title: Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions.
abstract: BACKGROUND
  Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society--Pakistan implemented an operational research project--'Evidence for Innovating to Save Lives', to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan.
  
  
  METHODS
  We conducted a quasi-experimental (pre- and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, (1) Suraj model (meaning 'Sun' in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and (2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model.
  
  
  RESULTS
  The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14% percentage points, current contraceptive use by 5% percentage points and long term modern method--intrauterine device (IUD) use by 6% percentage points. The CMW model significantly increased contraceptive awareness by 28% percentage points, ever use of contraceptives by 7% percentage points and, IUD use by 3% percentage points. Additionally the Suraj intervention led to a 35% greater prevalence (prevalence ratio: 1.35, 95% CI: 1.22-1.50) of contraceptive use among MWRA.
  
  
  CONCLUSIONS
  Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.
authors.affiliation: Department of Urogynecology, University of Ghent, Ghent, Belgium. syedkhurram.azmat@ugent.be.|The Hospital for Sick Children, Toronto, Ontario, Canada. syedkhurram.azmat@ugent.be.|Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan. syedkhurram.azmat@ugent.be.
authors.forename: Syed Khurram
authors.initials: SK
authors.lastname: Azmat
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Waqas
authors.initials: W
authors.lastname: Hameed
authors.affiliation: Freelance Public Health Professional, Adelaide, South Australia, Australia.
authors.forename: Hasan Bin
authors.initials: HB
authors.lastname: Hamza
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Ghulam
authors.initials: G
authors.lastname: Mustafa
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Ishaque
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Ghazunfer
authors.initials: G
authors.lastname: Abbas
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Omar Farooq
authors.initials: OF
authors.lastname: Khan
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Jamshaid
authors.initials: J
authors.lastname: Asghar
authors.affiliation: Research, Monitoring and Evaluation Department, Marie Stopes International, London, UK.
authors.forename: Erik
authors.initials: E
authors.lastname: Munroe
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Safdar
authors.initials: S
authors.lastname: Ali
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Wajahat
authors.initials: W
authors.lastname: Hussain
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Sajid
authors.initials: S
authors.lastname: Ali
authors.affiliation: Marie Stopes Society, Research, Monitoring and Evaluation Department, Technical Services, Karachi, Sindh, Pakistan.
authors.forename: Aftab
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Moazzam
authors.initials: M
authors.lastname: Ali
authors.affiliation: Department of Urogynecology, University of Ghent, Ghent, Belgium.
authors.forename: Marleen
authors.initials: M
authors.lastname: Temmerman
mesh_terms: D000328:Adult; D001721:Birth Intervals / Q000208:ethnology; D003150:Community Health Workers; D019058:Community Networks; D003267:Contraception / Q000009:adverse effects / Q000191:economics / Q000639:trends; D003268:Contraception Behavior / Q000208:ethnology; D000069216:Contraceptive Prevalence Surveys; D003430:Cross-Sectional Studies; D065246:Culturally Competent Care / Q000208:ethnology; D016656:Family Planning Policy / Q000639:trends; D005193:Family Planning Services / Q000193:education; D005260:Female; D005102:Health Expenditures; D006801:Humans; D007434:Intrauterine Devices / Q000009:adverse effects / Q000191:economics; D008880:Midwifery; D010154:Pakistan; D010353:Patient Education as Topic; D017149:Private Sector; D017150:Public Sector; D012423:Rural Health / Q000208:ethnology; D018454:Spouses / Q000208:ethnology
keywords: Birth spacing; Community midwives; Contraception; Family planning; Rural Pakistan; Suraj; Vouchers