Association for Public Policy Analysis & Management

Motivation: Over half of women receiving abortions in Nepal want to delay their next pregnancy by at least two years, but few leave health clinics with a contraceptive method post-abortion. Long acting reversible contraceptives (LARCs) are an effective way to extend gaps between pregnancies, yet uptake at Sunaulo Parivar Nepal (SPN)/Marie Stopes Nepal (MSIN), one of Nepal’s largest nongovernmental sexual and reproductive health (SRH) service providers, was low (22.6%). On the basis of extensive consultation with SPN stakeholders, providers, and clients across its 36 SRH centers, we determined that appropriate post-abortion family planning (PAFP) counseling by providers is a key determinant of a woman’s choice to take up LARC. While providers are intrinsically motivated to help clients, they do not consistently offer PAFP counseling because they tunnel on their primary roles as abortion providers, and have no benchmark for their performance administering PAFP methods relative to peers.

Intervention: We developed a peer-comparison tool allowing providers to benchmark their performance administering PAFP to that of other centers. Participating clinics received a poster prominently displaying the clinic’s LARC PAFP uptake rate, contextualized as either “high,” “low,” or “lowest” relative to other clinics with similar characteristics (number of staff, geographic location, client flow, etc.). Staff at high-performing clinics were commended as role models, while staff at low-performing clinics were prompted to think about ways to improve. The poster was updated and resent monthly with data from the previous month.

Methodology: We conducted a provider-level, stepped-wedge randomized controlled trial in which SPN/MSIN’s 36 clinics were randomly assigned to receive the intervention at one-month intervals over a seven-month period from July 2016 to January 2017 (sample size, n=17,149 safe abortion clients). Data were collected through existing medical records.

Results: The intervention increased LARC uptake by 6.96 percentage points [95% CI: 1.3 to 12.7, p-value < 0.05], which represents an increase of 32% from the control group baseline. We find that this behavior change occurs by cleints switching from short-acting to long-acting methods, instead of increasing LARC rates by reducing the proportion of clients receiving no contraceptive method. In addition, the effect is driven almost entirely by those receiving surgical abortion, a group that both present in the clinic for longer duration and has already gone through an invasive medical procedure, rather than by those receiving a non-invasive medical abortion (i.e., an oral abortaficient). Moreover, our analysis shows that there was no substitution of services such that the increase in LARC uptake did not crowd out the provision of other types of care.

Conclusion: Interventions employing social benchmarking have proven effective in other health and retail settings, and the current study suggests that giving SRH service providers timely and salient feedback on their performance relative to their peers is an effective way to improve provision of PAFP. A participatory behavioral approach to research can identify client- and provider-side barriers to desired health outcomes and guide the design of effective interventions to improve provider efficacy.