The impact of cascade training—A FIGO and WHO Department of Sexual and Reproductive Health and Research collaboration to improve access to quality family planning globally

Globally, there are considerable barriers to accessing safe and effective contraceptive methods. Increased awareness and utilization among obstetricians and gynecologists (OB/GYNs) and allied health professionals of the WHO's tools and guidelines on contraception is a possible avenue to changing this. A cascade‐training model, based on regional training‐of‐trainer workshops followed by national workshops, was used to share key WHO global family planning tools and guidelines among OB/GYNs in 29 countries across three regions—Anglophone Africa, Middle East and Mediterraean, and Francophone West Africa. Monitoring and evaluation was performed through pre‐ and post‐knowledge questionnaires as well as in‐depth interviews of key informants before and after the training was instituted. The training increased both participants' knowledge and understanding of the relevant guidelines, as well as their confidence in using them. Qualitative data suggested that this improved in‐country clinical practice and influenced national policy through dissemination and engagement with country leadership. The cascade‐training model was a practical, locally adaptable means of disseminating up‐to‐date WHO family planning guidelines and tools. It resulted in sustainable changes in many participating countries, including training curriculum updates, policy changes, and increased government engagement with family planning. Future iterations of the initiative would benefit from additional support for multidisciplinary training.

among national obstetrician/gynecologist (OB/GYN) societies through a series of regional and national workshops.This paper describes the impact of the SRH/FIGO collaboration on clinicians' knowledge before and after training as well as qualitative information on the value of the training.It also discusses the successes and limitations of the cascade design as a method for the dissemination of tools and guidelines in contraceptive use as well as its impact on policy and practice.

| Background: state of family planning globally, 2016-2022
In recent decades, the increased availability and use of contraception services has improved maternal and infant health-related outcomes globally. 1Access to effective contraception affords individuals and couples of reproductive age the autonomy to make decisions to avoid unintended pregnancies and to participate in optimal birth spacing. 2,3The unmet need in contraception is generally defined as the number of women who want to avoid a pregnancy but are not using a modern contraceptive method. 1,4 2017, 1.6 billion women of reproductive age (15-49 years)   were living in countries that were part of regions classified by the UNDP as "developing"; of these, 885 million women (approximately half) wanted to avoid a pregnancy, and of this subset, 671 million (approximately three-quarters) were using modern contraceptives. 5timates for 2019 showed that sexual and reproductive health services continued to fall well short of needs in low-and middle-income countries, with approximately 218 million women of reproductive age in these countries facing unmet needs in accessing modern contraception. 2 As of 2022, over 1 billion women of reproductive age (15-49)   were living in low-and lower-middle-income countries, of whom an estimated 371 million were using a modern method of family planning; their use of contraception averted more than 141 million unintended pregnancies, 29 million unsafe abortions, and almost 150 000 maternal deaths between 2021 and 2022. 6Globally, the number of women of reproductive age whose need for family planning was satisfied with modern methods (Sustainable Development Goal indicator 3.7.1)was 77%. 7Access to different methods continues to vary by region.Regions with the lowest availability of modern methods for women wanting to avoid pregnancy include sub-Saharan Africa (56%) and Oceania (52%), excluding Australia and New Zealand. 7In northern Africa, western Asia, and central and southern Asia, among women who want to avoid pregnancy, a higher proportion use traditional contraceptive methods (15% and 12%, respectively) compared with in other regions. 7 continue to improve universal access to sexual and reproductive services globally, it is essential to ensure that health workers, and specifically OB/GYNs, in each country have access to up-to-date training and resources for the provision of safe and effective contraceptive methods. 82 | Unmet need in family planning: a priority for WHO and FIGO WHO has identified family planning access as a priority and regularly produces contraception guidelines and tools in collaboration with many international agencies and organizations that are active in family planning policies and programs.9,10 The goal of such guidelines and tools is to provide policy and decision makers, the scientific community, and providers with global standards for developing and/ or updating national guidelines on contraceptive use.

| The collaboration
The objectives of this collaboration included: 1. to increase awareness of and utilization by OB/GYNs of the latest WHO recommendations for family planning/contraceptive use; 2. to increase the number of OB/GYNs providing family planning/ contraceptive information and services and; 3. to have greater engagement of OB/GYNs in moving forward the family planning agenda in the participating countries.
The project was implemented across two phases.The first took place across a 2-year period, from 2016 to 2018, with 10 countries participating from the Africa region and 12 countries participating from the Middle East and Mediterranean region (Table 1).The second phase took place across a 2-year period, from 2020 to 2022, with a further seven participating countries from the South-East Asia region and Francophone West Africa region (Table 1).
The implementation of the second phase was heavily impacted by global travel restrictions due to the COVID-19 pandemic from early 2020.Although this hindered national roll-out to varying extents in each country, the general pivot to online and hybrid training formats, for both regional and national workshops, made the continued implementation of the project possible to completion in 2022.

| The training-of-trainers methodology
The project took place through a cascade training design.This is a well-established mode of delivering training with many examples of its use in the literature. 13,14A core group of participants come together and are trained as trainers in specific tools, knowledge or skills.They then return to their location and proceed to cascade this training down through consecutive trainings in their localities, hence disseminating the tools, knowledge, or skills more widely.FIGO had used this method previously in its six-country PPIUD initiative 15 as has WHO in its Family Planning Accelerator Project. 16,17 this collaboration, each round began with a regional training-of-trainers workshop, attended by one to five participants from each country, facilitated by WHO and FIGO.Following the regional training-of-trainer workshops, trainers were supported to organize national cascade training workshops in their country (Table 2).These were usually held as half-day workshops in coordination with the society's annual national conference.In the second phase of the project, national training was separated into two workshops: a general workshop (for the dissemination of material and learning from the regional workshop) and a workshop focused on specific areas of family planning that had been identified by the country as areas of priority.Focus topics were pre-determined by the society in collaboration with FIGO and WHO ahead of the training.An all-country virtual meeting was held in September 2022 to ascertain the progress that had been made in each country and to promote sharing of experiences and challenges.

| Regional (training-of-trainer) workshops
Individual focal contacts from each country's national society, who had specialized training, skills, and interest in family planning and contraception, were identified by the national societies, and through TA B L E 1 Countries that participated in each regional (training-of-trainers) workshop involved in each round per phase.FIGO were invited to attend.In many cases invitees were OB/GYNs; in some countries, doctors in government and midwives were also invited.The regional workshops in each round were structured around a series of core modules.These included: • Overview of the WHO Family Planning Cornerstones (including the guideline development process)   25 All texts were available online with some physical copies also made available for the national workshops.Table 2 lists the national cascade workshops that were held in each country and includes the date and number of attendees.

| Monitoring and evaluation
In the second phase of the collaboration, participants were invited to undertake an anonymous knowledge-based questionnaire before and after each regional workshop.The comparison of participants' confidence and knowledge before and after each regional workshop provided an evidenced understanding of the impact of this workshop on knowledge acquisition.
Semi-structured, in-depth interviews were also undertaken in phase 2 in order to gain a better understanding of the issues faced in the different countries and how the workshops could potentially help or had helped in solving these.The interviews were held both in-person and online and took place in either English or French.The results are described below.These were conducted between 6 and 24 months after the regional workshops and analyzed together once all had been completed.

| Final all-country meeting
A final all-country meeting was organized by WHO and FIGO.The aim of this meeting was to unite participants from all previous phases of the project and to understand how work had developed in this area, to share experiences, and to discuss the challenges encountered.The all-country full-day meeting took place online in September 2022.
Representatives from all countries involved in the WHO/FIGO collaboration to date were invited to present a brief overview of the work that had taken place in their country.Participants included OB/GYNs, midwives, regional and national WHO office representatives, and Ministry of Health representatives.Representatives from FIGO presented monitoring and evaluation findings of the project.The meeting took place in English with simultaneous interpretation in French available.

| IMPAC T
From 2016 to 2022, a total of 29 countries were involved in the initiative across the two phases.Regional (training-of-trainer) workshops were held in South Africa, Lebanon, Myanmar, and online (via Zoom virtual platform) with Francophone West African countries.Table 1 shows the countries and dates of each regional meeting.

| Use of guidelines
In the pre-workshop questionnaire, participants were asked which of the contraceptive guidelines they had used in the last year.As Figure 1 shows, 95% of participants had already used the MEC criteria.On average, around half of delegates had also used the other WHO tools and guidelines, including the decision making tool and selected practice recommendations, in the last year.

| Participants' confidence
To assess existing levels of confidence in using different guidelines, participants before each regional workshop were asked to rate their confidence on a scale of 1-5 (with 1 being "not confident at all" and 5 being "very confident") in using the latest guidance (in medical eligibility for contraceptive use, contraception for postpartum women, and contraception for adolescents).Before the workshop, participants were on average fairly confident in their use of the latest guidance for eligibility and postpartum women, with an average confidence rating of over 3.5/5.Confidence levels pre-workshop were lower for utilization of the latest guidance on contraception for adolescents, with an average rating of around 2.5/5.On average, after the workshop, participants' confidence increased in all three areas indicated (latest guidance in medical eligibility, contraception for postpartum women, and contraception for adolescents).Figure 2 shows the comparison in pre-and post-workshop responses to this question.

| Participants' knowledge
The pre-workshop questionnaire also assessed participants' knowledge and understanding of a range of topics, including medical  In-depth interviews revealed more information on various issues pertaining to access to contraception in the country.The main topics that emerged from the in-depth interviews are described below.

| Barriers to accessing contraception
Multiple participants mentioned the impact of misconceptions and a general lack of access to accurate information about family planning in their countries, sometimes resulting from social taboos or superstitions.Misconceptions included that women could be concerned that the intrauterine contraceptive device could migrate out of their uterus, to their brains or livers, for example.
Reproductive autonomy (whether individuals are able to make independent and informed decisions regarding their own reproductive health) was also identified by various participants as a major issue.
Barriers today especially include opposition from husbands-it's true that women come to the postpartum family planning services alone, but then they hide their contraception (especially either IUD or injection) and their husbands are unaware-they do not understand.
(Round 4) Several participants highlighted the impact of financial limitations, both at the individual level (due to a lack of universal healthcare coverage) and at the health system level.
Contraceptive methods are not at all free, at the moment, there is a lot of advocacy going on, especially for young women, whose purchasing power is very low, who don't have enough money to access methods. ( Other barriers mentioned by participants included shortages of skilled and trained healthcare workers, cumbersome governmental procedures for altering curricula, and limited supply of contraceptive methods, which were compounded by setting-specific geographic factors.
In some places, the skilled providers are not thereespecially for copper Ts and implants-so women may not access contraception even if they want it. (

| Postpartum contraception
Interviewees identified numerous advantages to the provision of postpartum contraception in addressing the unmet need in family planning.This was especially the case in settings where women's contact with healthcare provision tended to be less regular (for example in rural areas).
There are enormous advantages [to providing postpartum contraception] in terms of reducing unmet need in family planning-because sometimes women struggle to come back after giving birth, so unwanted pregnancies often occur here… So I think it is a great opportunity to offer it to those who want safe and effective contraception.
(Round 4) One participant also highlighted the importance of midwifery engagement in providing postpartum contraception, a topic that both FIGO and WHO support strongly.
Midwives today understand that there is an increased risk of pregnancy in the first year after pregnancy and they know that postpartum family planning is one of the strategies today that can help us to reduce maternal mortality… Midwives must play a very important role in the reduction of maternal mortality.They know this, they agree with this, and they do this.

| Contraception for adolescents
With regards to adolescents and contraception, some of the interviewees were skeptical about its provision, pointing out that it is very much a taboo subject and that adolescents rarely come requesting the service alone.In some cases, interviewees also stated that they would not be able to provide intrauterine contraception to adolescents in their country of work.
Adolescents experience difficulties in accessing contraception, so we need to encourage awareness.
(Round 4) Secondary to the workshop, one of the participating countries established a new corner in their institution-"Adolescent Friendly Reproductive Health Services".

| Overall feedback
Generally, participants were very pleased with the methodology of a central regional training followed by national cascaded training sessions.Quantitative data showed that the regional meetings allowed participants to become more aware of the WHO guidelines, more confident in their use, and more knowledgeable about the pertinent issues in contraception, such as postpartum use and the needs of adolescents.Responses in the interviews largely suggested that the cascade design had significantly increased participants' and their colleagues' knowledge and understanding of the relevant guidelines, feeding into their routine practice in each setting.However, several participants mentioned that with more funding, more could have been done.

| The final meeting-Impact of in-country diffusion
The final all-country meeting was attended by a total of 50 participants from 17 countries.These countries presented on their initial involvement but also more importantly on the progress they had made since the first meeting.It became evident that huge advances in forwarding the agenda on expanding access to family planning had been made because of those first regional meetings.These effects were far more encompassing than just the first round of cas-  This synergy made the meetings highly effective in influencing long-term changes in-country.
The design of the workshops added to the ease of the whole process.Regional workshops were coordinated by WHO and FIGO.National cascade workshops were coordinated by each country's national society, often in collaboration with nursing and/or midwifery societies, with technical and some small financial support from WHO and FIGO.Travel to and from the national workshops was generally a practical possibility for participants and speakers.Although COVID-19 travel restrictions in the second phase impacted both regional and national workshops, the shift to virtual and/or hybrid meetings made both levels of training possible.Virtual regional training in the Francophone phase and final all-country meeting also enabled the addition of cost-effective online interpretation (French-English).
The cascade training design was highly cost-effective.Family planning specialists and senior clinical leadership from each country were invited to join the multidisciplinary regional training workshop Other reported barriers included the need for universal access to healthcare coverage (including whether family planning is provided at a cost or free), and a lack of healthcare services generally (for example in rural and/or deprived areas).Shortages of trained/skilled healthcare workers, low supply of specific contraceptive methods, the high cost of services for individuals (where universal healthcare coverage is not available), and limited funding for continued training of healthcare workers were also mentioned.

| Recommendations for further work
Given the success of this methodology and the reach achieved at a global level, the authors recommend expanding to other regions of the globe that were not included in the four rounds described.
Given the availability of materials, and the known methodology and familiarity with the processes in both institutions, this would be straightforward.The authors also suggest that in future iterations a component on advocacy is added in order that national societies are enabled to influence their governments to commit to prioritizing access to sexual and reproductive health including contraception.
Although no cost-effectiveness study was performed, the modality adopted in the fourth round with an on-line regional meeting with fewer countries and subsequent national cascade training required much less financial investment and complex logistics, but still achieved the goals required.
From the research perspective, it would be good to understand the longer-term impact and the authors would recommend further qualitative work looking at sustained impact 5 years after intervention.

| CON CLUS ION
The

FIGO
FIGO is the world's largest alliance of national societies of obstetrics and gynecology, bringing together over 130 national member societies across five regions.Before the start of the MEC (medical eligibility criteria) project for contraceptive use, FIGO had committed to making family planning provision and access a priority.At the 2019 Nairobi Summit of the International Conference on Population and Development (ICPD), FIGO was a signatory to the ICPD25 statement committing to support the achievement of universal access to sexual and reproductive health as part of universal health coverage. 11FIGO's earlier Postpartum intrauterine device (PPIUD) project (2013-2020), worked with six national OB/GYN societies to integrate quality counseling on postpartum family planning during the antenatal period and the provision of PPIUD services into routine maternity care. 12Following FIGO's 2015 World Congress, the SRH department and FIGO agreed to collaborate in the dissemination of WHO family planning guidelines and recommendations working with national OB/GYN FIGO-affiliated societies.This resulted in a successful collaboration on the project from 2016 to 2022.The project drew on the positions of both organizations as key stakeholders in the contraceptive world to introduce and disseminate WHO contraception guidelines and tools through a total of 29 national OB/GYN societies.

Following
the regional workshops, local project leads planned and coordinated national cascade training workshops, with support from country and regional WHO offices and FIGO.National workshops were generally planned to coincide with the societies' national conferences.This was in order to capitalize on the gathering of OB/ GYNs from around the country as well as to benefit on cost-effectiveness.The objectives of the national training were: (1) to introduce the WHO contraception guidelines and derivative documents to members of the national associations; (2) to plan how participants would use the WHO contraception guidelines and derivative documents; and (3) to plan the post-training follow up with participants.

FocusF I G U R E 1
Responses to "Which of the following resources have you used in the last 12 months?"(based on surveys of 21 delegates in phase 2 of the project).eligibility and contraception for specific groups such as postpartum women and adolescents.Before the regional workshop, the average score for delegates in this section of the questionnaire was 51% (Score 107/210 across 21 participants).The average score on the knowledge-based test increased to 75% (Score 157/210 across 21 participants).

4 )F I G U R E 2
The training of providers (especially forIUD) is not yet at national level.Also geographical barriers, outside of the city-the further you go away from the center, the fewer providers there are.(Round 4) Some barriers mentioned were specific to local country contexts, such as security concerns for travel for in-person meetings, or travel restrictions during the COVID-19 pandemic.The variable success of online training during COVID-19 travel restrictions was also clear, with implementation conditional upon individuals' access to internet and mobile technology.COVID-19 also resulted in healthcare workers being over worked and unable to participate in normal training sessions.There was also an expression of frustration when trying to implement changes, in that administrative processes are often long and cumbersome when trying to update and change curriculums.Certain countries also highlighted the lack of training resources available for pharmacy and community-level healthcare workers regarding WHO family planning guidelines, suggesting that this is also an important pipeline for women seeking services directly from pharmacies or via self-care in certain settings.Comparing pre-and post-workshop responses to "Please rate your confidence in the following areas (1-5)" (based on a survey of 21 delegates pre-workshop and 23 delegates post-workshop in phase 2).
cade training that had been agreed and supported by the FIGO/ WHO SRH project.Some examples of these achievements are described below.The South African Society (SASOG) became involved in the national update on family planning guidelines, and later national training curriculum updates.Training in-country was expanded to over 500 healthcare professionals from both the public and private sectors across all provinces.Training was also made available online through a knowledge hub, which over 1000 healthcare providers had accessed.The Pakistan Society (SOGP) reported that as a result of country-wide trainings in Pakistan, additional meetings occurred with individual medical institutions, and in collaboration with nurses, midwives, students, and other healthcare workers.Dissemination also resulted in the College of Physicians & Surgeons of Pakistan (CPSP) including PPIUD, implants, and MEC as a skills station in part of their accredited training.In Myanmar, despite the COVID-19 pandemic, the Myanmar Medical Association (MMA) was able to provide more than 4500 MEC wheels in 2020 and a further 3500 in 2021, achieving considerable dissemination.In-country, over 500 assistant surgeons, medical officers as well as 180 general practitioners and postgraduate trainees at the universities were trained.Continued Medical Education talks took place as well as direct further involvement in the MMA adolescent SRH program.The Moroccan Society (SRMGO) also reported the adaptation of MEC guidelines into Ministry of Health guidance, expansion of method choice to include subcutaneous depot medroxyprogesterone acetate through further collaboration with UNFPA, and the setting up of two national conferences on contraception gathering private and public serving OB/GYNs from around the country.

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| DISCUSS ION The cascade training model was found to offer a range of advantages to the provision of quality family planning care, including long-term sustainability, capacity for country-ownership, and adaptability.The main drawbacks to the training-of-trainer model are systemlevel challenges, which point to a broader need for health systems strengthening interventions globally.As two key stakeholders in global sexual and reproductive health, the collaboration between FIGO and WHO brought many strengths to the implementation of the project.WHO, as a global provider of contraception tools and guidelines, supplied essential resources for effective training and dissemination.FIGO offered the geographic reach and capacity to mobilize a global network of women's health professionals.Many of FIGO's individual members and member societies actively contribute to the development and implementation of national policies and programs on family planning.FIGO encouraged national societies to involve those in-country in leadership positions with regards to family planning policy and practice.WHO formally linked participants with their respective WHO country offices, facilitating the partnership and ensuring that required support was available after the meeting.
and were subsequently supported by FIGO and WHO to undertake roll-out of the same training at national level.The national workshops were generally organized in tandem with each national society's annual conference, to benefit from existing structures and processes and the fact that OB/GYNs from around the country were gathered together.This strengthened the cost-effective design, enabling a sustainable means of disseminating essential guidelines and updates, among family planning service providers around the country.The cascade design also enabled country ownership at the national level, which supported sustainable change in the use and implementation of global guidance.National groups were therefore supported to synergize with other initiatives already existent in country.Furthermore, the cascade structure adapted well to multidisciplinary engagement across each country's health system.In phase 2, FIGO and WHO facilitated the involvement of nurses and midwives in both regional and national workshops, which proved critical to the effective dissemination of the resources to all relevant practitioners in-country.In some countries, healthcare curriculum updates following the workshops were extended to nursing and midwifery training.In another country, midwives set up a new reproductive services space in their university hospital as a result of the collaboration.The cascade design is an adaptable model in the provision of training in different settings[13][14][15] Despite the barriers presented by the onset of the COVID-19 pandemic, virtual meetings due to travel restrictions were found to work almost as effectively as in-person meetings, with high levels of attendance and engagement.Connectivity issues in areas of poor broadband coverage were somewhat mitigated by the retention of hybrid or in-person groups of participants, who joined the regional virtual workshop from a shared office or hired space.The virtual/hybrid approach was additionally cost-effective, as the resources required for in-person meetings (accommodation and travel) were much less.The effectiveness of each workshop was influenced by the engagement and capacity of individual participants; it was found that smaller face-to-face meetings of a smaller selection of clinicians were more likely to lead to prompt follow up in the national roll-out stages, than larger meetings with many participants from wider geographical regions.Overall, given the limited extent of funding available to each country, the extent of the cascade roll-out was remarkable.In several countries, country ownership enabled further expansion of the cascade training to wider stakeholder groups including students and midwives via additional training.This offers a cost-effective, adaptable, and sustainable way of engaging clinicians in updates in global guidelines and tools.Although the engagement of clinical leadership in each country was one factor in the effectiveness of cascade implementation, the extent of diffusion of training and resources was more heavily influenced by the structure and politics of the health system in each country.In countries where national OB/GYN societies already held influence on policy and training, diffusion was easily facilitated.Likewise, societies with a lesser capacity for national decision-making experienced greater difficulty in extending training and resources.Nevertheless, the project sought to promote a stronger engagement of national societies with their governments not only in the capacity of technical experts but also as advocates for women's right to health.Further structured capacity-building for clinical leadership to engage in advocacy and policy setting regarding reproductive health services would be enormously valuable.Obstetricians and gynecologists are not the only clinicians involved in the provision of contraception and in attempting to change or update clinical practice, all relevant cadres of health should be involved.26There are many examples in the scientific literature of global family planning interventions that have benefitted enormously from the involvement of midwives and nurse-midwives.12,[27][28][29]Although there were efforts made to involve midwives internationally from the outset of the collaboration, this did not materialize into practical involvement of local societies in country.In phase 2, however, those countries with strong midwifery leadership did send representatives to the regional meetings, which resulted in their participation in the national cascade roll-out stages.It was not, however, possible to have this involvement systematically in all countries.Future efforts would benefit from secure involvement of midwifery societies from the outset.Many country participants reported that much higher levels of support, such as the interventions suggested in recent approaches to health system strengthening, would be required for their societies to truly begin to tackle the enormous financial and systemic barriers faced in making contraception truly universally accessible.30,31Increased structured financial investment across sectors is required to eliminate the unmet need and provide universal access to family planning.Clinicians play a vital role in training and provision of contraceptive services but this only addresses one of the very many barriers that women face when trying to access contraception.Concentrating on healthcare training alone, although a start, is not sufficient.Barriers to accessing family planning are not only linked to the involvement of clinicians in service access and availability.These barriers continue to be deeply rooted in structural and country-specific factors well outside the scope of this collaboration.
cascade training model, based on a series of regional trainingof-trainer workshops followed by national dissemination workshops, offered a cost-effective means of sharing up-to-date WHO guidelines and tools for contraceptive use with key stakeholder groups in each participating country.It allows for multidisciplinary training that is adaptable to country-specific factors.It also lends itself to in-country ownership and sustainability if continuous.Furthermore, the diffusion effect in many countries into curriculum updates, changes in policy, and engagement with governments on this important issue of family planning indicates the strong positive and sustained impact that the initiative promoted.In the context of the ongoing numerous structural barriers impacting the availability and access of family planning access globally, which are outside the scope of the clinical work of healthcare providers, the investment offered by this initiative was nevertheless able to create valuable and importantly sustainable changes in many of the countries involved.AUTH O R CO NTR I B UTI O N S Petrus Steyn, Sabaratnam Arulkumaran, and James Kiarie designed and planned the intervention.Anita Makins executed the intervention for FIGO with support from Francesca Hearing.Petrus Steyn oversaw the intervention for WHO with support from Rita Kabra and James Kiarie.Anita Makins and Neda Taghinejadi designed and executed the monitoring and evaluation components with support from Francesca Hearing.Francesca Hearing wrote the first draft with support from Anita Makins, and this was reviewed and amended by all authors.ACK N OWLED G M ENTSThe authors would like to acknowledge the following people for their important contributions to the work described: Leopold Ouedraogo, Chilanga Asmani, and Fatim Tall (from the WHO Regional Office for Africa); Dr Hnin Hnin Lwin and Prof. Aye Aung from Myanmar; Jennifer Brown, Annabel Miller, and Katherine Dean (from FIGO) for their administrative support during the various phases; Hani Fauzi and Jeanne Conry, FIGO President, for their enthusiasm and support for this work.The authors would also like to acknowledge the contributions of the participants of the final all-country meeting of the MEC project in September 2022, and their respective societies: Zainab Alipour, Mamdouh Wahba, Emmanuel Ameh, Diallo Abdourahamane, Ibrahima Conte, Sy Telly, Shantha Kumari, Madhuri Patel, Margret Kilonzo, Frank Taulo, Luis Gadama, Aoua Guindo, Youssouf Traore, Houcine Maaouni, Rachid Bezad, Aye Aung, Hnin Hnin Lwin, Moudi Lawali, Rahamatou

Phase Round/region Date of regional workshop Location of regional workshop No. of participating countries No. of individual participants Participating countries
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Round Participating countries Date(s) of national cascade workshop(s) No. of participants
TA B L E 2 Countries that held national (cascade) workshops in each round per phase.Francophone West African region (in this phase, national cascade workshops were separated into two types: general and focus) Guinea General workshop: November 2021 22