Seko After Mobutu overthrow, Kabila asked all Tutsis and Rwanda and Burundians to leave DRC so Rwandan, Burundian army and RCD led rebellion. Alliance soon fell apart as ethnic and land tensions rose. The power vacuum along with scramble for natural resources led to a semi-lawless state with multiple armed groups RCD (mainly Tutsi and described as Rwandan-led) MLC and LRA (Ugandan-led rebel groups) FAC (Congolese army ) FDLR, FDD, Interhamwe (mainly Hutu groups, some affiliated with Rwanda or Uganda) Mayi mayi (unaffiliated local Congolese rebel groups)
- A disaster situation characterized by …. There are still 46 refugee camps in North and South Kivu alone 70-80% are women – so how is women’s health and reproductive health affected by conflict situations?
- Conflicts have been assessed in disparate regions like Ethiopia, Beirut, former Yugoslavia, Angola have a difference balance of these factors. Desire to replace lost children…. Malnutrition leading to decreased conception rates While fertility and risk of pregnancy may change in a variety of ways - destruction of the health care system means that pregnancy outcomes are consistently worse.
- 13 of the 20 worst countries for safe motherhood are in or emerging from conflict The affect of prolonged conflict can be seen in Afghanistan where the MMR 2002 was 1600/100K >8x larger than that of any it’s neighbors (excluding Iraq) In Burma during the conflict, 1/3 women reported having induced an abortion via sticks, beating or local herbs Complications from abortion in refugee camps in sub-saharan Africa - 55/1000 live births
- This has also been confirmed in a variety of conflict settings The main increase is seen in assault by perpetrators outside the home, although IPV rates can also increase. Percentage of women who were raped in conflict-affected areas East timor decreased to 6% after conflict Kosovo decreased to 1%
- EFR compares to Africa average of 5.3 – how does this relate to some of the factors we discussed earlier like desire to replace lost children, contraceptive access, and resource limitations. Compare that to MMR in USA of 11 – which is actually quite poor for a well-resourced country Pregnancies in the East were 3 times more likely to end in miscarriage or stillbirth compared to the West Peaks in rate of a poor pregnancy outcome composite coincided with times of heightened conflict activity.
- Reported rape number is likely to be a large underestimate given the isolation and stigmatization of victims, as well as the ineffectiveness of reporting as a way to get justice. There were a number of public billboards against sexual violence like the one you see here. – “All the perpetrators of sexual violence go to jail”
- This leads to my research on the cont and fertility desires….. Within Eastern DRC we see that The Conflict has led to decimation of health care infrastructure decreasing access to obstetrical care and family planning. The war has also led to Increased levels of sexual violence. Both these factors contribute to a large genital fistula burden. The question then arises - How do women with fistula balance some of the issues we addressed before regarding fertility in conflict situations. What role does the previous birth experience and fistula-related medical concerns play. What about family planning access? We sought to determine What is the experience of women with fistula in this conflict situation, and How do they integrate all of these factors into fertility and contraceptive intentions and actions.
- The prevailing wisdom is that fistula patients want to return to childbearing as soon as possible after repair but fertility intentions have not been studied.
- In order to answer these questions we performed two assessments. In 2008 over the course of 5 weeks Verbally-administered questionnaires assessing demographics, obstetrical and fistula history, perceptions of the birth experience, fertility intentions and contraceptive knowledge and intentions. In 2008 over the course of 10 weeks we offered group contraception counseling sessions to fistula patients. Here you can see Nurse Joseph and Counselor Byani talking about the female condom (which always got a good laugh) With pre-counseling and post-counseling verbally-administered questionnaires wer measured changes in contraceptive knowledge. Finally uptake of modern methods of contraception was measured as methods were distributed to interested women at time of discharge.
- Just a brief aside to describe the importance of safety and security when conducting research or working in a conflict situation. Although the situation was much safer during my last visit earlier this year, the level of conflict continues to fluctuate.
- Eruption Jan 17 2002 – killed 45, made 120K homeless and displaced 400K from
- We have previously noted that eastern DRC has a large fistula burden due in part to the effects of conflict, but what is the burden of fistula worldwide. WHO estimates that … Because of it’s relationship to access to obstetrical care, … Health care disparities
- Fistula is as old as labor itself and the primary symptom of urinary incontinence has been noted throughout history. The Kahun Papyrus, The mummy of Queen Henhenit (2050 BC) found to have a VVF Persian physician Avicenna made the first written connection between obstructed labor and VVF. Founder of the American Gynecologic Association Silver wire suture published 1952
- Necrosis then leads to fistulous connections which can occur between any combination of bladder, vagina, rectum, cervix or uterus. Series from Ethiopia
- Let’s discuss these other causes of fistula Assault can cause fistula especially in the very young or when foreign objects are used. In young girls who suffer rape RVF most often seen. 899 women in Nigeria – 21 caused by genital cutting, 4 by trauma Some of the stories we were told were chilling and devastating. Including one fistula in a 9 year old girl who had been assaulted at the age of 4 and another women who had been stabbed repeatedly with a arrow and a knife in the pelvis and abdomen. The decrease in sexual trauma as a fistula cause in this population likely relates to the fact that warring activity has decreased. Although there is still violence in pockets in the region, the situation is much improved. Risk with lack of bladder decompression and poor conditions In wealthy countries 90% of fistulas occur post hysterectomy, primarily abdominal. : In poorer countries c/s is often the culprit and often leads to vesicouterine or vesicocervical fistulas Other Malignancy Foreign body Infection
- Returning to the most common cause of fistula – obstructed labor. What are the risk factors? By definition, either the pelvis is too small or the fetus is too big. The pelvic basin grows continuously through late adolescence. Size of the birth canal is smaller the first 3 years past menarche than at age 18 Married and become pregnant at a young age. The average age of marriage was 15.5yrs. 39% of patients had not yet menstruated at the time of marriage Malnutrition leads to delay in growth and smaller stature. In the large Ethiopian case series 77% had male fetuses.
- While cephalopelvic disproportion leads to obstructed labor, it is lack of access to obstetrical care that turns obstructed labor into obstetrical fistula because timely intervention with cesarean section can prevent fistula formation. Across many series Chart from the Nigerian series
- Let’s review how conflict impacts the fistula burden
- Genital fistula is much more though than just the symptom of urinary or fecal incontinence In fact there can be many injuries that result from the wide damage of obstructed labor – these include things like bladder stones (which can get quite large in this population) renal failure, vaginal stenosis, pelvic and bone infections, neurologic injury like food drop. Fistula is also associated with a high rate of stillbirth typically >90%. Vesicovaginal, urethrovaginal, ureterovaginal, uterovaginal fistula Complex combined fistulas Urethral damage, including complete urethral destruction Bladder stones Stress incontinence Secondary hydroureteronephrosis Chronic pyelonephritis Renal failure Amenorrhoea Vaginal stenosis Cervical injury, including complete cervical destruction Secondary pelvic inflammatory disease Rectovaginal fistula formation Rectal stenosis or complete rectal atresia Anal sphincter incompetence Osteitis pubis Foot-drop from lumbosacral or common peroneal nerve injury Complex neuropathic bladder dysfunction Chronic excoriation of skin from maceration by urine or feces Fetal case-fatality rate >90%
- In some ways though the most damaging injuries are the social effects from fistula. Due to the persistent incontinence and associated odor and hygiene difficulties, women with fistula suffer significantly from divorce and isolation from their families and communities – 70%. The also suffer mental anguish – 40% In DRC we found
- Here you can see what’s probably a 3cii with destruction of the urethral-vesical junction and yellow catheters visible in the ureteral orifices.
- but the outcome is unpredictable Excise fistula border Mobilize bladder wall and vagina Close bladder mucosa, perivesical fascia, and vagina. The mobilization step can be extremely challenging when widespread scarring has taken place.
- We started an electronic database to keep track of the fistula patients at HEAL Africa so success rates at HEAL Africa should soon be available.
- Scarring can be very significant - A number of patients required two large episiotomy incisions to be able to even access the upper vagina / fistula region. Some of our patients were on their 8th or 9th attempt at surgical repair. bulbocavernosus muscle and fat mobilized from labia majora preserving pudendal blood supply and transferred through a tunnel to vagina.
- Even for those in who the fistula is successfully closed there are still significant challenges. In the series of 77 pts from Nigeria Lead-pipe urethra, small bladder capacity, SUI Circumferential fistula → 44% post-op incontinence Simple fistulas → 9.8% Many women are still suffer stigma even after successful repair. Need to generate self-esteem, social capacity Subsequent trauma or delivery can lead to recurrence
- So how do we prevent genital fistula? With regards to the most common cause of obstructed labor The fundamental key though is to Improving the status of women - would decrease young age of pregnancy and marriage, decrease malnutrition, decrease sexual violence, and prioritize reproductive health.
- Reproductive health tends not to be top priority in crisis situations, but we know how deeply conflict and complex emergencies affect women’s health. In 1995 the IAWG=inter-agency working group – a groups of governmental and aid agencies headed by UNHCR and UNFPA
- As you can see family planning falls into objective 5 of the MISP – not even addressed beyond EC until it comes in as part of “comprehensive” RH services.
- Religious – leads to leaving out RH care especially FP, safe ab and PAC. Competition leads to lack of collaboration Limited resources – personnel and money
- HA has been a presence in eastern DRC throughout the conflict. During height of war the founder of HA, Dr Lusi hid from combatants under the operating table – to protect his own life and the surgical equipment. Their community programs include regional safe motherhood and female empowerment initiatives. Gender-based violence counseling, medical and legal services. They also have a large fistula repair program.
- Consistent with other groups of women with fistula.
- 62 women reported that they wanted to wait after fistula repair to have more children. 37.1%(23) wanted to wait 6 months, 22.6% one year, 9.7% 2 years, and 14.5%(9) said they didn’t want any more children. Reasons for waiting, of the 45 respondents who could give a reason, were 7 (15.5%) for fear, 7 because they were told to wait, and 28/45 (62.2%) to give themselves time to recover.
- Only 2/66 (3%) of respondents had ever used contraception (one of whom had had a tubal ligation) and only 17 or 26.2% had ever heard of contraception . OF those who had heard of contraception the most common method was OCPs known by 8 women and condoms and DMPA known by 3 women each.
- Despite low levels of contraceptive knowledge, Intent to use was high.. but would this intention translate into actual contraceptive use?
- This is the question we attempted to answer in the second phase of the study in 2010. After obtaining information on each woman’s history, fertility and contraceptive intentions, and contraceptive knowledge, all fistula patients were offered group contraception counseling sessions.
- We found that contraceptive knowledge improved
- We also found that contraceptive knowledge was valued by women.
- What about actual contraceptive use? 1 progestin injection, 7 OCPs Unfortunately there was an interruption in the supply of implant contraceptives