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Education for contraceptive use by women after childbirth
Abstract
Background:
Providing contraceptive education is now considered a standard component of postpartum care. The effectiveness is seldom examined. Questions have been raised about the assumptions on which such programs are based, e.g., that postpartum women are motivated to use contraception and that they will not return to a health center for family planning advice. Surveys indicate that women may wish to discuss contraception both prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women may have unmet needs for contraception. In the USA, many adolescents become pregnant again within a year a giving birth.
Objectives:
Assess the effects of educational interventions for postpartum mothers about contraceptive use
Search methods:
In May 2012, we searched the computerized databases of MEDLINE, CENTRAL, CINAHL, PsycINFO, and POPLINE. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. In addition, we examined reference lists of relevant articles, and contacted subject experts to locate additional reports.
Selection criteria:
Randomized controlled trials were considered if they evaluated the effectiveness of postpartum education about contraceptive use. The intervention must have started postpartum and have occurred within one month of delivery.
Data collection and analysis:
We assessed for inclusion all titles and abstracts identified during the literature searches with no language limitations. The data were abstracted and entered into RevMan. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI) was calculated. For continuous variables, we computed the mean difference (MD) with 95% CI. Due to varied study designs, we did not conduct meta-analysis.
Main results:
Ten trials met the inclusion criteria. Of four trials that provided one or two counseling sessions, two showed some evidence of effectiveness. In a study from Nepal, women with an immediate postpartum and a session three months later were more likely to use contraception at six months than those with only the later session (OR 1.62; 95% CI 1.06 to 2.50). However, most comparisons did not show evidence of effectiveness. In a trial conducted in Pakistan, women in the counseling group were more likely than those without counseling to use contraception at 8 to 12 weeks postpartum (OR 19.56; 95% CI 11.65 to 32.83). The assessments were short-term. The remaining two studies were from the USA; one did not provided sufficient data and one had too small a sample to detect differences.Six trials provided multifaceted programs with many contacts. Three showed evidence of effectiveness. Of those, two USA studies focused on adolescents. Adolescents in a home-visiting program were less likely to have a second birth in two years compared to adolescents who received usual care (OR 0.41; 95% CI 0.17 to 1.00). In the other trial, adolescents receiving enhanced well-baby care were less likely to have a repeat pregnancy by 18 months compared to those with usual well-baby care (OR 0.35; 95% CI 0.17 to 0.70). In an Australian study, teenagers in a structured home-visiting program were more likely to use contraception at six months than those who had standard home visits (OR 3.24; 95% CI 1.35 to 7.79). The trials without evidence of effectiveness included two for adolescents in the USA (computer-assisted motivational interviewing and cell phone counseling) and a home-visiting program for women in Syria.
Authors' conclusions:
The overall quality of evidence was moderate. Half of these postpartum interventions led to fewer repeat pregnancies or births or more contraceptive use. However, the evidence of intervention effectiveness was of low to moderate quality. Trials with evidence of effectiveness included two that provided one or two sessions and three that had multiple contacts. The former had limitations, such as self-reported outcomes and showing no effect for many comparisons. The interventions with multiple sessions were promising but would have to be adapted for other locations and then retested. Researchers and health care providers will have to determine which intervention might be appropriate for their setting and level of resources.
... Although it is routine prac- tice in many countries, studies investigating the efficacy of this strat- egy for improving contraception uptake have had mixed results. [9][10][11][12][13] Reviews 9,10 have shown that effective delivery of family planning information during multiple contacts in maternity care improves con- traceptive knowledge and use. Similarly, another review 14 indicated that education about postpartum family planning could be effective in increasing short-term use of contraception and decreasing unplanned pregnancy rates. ...
... Although it is routine prac- tice in many countries, studies investigating the efficacy of this strat- egy for improving contraception uptake have had mixed results. [9][10][11][12][13] Reviews 9,10 have shown that effective delivery of family planning information during multiple contacts in maternity care improves con- traceptive knowledge and use. Similarly, another review 14 indicated that education about postpartum family planning could be effective in increasing short-term use of contraception and decreasing unplanned pregnancy rates. ...
... Various researchers have indicated the need to establish the best way of delivering information to help women make appropriate con- traceptive choices. 9,15 Although WHO and other agencies offer broad guidelines on interventions that work, 16 specific approaches, including content and messaging modalities, could vary from one local setting to another. This discrepancy underscores the importance of conducting intervention studies within different sociocultural settings to develop specific messages that improve uptake and use of postpartum contra- ception. ...
... It is therefore important to identify what techniques work to change reproductive behaviour in LMICs, as this will ensure programmes are designed effectively and that scarce resources are used appropriately and interventions are cost-effective [7]. This review identifies effective community-based interventions that increase modern contraceptive use in LMICs, somewhat akin to existing reviews [5, 8] , however , our primary aim is to identify specific BCTs that have been proved to be effective in randomised controlled trials (RCTs), and provide recommendations on which particular techniques should be included in the design of future interventions. For the purposes of this review, contraception refers to use of modern contraceptives including: ...
... In the Bashour et al. [15] study using educative post-natal home visits by midwives in Syria, there was no significant difference in contraceptive uptake between research arms for contraceptive use (42 %, 37 % and 40.5 %). This low evidence of effectiveness is congruent with a Cochrane review on post-natal education, which found low evidence of effectiveness and suggested further research [8]. The findings also suggest that providing immediate access to contraceptives in the community promotes their use. ...
... These results however should be taken with caution considering these two trials used only one or two BCTs. This low evidence of effectiveness is however, congruent with a Cochrane review on post natal education which found the evidence of effectiveness as low and suggested further research [8]. These results also suggest that interventions that include home visits do have more of an impact and are a component of all but one of the interventions. ...
We aimed to identify effective behaviour change techniques to increase modern contraceptive use in low and middle income countries (LMICs). Literature was identified in Global Health, Web of Science, MEDLINE, PsycINFO and Popline, as well as peer reviewed journals. Articles were included if they were written in English, had an outcome evaluation of contraceptive use, modern contraceptive use, contraceptive initiation/uptake, contraceptive adherence or continuation of contraception, were a systematic review or randomised controlled trial, and were conducted in a low or middle income country. We assessed the behaviour change techniques used in each intervention and included a new category of male partner involvement. We identified six studies meeting the inclusion criteria. The most effective interventions were those that involve male partner involvement in the decision to initiate contraceptive use. The findings also suggest that providing access to contraceptives in the community promotes their use. The interventions that had positive effects on contraceptive use used a combination of behaviour change techniques. Performance techniques were not used in any of the interventions. The use of social support techniques, which are meant to improve wider social acceptability, did not appear except in two of the interventions. Our findings suggest that when information and contraceptives are provided, contraceptive use improves. Recommendations include reporting of behaviour change studies to include more details of the intervention and techniques employed. There is also a need for further research to understand which techniques are especially effective.
... At first, the quality of the intervention design, implementation, and reports was evaluated. Quality of intervention downgraded for each of the following studies: 1) implementing intervention in less than two sessions , 2) the accuracy of reported interventional information for fewer than three items (Table 1), and 3) lack of follow-up (Lopez, Hiller, Grimes, & Chen, 2012;Lopez, Steiner, Grimes, & Schulz, 2013). The quality of the interventions evidence was recorded (Table 2) among the overall assessments of the quality of evidence (Table 3), the quality trials were considered high, then in the case of any of the following, one level of the quality of evidence was downgraded, A) lack of information on random sequence, allocation concealed, or lack of allocation concealed B) low quality interventions, and c) loss of more than 20% at follow-up. ...
... The quality of the interventions evidence was recorded (Table 2) among the overall assessments of the quality of evidence (Table 3), the quality trials were considered high, then in the case of any of the following, one level of the quality of evidence was downgraded, A) lack of information on random sequence, allocation concealed, or lack of allocation concealed B) low quality interventions, and c) loss of more than 20% at follow-up. We considered a positive level for the studies that performed blinding procedures (Lopez et al., 2012). Zarepour ( Hosseinian (2012) Denton (2000) - ...
... At first, the quality of the intervention design, implementation, and reports was evaluated. Quality of intervention downgraded for each of the following studies: 1) implementing intervention in less than two sessions , 2) the accuracy of reported interventional information for fewer than three items (Table 1), and 3) lack of follow-up (Lopez, Hiller, Grimes, & Chen, 2012;Lopez, Steiner, Grimes, & Schulz, 2013). The quality of the interventions evidence was recorded (Table 2) among the overall assessments of the quality of evidence (Table 3), the quality trials were considered high, then in the case of any of the following, one level of the quality of evidence was downgraded, A) lack of information on random sequence, allocation concealed, or lack of allocation concealed B) low quality interventions, and c) loss of more than 20% at follow-up. ...
... The quality of the interventions evidence was recorded (Table 2) among the overall assessments of the quality of evidence (Table 3), the quality trials were considered high, then in the case of any of the following, one level of the quality of evidence was downgraded, A) lack of information on random sequence, allocation concealed, or lack of allocation concealed B) low quality interventions, and c) loss of more than 20% at follow-up. We considered a positive level for the studies that performed blinding procedures (Lopez et al., 2012). Zarepour ( Hosseinian (2012) Denton (2000) - ...
Background:
Lack of intimacy is currently the main concern rather than main concern of the experts in psychology and counseling. It is considered as one of the most important causes for divorce and as such to improve marital intimacy a great number of interventions have been proposed in the literature. Intimacy training and counseling make the couples take effective and successful steps to increase marital intimacy. No study has reviewed the interventions promoting marital intimacy after marriage. Thus, this review study aimed to classify the articles investigating the impact of interventional programs on marital intimacy after marriage.
Search Methods:
In April 2015, we performed a general search in Google Scholar search engines, and then we did an advanced search the databases of Science Direct, ProQuest, SID, Magiran, Irandoc, Pubmed, Scopus, Cochrane Library, and Psych info; Cumulative Index to Nursing and Allied Health Literature (CINAHL). Also, lists of the references of the relevant articles were reviewed for additional citations. Using Medical Subject Headings (MESH) keywords: Intervention (Clinical Trials, Non-Randomized Controlled Trials, Randomized Controlled Trials, Education), intimacy, marital (Marriage) and selected related articles to the study objective were from 1995 to April 2015. Clinical trials that evaluated one or more behavioral interventions to improve marital intimacy were reviewed in the study.
Main Results:
39 trials met the inclusion criteria. Eleven interventions had follow-up, and 28 interventions lacked follow-up. The quality evidence for 22 interventions was low, for 15 interventions moderate, and for one intervention was considered high. Findings from studies were categorized in 11 categories as the intimacy promoting interventions in dimensions of emotional, psychological, physical, sexual, temporal, communicational, social and recreational, aesthetic, spiritual, intellectual intimacy, and total intimacy.
Authors’ Conclusions:
Improving and promoting communication, problem solving, self-disclosure and empathic response skills and sexual education and counseling in the form of cognitive-behavioral techniques and based on religious and cultural context of each society, an effective step can be taken to enhance marital intimacy and strengthen family bonds and stability. Health care providers should consider which interventions are appropriate to the couple characteristics and their relationships.
... Studies in Family Planning 46(4) December 2015 In Kenya, according to the 2008-09 Kenya Demographic and Health Survey (KDHS) (KNBS and ICF Macro 2010), 17 percent of births were unwanted and an additional 26 percent were mistimed. Low use of contraception and high levels of unmet need for family planning are largely responsible for the country's high incidence of unintended pregnancies. ...
... The evidence therefore suggests that integrating postpartum family planning with antenatal care and postnatal services is a useful means to reach women and provide accurate information on postpartum fertility, breastfeeding, and options for timing of contraceptive uptake (Townsend 1990;Becker and Ahmed 2001;Borda and Winfrey 2010;Rossier and Hellen 2014). Family planning services that are offered to women at every contact point during antenatal and postnatal periods can be effective in increasing awareness of, demand for, and practice of contraception (Lopez et al. 2012). Integration of postpartum services during antenatal and postnatal visits, if carried out properly, can be an efficient tool to streamline service delivery. ...
Unmet need for contraception is highest within 12 months post-delivery, according to research. Using longitudinal data from the Nairobi Urban Health and Demographic Surveillance System, we assess the dynamics of contraceptive use during the postpartum period among women in Nairobi’s slums. Results show that by 6 months postpartum, 83 percent of women had resumed sexual activity and 51 percent had resumed menses, yet only 49 percent had adopted a modern contraceptive method. Furthermore, almost half of women discontinued a modern method within 12 months of initiating use, with many likely to switch to another short-term method with high method-related dissatisfaction. Women who adopted a method after resumption of menses had higher discontinuation rates, though the effect was much reduced after adjusting for other variables. To reduce unmet need, effective intervention programs are essential to lower high levels of discontinuation and encourage switching to more effective methods.
... Our group's previous qualitative work found that women preferred frequent and short provider-initiated contraceptive counseling during the antepartum period [10]. The Cochrane Collaborative Review on contraceptive counseling identified no current standard method, timing of initiation and content of contraceptive counseling, but found interventions with multiple contacts to be promising and warranting further investigation [11]. Guidelines on perinatal care from the American Congress of Obstetricians and Gynecologists (ACOG) recommend contraceptive counseling be a focus during antenatal visits and states that longacting reversible contraception should be first-line methods; however, recommendations for the means, frequency, timing, and style of such counseling are not described [12]. ...
... Current ACOG guidelines recommend that contraceptive counseling be included in antenatal visits but timing is not further specified [12]. Previous literature has demonstrated both antenatal678 and postnatal [6,11] counseling to increase postpartum contraception use. Given the timing preference of this group of women, along with controversy about the optimal period for counseling, we recommend that contraceptive education should occur multiple times throughout pregnancy and postpartum. ...
Background:
Contraceptive counseling can increase postpartum contraception use, yet the optimal method and timing for counseling are unknown. The objective was to investigate preferences of underserved pregnant and postpartum women regarding contraception use and counseling.
Method:
Surveys regarding contraception experiences and perceptions of contraceptive counseling were conducted with 57 women age 18 and older who were postpartum or antepartum with a previous delivery within 5 years and receiving Medicaid-funded care at an academic medical center. Health literacy was assessed using REALM-7. Responses were analyzed using descriptive statistics.
Results:
A majority of women reported unplanned pregnancies (78%). Women using contraception at the time of conception reported "not sure" (30%) and "taken wrong" (30%) as primary reasons for failure. Most subjects had at least a high school level of health literacy (88%), desired to use a postpartum contraceptive method (92%) and had a high self-reported understanding of that method (94%). Most women reported receiving counseling (91%) and stated that the best time for counseling was both before and after childbirth (84%). However, only 60% of subjects intended to use the method they were prescribed at discharge; reasons for changing included side effects (37%), desire for different contraception (23%) and too complicated of a method prescribed (17%).
Conclusion:
Women perceived the best timing of contraceptive education to be both antepartum and postpartum. Despite a high frequency of prior contraceptive failure, self-reported understanding of the chosen postpartum contraceptive method was high. Contraception counseling should be tailored to a woman's perceived needs, with such education occurring frequently and within the context of her health literacy.
... The National Institute for Clinical Excellence (NICE) guideline [4] recommends that methods and timing of resumption of contraception should be discussed within the first week after childbirth and not discussing contraception antenatally is considered a missed opportunity for preventing unintended preg- nancies [5, 6]. A recent revision of a Cochrane review concluded that, despite the low quality of the revised evidence, half of the evaluated interventions after childbirth led to fewer unplanned pregnancies or more contraceptive use [7] . In addition, several International Institutions , including the WHO, have recently proposed a statement for collective action for all programs that reach women during the first year following a birth to integrate postpartum family planning counselling and services into their programs [8] . ...
... Thus, contraceptive counselling is not yet provided as a standard by natal care services or by health professionals. The Cochrane review, updated to 2012 [7], on the effectiveness of educational interventions in the use of contraceptives by postpartum women, showed how half of these interventions led to fewer unplanned pregnancies or more contraceptive use. Although the overall quality of the evidence was moderate, the programs involving multiple contacts were promising. ...
Introduction:
Contraceptive counselling in the pre and post-natal period may be important for the use of postpartum contraception and prevention of induced abortion. This paper evaluates the use of postpartum contraceptives and the factors associated with it in a sample of Italian and immigrant women.
Materials and methods:
Data are drawn from two population-based follow-up surveys conducted to evaluate the quality of maternal care in 25 Italian Local Health Units in 2008/9 and 2010/1. Descriptive analyses and logistic regression models for complex survey data were used.
Results:
The use of effective contraceptives in the postpartum period is similar between Italians and immigrants (65%). Fifty-nine percent of Italians and 63% of immigrants received contraceptive counselling by natal care services. Women who received counselling are more likely to use effective contraceptives (Italians OR = 2.55 95% CI 2.06 - 3.14; immigrants OR = 4.01 95% CI 2.40 - 6.70).
Conclusions:
This study supports the notion that health professionals should take every opportunity during pregnancy, childbirth and puerperium to provide information and counselling to improve knowledge and awareness of contraception.
... Thus, health care providers should adapt according to their settings and resources. 28 Contraceptive counseling in the immediate postpartum period may be the proper time for promotion of contraceptive use, because it is the best period when mothers are curious to know and ready to initiate contraceptive methods for prevention of further pregnancy. However, there was only 1 previous report from Nepal that demonstrated more contraceptive use in women following health education immediately after birth. 1 In addition, findings from this study also confirmed the appropriateness of the immediate postpartum period for contraceptive counseling for increasing LARC use. ...
Background
Adolescent pregnancy is a global public health problem, particularly repeated pregnancy. The best strategy to lower prevalence of adolescent pregnancy and repeated pregnancy is promoting highly effective long-acting contraceptive methods along with special counseling programs. Long-acting reversible contraception (LARC) is the ideal contraceptive of choice for adolescents. It is not known whether immediate postpartum contraceptive counseling increases postpartum LARC use in adolescents.
Objective
To compare LARC use between immediate and conventional postpartum contraceptive counseling and discover predictive factors of postpartum LARC use.
Materials and methods
This prospective, randomized controlled trial was conducted among postpartum adolescents at Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand, from 1 July 2016 to 31 March 2017. The participants were assigned to receive immediate postpartum contraceptive counseling or conventional postpartum contraceptive counseling. The primary outcome was postpartum LARC use. The secondary outcome was predictive factors for LARC use in postpartum adolescents.
Results
Of the 233 postpartum adolescents, postpartum LARC use was 87 of 118 (73.7%) in the immediate postpartum counseling group and 49 of 115 (42.6%) in the conventional postpartum counseling group (odds ratio 3.780, 95% CI 2.18–6.57, p<0.001). A significant predictive factor for LARC use in postpartum adolescents was immediate postpartum counseling (odds ratio 3.67, 95% CI 2.10–6.41, p<0.001).
Conclusion
Immediate postpartum contraceptive counseling led to a significant increase in postpartum use of LARC in adolescents, when compared with conventional (4–6 weeks) postpartum contraceptive counseling. Adolescent mothers who received immediate postpartum counseling were 3.67 times more likely to use LARC than those who received conventional postpartum counseling.
... An evaluation of postpartum contraception educational method by the Cochrane database also failed to identify specific strategies that work universally to improve awareness of women in this regard. Thus, to date, research has not reached a consensus on the optimal timing and method to discuss postpartum contraception with patients [63]. ...
Postpartum contraception is important to prevent unintended pregnancies. Assisting women in achieving recommended inter-pregnancy intervals is a significant maternal-child health concern. Short inter-pregnancy intervals are associated with negative perinatal, neonatal, infant, and maternal health outcomes. More than 30% of women experience inter-pregnancy intervals of less than 18 months in the United States. Provision of any contraceptive method after giving birth is associated with improved inter-pregnancy intervals. However, concerns about the impact of hormonal contraceptives on breastfeeding and infant health have limited recommendations for such methods and have led to discrepant recommendations by organizations such as the World Health Organization and the U.S. Centers for Disease Control and Prevention. In this review, we discuss current recommendations for the use of hormonal contraception in the postpartum period. We also discuss details of the lactational amenorrhea method and effects of hormonal contraception on breastfeeding. Given the paucity of high quality evidence on the impact on hormonal contraception on breastfeeding outcomes, and the strong evidence for improved health outcomes with achievement of recommended birth spacing intervals, the real risk of unintended pregnancy and its consequences must not be neglected for fear of theoretical neonatal risks. Women should establish desired hormonal contraception before the risk of pregnancy resumes. With optimization of postpartum contraception provision, we will step closer toward a healthcare system with fewer unintended pregnancies and improved birth outcomes.
... In the 2012 Cochrane review of education for contraception for postpartum women the authors state, ''we know more about contraceptive methods appropriate for postpartum women than we do about how to help postpartum women choose and use a contraceptive'' [25, p. 3]. An updated systematic review of randomized control trials which examined postpartum education about contraceptive use found two-thirds of postpartum women have unmet needs for contraception and that the timing, location, and intensity of contraceptive counseling varied greatly among the trials included in the review [24]. As a result of the lack in evidence and understanding of effective counseling for postpartum contraception, current practices vary with regard to where and when most women are actually receiving contraceptive counseling. ...
Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women’s preferences with respect to postpartum care. Likewise, there is also limited information on providers’ practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers’ current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women’s use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.
... We have weak evidence about post-partum contraceptive educational interventions. [36] Poor or minority women in the US have reported poor communication with providers or feeling coerced; [37] it is unknown whether this also occurs in Mexico. Finally, this is a cross-sectional study. ...
Objectives:
To test the association of age (adolescents versus older women) and place of delivery with receipt of immediate post-partum contraception in Mexico.
Study design:
Retrospective cohort study, Mexico, nationally representative sample of women 12-39 years old at last delivery. We used multivariable logistic regression to test the association of self-reported receipt of post-partum contraception prior to discharge with age and place of delivery (public, employment-based, private, or out-of-facility). We included individual and household-level confounders and calculated relative and absolute estimates of association.
Results:
Our analytic sample included 7,022 women (population N = 9,881,470). Twenty per cent of the sample was 12-19 years old at last birth, 55% aged 20-29 and 25% 30-39 years old. Overall, 43% of women reported no post-partum contraceptive method. Age was not significantly associated with receipt of a method, controlling for covariates. Women delivering in public facilities had lower odds of receipt of a method (OR = 0.52; 95% CI 0.40 - 0.68) compared with employment-based insurance facilities. We estimate 76% (95% CI 74-78%) of adolescents (12-19 years) who deliver in employment-based insurance facilities leave with a method compared with 59% (95% CI 56-62%) who deliver in public facilities.
Conclusion:
Both adolescents and women ages 20-39 receive post-partum contraception, but nearly half of all women receive no method. Place of delivery is correlated with receipt of post-partum contraception, with lower rates in the public sector. Lessons learned from Mexico are relevant to other countries seeking to improve adolescent health through reducing unintended pregnancy. IMPLICATIONS Adolescents receive post-partum contraception as often as older women in Mexico but half of all women receive no method.
... Studies in Family Planning 46(4) (Soliman 1999;Smith et al. 2002), one intervention was delivered before discharge (Saeed et al. 2008), and one was administered later in the postpartum period (Bashour et al. 2008). The second Cochrane review identified ten RCTs of educational interventions delivered in the first month postpartum with the purpose of increasing contraceptive uptake (Lopez et al. 2012). Only three related to low-and middle-income countries, and only one- Bolam and colleagues (1998)-was additional to the studies identified by Arrowsmith and colleagues (2012). ...
This article provides programmatic guidance and identifies future research priorities through a review of interventions to improve postpartum contraception. Thirty-five interventions in low- and middle-income countries were identified and classified according to timing and nature of administration: antenatal, postnatal, both ante- and postnatal, and integration with other services. With the exception of single, short antenatal interventions, the evidence of impact is positive but incomplete. A major gap in knowledge concerns demand for, and means of promoting, immediate postpartum family planning services in Asia and Africa. Counseling before discharge is likely to have an impact on subsequent contraceptive uptake. Integration of family planning into immunization and pediatric services is justified, but policy and program obstacles remain. A case for relaxing the strict conditions of the lactational amenorrhea method (LAM) is strong, but qualitative evidence on the perspectives of women on pregnancy risks is required. Despite the gaps in knowledge, the evidence provides useful guidance for strategies to promote postpartum family planning, in ways that take different contexts into account.
... It is paramount that these opportunities, whether part of routine or emergency care, are utilized to provide life-saving contraceptive services However, in many settings, the choice of methods is limited, and counselling and method provision is inconsistent Evidence suggests that postpartum and post-abortion use of longer acting methods (e.g. intrauterine device (IUD) and implants) is safe and effective [12][13][14][15], but often underutilized in low-and middle-income settings. These methods are also recommended for adolescents [16,17]. ...
Background:
There is a high unmet need for modern contraception among adolescents, and adolescent girls who have already been pregnant are especially vulnerable to a rapid, repeat pregnancy (defined as a subsequent pregnancy within two years). The Adolescent Health Experience after Abortion or Delivery (AHEAD) trial will design, pilot, finalize, and ultimately evaluate an intervention targeted at reducing rapid repeat pregnancy. This protocol presents the methods for the first phase--formative research to identify key determinants of contraceptive use and rapid, repeat unintended pregnancy among adolescents.
Methods/design:
The determinants of adolescent pregnancy are known to vary by context; therefore, a dissimilar set of three countries will be selected to enable evaluation of the intervention in diverse cultural, political and economic environment, and to allow the intervention to be tested with a fuller range of ever-pregnant adolescents, including those who have chosen to terminate their pregnancy as well as those who are mothers. We will also consider marital status in settings where it is common for adolescents to marry. Focus group discussions (FGDs) will be conducted to examine barriers and facilitators to using contraception; preferred methods of overcoming these barriers; and perceptions of the services and information received. Key informant (KI) interviews will take place with various cadres of healthcare providers, health and education officials, and members of key youth and health organizations that work with adolescents. These interviews will focus on perceptions of pregnant adolescents; perceived information, skills, and motivations required for adolescent uptake of contraception; and experiences, challenges, and attitudes encountered during interactions.
Discussion:
The findings from this first formative phase will be used to develop an intervention for preventing rapid, repeat unintended pregnancy among adolescents. This intervention will be piloted in a second phase of the AHEAD trial.
... Our findings show that women's primary or secondary education predicted utilization of modern PPFP. This relationship is consistent with findings reported by other studies [2,7,27282930 . Higher education level attainment invariably gives postpartum women a better understanding of the available modern contraceptive methods and the benefits of fertility regulation and hence the need for contraception during the postpartum period. ...
Background: The rationale for promotion of family planning (FP) to delay conception after a recent birth is a best practice that can lead to optimal maternal and child health outcomes. Uptake of postpartum family planning (PPFP) remains low in sub-Saharan Africa. However, little is known about how pregnant women arrive at their decisions to adopt PPFP. Methods: We used 3298 women of reproductive ages 15-49 from the 2011 UDHS dataset, who had a birth in the 5 years preceding the survey. We then applied both descriptive analyses comprising Pearson's chi-square test and later a binary logistic regression model to analyze the relative contribution of the various predictors of uptake of modern contraceptives during the postpartum period. Results: More than a quarter (28%) of the women used modern family planning during the postpartum period in Uganda. PPFP was significantly associated with primary or higher education (OR=1.96; 95% CI=1.43-2.68; OR=2.73; 95% CI=1.88-3.97 respectively); richest wealth status (OR=2.64; 95% CI=1.81-3.86); protestant religion (OR=1.27; 95% CI=1.05-1.54) and age of woman (OR=0.97, 95% CI=0.95-0.99). In addition, PPFP was associated with number of surviving children (OR=1.09; 95 % CI=1.03-1.16); exposure to media (OR=1.30; 95% CI=1.05-1.61); skilled birth attendance (OR=1.39; 95% CI=1.12-1.17); and 1-2 days timing of post-delivery care (OR=1.68; 95% CI=1.14-2.47). Conclusions: Increasing reproductive health education and information among postpartum women especially those who are disadvantaged, those with no education and the poor would significantly improve PPFP in Uganda.
... Most studies examining the effect of postpartum interventions on increasing birth spacing or reducing frequent childbearing have been conducted in the United States and other developed countries, predominately among high-risk adolescent populations, and the results of these studies have been mixed (Corcoran and Pillai 2007;Lopez et al. 2012). These studies were predominately randomized controlled or quasi-experimental trials, with varying degrees of intensity in the intervention. ...
Meeting postpartum contraceptive need remains a major challenge in developing countries, where the majority of women deliver at home. Using a quasi-experimental trial design, we examine the effect of integrating family planning (FP) with a community-based maternal and newborn health (MNH) program on improving postpartum contraceptive use and reducing short birth intervals <24 months. In this two-arm trial, community health workers (CHWs) provided integrated FP counseling and services during home visits along with their outreach MNH activities in the intervention arm, but provided only MNH services in the control arm. The contraceptive prevalence rate (CPR) in the intervention arm was 15 percent higher than in the control arm at 12 months, and the difference in CPRs remained statistically significant throughout the 24 months of observation. The short birth interval of less than 24 months was significantly lower in the intervention arm. The study demonstrates that it is feasible and effective to integrate FP services into a community-based MNH care program for improving postpartum contraceptive use and lengthening birth intervals.
... This is in line with results from a review of Demographic and Health Surveys from 17 countries that indicate that nearly two-thirds of women in their first postpartum year have an unmet need for family planning. The review also indicates that return to sexual activity is associated with the return of menses, breastfeeding status, and postpartum duration but not generally associated with contraceptive use [19]. We were surprised that prenatal home visits and counselling on postpartum contraception did not affect utilisation of modern contraceptives demonstrated by non-significant statistical tests between the control and intervention arms. ...
Globally, most postpartum pregnancies are unplanned, mainly as a result of low level of knowledge and fear of contraceptive use especially in low-income settings. The aim of this study was to evaluate the effect of prenatal contraceptive counselling on postpartum contraceptive use and pregnancy outcomes after one year.
Sixteen health centres were equally and randomly allocated to control and intervention arms. Mothers were consecutively recruited during their first antenatal clinic consultations. In the intervention arm Village Health Team members made home visits and provided prenatal contraceptive advice and made telephone consultations with health workers for advice while in the control arm mothers received routine antenatal care offered in the health centres. Data were collected in 2014 in the two districts of Kiryandongo and Masindi. This data was collected 12-14 months postpartum. Mothers were asked about their family planning intentions, contraceptive use and screened for pregnancy using human Chorionic Gonadotropin (hCG) levels. Socio-demographic and obstetric indices were recorded. Our primary outcomes of interests were current use of modern contraceptive, decision to use a modern contraceptive method and pregnancy status. Multilevel analysis using the xtmelogit stata command was used to determine differences between intervention and control groups.
A total of 1,385 women, 748 (control) and 627 (intervention) were recruited. About 80% initiated breastfeeding within six hours of delivery 78.4% (control) and 80.4% (intervention). About half of the mothers in each arm had considered to delay the next pregnancy 47.1% (control) and 49% (intervention). Of these 71.4% in the control and 87% in the intervention had considered to use a modern contraceptive method, only 28.2% of the control and 31.6% in the intervention were current modern contraceptive users signifying unmet contraceptive needs among immediate postpartum mothers. Regarding pregnancy, 3.3% and 5.7% of the women were found to be pregnant in the control and intervention arms respectively. There were no statistical differences between the control and intervention arms for all primary outcomes of interests.
Prenatal contraceptive counseling did not affect postpartum contraceptive use among immediate postpartum mothers in Masindi and Kiryandongo districts. Interventions aiming at improving postpartum contraceptive use should focus on addressing unmet contraceptive needs.
... Studies examining the value of integration have mixed findings. A randomized control trial on educational interventions for contraceptive use reveals that women who received postpartum counseling with repeated contacts were more influenced to use FP methods [35]. However a review of trials found that there was little impact of integrated service delivery on outcomes of integration, costs or health system performance in developing country settings [36]. ...
Background
Counseling/advice is one of the key interventions to promote family planning (FP) in developing countries, including India. It helps to improve the quality of care and reduce maternal deaths. This paper investigates the continuity of maternal health (MH) service utilization from antenatal care to post-natal care and the impact this service utilization has on contraceptive use and on meeting the demand for family planning among currently married women in rural Uttar Pradesh, India.
Methods and Findings
The study assesses the impact of FP advice on unmet need and contraceptive use by adopting the propensity score matching method. It uses data from the District Level Household Survey (DLHS) (2007–08) that covered 76,147 currently married women (CMW) in the age group 15–44 years in Uttar Pradesh. Results show that the utilization of MH services [Antenatal care (ANC), institutional delivery, Postnatal care (PNC)] and FP advice during ANC and PNC has led to increase in current use of contraception by 3.7% (p<.01), 7.3% (p<.01) and 6.8% (p<.01), respectively. However, a greater utilization of these services has not translated into a reduction of unmet need for contraception at a similar manner.
Conclusion
MH service utilization including FP advice is more effective in increasing current use of spacing methods as compared to limiting methods. Findings support the need for “effective FP advice” interventions to reduce unintended births and unmet need. However, women from Scheduled Caste/Scheduled Tribe communities are less likely to receive MH services. Thus, efforts are required to ensure that currently married women across socio-economic backgrounds have equal opportunity to receive MH services and information on contraceptive use to meet the demand for family planning methods.
... However, because the proportion of migrant husbands was higher in the intervention area, the results are unlikely to be biased positively toward showing higher contraceptive use in that area. Most studies examining the effect of postpartum interventions on increasing birth spacing or reducing frequent childbearing have been conducted in the United States and other developed countries, predominately among high-risk adolescent populations, and the results of these studies have been mixed (Corcoran and Pillai 2007; Lopez et al. 2012were predominately randomized controlled or quasi-experimental trials, with varying degrees of intensity in the intervention. Although many of these interventions were found to be effective in improving contraceptive use and reducing repeat pregnancies in the initial period, their effectiveness could not be sustained for a longer period. ...
Background
In Bangladesh, median duration of breastfeeding is 32.8 months. However, the mean duration of exclusive breastfeeding is only 1.8 months. We describe an innovative intervention which attempted to integrate promotion of lactational amenorrhea method (LAM) with a community-based maternal, neonatal and child health program in a rural Bangladeshi community, where contraceptive use rate is low.
Intervention
The intervention consists of (i) training of community health workers on LAM (ii) community-based advocacy and behavior change communication targeting pregnant, postpartum women and their families. Community health workers, one per 4000 population, conduct antenatal and postpartum home visits to counsel families on maternal and newborn care, the LAM, transitional methods and healthy timing and spacing of pregnancy. Community Mobilizers organize advocacy and community meetings with influential persons including religious leaders, their wives; and identify people to serve as role models on LAM.
Evaluation Design
The study has a quasi-experimental design. It follows 4430 pregnant women longitudinally from the antenatal period to 36 months postpartum in eight time points.
Result
At three months postpartum the LAM use was 35% in the intervention group compared to zero in the comparison group. In intervention group, 56% of women at three months postpartum accepted any contraceptive method, compared to 24% in the comparison group (p=<0.001).
Conclusion
The inclusion of LAM counseling in a maternal and newborn care program, demonstrates significant potential for increasing contraceptive use among postpartum women during a particularly vulnerable period, the first six months postpartum.
... This is a summary of a Cochrane review containing 10 randomised controlled trials (RCTs) from five countries, assessing the effects of educational interventions on unplanned pregnancies and choice or use of contraception. Meta-analysis was not performed because of varied study designs (Lopez et al., 2012). ...
At present there is a lack of evidence on the effects of educational programs about contraceptive use for postpartum mothers. This systematic review has summarized all the available evidence of programs delivered by various health professionals including physicians nurses and midwives. The included trials delivered various types of postpartum educational interventions in various settings some during postpartum hospital stay and others a few weeks later. Four trials involved counseling programs with one or two contacts and six trials involved programs with multiple contacts (home phone or clinic). Although half of the interventions were effective in reducing repeat pregnancies or births and increasing contraceptive use the overall evidence of effectiveness was of low to moderate quality. Implications for practice across a range of settings and for research in the United States Asia and Australia need to be further evaluated.
Anne sütü ile beslenme; yalnızca bebek beslenmesi olmayıp aynı zamanda hem anne hem de bebek sağlığının korunması, geliştirilmesi, psiko-sosyal açıdan da oldukça önemli bir süreçtir. Bebeği, gerekli mineral ve vitamin takviyeleri dışında ilk altı ay yalnızca anne sütü ile besleme olarak tanımlanan etkili emzirme düzeyleri tüm dünyada düşük oranlardadır. Anne ve/veya bebeğe ait bazı etkenler emzirmeyi olumlu ya da olumsuz yönde etkilemektedir. Anne sütü bireyin tüm yaşamını etkileyerek, sağlıklı yaşamın başlangıcına önemli katkı sağlanmaktadır. Anne sütü ile beslenme oranlarının artmasını sağlayabilecek en önemli uygulamalardan birisi ebeler tarafından annelere verilen eğitimlerdir. Herhangi bir nedenle sağlık kuruluşlarına başvuran gebe adayı kadınlara, prekonsepsiyonel danışmanlık ve gebelere de emzirmeye hazırlık eğitimleri verilmelidir. Bebeği olan annelerin ise bebek beslenmesi sorgulanarak, emzirme danışmanlığının yapılması, gözlenmesi ve hatalı uygulama varsa düzeltilerek emzirmenin devam etmesi yönünde cesaretlendirilmelidir. Ayrıca bu eğitimlerde aile planlamasına vurgu yapılarak emzirme döneminde sıklıkla karşılaşılan istenmeyen gebelikler de önlenebilecektir. Ebeler anne sütü ve emzirme eğitimlerinin her aşamasında görev alarak hizmet içi eğitimler yapabilirler. Sağlık yöneticileri tarafından anne sütü ve emzirmeye yönelik kültürel uygulamalarımızı da kapsayan geniş kapsamlı nitel ve nicel çalışmaların yapılabilmesine olanak sağlayacak düzenlemeler yapılması önerilebilir.
Background: In Sub-Saharan Africa access to and utilization of sexual and reproductive healthcare is unsatisfactory. Consequently, rates of teenage pregnancy and unsafe abortions among adolescents in Sub-Saharan Africa, including in South Africa remain a public health challenge. The aim of this study was to explore nurses’ views on and perceptions of adolescent girls’ barriers and needs to accessing and utilizing sexual and reproductive healthcare services.
Methods: Twenty-four purposively selected healthcare workers from nine public healthcare facilities in Cape Town, South Africa participated in this qualitative descriptive study. Data were collected through nine group discussions, and audio-recorded with hand-written notes taken during the discussions. Data were analyzed using thematic analysis, following the Tesch’s eight steps for coding and analysing qualitative data.
Results: Sexual and reproductive healthcare nurses are generally supportive of adolescents who ask for and use contraceptives. Non-compliance to family planning regimens and repeated requests for termination of pregnancies were perceived by nurses as irresponsible behaviours which are particularly frustrating to them and not in concordance with their personal values. The subsequent nurse-adolescent interactions sometimes appeared to hinder access to and utilization of sexual and reproductive healthcare services by adolescents.
Conclusions: Nurses perceive certain behaviours of adolescent girls as irresponsible and warrant their negative attitudes and reactions toward them. The negative attitudes and reactions of nurses potentially further compromises access to and utilization of sexual and reproductive healthcare services by adolescent girls in South Africa and requires urgent attention. Adolescent-friendly clinic hours together with youth-friendly nurses is likely to encourage adolescent girls to access sexual and reproductive healthcare services and improve the use thereof.
Objective:
To investigate whether an early 3-week postpartum visit in addition to the standard 6-week visit increases LARC initiation by 8weeks postpartum compared to the routine 6-week visit alone.
Study design:
We enrolled pregnant and immediate postpartum women into a prospective randomized, non-blinded trial comparing a single 6-week postpartum visit (routine care) to two visits at 3 and 6weeks postpartum (intervention), with initiation of contraception at the 3-week visit, if desired. All participants received structured contraceptive counseling. Participants completed surveys in-person at baseline and at the time of each postpartum visit. A sample size of 200 total participants was needed to detect a 2-fold difference in LARC initiation (20% vs. 40%).
Results:
Between May 2016 and March 2017, 200 participants enrolled; outcome data are available for 188. The majority of LARC initiation occurred immediately postpartum (25% of the intervention arm and 27% of the routine care arm). By 8weeks postpartum,34% of participants in the intervention arm initiated LARC, compared to 41% in the routine care arm (p=.35). Overall contraceptive initiation by 8weeks was 83% and84% in the intervention and routine care arms, respectively (p=.79). There was no difference between the arms in the proportion of women who attended at least one postpartum visit (70% vs. 74%, p=.56).
Conclusion:
The addition of a 3-week postpartum visit to routine care does not increase LARC initiation by 8weeks postpartum. The majority of LARC users desired immediate rather than interval postpartum initiation.
Clinical trial registration:
Clinicaltrials.govNCT02769676 Implications. The addition of a 3-week postpartum visit to routine care does not increase LARC or overall contraceptive initiation by 8weeks post-partum when the option of immediate postpartum placement is available. The majority of LARC users desired immediate rather than interval postpartum initiation.
Objective:
Assess if video-based contraceptive education could be an efficient adjunct to contraceptive counseling and attain the same contraceptive knowledge acquisition as conversation-based counseling.
Study design:
This was a multi-center randomized, controlled trial examining contraceptive counseling during labor and maternity hospitalization regarding the options of immediate postpartum contraception. At two urban public hospitals, we randomized participants to a structured conversation with a trained counselor or a 14-min video providing the same information. Both groups received written materials and were invited to ask the counselor questions. Our primary outcome was to compare mean time for video-based education and conversational counseling; secondary outcomes included intended postpartum contraceptive method, pre- and post-intervention contraceptive knowledge, and perceived competence in choosing a method of contraception.
Results:
We enrolled 240 participants (conversation group=119, video group=121). The average time to complete either type of counseling was similar [conversational: 16.3min, standard deviation (SD) ±3.8min; video: 16.8min, SD±4.6min, p=.32]. Of women intending to use non-permanent contraception, more participants intended to use a long-acting reversible contraceptive (LARC) method after conversational counseling (72/103, 70% versus 59/105, 56%, p=.041). Following counseling, mean knowledge assessment scores increased by 2 points in both groups (3/7 points to 5/7 correct). All but two participants in the video group agreed they felt equipped to choose a contraceptive method after counseling.
Conclusions:
Compared to in-person contraceptive counseling alone, video-based intrapartum contraceptive education took a similar amount of time and resulted in similar contraceptive knowledge acquisition, though with fewer patients choosing LARC.
Implications:
Video-based contraceptive education may be useful in settings with limited personnel to deliver unbiased hospital-based, contraceptive counseling for women during the antepartum period.
This is the protocol for a review and there is no abstract. The objectives are as follows: We will review non-randomized studies (NRS) of educational strategies to improve postpartum contraceptive use. Our intent is to examine associations between interventions and postpartum contraceptive use or subsequent pregnancy.
Initiation of long-acting reversible contraception (LARC) in the immediate postpartum period is becoming more common, resulting in increased requests for early removal, primarily because of unpredictable bleeding patterns. Competing interests of healthful spacing of pregnancies, impact on breastfeeding, risks associated with pregnancy versus contraceptive method, potential adverse effects of LARC, and timing of informed consent make immediate postpartum initiation of LARC an important issue. Nearly 40% of women do not attend a postpartum visit at all, resulting in decreased initiation of contraception and increased risk of unplanned pregnancy. Nurses caring for women during the peripartum period can help women make informed decisions and can provide anticipatory guidance regarding this method of contraception. Evidence-based postpartum education and support can result in women’s increased continuation of and satisfaction with LARC.
Background
In Colombia, one out of five women between the ages of 15 and 19 years have been pregnant. Almost two-thirds (64%) of these pregnancies were unplanned.
Objectives
To examine the socio-demographic, psychosocial and clinical risk factors associated with adolescent pregnancy.
Methods
An analytical prevalence study was performed using secondary data from the First Demographic Study of Mental Health in Medellin, Colombia. Female adolescents between 13 and 19 years of age were included in the study. The population was evaluated using the Composite International Diagnosis Interview, a structured interview developed by the World Health Organization, which establishes diagnoses according to the DSM-IV and ICD-10 criteria.
Results
A sample of 499 female adolescents was obtained, in which 135 adolescent pregnancies were identified, representing a prevalence of 21.5%. The large majority (84.4%) were between 16 and 19 years old. The median age was 17 years, with an interquartile range of 2 years. Almost two-thirds (61.2%) of female adolescents had initiated sexual activity at the age of 15 or later. Almost one-third (31.9%) reported being physically abused during childhood, and 6.7% sexually abused. Of those who were pregnant, 66.7% reported previous sexual abuse. A bivariate analysis showed that sexual abuse (OR = 7.68), childhood negligence (OR = 4.33), and having a partner (OR = 6.31) were factors associated with an adolescent pregnancy.
Conclusions
Negligence and sexual abuse in childhood and adolescence can be prevented, and adolescent pregnancies can be decreased. This finding has important implications for clinical management and prognosis, and requires public preventive policies.
Objectives:
The optimal approach for provision and timing of postpartum contraceptive counselling for adolescents has not been established. To reduce repeat pregnancies from current USA levels of nearly 20%, a better understanding is needed of postpartum adolescent females' preferences regarding contraceptive counselling and delivery.
Methods:
Semi-structured interviews with 30 USA postpartum teens (97% Black) explored pregnancy prevention and contraceptive counselling. Transcripts were independently coded by two researchers and inter-rater reliability calculated using Kappa coefficients. With a standard content analysis approach, common themes were identified, coded and summarized.
Results:
Findings indicated pregnancy prevention was important - two thirds of subjects reported becoming pregnant 'too soon', almost all did not desire another child for at least 6 years and most indicated that pregnancy prevention was either 'very' or 'extremely' important right now. The subjects described doctors and their prenatal clinic as their most accurate sources of contraception information, but stated that doctors and parents were the most helpful sources. All were comfortable discussing contraception with providers and had a desire for shared decision making. While many had received written materials, most preferred in-person contraceptive counselling. Optimally, participants suggested that contraceptive counselling would be provided by a physician, begin antepartum and almost all preferred to leave the hospital with their chosen method of contraception.
Conclusions:
Pregnancy prevention is important for postpartum adolescents as most desired to delay future childbearing. In-person contraceptive counselling should begin in the antepartum period and include provision of contraception prior to discharge.
Context: Effective contraceptive use is important after a caesarean or operative delivery because of the possible risks a woman may face in subsequent pregnancies.
Objectives: The objective of the present study was to determine the uptake and choices of contraception among women with previous operative delivery.
Materials and Methods: A retrospective study was conducted at the Barau Dikko Teaching Hospital from 1 st January, 2000 to 31 st March, 2014. Family planning cards were retrieved, and relevant information was collected and analyzed using the Statistical Package for Social Sciences version 15. Chi-square test was used as a test of association, with significance level established at a P value of < 0.05.
Results: Of the 5992 cards retrieved, 164 (2.7%) had previous operative delivery; 152 caesarean sections and 12 laparotomies for ruptured uterus. Only 17.7% initiated contraception within 6 months. More women were spacers (86.6%) rather than limiters (13.4%). Age, education, religion, parity, prior contraception, and interval from the last delivery were significantly associated with the current choice of contraception (P < 0.05), whereas breast feeding status was not (P > 0.05). Overall, when comparing the pattern among those with a previous operative delivery and those without, there was no significant difference between both the groups; injectables was the most popular method chosen followed by intrauterine devices, oral contraceptive pills, and implants.
Conclusion: Most women with a previous operative delivery were at risk of unwanted pregnancies because they did not initiate contraception within 6 months of their last delivery. Their preferred forms of contraception were injectables and intrauterine devices, which was not significantly different from the methods chosen by other women.
The UK has one of the highest rates of teenage pregnancies in Western Europe. One-fifth of these are repeat pregnancies. Unintended conceptions can cause substantial emotional, psychological and educational harm to teenagers, often with enduring implications for life chances. Babies of teenage mothers have increased mortality and are at a significantly increased risk of poverty, educational underachievement and unemployment later in life, with associated costs to society. It is important to identify effective, cost-effective and acceptable interventions.
Objectives
To identify who is at the greatest risk of repeat unintended pregnancies; which interventions are effective and cost-effective; and what the barriers to and facilitators of the uptake of these interventions are.
Data sources
We conducted a multistreamed, mixed-methods systematic review informed by service user and provider consultation to examine worldwide peer-reviewed evidence and UK-generated grey literature to find and evaluate interventions to reduce repeat unintended teenage pregnancies. We searched the following electronic databases: MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the Health Technology Assessment Database), EMBASE (Excerpta Medica database), British Nursing Index, Educational Resources Information Center, Sociological Abstracts, Applied Social Sciences Index and Abstracts, BiblioMap (the Evidence for Policy and Practice Information and Co-ordinating Centre register of health promotion and public health research), Social Sciences Citation Index (supported by Web of Knowledge), Research Papers in Economics, EconLit (American Economic Association’s electronic bibliography), OpenGrey, Scopus, Scirus, Social Care Online, National Research Register, National Institute for Health Research Clinical Research Network Portfolio and Index to THESES. Searches were conducted in May 2013 and updated in June 2014. In addition, we conducted a systematic search of Google (Google Inc., Mountain View, CA, USA) in January 2014. Database searches were guided by an advisory group of stakeholders.
Review methods
To address the topic’s complexities, we used a structured, innovative and iterative approach combining methods tailored to each evidence stream. Quantitative data (effectiveness, cost-effectiveness, risk factors and effect modifiers) were synthesised with reference to Cochrane guidelines for evaluating evidence on public health interventions. Qualitative evidence addressing facilitators of and barriers to the uptake of interventions, experience and acceptability of interventions was synthesised thematically. We applied the principles of realist synthesis to uncover theories and mechanisms underpinning interventions (what works, for whom and in what context). Finally, we conducted an overarching narrative of synthesis of evidence and gathered service user feedback.
Results
We identified 8664 documents initially, and 816 in repeat searches. We filtered these to 12 randomised controlled trials (RCTs), four quasi-RCTs, 10 qualitative studies and 53 other quantitative studies published between 1996 and 2012. None of the RCTs was based in the UK. The RCTs evaluated an emergency contraception programme and psychosocial interventions. We found no evidence for effectiveness with regard to condom use, contraceptive use or rates of unprotected sex or use of birth control. Our primary outcome was repeat conception rate: the event rate was 132 of 308 (43%) in the intervention group versus 140 of 289 (48%) for the control goup, with a non-significant risk ratio (RR) of 0.92 [95% confidence interval (CI) 0.78 to 1.08]. Four studies reported subsequent birth rates: 29 of 237 (12%) events for the intervention arm versus 46 out of 224 (21%) for the control arm, with a RR of 0.60 (95% CI 0.39 to 0.93). Many repeat conceptions occurred in the context of poverty, low expectations and aspirations, and negligible opportunities. Service user feedback suggested that there were specific motivations for many repeat conceptions, for example to replace loss or to please a partner. Realist synthesis highlighted that context, motivation, planning for the future and letting young women take control with connectedness and tailoring provide a conceptual framework for future research.
Limitations
Included studies rarely characterised adolescent pregnancy as intended or unintended, that is interventions to reduce repeat conceptions rarely addressed whether or not pregnancies were intended. Furthermore, interventions were often not clearly defined, had multiple aims and did not indicate which elements were intended to address which aims. Nearly all of the studies were conducted in the USA and focused largely on African American or Hispanic and Latina American populations.
Conclusions
We found no evidence to indicate that existing interventions to reduce repeat teenage pregnancy were effective; however, subsequent births were reduced by home-based interventions. Qualitative and realist evidence helped to explain gaps in intervention design that should be addressed. More theory-based, rigorously evaluated programmes need to be developed to reduce repeat teenage pregnancy in the UK.
Study registration
This study is registered as PROSPERO CRD42012003168. Cochrane registration number: i=fertility/0068.
Funding
The National Institute for Health Research Health Technology Assessment programme.
Cassandra Blazer, Ndola Prata Bixby Center for Population, Health, and Sustainability, School of Public Health, University of California, Berkeley, CA, USA Abstract: We reviewed existing evidence of the efficacy of postpartum family planning interventions targeting women in the 12 months postpartum period in low- and middle-income countries. We searched for studies from January 1, 2004 to September 19, 2015, using the US Preventive Services Task Force recommendations to assess evidence quality. Our search resulted in 26 studies: 11 based in sub-Saharan Africa, six in the Middle East and North Africa, and nine in Asia. Twenty of the included studies assessed health facility-based interventions. Three were focused on community interventions, two had community and facility components, and one was a workplace program. Overall quality of the evidence was moderate, including evidence for counseling interventions. Male partner involvement, integration with other service delivery platforms, such as prevention of mother-to-child transmission of HIV and immunization, and innovative product delivery programs may increase knowledge and use during the postpartum period. Community-based and workplace strategies need a much stronger base of evidence to prompt recommendations. Keywords: postpartum period, family planning, birth spacing, interventions, systematic review, contraception, less developed countries
Introduction:
The aim of the study was to assess the level of awareness and knowledge of contraception among women in Singapore, and to identify the factors that influence contraception choice.
Methods:
We conducted a cross-sectional survey of 259 female patients, aged 21-49 years, from the Obstetrics and Gynaecology Clinic of National University Hospital, Singapore. An original questionnaire that tested on nine contraceptive methods was used. Respondents with ≥ 2 correct answers for a method (out of four questions) were considered to have good knowledge of that method. The women were asked to rate factors known to influence contraceptive choice as important or not important.
Results:
Awareness was high for the following methods: condom (100.0%), oral contraception pill (89.2%), ligation (73.0%) and copper intrauterine device (IUD) (72.2%). The women were least aware of hormonal IUD (24.3%). Women who were parous, had previous abortion, completed their family or had used contraception before were more likely to have a higher awareness of contraception. Among the women, 89.2% had good knowledge on condoms; among those aware of hormonal IUD, only 46.0% had good knowledge on it. Women who had used hormonal IUD and condoms before were more likely to have good knowledge on these methods. Many rated efficacy (90.5%) and healthcare professional's advice (90.1%) as important in contraception choice. Few considered peer influence (21.0%) and cultural practices (16.3%) to be important.
Conclusion:
Women in Singapore have poor awareness and knowledge of contraception, especially long-acting reversible methods. There should be more efforts placed on educating women about contraceptive methods.
Background Women in the postpartum period need effective contraception. Unintended pregnancies soon after childbirth may lead to abortion or short inter-pregnancy intervals associated with adverse outcomes. Using databases for a 6-month period (September 2013–February 2014) we examined the proportion of women attending for abortion in Edinburgh, Scotland who had given birth in the preceding 12 months, and the proportion of women giving birth in this region after an inter-pregnancy interval of 12 months or less. We also surveyed 250 women prior to discharge from the same maternity service about their contraceptive intentions.
Results Some 75/1175 (6.4%) attending for abortion had given birth within the preceding 12 months and 332/4713 (7.0%) postpartum women gave birth following an inter-pregnancy interval of 12 months or less. When considering parous women, percentages were 13.3% and 13.9%, respectively. The majority (n=237, 96.7%) of postpartum women were not planning another pregnancy within the year but only a minority (n=32, 12.8%) were planning on using long-acting reversible contraception (LARC), namely the implant or intrauterine device. However, 42.8% (n=107) indicated that if the implant or intrauterine contraception could be inserted before they left hospital then they would choose these methods (p<0.0001).
Discussion Almost one in thirteen women in our population presenting for abortion or giving birth has conceived within 1 year of giving birth. Provision of LARC immediately postpartum appears to be an attractive option to mothers, and could be an important strategy to prevent unintended pregnancy and short inter-pregnancy intervals.
Anita L Nelson Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA Abstract: Postpartum contraception is undergoing major changes, not only in timing, but also in content. Failure to provide immediate postpartum contraception contributes to the problems of unintended pregnancies and rapid repeat pregnancy because often the highest-risk women do not return for postpartum care. If they do attend that visit, they have often lost the insurance coverage that would enable them to use the most effective forms of birth control. Most of the issues surrounding early initiation of progestin-only methods and breastfeeding have been favorably resolved. In some cases, insurance coverage for delivery has been expanded to cover the costs of providing intrauterine devices and implants before the woman is discharged home. All of these new opportunities shift the burden of counseling about postpartum contraception onto the shoulders of the prenatal care provider. This article provides information about the advantages and disadvantages of providing immediate postpartum contraception with each of the eligible methods so clinicians can provide the needed counseling both during pregnancy and during hospitalization for delivery. It also provides guidance for initiation of bridging contraception, if needed, to initiate a method for a woman later in the postpartum period. Keywords: postpartum contraception, counseling, breastfeeding, implants, IUDs, hormonal methods
The rationale for promotion of family planning (FP) to delay conception after a recent birth is a best practice that can lead to optimal maternal and child health outcomes. Uptake of postpartum family planning (PPFP) remains low in sub-Saharan Africa. However, little is known about how pregnant women arrive at their decisions to adopt PPFP.
We used 3298 women of reproductive ages 15–49 from the 2011 UDHS dataset, who had a birth in the 5 years preceding the survey. We then applied both descriptive analyses comprising Pearson’s chi-square test and later a binary logistic regression model to analyze the relative contribution of the various predictors of uptake of modern contraceptives during the postpartum period.
More than a quarter (28%) of the women used modern family planning during the postpartum period in Uganda. PPFP was significantly associated with primary or higher education (OR=1.96; 95% CI=1.43-2.68; OR=2.73; 95% CI=1.88-3.97 respectively); richest wealth status (OR=2.64; 95% CI=1.81-3.86); protestant religion (OR=1.27; 95% CI=1.05-1.54) and age of woman (OR=0.97, 95% CI=0.95-0.99). In addition, PPFP was associated with number of surviving children (OR=1.09; 95 % CI=1.03-1.16); exposure to media (OR=1.30; 95% CI=1.05-1.61); skilled birth attendance (OR=1.39; 95% CI=1.12-1.17); and 1–2 days timing of post-delivery care (OR=1.68; 95% CI=1.14-2.47).
Increasing reproductive health education and information among postpartum women especially those who are disadvantaged, those with no education and the poor would significantly improve PPFP in Uganda.
Background:
Nearly two-thirds of women in their first postpartum year have an unmet need for family planning. Adolescents often have repeat pregnancies within a year of giving birth. Women may receive counseling on family planning both antepartum and postpartum. Decisions about contraceptive use made right after counseling may differ considerably from actual postpartum use. In earlier work, we found limited evidence of effectiveness from randomized trials on postpartum contraceptive counseling. For educational interventions, non-randomized studies may be conducted more often than randomized trials.
Objectives:
We reviewed non-randomized studies of educational strategies to improve postpartum contraceptive use. Our intent was to examine associations between specific interventions and postpartum contraceptive use or subsequent pregnancy.
Search methods:
We searched for eligible non-randomized studies until 3 November 2014. Sources included CENTRAL, PubMed, POPLINE, and Web of Science. We also sought current trials via ClinicalTrials.gov and ICTRP. For additional citations, we examined reference lists of relevant reports and reviews.
Selection criteria:
The studies had to be comparative, i.e., have intervention and comparison groups. The educational component could be counseling or another behavioral strategy to improve contraceptive use among postpartum women. The intervention had to include contact within six weeks postpartum. The comparison condition could be another behavioral strategy to improve contraceptive use, usual care, other health education, or no intervention. Our primary outcomes were postpartum contraceptive use and subsequent pregnancy.
Data collection and analysis:
Two authors evaluated abstracts for eligibility and extracted data from included studies. We computed the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous measures, both with 95% Confidence Intervals (CI). Where studies used adjusted analyses for continuous outcomes, we presented the results as reported by the investigators. Due to differences in interventions and outcome measures, we did not conduct meta-analysis. To assess the evidence quality, we used the Newcastle-Ottawa Quality Assessment Scale.
Main results:
Six studies met our inclusion criteria and included a total of 5143 women. Of three studies with self-reported pregnancy data, two showed pregnancy to be less likely in the experimental group than in the comparison group (OR 0.48, 95% CI 0.27 to 0.87) (OR 0.60, 95% CI 0.41 to 0.87). The interventions included a clinic-based counseling program and a community-based communication project.All studies showed some association of the intervention with contraceptive use. Two showed that treatment-group women were more likely to use a modern method than the control group: ORs were 1.77 (95% CI 1.08 to 2.89) and 3.08 (95% CI 2.36 to 4.02). In another study, treatment-group women were more likely than control-group women to use pills (OR 1.78, 95% CI 1.26 to 2.50) or an intrauterine device (IUD) (OR 3.72, 95% CI 1.27 to 10.86) but less likely to use and injectable method (OR 0.23, 95% CI 0.05 to 1.00). One study used a score for method effectiveness. The methods of the special-intervention group scored higher than those of the comparison group at three months (MD 13.26, 95% CI 3.16 to 23.36). A study emphasizing IUDs showed women in the intervention group were more likely to use an IUD (OR 1.79, 95% CI 1.20 to 2.69) and less likely to use no method (OR 0.48, 95% CI 0.31 to 0.75). In another study, contraceptive use was more likely among women in a health service intervention compared to women in a community awareness program at four months (OR 1.79, 95% CI 1.40 to 2.30) or women receiving standard care at 10 to 12 months (OR 2.08, 95% CI 1.58 to 2.74). That study was the only one with a specific component on the lactational amenorrhea method (LAM) that had sufficient data on LAM use. Women in the health service group were more likely than those in the community awareness group to use LAM (OR 41.36, 95% CI 10.11 to 169.20).
Authors' conclusions:
We considered the quality of evidence to be very low. The studies had limitations in design, analysis, or reporting. Three did not adjust for potential confounding and only two had sufficient information on intervention fidelity. Outcomes were self reported and definitions varied for contraceptive use. All studies had adequate follow-up periods but most had high losses, as often occurs in contraception studies.
As birth spacing has demonstrated health benefits for a woman and her children, contraception after childbirth is recognized as an important health issue. The potential risk of pregnancy soon after delivery underscores the importance of initiating postpartum contraception in a timely manner. The contraceptive method initiated in the postpartum period depends upon a number of factors including medical history, anatomic and hormonal factors, patient preference, and whether or not the woman is breastfeeding. When electing a contraceptive method, informed choice is paramount. The availability of long-acting reversible contraceptive methods immediately postpartum provides a strategy to achieve reductions in unintended pregnancy.
In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.
Childbirth and the postnatal period, spanning from right after birth to the following several weeks, presents a time in which the number of deaths reported still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily while almost 75% of neonatal deaths occur within the first seven days of delivery and a vast majority of these occur in the first 24 hours. Unfortunately, this alarming trend of mortality persists, as287,000 women lost their lives to pregnancy and childbirth related causes in 2010. Almost all of these deaths were preventable and occurred in low-resource settings, pointing towards dearth of adequate facilities in these parts of the world. The main objective of this paper is to review the evidence based childbirth and post natal interventions which have a beneficial impact on maternal and newborn outcomes. It is a compilation of existing, new and updated interventions designed to help physicians and policy makers and enable them to reduce the burden of maternal and neonatal morbidities and mortalities. Interventions during the post natal period that were found to be associated with a decrease in maternal and neonatal morbidity and mortality included: advice and support of family planning, support and promotion of early initiation and continued breastfeeding; thermal care or kangaroo mother care for preterm and/or low birth weight babies; hygienic care of umbilical cord and skin following delivery, training health personnel in basic neonatal resuscitation; and postnatal visits. Adequate delivery of these interventions is likely to bring an unprecedented decrease in the number of deaths reported during childbirth.
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of fewer than 12 neonatal deaths and fewer than 12 stillbirths per 1000 births in every country by 2030 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6–2·1 million]), 33% of stillbirths (0·82 million [0·60–0·93 million]), and 54% of maternal deaths (0·16 million [0·14–0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality—preterm, intrapartum, and infection-related deaths—by 58%, 79%, and 84%, respectively.
Objective
In 2006, the incidence of unintended pregnancy among rural-to-urban migrant women (RUMW) in Shanghai was reported as 12.8 per 100 women-years during the first year postpartum. Among permanent residents of Shanghai, that same rate was 3.8 per 100 women-years. An intervention study was designed to address the unmet need for family planning services among this underserved population of RUMW and reduce their high postpartum unintended pregnancy incidence.
Study Design
We enrolled 840 migrant women into an intervention study that provided free contraceptive counseling and a choice of methods.
Subjects were recruited into the study during hospitalization for childbirth and offered a contraceptive method according to their choice prior to discharge. Counseling and further support were offered at 6 weeks and at 3-, 6-, 9- and 12-months postpartum via scheduled telephone calls and/or clinic visits.
Results
Among all study participants, the median time to contraceptive initiation and sexual resumption was 2 months postpartum, respectively. The overall contraceptive prevalence at 12 months was 97.1%, and more than half of the women were using long-acting contraception. The incidence rate of unintended pregnancy during the first year postpartum was 2.2 per 100 women-years (95% CI: 1.3 – 3.6).
Conclusions
Integrating free family planning services into existing childbirth delivery services in a maternity setting in Shanghai was effective in addressing the unmet need for family planning and reduced the risk of unintended pregnancy during the first year postpartum.
To describe what puerperal women know about postpartum contraception and to identify their related needs and expectations.
Puerperal women face the problem of beginning or resuming contraception, the choice of the right method of contraception and the right time to start it. This choice becomes particularly important in case they breastfeed since the contraceptive method should not interfere with breastfeeding. Different factors, such as the level of knowledge women have about various contraceptive methods, their individual preferences or their desire to have a baby, can strongly influence this choice.
A cross-sectional study had been carried out within the period of six months, from November 2011-February 2012.
Three hundred puerperal women were interviewed before their discharge from a Maternity Home. The women were asked for their personal characteristics, their maternity history, the information they had received, their knowledge and expectations about postpartum contraception and their intention to use contraception.
During pregnancy and postpartum, 45·5% of the women reported that they had received adequate information about contraception. Of these ones, 64·3% reported their intention to use contraception either to avoid pregnancy or to space out future births, even if they did not always have appropriate knowledge about fertility and the use of contraceptive methods during postpartum. During this study, we also discovered that women's intention to use contraception was proportional to their level of education.
Women need more and appropriate information about postpartum contraception, to make a conscious choice in relation to their needs and without putting their health at risk.
To promote awareness of the choices related to postpartum contraception, it is important to understand the personal characteristics that influence or hinder this choice. Midwives can play a very important role in informing women and in developing educational interventions to support a safe contraceptive choice.
Substantial numbers of adolescents experience the negative health consequences of early, unprotected sexual activity - unintended pregnancy, unsafe abortions, pregnancy-related mortality and morbidity and Sexually Transmitted Infections including Human Immunodeficiency Virus; as well as its social and economic costs. Improving access to and use of contraceptives - including condoms - needs to be a key component of an overall strategy to preventing these problems. This paper contains a review of research evidence and programmatic experiences on needs, barriers, and approaches to access and use of contraception by adolescents in low and middle income countries (LMIC). Although the sexual activity of adolescents (ages 10-19) varies markedly for boys versus girls and by region, a significant number of adolescents are sexually active; and this increases steadily from mid-to-late adolescence. Sexually active adolescents - both married and unmarried - need contraception. All adolescents in LMIC - especially unmarried ones - face a number of barriers in obtaining contraception and in using them correctly and consistently. Effective interventions to improve access and use of contraception include enacting and implementing laws and policies requiring the provision of sexuality education and contraceptive services for adolescents; building community support for the provision of contraception to adolescents, providing sexuality education within and outside school settings, and increasing the access to and use of contraception by making health services adolescent-friendly, integrating contraceptive services with other health services, and providing contraception through a variety of outlets. Emerging data suggest mobile phones and social media are promising means of increasing contraceptive use among adolescents.
To evaluate the impact of group prenatal care (GPNC) on postpartum family planning utilization.
A retrospective cohort of women continuously enrolled in Medicaid for twelve months (n=3,637) was used to examine differences in postpartum family planning service utilization among women participating in GPNC (n=570) and those receiving individual prenatal care (IPNC; n=3,067). Propensity scoring methods were used to derive a matched cohort for additional analysis of selected outcomes.
Utilization of postpartum family planning services was higher among women participating in GPNC than among women receiving IPNC at four points in time: three (7.72% vs. 5.15%, p<0.05), six (22.98% vs. 15.10%, p<0.05), nine (27.02% vs. 18.42%, p<0.05), and twelve (29.30% vs. 20.38%, p<0.05) months postpartum. Postpartum family planning visits was highest among non-Hispanic black women at each interval, peaking with 31.84% by twelve months postpartum. After propensity score matching, positive associations between GPNC and postpartum family planning service utilization remained consistent by six (OR=1.42; 95% CI=1.05-1.92), nine (OR=1.43; 95% CI=1.08-1.90), and twelve (OR=1.44; 95% CI=1.10-1.90) months postpartum.
These findings demonstrate the potential that GPNC has to positively influence women's health outcomes after pregnancy, and to improve the utilization rate of preventive health services. Utilization of postpartum family planning services was highest among non-Hispanic black women, further supporting evidence of the impact of GPNC in reducing health disparities. However, despite continuous Medicaid enrollment, postpartum utilization of family planning services remained low among all women, regardless of the type of prenatal care they received.
Adolescent pregnancy and its consequences represent a major public health concern in many low-middle income countries of the world. The World Health Organization has recently developed evidence-based guidelines addressing six areas: preventing early marriage; preventing early pregnancy through sexuality education, increasing education opportunities and economic and social support programs; increasing the use of contraception; reducing coerced sex; preventing unsafe abortion; and increasing the use of prenatal care childbirth and postpartum care. In each of these areas, World Health Organization recommends directions for future research. The summary concludes with a brief look at global and regional initiatives that provide a window of opportunity for stepping up action in this important area.
Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to the increased availability of antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. This review examines behavioral interventions to improve contraceptive use, for family planning, among women who are HIV-positive.
We systematically reviewed studies that examined behavioral interventions for HIV-positive women that were intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.
Through October 2012, we searched MEDLINE, CENTRAL, POPLINE, EMBASE, CINAHL, PsycINFO, ClinicalTrials.gov and ICTRP. For other relevant papers, we examined reference lists and unpublished project reports, and contacted investigators in the field.
Studies evaluated a behavioral intervention for improving contraceptive use for contraception. The comparison could be another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive women versus HIV-negative women. We included nonrandomized (observational) studies as well as randomized trials.Primary outcomes were pregnancy and contraception use, e.g., uptake of a new method, improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception in general or about a specific contraceptive method.
Two authors independently extracted the data. One author entered the data into RevMan and a second verified accuracy. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale.Given the need to control for confounding factors in observational studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs, we did not conduct meta-analysis.
The seven studies meeting our inclusion criteria had a total of 8882 women. All were conducted in Africa. Three studies compared a special intervention versus standard services. In one, the special intervention site showed greater use of non-condom contraceptives per visit (OR 6.40; 95% CI 5.37 to 7.62) and reported a lower pregnancy incidence. In another study, use of modern contraceptives was more likely for women at sites with enhanced versus basic integrated services (OR 2.48; 95% CI 1.31 to 4.72), but the groups did not differ significantly in change from baseline. In the third study, new use of modern contraceptives, excluding condoms, was less likely for women with integrated services versus those with routine care (OR 0.56; 95% CI 0.42 to 0.75), but new use of condoms was more likely (OR 1.73; 95% CI 1.52 to 1.98).Four older studies compared HIV-positive women versus HIV-negative women. None showed any significant difference between the HIV-status groups in use of modern contraceptives. Two did not provide an intervention for the HIV-negative women. In the larger of the two studies, HIV-positive women were less likely to become pregnant (OR 0.55; 95% CI 0.43 to 0.69). HIV-positive women were more likely to discontinue their hormonal contraceptive (OR 2.52; 95% CI 1.53 to 4.14) but more likely to use condoms (OR 2.82; 95% CI 2.18 to 3.65) and spermicide (OR 2.36; 95% CI 1.69 to 3.30). Two studies provided the intervention to both HIV-status groups. One included many of the women from the study just mentioned, and also showed fewer pregnancies for HIV-positive women (OR 0.39; 95% CI 0.23 to 0.68). In the other study, the HIV-status groups were not significantly different for pregnancy or consistent condom use.
Comparative research on contraceptive counseling for HIV-positive women has been limited. We found little innovation in the behavioral interventions. Our ability to make statements about overall results is hampered by varied study designs, interventions, and outcome assessments. The quality of evidence was moderate. Since some of these studies were conducted, improvements in HIV treatment have influenced the fertility intentions of HIV-positive people.The family planning field needs better ways to help women choose an appropriate contraceptive and continue using that chosen method. Women with HIV may have special concerns regarding family planning. Research could focus on assessing the woman's needs and training providers to address those issues rather than delivering standardized information.
Context: The year after a woman gives birth presents a rising risk of an unwanted conception and an often frustrated desire for contraceptive protection. At present, contraceptive use levels during this period fall short, resulting in unplanned pregnancies and unwanted childbearing. Methods: Data from 27 surveys conducted as part of the Demographic and Health Surveys series between 1993 and 1996 are analyzed to assess intentions to practice contraception and unmet need for it, both in the first year after birth. Unmet need is partly redefined here to focus on future wishes rather than on past pregnancies and births. Results: Across the 27 countries, there is much unsatisfied interest in, and unmet need for, contraception. Unweighted country averages indicate that two-thirds of women who are within one year of their last birth have an unmet need for contraception, and nearly 40% say they plan to use a method in the next 12 months but are not currently doing so. Moreover, of all unmet need, on average nearly two-fifths falls among women who have given birth within the past year. Similarly, nearly two in five women intending to use a method are within a year of their last birth. The two groups-those with an unmet need and those intending to use a method-overlap; their common members include nearly all of those intending to use a method and about two-thirds of those with an unmet need (which is the larger group of the two). Only trivial proportions of both of these groups want another birth within two years. Between 50% and 60% of pregnant women make prenatal visits or have contact with health care providers at or soon after delivery, and additional contacts occur for infant care and other health services. Conclusions: Women who have recently given birth need augmented attention from family planning and reproductive health programs if they are to reduce their numbers of unwanted births and abortions and to lengthen subsequent birth intervals. Prenatal visits, delivery services and subsequent health system contacts are promising avenues for reaching postpartum women with an unmet need for and a desire to use family planning services.
Background
It is often assumed, with little supportive, empirical evidence, that women who use maternal health care are more likely than those who do not to use modern contraceptives. This study aims to add to the existing literature on associations between the use of antenatal (ANC) and post-natal care (PNC) and post-partum modern contraceptives.
Methods
Data come from the most recent Demographic and Health Surveys (DHS) in Kenya (2008–09) and Zambia (2007). Study samples include women who had a live birth within five years before the survey (3,667 in Kenya and 3,587 in Zambia). Multivariate proportional hazard models were used to examine the associations between the intensity of ANC and PNC service use and a woman’s adoption of modern contraceptives after a recent live birth.
Results
Tests of exogeneity confirmed that the intensity of ANC and PNC service use and post-partum modern contraceptive practice were not influenced by common unobserved factors. Cox proportional hazard models showed significant associations between the service intensity of ANC and PNC and post-partum modern contraceptive use in both countries. This relationship is largely due to ANC services; no significant associations were observed between PNC service intensity and post-partum FP practice.
Conclusions
While the lack of associations between PNC and post-partum FP use may be due to the limited measure of PNC service intensity, the study highlights a window of opportunity to promote the use of modern contraceptives after childbirth through ANC service delivery. Depending on the availability of data, further research should take into account community- and facility-level factors that may influence modern contraceptive use in examining associations between ANC and PNC use and post-partum FP practice.
Social marketing interventions are important in developing nations. Both increasing use and shifting users from receiving subsidised condoms need to be pursued using a Total Market Approach (TMA). This paper reviews the performance of social marketing through a cross-country comparison of condom use, equity and market share, plus a case study illustrating how TMA can be applied.
Demographic and Health Survey data (1998-2007) provide condom use trends, concentration indices and sources of supply by gender for 11 African countries. Service delivery information and market research provide market share data for the same period. For the case study, two-yearly surveys (2001-09) are the source of condom trends, and retail audit data (2007-09) provide sustainability data.
Among women, condom use with a non-marital, non-cohabiting partner increased significantly in 7 of 11 countries. For men, 5 of 11 countries showed an increase in condom use. Equity improved for men in five countries and was achieved in two; for women, equity improved in three. Most obtained condoms from shops and pharmacies; social marketing was the dominant source of supply. Data from Kenya were informative for TMA, showing improvements in condom use over time, but sustainability results were mixed and equity was not measured. Overall market value and number of brands increased; however, subsidies increased over time.
Condom social marketing interventions have advanced and achieved the goals of improving use and making condoms available in the private sector. It is time to manage interventions and influence markets to improve equity and sustainability.
Adolescent mothers in Washington, DC have a high rate of subsequent teen pregnancies, often within 24 months. Children of teen mothers are at risk for adverse psychosocial outcomes. When adolescents are strongly attached to parents, schools, and positive peers, they may be less likely to repeat a pregnancy. This study tested the efficacy of a counseling intervention delivered by cell phone and focused on postponing subsequent teen pregnancies by strengthening healthy relationships, reproductive practices, and positive youth assets. The objective of this study was to compare time to a repeat pregnancy between the intervention and usual care groups, and, secondarily, to determine whether treatment intensity influenced time to subsequent conception. Primiparous pregnant teens ages 15-19, were recruited in Washington, DC. Of 849 teens screened, 29.3% (n = 249) met inclusion criteria, consented to participate, and completed baseline measures. They were then randomized to the intervention (N = 124) or to usual care (N = 125). Intervention group teens received cell phones for 18 months of counseling sessions, and quarterly group sessions. Follow-up measures assessed subsequent pregnancy through 24 months post-delivery. A survival analysis compared time to subsequent conception in the two treatment groups. Additional models examined the effect of treatment intensity. By 24 months, 31% of the intervention and 36% of usual care group teens had a subsequent pregnancy. Group differences were not statistically significant in intent-to-treat analysis. Because there was variability in the degree of exposure of teens to the curriculum, a survival analysis accounting for treatment intensity was performed and a significant interaction with age was detected. Participants who were aged 15-17 years at delivery showed a significant reduction in subsequent pregnancy with increased levels of intervention exposure (P < 0.01), but not those ≥ 18 years. Adolescents ≥ 18 years faced considerable challenges to treatment success. Individual, social, and contextual factors are all important to consider in the prevention of repeat teen pregnancy. Cell phone-based approaches to counseling may not be the most ideal for addressing complex, socially-mediated behaviors such as this, except for selective subgroups. A lack of resources within the community for older teens may interfere with program success.
To evaluate impact of postnatal health education for mothers on infant care and postnatal family planning practices in Nepal.
Randomised controlled trial with community follow up at 3 and 6 months post partum by interview. Initial household survey of study areas to identify all pregnant women to facilitate follow up.
Main maternity hospital in Kathmandu, Nepal. Follow up in urban Kathmandu and a periurban area southwest of the city.
540 mothers randomly allocated to one of four groups: health education immediately after birth and three months later (group A), at birth only (group B), at three months only (group C), or none (group D).
Structured baseline household questionnaire; 20 minute, one to one health education at birth and three months later.
Duration of exclusive breast feeding, appropriate immunisation of infant, knowledge of oral rehydration solution and need to continue breast feeding in diarrhoea, knowledge of infant signs suggesting pneumonia, uptake of postnatal family planning.
Mothers in groups A and B (received health education at birth) were slightly more likely to use contraception at six months after birth compared with mothers in groups C and D (no health education at birth) (odds ratio 1.62, 95% confidence interval 1.06 to 2.5). There were no other significant differences between groups with regards to infant feeding, infant care, or immunisation.
Our findings suggest that the recommended practice of individual health education for postnatal mothers in poor communities has no impact on infant feeding, care, or immunisation, although uptake of family planning may be slightly enhanced.
One-quarter of adolescent mothers bear another child within 2 years, compounding their risk of poorer medical, educational, economic, and parenting outcomes. Most efforts to prevent rapid subsequent birth to teenagers have been unsuccessful but have seldom addressed motivational processes.
We conducted a randomized trial to determine the effectiveness of a computer-assisted motivational intervention (CAMI) in preventing rapid subsequent birth to adolescent mothers. Pregnant teenagers (N = 235), aged 18 years and older who were at more than 24 weeks' gestation, were recruited from urban prenatal clinics serving low-income, predominantly African American communities. After completing baseline assessments, they were randomly assigned to 3 groups: (1) those in CAMI plus enhanced home visit (n = 80) received a multi-component home-based intervention (CAMI+); (2) those in CAMI-only (n = 87) received a single component home-based intervention; (3) and those in usual-care control (n = 68) received standard usual care. Teens in both intervention groups received CAMI sessions at quarterly intervals until 2 years' postpartum. Those in the CAMI+ group also received monthly home visits with parenting education and support. CAMI algorithms, based on the transtheoretical model, assessed sexual relationships and contraception-use intentions and behaviors, and readiness to engage in pregnancy prevention. Trained interventionists used CAMI risk summaries to guide motivational interviewing. Repeat birth by 24 months' postpartum was measured with birth certificates.
Intent-to-treat analysis indicated that the CAMI+ group compared with the usual-care control group exhibited a trend toward lower birth rates (13.8% vs 25.0%; P = .08), whereas the CAMI-only group did not (17.2% vs 25.0%; P = .32). Controlling for baseline group differences, the hazard ratio (HR) for repeat birth was significantly lower for the CAMI+ group than it was with the usual-care group (HR = 0.45; 95% CI, 0.21-0.98). We developed complier average causal effects models to produce unbiased estimates of intervention effects accounting for variable participation. Completing 2 or more CAMI sessions significantly reduced the risk of repeat birth in both groups: CAMI+ (HR = 0.40; 95% CI, 0.16-0.98) and CAMI-only (HR = 0.19; 95% CI, 0.05-0.69).
Receipt of 2 or more CAMI sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth to adolescent mothers.
The main aim of the study was to discover if a midwife home visiting programme has a significant effect on the prevalence of health problems and breast feeding behaviour of mothers who delivered normally and their healthy fullterm newborn babies, during a period of 42 days after delivery. Another aim was to compare the mothers', the midwife's, and the doctor's findings of prevalence of health problems at the end of the puerperium period.
A randomised controlled trial was carried out. One group of mothers and their infants were randomly allocated to a home visiting group (Group A); the other group (Group B) was only visited at day 42.
The study was carried out at the University Teaching Hospital (UTH) in Lusaka, the capital city of Zambia.
A total of 408 mothers who had a normal delivery and gave birth to a healthy fullterm infant, as assessed by the attending midwife, were randomised to two groups. Group A consisted of 208 mother/infant dyads who were visited by a midwife in their homes at days 3, 7, 28, and 42 after delivery and Group B consisted of 200 mother/infant dyads who were only visited at day 42.
At day 42 an equal proportion (30%) of mothers in both groups perceived that they had health problems. The prevalence of infant health problems in Group B was significantly higher (p < 0.01) as perceived by mothers. There were more mothers in Group B (p < 0.01) perceiving insufficient milk production and giving supplementary feeding. At day 42, mothers in Group A (56%) took more actions than mothers in Group B (41%) to solve infant health problems (p < 0.03). In both groups the mothers' perceived own health problems, were significantly higher (p < 0.01) than those observed by the obstetrician and those observed by the midwife. The midwife found more infant health problems in Group B (p < 0.01) than in Group A and more infants with health problems in both groups compared with the paediatrician's findings (p < 0.01).
There was a significant difference between the mothers' reported health problems and the health problems identified by the midwife and the doctors. The study shows that a midwife home visit and individual health education to mothers, reduce the prevalence of infant health problems, and enables the mother to more often take action when an infant health problem is identified. There is a need to re-evaluate the midwifery training curriculums with the intention to include more infant management care.
The American Academy of Pediatrics, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the World Health Organization recommend that infants receive only breast milk or formula for the first 4 to 6 months of life, followed by the introduction of complementary foods. Despite these recommendations, many infants, particularly those with adolescent mothers, receive solid foods (often cereal mixed with formula in a bottle) and liquids other than formula or breast milk in the first few weeks of life. Decisions on early feeding are often guided by grandmothers and influenced by beliefs that infants need complementary food to counteract signals of hunger, reduce crying, and sleep through the night.
This investigation evaluated the efficacy of an intervention to delay the early introduction of complementary feeding among first-time, black, adolescent mothers living in multigenerational households. The intervention focused on reducing the cultural barriers to the acceptance of the recommendations of the American Academy of Pediatrics, WIC, and World Health Organization on complementary feeding by highlighting 3 topics: 1) recognition of infants' cues; 2) nonfood strategies for managing infant behavior; and 3) mother-grandmother negotiation strategies. The intervention was delivered through a mentorship model in which a videotape made by an advisory group of black adolescent mothers was incorporated into a home-visiting program and evaluated through a randomized, controlled trial.
One hundred eighty-one first-time, low-income, black mothers <18 years old, living in multigenerational households were recruited from 3 urban hospitals. Infants were born at term, with birth weight appropriate for gestational age and no congenital problems. Shortly after delivery, mothers and grandmothers completed a baseline assessment and mothers were randomized into an intervention or control group. Intervention group mothers received home visitation every other week for 1 year. At 3 months, a subset of 121 adolescent mothers reported on their infant's intake through a food frequency questionnaire. Mothers who fed their infant only breast milk, formula, or water were classified as optimal feeders. Mothers who provided complementary foods other than breast milk, formula, or water were classified as less optimal feeders.
Sixty-one percent of the infants received complementary foods before 3 months old. Multivariate hierarchical logistic regression was used to evaluate the determinants of being in the optimal versus less optimal feeders group. After controlling for infant age and family income, mothers of infants in the optimal feeders group were more likely to report accurate messages from WIC regarding the timing of complementary food and nearly 4 times more likely to be in the intervention group. The most common complementary food was cereal mixed with formula in the bottle.
The success of this relatively brief intervention demonstrates the importance of using ecological theory and ethnographic research to design interventions that enable participants to alter their behavior in the face of contradictory cultural norms. The intervention focused on interpreting infants' cues, nonfood methods of managing infant behavior, and mother-grandmother negotiations. It was delivered through methods that were familiar and acceptable to adolescent mothers-a mentorship model incorporating home visits and videotape. The skill-oriented aspects of the intervention delivered in a culturally sensitive context may have enabled the young mothers to follow the guidelines that they received from WIC and from their pediatricians. Strategies, such as those used in this intervention, may be effective in promoting other caregiving recommendations, thereby enabling providers to meet the increasing demands from parents for advice regarding children's early growth and development.
To examine the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health when both types of visitors are trained in a program model that has demonstrated effectiveness when delivered by nurses.
A randomized, controlled trial was conducted in public- and private-care settings in Denver, Colorado. One thousand one hundred seventy-eight consecutive pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were invited to participate. Seven hundred thirty-five women were randomized to control, paraprofessional, or nurse conditions. Nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the children's second birthdays. Paraprofessionals completed an average of 6.3 home visits during pregnancy and 16 visits from birth to the children's second birthdays. The main outcomes consisted of changes in women's urine cotinine over the course of pregnancy; women's use of ancillary services during pregnancy; subsequent pregnancies and births, educational achievement, workforce participation, and use of welfare; mother-infant responsive interaction; families' home environments; infants' emotional vulnerability in response to fear stimuli and low emotional vitality in response to joy and anger stimuli; and children's language and mental development, temperament, and behavioral problems.
Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control-group counterparts (99.45 vs 97.54 standard score points). There were no other statistically significant paraprofessional effects. In contrast to their control-group counterparts, nurse-visited smokers had greater reductions in cotinine levels from intake to the end of pregnancy (259.0 vs 12.32 ng/mL); by the study child's second birthday, women visited by nurses had fewer subsequent pregnancies (29% vs 41%) and births (12% vs 19%); they delayed subsequent pregnancies for longer intervals; and during the second year after the birth of their first child, they worked more than women in the control group (6.83 vs 5.65 months). Nurse-visited mother-child pairs interacted with one another more responsively than those in the control group (100.31 vs 98.99 standard score points). At 6 months of age, nurse-visited infants, in contrast to their control-group counterparts, were less likely to exhibit emotional vulnerability in response to fear stimuli (16% vs 25%) and nurse-visited infants born to women with low psychological resources were less likely to exhibit low emotional vitality in response to joy and anger stimuli (24% vs 40% and 13% vs 33%). At 21 months, nurse-visited children born to women with low psychological resources were less likely to exhibit language delays (7% vs 18%); and at 24 months, they exhibited superior mental development (90.18 vs 86.20 Mental Development Index scores) than their control-group counterparts. There were no statistically significant program effects for the nurses on women's use of ancillary prenatal services, educational achievement, use of welfare, or their children's temperament or behavior problems. For most outcomes on which either visitor produced significant effects, the paraprofessionals typically had effects that were about half the size of those produced by nurses.
When trained in a model program of prenatal and infancy home visiting, paraprofessionals produced small effects that rarely achieved statistical or clinical significance; the absence of statistical significance for some outcomes is probably attributable to limited statistical power to detect small effects. Nurses produced significant effects on a wide range of maternal and child outcomes.
To examine the effects of prenatal and infancy home visiting by paraprofessionals and by nurses from child age 2 through age 4 years.
We conducted, in public and private care settings in Denver, Colorado, a randomized, controlled trial with 3 arms, ie, control, paraprofessional visits, and nurse visits. Home visits were provided from pregnancy through child age 2 years. We invited 1178 consecutive, low-income, pregnant women with no previous live births to participate, and we randomized 735; 85% were unmarried, 47% Mexican American, 35% white non-Mexican American, 15% black, and 3% American Indian/Asian. Outcomes consisted of maternal reports of subsequent pregnancies, participation in education and work, use of welfare, marriage, cohabitation, experience of domestic violence, mental health, substance use, and sense of mastery; observations of mother-child interaction and the home environment; tests of children's language and executive functioning; and mothers' reports of children's externalizing behavior problems.
Two years after the program ended, women who were visited by paraprofessionals, compared with control subjects, were less likely to be married (32.2% vs 44.0%) and to live with the biological father of the child (32.7% vs 43.1%) but worked more (15.13 months vs 13.38 months) and reported a greater sense of mastery and better mental health (standardized scores [mean = 100, SD = 10] of 101.25 vs 99.31 and 101.21 vs 99.16, respectively). Paraprofessional-visited women had fewer subsequent miscarriages (6.6% vs 12.3%) and low birth weight newborns (2.8% vs 7.7%). Mothers and children who were visited by paraprofessionals, compared with control subjects, displayed greater sensitivity and responsiveness toward one another (standardized score [mean = 100, SD = 10] of 100.92 vs 98.66) and, in cases in which the mothers had low levels of psychologic resources at registration, had home environments that were more supportive of children's early learning (score of 24.63 vs 23.35). Nurse-visited women reported greater intervals between the births of their first and second children (24.51 months vs 20.39 months) and less domestic violence (6.9% vs 13.6%) and enrolled their children less frequently in preschool, Head Start, or licensed day care than did control subjects. Nurse-visited children whose mothers had low levels of psychologic resources at registration, compared with control group counterparts, demonstrated home environments that were more supportive of children's early learning (score of 24.61 vs 23.35), more advanced language (score of 91.39 vs 86.73), superior executive functioning (score of 100.16 vs 95.48), and better behavioral adaptation during testing (score of 100.41 vs 96.66). There were no statistically significant effects of either nurse or paraprofessional visits on the number of subsequent pregnancies, women's educational achievement, use of substances, use of welfare, or children's externalizing behavior problems.
Paraprofessional-visited mothers began to experience benefits from the program 2 years after the program ended at child age 2 years, but their first-born children were not statistically distinguishable from their control group counterparts. Nurse-visited mothers and children continued to benefit from the program 2 years after it ended. The impact of the nurse-delivered program on children was concentrated on children born to mothers with low levels of psychologic resources.
A. Bellg, B. Borrelli, et al. (2004) previously developed a framework that consisted of strategies to enhance treatment fidelity of health behavior interventions. The present study used this framework to (a) develop a measure of treatment fidelity and (b) use the measure to evaluate treatment fidelity in articles published in 5 journals over 10 years. Three hundred forty-two articles met inclusion criteria; 22% reported strategies to maintain provider skills, 27% reported checking adherence to protocol, 35% reported using a treatment manual, 54% reported using none of these strategies, and 12% reported using all 3 strategies. The mean proportion adherence to treatment fidelity strategies was .55; 15.5% of articles achieved greater than or equal to .80. This tool may be useful for researchers, grant reviewers, and editors planning and evaluating trials.
Rates of rapid second births among low-income black adolescent mothers range from 20% to 50%. Most efforts to prevent rapid second births have been unsuccessful.
There were 4 objectives: (1) to examine whether a home-based mentoring intervention was effective in preventing second births within 2 years of the adolescent mother's first delivery; (2) to examine whether greater intervention participation increased the likelihood of preventing a second birth; (3) to examine whether second births were better predicted from a risk practice perspective or a family formation perspective, based on information collected at delivery; and (4) to examine how risk practices or family formation over the first 2 years of parenthood were related to a second birth.
We conducted a randomized, controlled trial of a home-based intervention curriculum, based on social cognitive theory, and focused on interpersonal negotiation skills, adolescent development, and parenting. The curriculum was delivered biweekly until the infant's first birthday by college-educated, black, single mothers who served as mentors, presenting themselves as "big sisters." The control group received usual care. Follow-up evaluations were conducted in the homes 6, 13, and 24 months after recruitment.
Participants were recruited from urban hospitals at delivery and were 181 first time, black adolescent mothers (< 18 years of age); 82% (149 of 181) completed the 24-month evaluation.
Intent-to-treat analyses revealed that control mothers were more likely than intervention mothers to have a second infant. The complier average causal effect was used to account for variability in intervention participation. Having > or = 2 intervention visits increased the odds of not having a second infant more than threefold. Only 1 mother who completed > or = 6 visits had a second infant. At delivery of their first infant, mothers who had a second infant were slightly older (16.7 vs 16.2 years) and were more likely to have been arrested (30% vs 14%). There were no differences in baseline contraceptive use or other measures of risk or family formation. At 24 months, mothers who had a second infant reported high self-esteem, positive life events, and romantic involvement and residence with the first infant's father. At 24 months, there were no differences in marital rates (2%), risk practices, or contraceptive use between mothers who did and did not have a second infant. Mothers who did not have a second infant were marginally more likely to report no plans for contraception in their next sexual contact compared with mothers who had a second infant (22% vs 8%, respectively).
A home-based intervention founded on a mentorship model and targeted toward adolescent development, including negotiation skills, was effective in preventing rapid repeat births among low-income, black adolescent mothers. The effectiveness of the intervention could be seen after only 2 visits and increased over time. There were no second births among mothers who attended > or = 8 sessions. There was no evidence that risk behavior or contraceptive use was related to rapid second births. There was some evidence that rapid second births among adolescent mothers were regarded as desirable and as part of a move toward increasing autonomy and family formation, thereby undermining intervention programs that focus on risk avoidance. Findings suggest the merits of a mentoring program for low-income, black adolescent mothers, based on a relatively brief (6-8 sessions) curriculum targeted toward adolescent development and interpersonal negotiation skills.
In the intervention study carried out in a maternity hospital; family planning information, education and counselling (IEC) were given to 197 pregnant women aged 15-49 during antenatal care, and method acceptance in early and late postpartum period was compared to a control group of 201 women. Eleven per cent of women in the intervention group and 2% of women in the control group accepted a family planning method during early postpartum period. The provision of family planning IEC during the antenatal period effects the use of an effective method mainly in the early, and to a lesser extent, the late postpartum period.
The effectiveness and cost-effectiveness of postpartum family planning service provision were assessed in a study of 1,560 women giving birth in 1988-1989 at the largest hospital of the Peruvian Social Security Institute (IPSS). Contraceptive counseling and temporary methods were offered to one ward of postpartum women, while a second ward, acting as a control group, was discharged without being offered comparable services. In the second half of the study period, almost 90% of the experimental group accepted family planning prior to discharge, and 25% of the women received an IUD. Six months after delivery, 82% of the members of the experimental group were using a contraceptive method, with 40% using an IUD; by comparison, 69% of controls were using a method, and 27% an IUD. Because in-patient IUD insertion was estimated to cost $9.38 per woman, compared with $24.16 for an interval insertion, implementing postpartum family planning services in all IPSS hospitals in Lima could save 3-5% of the annual projected IPSS family planning budget for Lima and free up 6% of the current outpatient delivery capacity.
To inform women of the risks associated with high parity and to increase understanding of birth control methods, especially voluntary surgical contraception, the University of Benin Teaching Hospital launched a family planning and education program for pregnant women who had had four or more previous deliveries. More than 1,000 high-parity women admitted for prenatal care during a 19-month period were randomly allocated either to a treatment group exposed to four individualized counseling sessions on family planning methods and the health risks associated with high parity or to a control group that received only the standard family planning information provided at the prenatal clinic. Overall, 71 percent of the women in the treatment group were using an effective method of birth control at six weeks postpartum, compared with 51 percent of the women in the control group. About 40 percent of women in both groups had indicated at admission that they did not want more children, but women in the treatment group were significantly more likely to choose female sterilization as their postpartum contraceptive method than women in the control group--13 percent, compared with three percent. By age, the proportions sterilized in the treatment group ranged from four percent of those younger than 30 to 28 percent of those 35 and older; comparable proportions for the control group were two percent and nine percent, respectively. Six percent of women in the treatment group who had four living children underwent sterilization, compared with 46 percent of those with seven or more living children. Among control patients, the proportions were zero and five percent, respectively.
Objective To determine the influence of multiple contraceptive counselling sessions during antenatal care on use of modern postpartum contraception. Method A total of 216 eligible pregnant women were randomised into antenatal and postnatal counselling groups. The 'Antenatal group' received one-to-one antenatal contraceptive counselling on several occasions while the 'Postnatal group' received a single one-to-one contraceptive counselling session at the sixth week postnatal check, as is routinely practised. All participants were contacted six months postpartum by telephone or personal visit, and questioned about their contraceptive use, if any. Results More women who had multiple antenatal contraceptive counselling sessions used modern contraceptive methods than those who had a single postnatal counselling session (57% vs. 35%; p = 0.002). There was also a significantly more frequent use of contraception among previously undecided patients in the Antenatal group (p = 0.014). Conclusion Multiple antenatal contraceptive counselling sessions improve the use of modern postpartum contraception.
Background:
Many women who intend to use long-acting, reversible contraceptives (LARCs) postpartum do not follow through with initiating use. The objectives of this study were to determine whether support from a contraceptive personal assistant could increase the uptake of LARCs by 3 months postpartum, and to identify risk factors for nonuptake of LARCs among women who planned LARC use.
Study design:
This is a randomized, controlled trial of 50 low-income postpartum women who desired LARC. The intervention group received telephone contact from a personal assistant who provided contraception education, facilitation of insurance coverage, appointment scheduling and assistance with childcare and transportation. The control group received routine follow up. Women were surveyed immediately and 3 months postpartum regarding contraceptive use and anticipated barriers to LARC use.
Results:
A similar proportion of women in both groups received LARC [control 16/24 (67%), intervention 18/25 (72%), p=.76]. More primiparous (86.4%) than multiparous (55.5%) women obtained LARC (p=.04). In addition, women with more prenatal visits were more likely to have initiated LARC (odds ratio, 95% confidence interval for each increased visit: 1.50, 1.15-1.96). No other demographic factors were related to LARC uptake.
Conclusions:
Providing telephone assistance to help navigate barriers did not increase postpartum uptake of LARCs. A personal history of clinic visit no-shows and/or infrequent prenatal visits were related to poor uptake of LARCs postpartum.
Background:
Short interpregnancy intervals lead to adverse perinatal outcomes and could be prevented with increased use of long-acting reversible contraception (LARC) in the postpartum period. The primary objective of this study was to assess which baseline characteristics are associated with the intent to use LARC among postpartum women.
Study design:
This study was a substudy of baseline data from a randomized controlled trial. Eight hundred women completed a pre-intervention survey of demographics and reproductive health history and intentions. We estimated adjusted relative risks (RRs) of intent to use LARC for baseline characteristics of interest.
Results:
Three hundred three postpartum women (38%) intended to use LARC. Two out of 10 baseline characteristics were significantly associated with intent to use LARC: not trying for pregnancy at time of conception [adjusted RR, 1.6; 95% confidence interval (CI), 1.2-2.1] and no desire for another pregnancy within 2 years (adjusted RR, 1.9; 95% CI, 1.2-2.8).
Conclusions:
High interest in LARC exists among postpartum women, particularly among women with a recent unintended pregnancy and women who do not desire pregnancy for at least 2 years. Past and future pregnancy intentions should be incorporated into future models and frameworks that evaluate postpartum contraceptive choice. Educational intervention studies are also needed to assess if LARC interest can be increased among postpartum women who are less likely to intend to use LARC but at risk for future adverse perinatal outcomes.
Abstract This article describes the outcomes at 1 year for a randomized clinical trial of Resources, Education and Care in the Home—Futures: a program to reduce infant mortality through home visits by a team of trained community residents led by a nurse. Low-income, inner-city pregnant women who self-identified as African American or Mexican American were recruited in two university prenatal clinics in Chicago. Because African Americans and Mexican Americans differed greatly at intake, we compared their outcomes at 12 months and then examined the effects of the intervention separately for these two groups. Participants were randomly assigned to the intervention or control group and were interviewed during the last trimester of pregnancy and at 2, 6, and 12 months after birth. The effects of the program varied by race/ethnicity. For African Americans, the program was associated with better maternal documentation of infant immunizations, more developmentally appropriate parenting expectations, and higher 12-month infant mental development scores. For Mexican Americans, the program had positive effects on maternal daily living skills and on the play materials subscale of the Home Observation for the Measurement of the Environment assessment. This study, along with previous research, suggests that home visits by a nurse-health advocate team can improve maternal and infant outcomes even for inner-city, low-income, minority families. Effective programs must be culturally sensitive, intensive, and adequately staffed and financed.
This report describes four diverse programs of community-engaged research, all of which demonstrated positive health outcomes. Three of the programs were focused on communities of people with diabetes, and one program targeted at-risk young families raising infants and young children. Brief descriptions of each research study and outcomes are presented as well as a discussion of the processes and lessons that were learned from each model of successful interdisciplinary community-university health research partnerships. Clin Trans Sci 2011; Volume 4: 285–297
Effective contraceptive use among first-time adolescent mothers can reduce the risk of a rapid repeat pregnancy and associated negative maternal and child health outcomes. Many adolescent mothers begin using a highly effective method after delivery; however, their rates of contraceptive discontinuation are high. Little research has explored the factors that influence adolescents' postpartum contraceptive use.
In-depth interviews were conducted with 21 black, white and Latina adolescent first-time mothers from rural and urban areas of North Carolina between November 2007 and February 2009. In addition, interviews were conducted with 18 key informants-professionals who work closely with adolescent mothers. Interviews explored adolescent mothers' health behaviors, including contraceptive use, before and after pregnancy. Content analysis was used to identify key themes and patterns.
Teenagers' use of contraceptives, particularly injectables, IUDs and implants, increased postpartum. Reasons for this improvement included improved clarity of intention to avoid pregnancy and improved contraceptive knowledge, support and access after delivery. However, this increased access often did not continue long after delivery, and levels of method switching were high. Among the barriers to postpartum contraceptive use that key informants cited were lack of information and parental support, as well as the loss of Medicaid and continuity of care.
Ongoing follow-up may help reduce adolescent mothers' risk of contraceptive discontinuation postpartum. Increasing use of long-acting methods also may help reduce their vulnerability to gaps in contraceptive use and discontinuation, which increase the risk of unintended pregnancy.
Unintended pregnancies can lead to poor maternal and child health outcomes. Family planning use during the first year postpartum has the potential to significantly reduce at least some of these unintended pregnancies. This paper examines the relationship of menses return, breastfeeding status, and postpartum duration on return to sexual activity and use of modern family planning among postpartum women. This paper presents results from a secondary data analysis of Demographic and Health Surveys from 17 countries. For postpartum women, the return of menses, breastfeeding status, and postpartum duration are significantly associated with return to sexual activity in at least 10 out of the 17 countries but not consistently associated with family planning use. Only menses return had a significant association with use of modern family planning in the majority of countries. These findings point to the importance of education about pregnancy risk prior to menses return.
To discuss methods of preservation of treatment fidelity in health behavior change trials conducted in public health contexts.
The treatment fidelity framework provided by the National Institutes of Health's Behavioral Change Consortium includes five domains of treatment fidelity (Study Design, Training, Delivery, Receipt, and Enactment). A measure of treatment fidelity was previously developed and validated using these categories.
Strategies for assessment, monitoring, and enhancing treatment fidelity within each of the five treatment fidelity domains are discussed. The previously created measure of treatment fidelity is updated to include additional items on selecting providers, additional confounders, theory testing, and multicultural considerations.
Implementation of a treatment fidelity plan may require extra staff time and costs. However, the economic and scientific costs of lack of attention to treatment fidelity are far greater than the costs of treatment fidelity implementation. Maintaining high levels of treatment fidelity with flexible adaptation according to setting, provider, and patient is the goal for public health trials.