Sample and recruitment.

Fifty-three MMs were employed by Siphilile and 29 were asked to participate face-to-face by the first author (JNH), as this number could include several MMs from each geographical region where Siphilile is active. We estimated three to four focus groups at baseline and at follow-up would be sufficient. We allowed for a 25% drop out of informants and scheduled nine to ten informants in each FGD. However, all MMs agreed to participate; 20 MMs were working in the Manzini region and nine MMs in the Lubombo region.

The intervention.

We started the intervention in January 2018 and a tailored RLP tool was developed together with the Siphilile management and the MMs during two work-shops with JNH (Fig 1). The MMs gave suggestions on what topics to discuss when clients wanted or did not want children, and JNH suggested additional topics based on current research and recommendations on preconception care and on reproductive life planning [1, 5]. The adapted RLP tool was reviewed by the management and by the research team. Tailoring the RLP was essential, as cultural appropriateness and contextual relevance is important for successful implementation [30]. The MMs and their supervisors were trained in using the RLP by JNH. The work-shop was followed by learning activities in preconception health and contraceptive counselling. The MMs were instructed to use the RLP with their clients and were given the adapted RLP tool (S1 Appendix) and a report sheet to document which clients that had been approached. The MMs were encouraged to include partners in the discussion if the client approved.

Data collection.

After the RLP training, FGDs with the MMs were held. All FGDs were moderated by JNH in English as all MMs speak English fluently. We used a semi-structured discussion guide (S2 Appendix). Questions were open-ended, covering perceptions of using the RLP, factors affecting FP discussions and partner involvement. The discussion guide was checked by the research team for cultural accuracy and relevance before the FGDs started. The MMs also answered a questionnaire (Q1), covering age, years working as a MM, relationship status, number of children, as well as own FP history.

We evaluated the intervention in May 2018. Four new FGDs were held with the MMs, with partly new group combinations. The FGDs covered experiences from using the RLP and determinants of its use. The semi-structured discussion guide included open-ended questions as well as questions on the implementation process inspired by the Checklist for Determinants of Practice (TICD checklist) developed by Flottorp et al. [30, 31]. Determinants of practice are factors that can enable or disable implementation of an innovation and the checklist is used to identify those. Determinants are categorized into guideline factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change as well as social, political, and legal factors [30, 31].

The MMs answered a questionnaire (Q2) covering experiences from and implementation of the intervention. Q2 was pilot-tested in a group of four MMs who gave their feedback and amendments were made where needed. Questions were adapted from the NoMAD instrument [32, 33]. NoMAD is an implementation measure based on a social theory to understand the dynamics of implementing complex health interventions, called Normalization Process Theory [33]. Key constructs of this theory include coherence (sense-making), cognitive participation (engagement to sustain a practice), collective action (work done to enable the intervention to occur) and reflective monitoring (evaluation of the intervention’s benefits and costs) [33]. Using the NoMAD offers a structured assessment of implementation processes from the MMs’ perspectives [33].

Qualitative data and the use of i-PARIHS.

Data collection stopped when the research team deemed that data saturation was reached. FGDs were audio-recorded and transcribed verbatim by JNH, starting immediately after each FGD to see if any of the topics needed clarification from the MMs. The transcripts were not returned to the participants for comments or correction. Initial ideas or themes were noted as well as memos, written directly after each FGD finished. Recordings were listened to and transcripts were read multiple times by JNH and the second author (EE). Guided by the research questions, descriptive and in vivo codes were generated openly by JNH and cross-checked by EE. In vivo codes were used as we wanted to prioritize the MMs’ voices [34]. No software was used.

After coding, we used a deductive approach driven by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework [35, 36]. This is a framework to describe implementation processes. Its ancestor, the PARIHS framework was first published in Implementation Science in 1998 [35], aiming to help explain and predict why the implementation of evidence into practice is successful or not. The theory that the i-PARIHS framework builds upon claims that successful implementation is a function of four constructs: the innovation, the recipients and the inner and outer context, and facilitation is the active component. Each of these constructs have characteristics that either enables or disables implementation. For example, to be successfully implemented the innovation should be usable, fit well with existing practices, and give observable results. Recipients, i.e. individuals who are affected by and influence the implementation, should have enough knowledge, time and support to perform the innovation. Implementation is also affected by contextual factors such as working culture, leadership and policies. Facilitation activates implementation through assessing and responding to characteristics of the innovation, its recipients and the context where it is implemented [35]. Both the PARIHS and the i-PARIHS framework have formerly been used in similar settings to evaluate implementation of innovations [37, 38].

Codes were grouped into the i-PARIHS constructs (facilitation, innovation, recipients and context), constantly going back to the transcripts to make sure our interpretations of the codes were valid. The same code could appear in more than one construct and codes that did not fit into any of the constructs were saved for potential later categorization. We used thematic analysis by Braun et al. [39], and mainly applied a realist perspective as we sought to report the experiences and reality of the participants. After grouping the codes, they were printed on paper and we searched for patterns among the codes within each construct. We manually grouped codes that had a pattern capturing something relevant to the research questions and created themes based on these codes. Each theme was controlled to make sure that it was supported by the codes and if it was congruent with the entire data set. The creation of themes was undertaken in groups of two to three members of the research team during five work-shops, and different constellations of researchers participated in each work-shop. Finally, the themes were reviewed, refined and negotiated within the whole research team. The participants did not provide feedback on the themes.

Quantitative data.

Quantitative data from Q1 and Q2 were analyzed using frequencies in IBM SPSS Statistics 23.

Theme: Longing for more knowledge.

The MMs expressed that the RLP training had been helpful. One discussed how knowledge about the interaction between HIV-medication and progesterone had been crucial for her FP counselling. This interaction has been described by Nanda et al. [40]. The MMs also expressed how they needed to be equipped with more knowledge on contraception to be able to fight FP myths and to address contraceptive failure:

‘I think we still need more about the contraceptives, and straight to the contraceptives, how do they work exactly? Yes, because the clients they do have experiences with these things. […], say ‘I have taken that [contraception], but I was pregnant’. So how to address that?’

Qondile FGD 2:2

During the FGDs, the MMs suggested provision of additional training through seminars or open group discussions as well as learning material such as handouts and brochures. This was provided at follow-up. JNH also started a WhatsApp group with the MMs and their supervisors with the aim of providing weekly updates on contraception.

Results from Q2 (Table 2) showed that most MMs agreed that enough training was provided (77%, n = 19). Three neither agreed nor disagreed and two disagreed.

Theme: Supportive supervision with preserved autonomy.

The MMs emphasized that their supervisors supported them in using the RLP by repeatedly asking them if they used it, and by assisting if there were any challenges. Supervision in the RLP, specifically, was integrated in the ordinary monthly supervision. More supervision was seldom requested by the MMs, who generally had a high degree of self-reliance in meeting their clients.

‘I think our supervisors, they supervise it, because we use to talk about it even when they are visiting them [the clients]. So, I don’t think there is more need of it.’

Gugu FGD 2:2

Most of the MMs (75% n = 18) agreed that staff within Siphilile (manager, supervisors, other MMs) had a shared understanding of the purpose of the RLP and a majority of the MMs (71% n = 17) agreed that the management provided enough support for the RLP. Three MMs disagreed (Table 2).

Theme: Observing progress in a disadvantaged community.

The innovation (the RLP) was seen as advantageous and results from using it were clearly observable by the MMs in these disadvantaged communities with high rates of unplanned pregnancies. At baseline, the perceived benefits of the innovation were that unplanned pregnancies would decrease, that it would facilitate discussion with partners and increase clients’ knowledge. This foreseen progress would then have an impact on the whole community:

‘Because you have to begin here, from us, from our home, from our sisters in law. From explaining to the community, it will work. They [the clients] will see the goodness of this. That it will limit, it will save us from poverty. We are poor because we have many unplanned pregnancies, children take much responsibilities in matter of financial’

Temalangeni FGD 1:2

Some of the beliefs mentioned above were confirmed at follow-up, when the MMs expressed that clients had started to plan pregnancies and use contraception. The teenagers were highlighted as a group that had benefitted much from the intervention. However, more resources were needed to reach teenagers that were not pregnant or had not given birth, as they are not part of the Siphilile intervention.

‘With the RLP-tool, we are able to encourage them [the clients] to stop giving birth to unwanted and or unplanned children.’

Babhekile FGD 2:1

‘It has had a great impact on our client. I once had a client where by maybe yearly, give birth, yes, […] but now, she’s on implant and even her husband saying she, he appreciate’

Thandiwe FGD 2:2

All except one MM (n = 23) agreed or strongly agreed that they valued the effect the RLP has had on their work (Table 2).

Theme: Improved confidence and quality of care.

The MMs expressed how the RLP intervention had improved their confidence in contraceptive and preconception counselling. The RLP-questions were perceived as advantageous as they opened up discussions with the client and enabled reflection, both from the client’s and the MM’s sides:

‘What I see on these questions is that there are things that are opening her mind and even my mind. When I ask the question [Do you want to have any more children?], I listen to the answer and then I can tell her “you can do this”. Sometimes I don’t know what to say, but now I know.’

Nosipho FGD 2:3

‘I think it has been an eye-opener to me and to some of my clients. [….] Like, changing your [preconception] lifestyle it has been one of the most important things I have experienced, and I have learned to, shared with my clients.’

Babhekile FGD 2:1

Before the RLP intervention, the MMs had discussed FP but focused solely on contraception and not on preconception health. Former counselling had been limited to postpartum women before the six-week control at the clinic, briefly mentioning the contraceptive methods available, and follow-up was not provided. With the RLP, the MMs perceived the contraception care they provided as improved, since the RLP enabled them to elaborate more on contraceptive methods and to follow-up on their clients:

‘I have to make a good follow-up, because last time [before the RLP] I was talking that ‘you must do family planning, you must do family planning’, now I have to elaborate’

Nomzamo FGD 2:3

All the MMs (n = 24) agreed that the RLP made it easier for them to support clients in forming reproductive goals, as well as in discussing family planning and how to improve preconception health (Table 2).

Theme: A high degree of fit with Siphilile’s practices.

Implementing the RLP in daily practice was easy as it fit well with existing practices. Many parts of the intervention were not new, as contraception, HIV-testing and birth spacing were already within the MMs’ curriculum. The RLP intervention was perceived as best when used in one-on-one discussions and when the MMs listened carefully to the client; practices that were already standard. At follow-up, the MMs expressed how the RLP was easy to integrate, required little effort and how it fitted well in their daily schedule:

‘[RLP] It’s like, it’s a daily thing, like you are moving from house to house, the work that we are doing. […]. So, it’s not hard. It’s a daily thing that you are doing in the field, it’s simple.’

Nosipho FGD 2:3

On the statement ‘I can see how the RLP is different from our usual ways of working’ (Q2), eight MMs disagreed and twelve agreed. All except one agreed that they could easily combine the RLP with their existing work (Table 2).

Theme: Influencing but respecting client’s decision.

When the MMs were asked about how they applied the RLP, some expressed they asked rhetorical questions, such as ‘do you want to go back to the labor ward?’ instead of the instructed patient-centered question ‘do you want to have any more children?’ Some MMs were concerned when clients’ reproductive intentions were not in line with the well-being of the whole family, as the MMs were well aware of the consequences of unplanned childbearing. This family-centered approach sometimes created a dilemma when trying to help women achieve their reproductive goals:

‘I have a client that has had her fifth child. When I ask her “do you want another child?”, and she says, “Yes soon”, I will be like “Oh, no!” Because I know the importance of birth spacing, I will be like no… Then she can get angry.’

Phetsile FGD 1:1

Some expressed how they had tried to influence the client’s decision by providing information about dangers associated with childbearing and the benefits of birth spacing. Nevertheless, they emphasized the importance of not trying to push the client, and of always respecting her decision:

‘[Using the RLP] we are able to make them talk. But you can say it now and again, but it’s them to take a decision. You have given them the options but it’s them to take their own decisions’

Thandiwe FGD 2:2

Theme: The RLP is our duty.

Most of the MMs were strongly motivated to implement the RLP. They expressed the importance of providing correct information to the client, of teaching her until she understands, and of discussing both advantages and disadvantages with different contraceptive methods. This, they believed, would help create an alliance with their clients and lack of knowledge would make clients doubt them. The goal, or rather the responsibility, of the MMs was to help clients make informed decisions.

‘The RLP it will reduce most of the poverty that we see now in the community. Yeah, because having a lot of children, unplanned children, there are so many, then if you don’t introduce that, you are actually also bringing poverty yourself because you’ve got the information, but you are keeping it.’

Nosipho FGD 2:3

All except one MM (n = 23) agreed that participating in the RLP was a legitimate part of their role and that they will continue to support the RLP (Table 2).

Theme: Peer motivation is key.

The MMs expressed how their role as peer supporters was key in successful RLP-counselling. The relationship between the MM and the client, starting from when she first became pregnant, and the client’s trust in their MM, facilitated and deepened the RLP discussions:

‘I think this thing [the RLP] is going to work. Because we have already bonded with our clients. […] Now it will be superb, because we are talking to somebody who knows me, and we’ve been together for the past 4 years, it will help them to think outside the box.’

Tengetile FGD 1:1

The MMs suggested that the use of peer motivation in pregnancy planning could be expanded to include teenage clubs and training of Mentor Fathers. Finally, the MMs took pride in their role as peer supporters and hoped their own experiences would help their clients:

‘You know what, I know what I want because of the mistakes I have made. I’ve take up a stand because of the mistake I’ve had. I have had maybe unwanted pregnancies, maybe all of my kids are unwanted. I’ve never planned kids. I think, those who plan they are rich. […] Maybe we can say, please learn from my mistake—I have had three unwanted pregnancies, you know.’

Temalangeni FGD 1:2

Theme: Partners using reproduction to control.

The MMs explained that reproduction was sometimes used by partners as a way of exercising power on one another. While men were sometimes making women pregnant as a way of controlling them, women also tried to exercise power through reproduction, by ‘tricking’ men to make them pregnant. Thereby they hoped for love or financial support for them and their child.

‘The girlfriend loves the boy and she feels like “I will catch him by giving him the baby”. So, they just neglect themselves, the girls. Even the boy, sometimes feel that if the woman can have more babies she cannot look for other men because she will be busy with the children all the time.’

Nolwazi FGD 1:2

‘She gets the income by giving birth. She’ll follow the men, sometimes she follow the men, he gives her nothing, but keep on giving birth.’

Nomzamo FGD 2:3

Theme: Reproduction is often neither a conscious, nor possible decision.

The MMs expressed that on the individual and family level, many women and couples had not reflected upon the wanted number of children. In some cases, this was attributed to vulnerability such as depression and poverty. Other MMs expressed that many women know how many children they want, and they repeatedly expressed that most children were unplanned or unwanted and that almost all their clients wanted to prevent pregnancies.

‘I don’t know if it is our culture or what, sometimes it is very difficult that you find couples discussing of their way forward. Maybe now with the new generation, but to be honest, from my generation with the experience I have had, we had never sat down and discussed about how many children really are we planning to have as a family, and that’s a fact. Yeah, so the children you give birth to, they are all unplanned.’

Nok´lunga FGD 1:1

Discussing number of children with partners outside a marriage was considered a taboo according to Swati culture and disagreement between partners was common, men generally desired more children than women. Men were often decision-makers on both contraception and on sexual intercourse. Yet, women were repeatedly blamed when they became pregnant as well as if the couple could not conceive. The MMs gave testimony about abusive husbands, and encouraged by the MMs, some clients hid their contraception from their partners, as revealing would result in partner refusal of dual protection with condom:

‘So, I say, “don’t tell your husband”. You see that is not good, that you hide something [contraception] from your partner, but I’ve said so, “don’t tell it, don’t tell him”, so that he will put the condom.’

Phangisile FGD 2:2

‘By that time she was having four children. Then she decided, “I want to go with you, can you take me to the clinic?” I said, “Hey what are you going to do if the man hears that you’ve been to the clinic?” She says “no, I won’t tell him, it will be my responsibility”. We went here at the Nazareen [hospital]. They put her on implant. […] One day she told me, “Sawubona, he has find out”. […] Okay, after that there was a big quarrel, a fight also.’

Tandzile FGD 1:2

The MMs also expressed that men had limited power in reproductive decisions as they lack knowledge and are not involved in FP. This hampered their ability to provide emotional support. The importance of the partner’s support and involving him in the RLP conversations was highlighted in all FGDs as key for successful family planning. However, due to the partner being absent during daytime, this was seldom possible:

‘The problem is the husband is always at work.’

Melokhule FGD 2:4

‘They [the men] don’t know if you have done it [FP], they are not involved. […] maybe they lack knowledge, they need to be supportive, also they need to be part of this thing. They are the ones who will suffer the consequences of having this unplanned pregnancies.’

Temalangeni FGD 1:2

Theme: Restricting women’s reproductive health and rights.

Women’s reproductive health and rights were also restricted on a societal and cultural level. Achieving reproductive goals was hindered on a national level by legislations such as women needing a family member’s signature to get access to sterilization. Concerns were raised about the quality of healthcare and attitudes among family planning nurses. Nurses not informing about all contraceptive methods available, only providing brief and sometimes incorrect information, were commonly expressed by the MMs:

‘They just chase you away and say you cannot have FP because you have these [varicose] veins and high BP [blood pressure].’

Temalangeni FGD 1:2

Other structural barriers included few contraceptive methods available at government clinics, preconception care limited to HIV-testing, and lack of money for contraception and healthy food.

‘You have to go for Manzini for a loop. Plus, it’s costly.’

Gcinile FGD 2:4

Finally, important concerns were raised about stigmatizing teenagers that wanted to use contraception, as the clinics are not welcoming women below the age of 18.

Theme: Family planning failure as barriers and motivators.

In this context, the MMs described problems with side-effects and a high incidence of contraceptive failure and of unplanned pregnancies. This carried great consequences for both the woman, the child and the family; school drop-out for young mothers, financial constraints in the family and not being taken care of as a child. These consequences of family planning failure was a rationale for engaging in the RLP and for teenagers, going back to school was a strong motivating factor.

‘You see the reason and the need to preach about these things [Pregnancy planning and preconception health]’

Babhekile FGD 2:1

Although the MMs own and clients’ experiences of FP failure often motivated the MMs, it sometimes created doubts. The MMs expressed that using the RLP was challenging with women that had experienced contraceptive failure, which was common among HIV-positive women. This made it hard for the MMs to motivate those clients.

‘As for me, not as a Mentor Mother, I felt it has not worked for me. […] Which method should I choose? Because I don’t want ten children, but I’m still confused, what must I do?’

Noluntu FGD 1:2