Influence of integrated services on postpartum family planning use: a cross-sectional survey from urban Senegal

Pregnancy risks and contraceptive use among postpartum mothers in Cameroon: implications for improving the coverage of postpartum family planning services

BACKGROUND

The health hazards of short inter-birth intervals are severe in Cameroon. One-quarter of inter-birth intervals are less than 24 months and the probability of death before age 5 for children born after a short interval is double that associated with intervals of 36-47 months. We examine the risk of an unintended pregnancy in the 18 months following childbirth in Cameroon, taking into account the protective effects of lactational amenorrhea, delayed resumption of sex as well as contraceptive use.

METHODS

Data from 3007 postpartum women in the nationally representative 2018 Cameroon Demographic and Health Survey were used. Risk of an unintended pregnancy was defined from current status information on resumption of sex and menses, contraceptive use, desire for another child within 12 months, and, for the minority of pregnant women, whether the conception was intended. Predictors of risk, and of modern method use, were assessed by bivariate and multivariate analysis.

RESULTS

In the first 6 postpartum months, only 8% of women were fully at risk (i.e., sex and menses resumed but no contraceptive use), rising to 24% at 6-11 postpartum months, and further to 30% at months 12-17. Though 89% wanted to delay the next birth by at least 1 year, only 17% were currently using a modern method. Menstruating women were much more likely to be users than amenorrheic women: 27% versus 15% at months 12-17 postpartum. Urban and better educated women recorded higher contraceptive use but lower protection from other factors than rural, less educated women, with the net result that risk differed little across these population strata. Uptake of maternal and child health (MCH) services was high but only one-third of women had discussed family planning at a facility visit during the preceding 12 months.

CONCLUSIONS

These results underscore the need for improved postpartum family planning services by means of closer integration with mainstream health services. In view of evidence from other sources of heavy workload and weak motivation of health staff, this will require strong leadership. A related priority is to increase the number of staff trained in provision of long-acting methods, such as implants.

Influence of family planning and immunization services integration on contraceptive use and family planning information and knowledge among clients: A cross-sectional analysis in urban Nigeria

Reproductive autonomy necessitates that women have access to high quality family planning information and services. Additionally, closely spaced pregnancies increase maternal and infant morbidity and mortality. Although integrating family planning into child immunization services may increase access to information and services and postpartum contraceptive use, evidence on how integration affects service delivery and health outcomes is scarce. One limitation of previous studies is the use of binary integration measures. To address this limitation, this study applied Provider and Facility Integration Index scores to estimate associations between integration and contraceptive use, receipt of family planning information, and knowledge of family planning services availability. This study leveraged pooled cross-sectional health facility client exit interview data collected from 2,535 women in Nigeria. Provider and Facility Integration Index scores were calculated (0–10, 0 = low, 10 = high) for each facility (N = 94). The Provider Integration Index score measures provider skills and practices that support integrated service delivery; the Facility Integration Index score measures facility norms that support integrated service delivery. Logistic regression models identified associations between Provider and Facility Integration Index scores and (a) contraceptive use among postpartum women, (b) receipt of family planning information during immunization visits, and (c) correct identification of family planning service availability. Overall, 46% of women were using any method of contraception, 51% received family planning information during the immunization appointment, and 83% correctly identified family planning service availability at the facility. Mean Provider and Facility Integration Index scores were 6.46 (SD = 0.21) and 7.27 (SD = 0.18), respectively. Provider and Facility Integration Index scores were not significantly associated with postpartum contraceptive use. Facility Integration Index scores were negatively associated with receipt of family planning information. Provider Integration Index scores were positively associated with correct identification of family planning service availability. Our results challenge the position that integration provides a clear path to improved outcomes. The presence of facility and provider attributes that support integration may not result in the delivery of integrated care.

Effect of integrating maternal and child health services, nutrition and family planning services on postpartum family planning uptake at 6 months post-partum in Burkina Faso, Cote d’Ivoire and Niger: a quasi-experimental study protocol

Background

Although several interventions integrating maternal, neonatal, child health and nutrition with family planning have been implemented and tested, there is still limited evidence on their effectiveness to guide program efforts and policy action on health services integration. This study aims to assess the effectiveness of a service delivery model integrating maternal and child health services, nutrition and family planning services, compared with the general standard of care in Burkina Faso, Cote d'Ivoire, and Niger.

Methods

This is a quasi experimental study with one intervention group and one control group of 3 to 4 health facilities in each country. Each facility was matched to a control facility of the same level of care that had similar coverage on selected reproductive health indicators such as family planning and post-partum family planning. The study participants are pregnant women (up to 28 weeks of gestational age) coming for their first antenatal care visit. They will be followed up to 6 months after childbirth, and will be interviewed at each antenatal visit and also during visits for infant vaccines. The analyzes will be carried out by intention to treat, using generalized linear models (binomial log or log Poisson) to assess the effect of the intervention on the ratio of contraceptive use prevalence between the two groups of the study at a significance level of 5%, while taking into account the cluster effect and adjusting for potential confounding factors (socio-demographic characteristics of women unevenly distributed at inclusion).

Discussion

This longitudinal study, with the provision of family planning services integrated into the whole maternal care continuum, a sufficiently long observation time and repeated measurements, will make it possible to better understand the timeline and the factors influencing women’s decision-making on the use of post-partum family planning services. The results will help to increase the body of knowledge regarding the impact of maternal and child health services integration on the utilization of post-partum family planning taking into account the specific context of sub-Saharan Africa French speaking countries where such information is very needed.

One strategy to improve the utilization of health services by mothers and their children is the integration of maternal and child health services. For instance, a pregnant woman coming for an antenatal care visit would also receive counseling on post-partum family planning services and maternal nutrition. Similarly, a woman coming for her infant’s vaccines would be offered counseling on post-partum family planning, maternal nutrition and breastfeeding. Although several interventions have been implemented and tested, there is still limited evidence on the conditions and factors required for successful maternal and child health services integration strategies. This study aims to assess the effectiveness of an intervention integrating maternal and child health services, nutrition and family planning services. For the purpose of the evaluation, 2 distincts groups of health facilities will be selected in each country, one group of 3 or 4 health facilities where the intervention will be implemented, and another group of 3 or 4 health facilities with the general standard of care. The study participants are pregnant women (up to 28 weeks of gestational age), coming for their first antenatal care visit, who will be followed up to 6 months after childbirth.The analyzes will be carried out to assess the effect of the intervention on contraceptive use prevalence between the two groups of health facilities. This study will make it possible to better understand the timeline and the factors influencing women’s decision-making on the use of post-partum family planning services.

Midwives’ Perspectives on Family Planning With Pregnant and Postpartum Women in the Philippines’ Mindanao Region: A Qualitative Study

Background

This study sought to identify factors significantly impacting access to and utilization of modern contraceptive methods among Filipinas from the perspective of midwives who are caring for women during pregnancy and the postpartum period.

Methods

In-depth, semi-structured interviews were conducted with 10 midwives working at three birthing clinics within the Mindanao region of the Philippines. Data were coded and analyzed for major themes using a grounded theory approach.

Results

Logistics of obtaining the desired contraceptive method, superstitions associated with family planning (FP) methods, opinions of community leaders and partners, and education regarding fertility and birth spacing benefits are significant factors impacting Filipina family planning use. Religion and midwives’ preferences are not significant factors.

Conclusions

Cultural and social factors play a large role in family planning decisions. There is a need for enhanced education, beginning in schools, regarding the fertility cycle, birth spacing benefits, and the importance of individual family planning. Filipino public health infrastructure operating consistently is a key factor for women to reliably access contraception.

A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to?

BACKGROUND

Severe maternal morbidity or maternal near miss (MNM) events can have significant consequences for individuals, their families and society and the study of these events may inform practices to reduce future adverse pregnancy outcomes.

AIMS

To review the scope of MNM studies undertaken in Australia, New Zealand, South-East Asia and the South Pacific region.

MATERIALS AND METHODS

A systematic search of four online databases (MEDLINE, EMBASE, SCOPUS and CINAHL) and the World Health Organization Library was conducted to identify all relevant studies published between 1 January 2011 and 31 December 2020. The studies were reviewed and included if they assessed MNM using a composite outcome or a predefined set of indicators.

RESULTS

The literature search yielded 143 articles of which 49 are included in this review. There were substantial differences in the monitoring approach to MNM in the Australasian region. Overall rates of MNM in the region ranged from two to 100/1000 births and the most common aetiologies identified were direct obstetric causes such as postpartum haemorrhage, pre-eclampsia and sepsis. Multidisciplinary review indicated a substantial number of MNM cases were preventable or amenable to improved management, mostly from a provider perspective.

CONCLUSIONS

Assessment of MNM is an important part of the evaluation of maternity care provision. Reaching a consensus on indicators and how best to collect information will allow a more discerning assessment of MNM including longer-term health outcomes, aspects of preventability and financial implications for health services.

Urban Family Planning in Low- and Middle-Income Countries: A Critical Scoping Review

Health agendas for low- and middle-income countries (LMICs) should embrace and afford greater priority to urban family planning to help achieve a number of the global Sustainable Development Goals. The urgency of doing so is heightened by emerging evidence of urban fertility stalls and reversals in some sub-Saharan African contexts as well as the significance of natural increase over migration in driving rapid urban growth. Moreover, there is new evidence from evaluations of large programmatic interventions focused on urban family planning that suggest ways to inform future programmes and policies that are adapted to local contexts. We present the key dimensions and challenges of urban growth in LMICs, offer a critical scoping review of recent research findings on urban family planning and fertility dynamics, and highlight priorities for future research.

Facility-level characteristics associated with family planning and child immunization services integration in urban areas of Nigeria: a longitudinal analysis

Background

Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria.

Methods

This study utilizes health facility data collected at baseline (n = 400) and endline (n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics.

Results

Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly (p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores.

Conclusion

Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11436-x.

Perceived norms, personal agency, and postpartum family planning intentions among first-time mothers age 15-24 years in Kinshasa: A cross-sectional analysis

Unintended pregnancy is an important global health problem and frequently occurs during the immediate postpartum period. However, few studies have examined postpartum family planning (PPFP) intentions among adolescent girls and young women. This study assessed whether perceived norms and personal agency predicted PPFP intentions among first-time mothers age 15–24 in Kinshasa, the Democratic Republic of Congo. Data were derived from the 2018 Momentum Project baseline survey. Analysis was based on 2,418 nulliparous pregnant women age 15–24 who were approximately six months pregnant with their first child in six health zones of Kinshasa. Overall PPFP intentions were low and ten to thirteen percent of women stated they were very likely to discuss PPFP next month with (a) their husband/male partner and (b) a health worker, and to (c) obtain and (d) use a contraceptive method during the first six weeks following childbirth. The results of multivariable linear regression models indicated that the PPFP intention index was predicted by description norms, perceptions of the larger community’s approval of PPFP, normative expectations, perceived behavioral control, self-efficacy, and autonomy. Rejection of family planning myths and misconceptions was also a significant predictor. Interaction terms suggested that the association of normative expectations with PPFP intentions varied across ethnic groups and that the positive association of injunctive norms with PPFP intentions was significantly increased when the larger community was perceived to disapprove of PPFP use. Normative expectations and PPFP-related self-efficacy accounted for two-thirds of the variance in PPFP intentions. The results suggested that understanding different normative influences may be important to motivate women to use contraception in the immediate postpartum period. In addition to addressing institutional, individual, and social determinants of PPFP, programs should consider integrating norm-based and empowerment strategies.

Determinants contraceptive use after labor in Parepare (comparison between health and health Cempae Lompoe)

OBJECTIVE

This study aims to analyze the determinants of postpartum contraceptive use in Parepare (comparison between community health centers and clinics Cempae Lompoe).

METHOD

The design of this study is cross-sectional. Interviews conducted on 164 mothers of infants aged 0-6 months around community health centers Cempae and Lompoe. Data analyze using Chi-square and logistic regression.

RESULT

The factors influenced the use of contraception postpartum were age (p=0.000 and p=0.005), education (p=0.012), knowledge (p=0.043), parity (p=0.006 and p=0.031) and husband's support (p=0.015). After logistic regression analysis obtained parity and education are the variables that most influence on postpartum contraceptive use.

CONCLUSION

Health workers need to provide and improve family planning counseling during antenatal care.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria

Background

Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities.

Methods

This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high).

Results

Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high.

Conclusion

Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

The unmet needs for modern family planning methods among postpartum women in Sub-Saharan Africa: a systematic review of the literature

BACKGROUND

Sub-Saharan Africa has the highest fertility rate in the world, with the highest unmet need for family planning (FP). Yet, there is a lack of knowledge about the determinants for non-utilisation of modern contraceptive methods among women of reproductive age. This systematic review of literature assessed factors affecting the unmet need and reasons for non-utilisation of modern contraceptive methods during the postpartum period in Sub-Saharan African women.

METHODS

An online literature search was conducted in several databases: MEDLINE, Cochrane Review, PubMed, Elsevier's Science Direct and Web of Science. The search was completed by hand searching. Data were extracted and summarised using the Arksey and O'Malley methodology.

RESULTS

In total, 19 studies were included; one qualitative study, seventeen quantitative, and one used a mixed-methods approach. Studies were conducted in Ethiopia (n = 11), Nigeria (n = 3), Kenya (n = 2), Malawi (n = 2) and Uganda (n = 1). Factors affecting the unmet need for modern contraceptive methods were described at three levels: (a) individual; (b) household; and (c) healthcare facility level. Reasons for non-use of FP included: fear of side effects; husband's disapproval; the absence of menses; abstinence; and low perception of risk of pregnancy.

CONCLUSION

Unmet needs in postpartum FP in women from Sub-Saharan Africa were associated with health-system and socio-demographic determinants. We suggest that there is a need to improve the awareness of modern contraceptive methods through effective interventions. Further research is needed for under-studied countries in this continent.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

When designing a family planning (FP) strategy, decision-makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost-effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision-makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.

Effect of integrating maternal health services and family planning services on postpartum family planning behavior in Ethiopia: results from a longitudinal survey

Background

Very few postpartum women want to become pregnant within the next 2 years, but approximately 60% of postpartum women in low- and middle-income countries are not using contraceptive methods. The World Health Organization recommends that women receive postpartum family planning (PPFP) counseling during antenatal, immediate postpartum, and postnatal services. Our objective was to establish whether PPFP counseling is being provided in antenatal and postnatal care services in SNNPR, Ethiopia and whether receipt of PPFP counseling improved uptake of postpartum family planning use by 6 months postpartum.

Methods

Longitudinal data from the Performance Monitoring for Accountability 2020 – Maternal and Newborn Health study were used. At screening, 329 women were identified as six or more months pregnant; 307 completed the survey at 6 months postpartum. We used weighted parametric survival analysis with Weibull distribution to assess the effect of receipt of postpartum counseling in antenatal and/or postnatal care by 6 weeks postpartum on contraceptive uptake, after adjusting for intention to use family planning, wantedness of the index pregnancy, delivery location, amenorrhea, exclusive breastfeeding, residence, parity, and education.

Results

Coverage of PPFP counseling is low; by six-weeks postpartum only 20% of women had received counseling. Women who received counseling in postnatal care only and postnatal care and antenatal care took up contraception at significantly higher rates than women who did not receive any counseling (HR: 3.4, p < .01 and HR: 2.5, p = .01, respectively). There was no difference between women who received PPFP counseling only in ANC and women who did not receive counseling at all. Women who did not want the child at all took up contraception at significantly lower rates than women who wanted the child at that time (HR: 0.3, p = .04). Women who had four or more children took up contraception at significantly lower rates than woman with 1–3 children (HR: 0.3, p = .01). There were no significant differences by delivery location, exclusive breastfeeding, residence, or education.

Conclusion

Integration of postpartum family planning counseling into postnatal care services is an effective means to increase postpartum contraceptive uptake, but significant gaps in coverage, particularly in the delivery and postnatal period, remain.

Postpartum Contraceptive Use In Parakou (A City In Northern Benin) In 2018: A Community Based Cross-Sectional Study

Background

Over 30% of maternal deaths and 10% of infant deaths are avoidable if couples space out births at intervals of 2 years or greater. This study aimed to identify factors associated with contraceptive use in the postpartum period.

Methods

This was a cross-sectional study among postpartum women living in Parakou. Participants were selected using a two-stage sampling method. Postpartum contraceptive use was defined as the use of at least one contraceptive method at the time of the survey. Independent variables included socio demographic and reproductive history. For the analysis we performed a multiple logistic regression and we calculated odds ratios with 95% confidence intervals.

Results

The study included 453 postpartum women. Among the participants, 59 (13%) were using a contraceptive method. Injectable contraceptives were the most common method used (25.4%). Factors associated with contraceptive use in the postpartum period included history of contraceptive use (AOR=9.4; p<0.001), resumption of sexual intercourse (AOR=5.7; p<0.001), discussion with partner about contraceptive method (AOR=5.7; p=0.005), need of partner’s approval before adopting a contraceptive method (AOR=0.4; p=0.014) and counseling during pregnancy, in the delivery room, and during postnatal visits (AOR=2.7; p=0.019).

Conclusion

The prevalence of contraceptive use during the postpartum period remains low. Interventions should be designed with a focus on the associated factors in order to increase postpartum contraceptive use in Parakou.

Quality and Cost Interventions During the Extended Perinatal Period to Increase Family Planning Use in Kinshasa, DRC: Results From an Initial Study

The combined intervention of free contraceptives plus a set of quality inputs for family planning during the extended perinatal period, including provision of long-acting methods immediately postpartum, had the strongest effect on use of modern contraceptives, especially long-acting methods.

Background:

Most women worldwide do not desire another pregnancy within a year after giving birth, but uptake of modern contraception during this time period is low. We independently tested 2 approaches to increasing contraceptive uptake and the 2 approaches combined using a quasi-experimental study design in Kinshasa, the Democratic Republic of the Congo.

Methods:

The primary analytic data came from client exit interviews conducted post-intervention (N=563) from 4 study groups. The first arm (n=150) received free family planning, and the second arm (n=113) a quality inputs intervention involving systematic screening, referral, and immediate provision of long-acting reversible contraceptives (LARCs) after labor and delivery. The third arm (n=150) received a combination of the 2 interventions, and the fourth (n=150) no intervention. Family planning service statistics were also collected throughout the intervention period.

Results:

Women in the quality arm (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.8 to 10.9) and free/quality arm (OR=6.7; 95% CI, 2.8 to 16.1) were more likely to be properly screened for family planning than women in the control group, but paper referral was seldom implemented in any group. Women in the free arm (OR=3.8; 95% CI, 1.6 to 9.0) and in the free/quality arm (OR=11.0; 95% CI, 4.3 to 27.9) were more likely than the control group to report being properly counseled on family planning. Clients were more likely to be modern contraceptive users (excluding condoms) in the free arm (OR=3.2; 95% CI, 1.4 to 7.2) and in the free/quality arm (OR=8.6; 95% CI, 3.9 to 19.0) than in the control group. Clients in all study arms were more likely to use a LARC compared with the control group (Quality arm: OR=2.9; 95% CI, 1.1 to 7.9. Free arm: OR=5.6; 95% CI, 2.3 to 13.7. Free/quality arm: OR=8.4; 95% CI, 3.4 to 20.6). Service statistics from the combined intervention arm showed that a significantly greater proportion of family planning adoption occurred within the immediate postpartum period (0 to 2 days) in the quality arm (P<.001) and free/quality arm (P<.001) than in the control arm. Quality inputs, free contraceptives, and the combined intervention had positive impacts on aspects of screening and contraceptive uptake. The combined intervention performed best by all measures.

Conclusion:

Providing family planning, including LARCs, in the immediate postpartum period, implementing a systematic screening and referral system, and providing free methods may improve family planning access and uptake in the extended perinatal period in this environment.

Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016

BACKGROUND

Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies.

METHODS

Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05).

RESULTS

Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts.

CONCLUSIONS

Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality.

Family planning use and its associated factors among women in the extended postpartum period in Addis Ababa, Ethiopia

BACKGROUND

Postpartum period is an important entry point for family planning service provision; however, women in Ethiopia are usually uncertain about the use of family planning methods during this period. Limited studies have been conducted to assess postpartum family planning use in Addis Ababa, in particular and in the country in general. So, this study was conducted to assess postpartum family planning use and its associated factors among women in extended postpartum period in Kolfe Keranyo sub city of Addis Ababa.

MATERIALS AND METHODS

A community-based cross sectional study was conducted from May to June 2015 on 803 women who have had live births during the year (2014) preceding the data collection in the sub city. The multi-stage cluster sampling technique was used to select study participants. Data were collected by interviewer administered structured questionnaire, entered into EPI INFO version 7 and analyzed by SPSS Version 20. Bivariable and Multivariable logistic regression models were employed to see the presence and strength of the association between the dependent and independent variables by computing the odds ratios with a 95% confidence intervals and p-values.

RESULTS

The prevalence of postpartum family planning use was 80.3% (95% CI: 74.5, 83.1). Marriage, (AOR 0.09, 95% CI: 0.03, 0.22), menses resumption after birth, (AOR 2.12, 95% CI: 1.37, 3.41), length of time after delivery, (AOR 2.37, 95% CI: 1.18, 4.75), and history of contraceptive use before last pregnancy, (AOR 0.12, 95% CI: 0.07, 0.18) were the factors associated with postpartum family planning use.

CONCLUSION

The prevalence of postpartum family planning use was high and the main factors associated with it were marriage, menses resumption, length of time after delivery, and history of previous contraceptive use. Therefore women should get appropriate information about the possibility of exposure to pregnancy prior to menses resumption by giving special emphasis to those who had no previous history of contraceptive use and exposure to the other identified factors.

Levels, trends and correlates of unmet need for family planning among postpartum women in Indonesia: 2007-2015

BACKGROUND

Although Indonesia has relatively high contraceptive prevalence, postpartum family planning (PP-FP) has not been a particular point of emphasis. This article reports the results of analyses undertaken in order to (1) better understand levels and trends in unmet need for family planning among postpartum women, (2) assess the extent to which unmet need is concentrated among particular population sub-groups, and (3) assess the policy priority that PP-FP should have in relation to other interventions.

METHODS

The analyses were based on data from the 2007 and 2012 Indonesia Demographic and Health Surveys (IDHS) and the 2015 PMA2020 survey. Postpartum contraceptive use and unmet need were analyzed for fecund women who had given birth in the 3-5 years of preceding the respective surveys who were in the extended postpartum period at the time of the respective surveys. Factors associated with contraceptive use and unmet were assessed via multivariable logistic regressions using merged data from all three surveys. A wide range of biologic, demographic, socio-economic, geographic and programmatic factors were considered.

RESULTS

Contraceptive use during the extended postpartum period is high in Indonesia, with more than 74% of post-partum women reporting currently using a family planning method in the 2015 PMA2020 survey. This is up from 68% in 2007 and 70% in 2012. Total unmet need was 28% in 2007, falling slightly to 23% in 2012 and 24% in 2015. However, the timing of contraceptive initiation is less than optimal. By six months postpartum, only 50% of mothers had begun contraceptive use. Unmet need was highest among older women, women with 4+ children, with limited knowledge of contraceptive methods, making fewer ANC visits, from poor families and residents of islands other than Java and Bali.

CONCLUSION

Unmet need for family planning among postpartum women in Indonesia is low in comparison with other low- and middle-income countries. However, because of limited durations of exclusive breastfeeding, many Indonesian women do not initiate contraception early enough after delivering children. Given already high contraceptive prevalence, targeting postpartum women for increased programmatic attention would seem strategically prudent.

Meeting Postpartum Women's Family Planning Needs Through Integrated Family Planning and Immunization Services: Results of a Cluster-Randomized Controlled Trial in Rwanda

Integrating contraceptive services into infant immunization services was effective, acceptable, and feasible without negatively affecting immunization uptake. Yet unmet need for contraception remained high, including among a substantial number of women who were waiting for menses to return even though, at 6 months or more postpartum, they were at risk of an unintended pregnancy. More effort is needed to educate women about postpartum return to fertility and to encourage those desiring to space or limit pregnancy to use effective contraception.

Objective

The primary objective of this study was to test the effectiveness of integrating family planning service components into infant immunization services to increase modern contraceptive method use among postpartum women.

Methods

The study was a separate sample, parallel, cluster-randomized controlled trial. Fourteen randomly selected primary health facilities were equally allocated to intervention (integrated family planning and immunization services at the same time and location) and control groups (standard immunization services only). At baseline (May–June 2010), we interviewed postpartum women attending immunization services for their infant aged 6 to 12 months using a structured questionnaire. A separate sample of postpartum women was interviewed 16 months later after implementation of the experimental health service intervention. We used linear mixed regression models to test the study hypothesis that postpartum women attending immunization services for their infants aged 6–12 months in the intervention facilities will be more likely to use a modern contraceptive method than postpartum women attending immunization services for their infants aged 6–12 months in control group facilities.

Results

We interviewed and analyzed data for 825 women from the intervention group and 829 women from the control group. Results showed the intervention had a statistically significant, positive effect on modern contraceptive method use among intervention group participants compared with control group participants (regression coefficient, 0.15; 90% confidence interval [CI], 0.04 to 0.26). Although we conducted a 1-sided significance test, this effect was also significant at the 2-sided test with alpha = .05. Among those women who did not initiate a contraceptive method, awaiting the return of menses was the most common reason cited for non-use of a method. Women in both study groups overwhelmingly supported the concept of integrating family planning service components into infant immunization services (97.9% in each group), and service data collected during the intervention period did not indicate that the intervention had any negative effect on infant immunization service uptake.

Conclusion

Integrating family planning service components into infant immunization services can be an acceptable and effective strategy to increase contraceptive use among postpartum women. Additional research is needed to examine the extent to which this integration strategy can be replicated in other health care settings. Future research should also explore persistent misconceptions regarding the relationship between return of menses and return to fertility during the postpartum period.

Enhancing contraceptive choice for postpartum women in sub-Saharan Africa with the progesterone vaginal ring: a review of the evidence

It is increasingly recognized that women who have just given birth have a high unmet need and require contraceptive protection in the first year postpartum. A majority of women in developing countries do breastfeed exclusively but for short durations, hence they may be sometimes unknowingly exposed to the risk of pregnancy if they are relying on nursing for contraceptive protection. The WHO’s Medical Eligibility Criteria for Contraceptive Use recommends the use of different contraceptives in the first year postpartum depending on whether the woman is nursing or not and the time since delivery. Some of the options available for breastfeeding women include implants, IUDs and injectables, which can be obtained only from a trained family planning provider. Since 2013, Population Council has been carrying out a study in Senegal, Nigeria, and Kenya to assess the acceptability of progesterone vaginal ring (PVR) as a new contraceptive option designed specifically for use by breastfeeding women to extend the period of lactational amenorrhea and promote birth spacing. Breastfeeding in sub-Saharan Africa is near universal with fairly long durations, a situation that increases the effectiveness of PVR. Each ring delivers a daily dose of 10 mg of progesterone and can be used continuously up to 3 months with a woman being able to continue with its use up to 1 year (four rings used consecutively). Preliminary results indicate that many women who had used the method found it acceptable and their partners supported its use. Activities aimed at having PVR registered and made available in focal countries are ongoing. Integration of family planning and immunization services for mothers and their newborns will be a key strategy in introducing PVR into targeted health care markets. Given that the use of PVR does not require extensive clinical training, it will be easier to integrate it at all levels of the health system from tertiary health facilities to community-based services. The PVR has been recently included in the WHO Model List of Essential Medicines and the WHO’s fifth edition of the Medical Eligibility Criteria for Contraceptive Use which should facilitate its introduction into the public and private sectors.

Predictors of modern contraceptive use during the postpartum period among women in Uganda: a population-based cross sectional study

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.

Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries

OBJECTIVES

To analyze data from recent Demographic and Health Surveys (DHS) conducted in 21 low- and middle-income countries (LMICs) to examine patterns of interpregnancy intervals, unmet need, pregnancy risk and family planning method use and method mix among women 0-23 months postpartum.

STUDY DESIGN

Secondary analysis of postpartum women aged 15-49 years in 22 DHS surveys from 21 LMICs conducted between 2005 and 2012. We applied an adapted unmet need definition for postpartum women to look at prospective fertility preferences. We also constructed a new composite pregnancy risk indicator for postpartum women who have been sexually active since their last birth.

RESULTS

In 9 of 22 surveys, 50% or more of nonfirst births occur at interpregnancy intervals that are too short. Overall prospective unmet need for family planning by postpartum women has not changed demonstrably since a 2001 analysis and is universally high: 61% of all postpartum women across the 21 countries have an unmet need for family planning. In 10 of 22 surveys, pregnancy risk rises steadily throughout the 2 years after birth. In the remaining 12 surveys, the risk of pregnancy peaks at 6-11 months after birth. Even when postpartum women are using family planning, they rely overwhelmingly on short-acting methods (51-96% in 21 of 22 surveys).

CONCLUSION

Our approach of estimating pregnancy risk by postpartum timing confirms a high probability for pregnancies to be less than optimally spaced within 2 years of a prior birth and suggests that special consideration is needed to effectively reach this population with the right messages and services.

IMPLICATIONS

Using recent, multicountry data for women within 2 years postpartum in LMICs, this paper updates existing estimates of high prospective unmet need for family planning and presents a new composite pregnancy risk analysis based on postpartum women's actual practices to demonstrate the magnitude of missed opportunities for programmatic intervention for the postpartum population.

Postpartum contraception utilization among low-income women seeking immunization for infants in Mumbai, India

OBJECTIVE

The objective was to examine postpartum contraception utilization among Indian women seeking immunization for their infants in three low-income communities in Mumbai, India.

STUDY DESIGN

We conducted a cross-sectional questionnaire of low-income postpartum women seeking immunization for their infants at three large urban health centers in Mumbai. Contraceptive utilization data were collected as part of a larger study focused on the impact of postpartum domestic violence on maternal and infant health. Descriptive, bivariate and multivariate analyses were conducted to describe and identify predictors of postpartum contraceptive utilization.

RESULTS

Postpartum women aged 17-45 years (N=1049) completed the survey; 44.5% (n=467) reported resuming sexual relations with their husbands. Among these women, the majority (65.3%; n=305) reported not currently using contraception. In multivariate analyses, women who did not discuss postpartum family planning with their husbands, had not used contraception previous to the recent birth, and had experienced physical violence or forced sex were more likely to not use postpartum contraception (adjusted odds ratios=1.47-1.77). Among the 162 women using contraception, the most common time to initiation of contraception was 5 weeks postpartum, and the most common method used was condoms 77.8% (n=126).

CONCLUSION

Contraception nonuse was common among urban, low-income postpartum women in India. This study highlights the importance of developing interventions to increase use of highly effective contraceptive methods postpartum, and that spousal violence and lack of marital communication may present barriers to postpartum contraception utilization. Infant immunization may represent an opportunity for provision of contraceptives and contraceptive counseling.

IMPLICATIONS

This original research study is a unique contribution to the literature because it presents data regarding the nonuse of postpartum contraception among women seeking immunizations for their infants in urban centers in a developing country. It also reveals barriers to not using postpartum contraception and provides data for future interventions.