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Ghana has made great progress in meeting most Millennium Development Goals; 1 however, the country's reproductive health indicators continue to lag. Among married women, use of modern contraceptives is low (23%) and unmet need for family planning remains high (26%). 2 Similarly, the total fertility rate decreased only slightly between 1998 and 2008, from 4.4 to 4.0. 3 As a result, the Ghanaian government has identified increasing contraceptive prevalence as a priority. 4Among the reasons for low use of contraceptives in Ghana are barriers to access, stock-outs and a shortage of trained health staff.5 These problems are more acute in rural areas of the country, where health facilities tend to be few and the distribution chain is often weaker-conditions that contribute to an urban-rural disparity in contraceptive use and unmet need. 3 In addition, access to communitybased family planning services is limited outside of select hard-to-reach areas where nurses have been mandated to provide family planning as part of the Community-Based Health Planning and Services (CHPS) model. CHPS zones are currently being scaled up, but as of 2011, only 22% of the population was being served under CHPS. 6In many countries, private-sector drug shops are the first place people seek health care, especially in areas with few health facilities or pharmacies. [7][8][9][10] In Ghana, such shops are called licensed chemical sellers and are independent businesses operated by nonpharmacists who have a minimum of a secondary education and are licensed by the Pharmacy Council to sell some over-the-counter medicines. Shop operators sometimes receive training from the Licensed Chemical Seller Association and Pharmacy Council, but it is not required to obtain a license. As privately owned enterprises, licensed chemical seller shops are positioned to provide socially marketed family planning methods using their existing infrastructure, which is sustained by the sale of other health products. Most pill and condom users in Ghana (75% and 54%, respectively) receive their contraceptives from such shops; however, the country's most popular method-the threemonth injectable contraceptive, depot medroxyprogesterone acetate or DMPA-is a prescription drug and is available only from a qualified medical provider or for purchase, but not injection, from a pharmacy.3 Most injectable users (87%) rely on public-sector health facilities to receive their injections, even though these facilities often experience stock-outs of the method.

Although most contraceptive implant users in Ghana are able to access removal services, barriers, including cost, provider reluctance to remove, and difficult removals, exist.n Providers express confidence in removing implants, but many are less confident in their ability to perform difficult removals.

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Interventions aimed at prevention of mother-to-child transmission (PMTCT) of HIV are extremely effective but remain underutilized in many countries. Common economic barriers to PMTCT experienced by pregnant women with HIV are well documented. Addressing these economic barriers has a potential to improve PMTCT utilization and further reduce mother-to-child HIV transmission. This review examines the evidence of the effects economic strengthening (ES) interventions have on use of and adherence to PMTCT and other health services relevant to PMTCT cascade. While very few studies on ES interventions were conducted in PMTCT settings, the results of a recent randomised trial demonstrate that conditional cash transfers offered to women in PMTCT programme can significantly improve retention in care and adherence to treatment. This review also considers evidence on ES interventions conducted within other health care settings relevant to PMTCT cascade. While the evidence from other settings is promising, it may not be fully applicable to PMTCT and more quality research on ES interventions among population of pregnant women with HIV is needed. Answering some of the research questions formulated by this review can provide more evidence for programme implementers and guide decisions about how to increase women’s use of and adherence to PMTCT services.

a b s t r a c t a r t i c l e i n f o Keywords:Depot medroxyprogesterone acetate Family planning Geospatial analysis Ghana Geographic information systems Licensed chemical sellers Objectives:To map access to depot medroxyprogesterone acetate (DMPA) from licensed chemical sellers (LCS); to estimate the proportion of women of reproductive age in areas with access; and to examine affordability and variability of costs. Methods: A geospatial analysis was conducted using data collected from 298 women who purchased DMPA from 49 geocoded LCS shops in the Amansie West and Ejisu-Juabeng districts of Ghana from June 4 to August 31, 2012. The women reported on cost and average distance traveled to purchase DMPA. Results: In Amansie West, 21.1% of all women of reproductive age lived within average walking distance and 80.4% lived within average driving distance of an LCS. In Ejisu-Juabeng, 41.9% and 60.1% of women lived within average walking and driving distance, respectively. Distribution of affordability varied across each district. Conclusions: Access to LCS shops is high, and training LCS to administer DMPA would increase access to family planning in Ghana, with associated time and cost savings.

Background: As the number of implants and intrauterine devices (IUD) used in sub-Saharan Africa continues to grow, ensuring sufficient service capacity for removals is critical. This study describes public sector providers’ experiences with implant and IUD removals in two districts of Senegal. Methods: We conducted a cross-sectional study with providers trained to insert implants and IUDs from all public facilities offering long-acting reversible contraceptives. Data collection elements included a survey with 55 providers and in-depth interviews (IDIs) with eight other providers. We performed descriptive analysis of survey responses and analyzed qualitative data thematically. Results: Nearly all providers surveyed were trained in both implant and IUD insertion and removal; 42% had received training in the last two years. Over 90% of providers felt confident inserting and removing implants and removing IUDs; 15% were not confident removing non-palpable implants and 27% IUDs with non-visible strings. Challenges causing providers to refer clients or postpone removals include lack of consumables (38%) for implants, and short duration of use for implants (35%) and IUDs (20%). Many providers reported counseling clients presenting for removals to keep their method (58% implant, 31% IUD), primarily to attempt managing side effects. Among providers with removal experience, 78% had ever received a removal client with a deeply-placed implant and 33% with an IUD with non-visible strings. Qualitative findings noted that providers were willing to remove implants and IUDs before their expiration date but first attempted treatment or counseling to manage side effects. Providers reported lack of equipment and supplies as challenges, and mixed success with difficult removals. Conclusions: Findings on provider capacity to perform insertions and regular removals are positive overall. Potential areas for improvement include availability of equipment and supplies, strengthening of counseling on side effects, and support for managing difficult removals.