The effect of a postpartum intrauterine device program on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial.

Vertical global health programs often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum IUD (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster RCT took place in five Tanzanian hospitals. Hospitals were randomised to receive immediate (Group 1; n=11,483 participants) or delayed (Group 2; n=8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n=9786) or unexposed (n=10,145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was seven percentage-points higher among the exposed (95% CI:0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI:0.10, 2.34). Likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on IUD alone was fourteen percentage-points higher among the exposed (95% CI:0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health program planning and implementation. [ABSTRACT FROM AUTHOR]