Understanding Feasibility and Acceptability of Implementation of Linking Delivery of Family Planning and Infant Vaccination Care in Rural Maharashtra, India: A Qualitative Study

"A gender-transformative intervention that addresses gender and social norms has greater potential to impact reproductive autonomy and couples' contraceptive decision-making."

India's Ministry of Health and Family Welfare offers monthly childhood vaccination services at Village Health and Nutrition Days (VHNDs). These services are routinely used by families of infants, which provides an opportunity to reach postpartum women and couples. This study sought to understand community and provider perceptions of the feasibility and acceptability of community-based delivery of family planning at the time of infant vaccination in rural Maharashtra, India. The goal was to engage potential users of the intervention to inform an implementation strategy that is responsive to the needs of their community.

From March to May 2022, the researchers conducted 60 semi-structured interviews with key stakeholders including: postpartum married women aged 20-31 (n = 20), husbands aged 27-42 (n = 10), and mothers-in-law (n = 10) of postpartum women; frontline healthcare workers (auxiliary nurse midwives (ANMs) and Accredited Social Health Activists (ASHAs) (n = 10); and community leaders (village panchayat leaders, physician medical officers, and managers in non-governmental organisations engaged in delivery of family planning in the region) (n = 10). The researchers used the Consolidated Framework for Implementation Science Research (CFIR) to structure the interview guide and analysis, focusing on the five key domains: (i) inner setting (i.e., the culture, available resources, and implementation climate); (ii) outer setting (i.e., political and organisational context where the intervention occurs); (iii) intervention characteristics (i.e., features of the intervention that affect implementation such as cost, strength of the evidence for the intervention, adaptability); (iv) participant characteristics (i.e., attitudes and preferences of the intervention participants); and (v) the process of implementation (i.e., planning, leadership, and execution of the intervention).

Three major themes emerged:

1. Social fertility and gender norms, including son preference and male control over contraceptive decision-making, influence postpartum contraceptive access and choice. Family members, particularly mothers-in-law, influenced couples' contraceptive decision making. Women sometimes chose to use contraception covertly or without involving their husband in the decision.

Per the researchers, family planning interventions in rural India should address community social norms, be inclusive of husbands and mothers-in-laws, and also engage men in the process of family planning decision making. An intervention aimed at meeting the reproductive health needs of women in India should consider gender-equity-informed family planning counseling that engages women and communities on issues related to reproductive autonomy and the value of women and girls in society. It is important that this counseling is accessible to couples with a wide range of educational attainment.

2. Linking contraceptive care and infant vaccination is perceived as potentially feasible and acceptable to implement by families, health workers, and community leaders. Multiple ASHAs and ANMs shared concerns about privacy when doing contraceptive counseling during home visits and reported that the vaccination camps could be a more ideal place to provide contraceptive care. Most participants agreed that the intervention would be beneficial to community.

The findings suggest that co-locating the services in the vaccination camp setting potentially offers an opportunity to reach postpartum women outside of their homes or health clinics where they are in their communities. Providing postpartum contraception at the infant vaccine visit leverages the frequent infant vaccine dosing schedule, which includes three vaccine visits that occur over an eight-week period, allowing for multiple opportunities for contact to support women and couples in shared decision-making around family planning after birth. Offering the option of multiple opportunities to engage with family planning providers could remove perceived barriers to contraception use in the postpartum period.

3. Barriers and facilitators to linked infant postpartum contraception and infant vaccination were identified across the five CFIR domains. Key barriers included limited staff and space (inner setting) and contraceptive method targets for clinics and financial incentives for clinicians who provide specific methods (outer setting). Key facilitators included convenience of timing and location for families (intervention characteristics), the opportunity to engage husbands in decision-making when they attend infant vaccination visits (participant characteristics), and programmatic support from governmental and community leaders (process of implementation). Many women and husbands recommended the use of media in order to inform the community about the intervention and family planning methods available in advance of the vaccine camp: promoting the programme through the ASHAs during prenatal care, through posters in community centres, and even via television, newspapers, and social media to generate both awareness and acceptance of the intervention.

Engaging participants in intervention design, including different levels of healthcare personnel and community members, allowed the researchers to identify multilevel barriers and facilitators to linked infant vaccination and postpartum family planning. For example, the interviews highlighted that private space for family planning counseling and care must be set aside from the vaccination area to facilitate delivery of respectful high-quality family planning care. In addition, the data suggests that engaging community leaders, such as the gram panchayat, will be vital to successful community integration.

Thus, this study found that linked provision of family planning and infant vaccination care may be feasible and accessible in rural India, utilising strategies identified to reduce barriers and facilitate provision of care. "These findings have the potential to guide implementation of an innovative patient-centered gender-transformative family planning intervention which increases access to contraception for postpartum women with unmet need."