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Rohr JK, Huber-Krum S, Rugarabamu A, Pearson E, Francis JM, Guo M, Siril H, Shah I, Canning D, Ulenga N, Bärnighausen TW. Impact of a post-partum family planning intervention on contraception and fertility in Tanzania: two-year follow-up of a cluster-randomised controlled trial. EUR J CONTRACEP REPR 2024; 29:24-31. [PMID: 38230668 DOI: 10.1080/13625187.2023.2290985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/29/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE We evaluate contraceptive use and pregnancy two years following an intervention in Tanzania, which provided antenatal post-partum family planning counselling and post-partum intrauterine device (PPIUD) services following delivery. METHODS We analyse data from five hospitals in Tanzania using a difference-in-difference cluster randomised design, with randomisation at the hospital level. We use women-level data collected at the index birth and a follow-up survey two years later among 6,410 women. Outcomes (overall modern contraceptive use, contraceptive type, pregnancy) are modelled with an intent-to-treat (ITT) approach using linear regression. We compare with the complier average causal effect (CACE) of the intervention among those counselled. RESULTS The intervention increased long-term PPIUD use by 5.8 percentage points (95% CI: 0.7-11.2%) through substitution away from other modern methods. There was no impact on overall modern contraceptive prevalence or pregnancy. Only 29% of women reported receiving PPIUD counselling. When accounting for this in the CACE analysis we saw a larger impact with 25.7% percentage point increase in PPIUD use (95% CI: 22.7-28.6%). CONCLUSION The intervention provided women an additional contraceptive choice, resulting in higher use of PPIUD over two years. Increase in PPIUD use was brought about by shifting methods, not creating new modern contraceptive users.
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Affiliation(s)
- Julia K Rohr
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | | | | | - Erin Pearson
- Center on Gender Equity and Health, University of CA San Diego, San Diego, CA, USA
| | - Joel M Francis
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Muqi Guo
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hellen Siril
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Iqbal Shah
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David Canning
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Till W Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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Nabhan A, Kabra R, Allam N, Ibrahim E, Abd-Elmonem N, Wagih N, Mostafa N, Kiarie J. Implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning, a mixed-methods systematic review. BMC Womens Health 2023; 23:379. [PMID: 37468942 PMCID: PMC10357879 DOI: 10.1186/s12905-023-02518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. This review aimed to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning. METHODS Electronic bibliographic databases (MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus) were searched from inception to October 2022 for primary quantitative, qualitative, and mixed method reports on scaling up post pregnancy family planning. Abstracts, titles, and full-text papers were assessed according to the inclusion criteria to select studies regardless of country, language, publication status, or methodological limitations. Data were extracted and methodological quality assessed using the Mixed Methods Appraisal Tool. The convergent integrated approach and a deductive thematic synthesis were used to identify themes and sub-themes of strategies to scale up post pregnancy family planning. The health system building blocks were used to summarize barriers and facilitators. GRADE-CERQual was used to assess our confidence in the findings. RESULTS Twenty-nine reports (published 2005-2022) were included: 19 quantitative, 7 qualitative, and 3 mixed methods. Seven were from high-income countries, and twenty-two from LMIC settings. Sixty percent of studies had an unclear risk of bias. The included reports used either separate or bundled strategies for scaling-up post pregnancy family planning. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and / or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods. CONCLUSION Post pregnancy family planning scaling up strategies, representing a range of styles and settings, were associated with improved post pregnancy contraceptive use. Factors that influence the success of implementing these strategies include issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms. TRIAL REGISTRATION Center for Open Science, OSF.IO/EDAKM.
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Affiliation(s)
- Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, Egypt.
| | - Rita Kabra
- Department of Sexual and Reproductive Health Including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Nahed Allam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Cairo, Egypt
| | - Eman Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Cairo, Egypt
| | | | - Nouran Wagih
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - James Kiarie
- Department of Sexual and Reproductive Health Including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
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Perinpanathan T, Maiya S, van Velthoven MHH, Nguyen AT, Free C, Smith C. Mobile phone-based interventions for improving contraception use. Cochrane Database Syst Rev 2023; 7:CD011159. [PMID: 37458240 PMCID: PMC10363274 DOI: 10.1002/14651858.cd011159.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Contraception provides significant benefits for women's and children's health, yet many women have an unmet need for contraception. Rapid expansion in the use of mobile phones in recent years has had a dramatic impact on interpersonal communication. Within the health domain text messages and smartphone applications offer means of communication between clients and healthcare providers. This review focuses on interventions delivered by mobile phone and their effect on use of contraception. OBJECTIVES To evaluate the benefits and harms of mobile phone-based interventions for improving contraception use. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was August 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of mobile phone-based interventions to improve forms of contraception use amongst users or potential users of contraception. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. uptake of contraception, 2. uptake of a specific method of contraception, 3. adherence to contraception method, 4. safe method switching, 5. discontinuation of contraception and 6. pregnancy or abortion. Our secondary outcomes were 7. road traffic accidents, 8. any physical or psychological effect reported and 9. violence or domestic abuse. MAIN RESULTS Twenty-three RCTs (12,793 participants) from 11 countries met our inclusion criteria. Eleven studies were conducted in high-income resource settings and 12 were in low-income settings. Thirteen studies used unidirectional text messaging-based interventions, six studies used interactive text messaging, four used voice message-based interventions and two used mobile-phone apps to improve contraception use. All studies received funding from non-commercial bodies. Mobile phone-based interventions probably increase contraception use compared to the control (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.06 to 1.60; 16 studies, 8972 participants; moderate-certainty evidence). There may be little or no difference in rates of unintended pregnancy with the use of mobile phone-based interventions compared to control (OR 0.82, 95% CI 0.48 to 1.38; 8 trials, 2947 participants; moderate-certainty evidence). Subgroup analysis assessing unidirectional mobile phone interventions versus interactive mobile phone interventions found evidence of a difference between the subgroups favouring interactive interventions (P = 0.003, I2 = 88.5%). Interactive interventions had an OR of 1.71 (95% CI 1.28 to 2.29; P = 0.0003, I2 = 63%; 8 trials, 3089 participants) whilst unidirectional interventions had an OR of 1.03 (95% CI 0.87 to 1.22; P = 0.72, I2 = 17%; 9 trials, 5883 participants). Subgroup analysis assessing high-income versus low-income trial settings found no difference between groups (subgroup difference test: P = 0.70, I2 = 0%). Only six trials reported on safety and unintended outcomes; one trial reported increased partner violence whilst another four trials reported no difference in physical violence rates between control and intervention groups. One trial reported no road traffic accidents with mobile phone intervention use. AUTHORS' CONCLUSIONS This review demonstrates there is evidence to support the use of mobile phone-based interventions in improving the use of contraception, with moderate-certainty evidence. Interactive mobile phone interventions appear more effective than unidirectional methods. The cost-effectiveness, cost benefits, safety and long-term effects of these interventions remain unknown, as does the evidence of this approach to support contraception use among specific populations. Future research should investigate the effectiveness and safety of mobile phone-based interventions with better quality trials to help establish the effects of interventions delivered by mobile phone on contraception use. This review is limited by the quality of the studies due to flaws in methodology, bias or imprecision of results.
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Affiliation(s)
- Tanaraj Perinpanathan
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Shilpa Maiya
- Society for Education, Action and Research in Community Health (SEARCH), Gadchiroli, Maharashtra, India
| | | | - Amy T Nguyen
- Department of Research, Darkness to Light, Baltimore, North Charleston, South Carolina, USA
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Smith
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Rosa Bolling K, Wahdan Y, Warnock N, Lott J, Schoendorf J, Pisa F, Gomez-Espinosa E, Kistler K, Maiese B. Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:e1. [PMID: 36600467 PMCID: PMC10176355 DOI: 10.1136/bmjsrh-2022-201579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/25/2022] [Indexed: 05/14/2023]
Abstract
BACKGROUND Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden. METHODS This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included. RESULTS 133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare. CONCLUSIONS PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.
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Affiliation(s)
| | | | | | - Jason Lott
- Bayer Healthcare, Whippany, New Jersey, USA
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Wall KM, Ingabire R, Mazzei A, Umuhoza C, Parker R, Tichacek A, Nizam A, Sales JM, Haddad LB, Corso P, Allen S, Nyombayire J, Karita E. Implementation and evaluation of a large-scale postpartum family planning program in Rwanda: study protocol for a clinic-randomized controlled trial. Trials 2022; 23:337. [PMID: 35459259 PMCID: PMC9027832 DOI: 10.1186/s13063-022-06261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Though the Rwandan Ministry of Health (MOH) prioritizes the scale-up of postpartum family planning (PPFP) programs, uptake and sustainability of PPFP services in Rwanda are low. Furthermore, highly effective long-acting reversible contraceptive method use (LARC), key in effective PPFP programs, is specifically low in Rwanda. We previously pilot tested a supply-demand intervention which significantly increased the use of postpartum LARC (PPLARC) in Rwandan government clinics. In this protocol, we use an implementation science framework to test whether our intervention is adaptable to large-scale implementation, cost-effective, and sustainable. METHODS In a type 2 effectiveness-implementation hybrid study, we will evaluate the impact of our PPFP intervention on postpartum LARC (PPLARC) uptake in a clinic-randomized trial in 12 high-volume health facilities in Kigali, Rwanda. We will evaluate this hybrid study using the RE-AIM framework. The independent effectiveness of each PPFP demand creation strategy on PPLARC uptake among antenatal clinic attendees who later deliver in a study facility will be estimated. To assess sustainability, we will assess the intervention adoption, implementation, and maintenance. Finally, we will evaluate intervention cost-effectiveness and develop a national costed implementation plan. DISCUSSION Adaptability and sustainability within government facilities are critical aspects of our proposal, and the MOH and other local stakeholders will be engaged from the outset. We expect to deliver PPFP counseling to over 21,000 women/couples during the project period. We hypothesize that the intervention will significantly increase the number of stakeholders engaged, PPFP providers and promoters trained, couples/clients receiving information about PPFP, and PPLARC uptake comparing intervention versus standard of care. We expect PPFP client satisfaction will be high. Finally, we also hypothesize that the intervention will be cost-saving relative to the standard of care. This intervention could dramatically reduce unintended pregnancy and abortion, as well as improve maternal and newborn health. Our PPFP implementation model is designed to be replicable and expandable to other countries in the region which similarly have a high unmet need for PPFP. TRIAL REGISTRATION ClinicalTrials.gov NCT05056545 . Registered on 31 March 2022.
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Affiliation(s)
- Kristin M Wall
- Department of Epidemiology, School of Public Health, Emory University, Atlanta, USA.
| | - Rosine Ingabire
- Projet San Francisco (PSF)/Center for Family Health Research (CFHR), Kigali, Rwanda
| | - Amelia Mazzei
- Projet San Francisco (PSF)/Center for Family Health Research (CFHR), Kigali, Rwanda
- Department of Pathology, School of Medicine, Emory University, Atlanta, USA
| | - Claudine Umuhoza
- Projet San Francisco (PSF)/Center for Family Health Research (CFHR), Kigali, Rwanda
| | - Rachel Parker
- Department of Pathology, School of Medicine, Emory University, Atlanta, USA
| | - Amanda Tichacek
- Department of Pathology, School of Medicine, Emory University, Atlanta, USA
| | - Azhar Nizam
- Department of Biostatistics and Bioinformatics, School of Public Health, Emory University, Atlanta, USA
| | - Jessica M Sales
- Department of Behavioral, Social and Health Education Sciences, School of Public Health, Emory University, Atlanta, USA
| | | | - Phaedra Corso
- Office of Research, Department of Health Policy, Kennesaw State University, Kennesaw, USA
| | - Susan Allen
- Department of Pathology, School of Medicine, Emory University, Atlanta, USA
| | - Julien Nyombayire
- Projet San Francisco (PSF)/Center for Family Health Research (CFHR), Kigali, Rwanda
| | - Etienne Karita
- Projet San Francisco (PSF)/Center for Family Health Research (CFHR), Kigali, Rwanda
- Department of Pathology, School of Medicine, Emory University, Atlanta, USA
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