The Effect of Improved Access to Family Planning on Postpartum Women: Protocol for a Randomized Controlled Trial

Factors Influencing Modern Family Planning Utilization and Barriers in Women of Reproductive Age in the Iringa Region, Tanzania: A Mixed-Methods Study

Background

Preventing unwanted pregnancies, achieving optimal child spacing, and improving quality of life are benefits of modern family planning (FP). This study aimed to assess modern FP use, identify the factors influencing its use and determine the barriers to FP use among women of reproductive age.

Methods

A mixed-methods approach was conducted in the Iringa Region between March and July 2022. Conveniently, 368 women of reproductive age were included in the quantitative study, and 48 were purposively selected for the qualitative study based on reported barriers to using modern FP. Interviewer-administered questionnaires and interview guides were used for data collection. The factors of modern FP use were determined using multivariable logistic regression analysis. The p < 0.05 was considered to be significant. For qualitative data, all interviews were recorded and transcribed. Data were analyzed manually through thematic analysis.

Results

The prevalence of modern FP use was 181 (49%). Being married (adjusted odds ratio [AOR] = 5.44, 95% confidence interval [CI] = 1.77-16.73, p = .003), parity of 6 and more (AOR = 2.43, 95% CI = 1.99-5.95, p = .052), availability of modern FP methods (AOR = 1.71, 95% CI = 1.03-2.85, p = .038), and women with primary education level (AOR = 2.99, 95% CI = 1.03-3.25, p = .001), women with secondary and higher education (AOR = 3.53, 95% CI = 1.41-4.38, p = .001), were predictors for modern FP utilization. Four main themes merged (1) individual barriers, (2) hospital barriers, (3) cultural barriers, and (4) knowledge of modern FP methods.

Conclusion

The use of modern FP increases with women's education. There is a need for the government to invest in women's education and raise awareness and knowledge of the benefits of modern FP methods.

Family Planning and Children's Human Capital: Experimental Evidence From Urban Malawi

We conduct a randomized controlled trial that provides pregnant and immediate postpartum women with improved access to family planning through counseling, free transportation to a clinic, and financial reimbursement for family planning services over two years. We study the effects of our intervention on child growth and development outcomes among 1,034 children born to participating women directly before the intervention rollout. We find that children born to mothers assigned to the family planning intervention arm were 0.28-0.34 standard deviations taller for their age and 10.7-12.0 percentage points less likely to be stunted within a year of exposure to the intervention. Children born to mothers assigned to the intervention arm also scored 0.17-0.20 standard deviations higher on a caregiver-reported measure of cognitive development after two years of intervention exposure. Although the nonmeasurement of children is a challenge in our study, our estimates are robust to multiple methods of correcting for potential attrition bias. Our results are consistent with models of fertility that link couples' fertility decisions to child health and human capital. Our results also suggest that improved access to family planning might have positive downstream effects on child health beyond contraceptive use and fertility outcomes.

Adjusting Injectable Contraceptive Use for Months Since the Last Injection

Injectables are one of the most popular methods of contraception worldwide, particularly in sub-Saharan Africa. An advantage of injectables over shorter-acting methods is that they provide additional flexibility by not requiring re-supply as frequently. However, there is a risk that injectable users may delay their next injection and may therefore have reduced or no protection from pregnancy. In surveys, women may report that they are using contraception in the form of injectables when the time since they had their last injection (more than four months) would imply that they have reduced protection against the risk of pregnancy. We carried out two field studies in urban Malawi, and we record reported injectable contraceptive use while also asking the number of months since women received their last injection. We observe that 13.8 percent of women who report using injectables also report that they received their last injection more than four months ago, and 11 percent report that they received their last injection more than six months ago. Our analysis highlights the need for additional follow-up with women who report using injectables in surveys to confirm whether they are, in fact, using the method effectively.

Providing family planning counseling services for women with chronic medical conditions in an inpatient setting: A randomized feasibility trial

OBJECTIVES

This study aimed to evaluate the feasibility and effectiveness of providing bedside family planning services to women with chronic medical conditions in the inpatient setting.

STUDY DESIGN

We initiated a parallel randomized controlled trial of patients listed as female aged 18 to 44 years who were admitted to the hospital from February 2018 to May 2021 with at least one chronic medical condition associated with lower rates of contraception usage and no documentation of contraception. Patients who confirmed they were not using contraception were enrolled and randomized to one of the three arms. They received bedside family planning counseling and an offer of contraception prior to discharge (oral contraceptive pills, etonogestrel implant, or medroxyprogesterone injection), received a flyer recommending they talk with their outpatient physician about contraception, or received standard care. The primary outcomes were contraception use at 3 months and 12 months after discharge.

RESULTS

Altogether 76 subjects were enrolled and randomized with 22 in the counseling arm and 27 each in the other arms. In the counseling arm, five (23%; 95% CI: 8.0%-45%) elected to receive contraception prior to discharge. Inferential statistics at follow-up were not able to be calculated due to high attrition.

CONCLUSIONS

Providing counseling and offering immediate contraception initiation in the inpatient setting may be a feasible approach to improving contraception access for this population. Additional investigation into the acceptability, efficacy, and generalizability of this approach is warranted.

IMPLICATIONS

Utilizing the inpatient setting may be a feasible approach for delivering contraception counseling to women with chronic medical conditions. This approach merits further study for effectiveness and acceptability. This study highlights the need for contraceptive counseling and initiation to become a standard part of hospital care for pregnancy-capable individuals.

Exploring the Relationship between Anemia and Postpartum Depression: Evidence from Malawi

PURPOSE

Study findings suggest association between anemia and postpartum depression, but available evidence is scant and inconsistent. We investigate whether anemia is related to postpartum depression among women who have recently given birth in Malawi, where anemia prevalence is high.

METHODS

We use cross-sectional data from 829 women who were 18-36 years old, married, lived in Lilongwe, Malawi, and gave birth between August 2017 and February 2019. The primary outcome is postpartum depression in the year after birth, defined by the Patient Health Questionnaire-9 (PHQ-9). Anemia status was assessed using hemoglobin levels that were measured at the time of the interview. Multivariate logistic regression analyses were used to investigate the relationship between postpartum depression and anemia status.

RESULTS

Our analysis sample consists of 565 women who completed the PHQ-9, tested for anemia, and had no missing values for covariates. Of these women, 37.5% had anemia (hemoglobin levels ≤ 110 g/L), and 2.7% were classified as showing symptoms of a major depressive disorder (MDD). After adjusting for potential confounders, anemia was significantly associated with increased risk of MDD (OR: 3.48, 95% CI: 1.15-10.57, p-value: 0.03). No significant associations were found between other covariates and postpartum depression.

CONCLUSIONS

Our findings suggest a potential association between anemia and postpartum depression among women in Malawi. Policies that aim to improve nutrition and health outcomes for pregnant and postpartum women could generate a "double benefit" by both preventing anemia and reducing the risk of postpartum depression.

The causal effect of a family planning intervention on women's contraceptive use and birth spacing

SignificanceImproving access to family planning may promote contraceptive use after childbirth and reduce the likelihood of closely spaced high-risk births; however, empirical evidence for these claims is limited. We present findings from a field experiment that examines the causal impact of a broad-based family-planning intervention on postpartum contraceptive use and fertility over a 2-y period, which allows us to assess impact on high-risk short pregnancy intervals. Our findings demonstrate that the benefits of family planning extend beyond contraceptive use to improve fertility and healthy birth spacing. Evidence from this study will contribute to the design of effective family-planning programs and to informing the ongoing policy debate about how such programs impact longer-term health and development more broadly.

Migration and interbirth transition rate using Benin Demographic and Health Survey data: Does episode-splitting matter?

BACKGROUND

The relationship between migration and fertility has vexed demographers for years. One issue missing in the literature is the lack of careful temporal consideration of when women migrate and specifically, the extent to which they do either before or after live births.

OBJECTIVE

Here, we opt for a more appropriate methodological approach to help remedy the complexity of the temporal aspect of migration and childbirth processes: regression models using the episode-splitting method.

METHODS

This paper applies a rarely used methodological approach (episode-splitting) in the literature of migration-fertility relationship to investigate how internal in-migration is associated with inter-birth intervals among women in Cotonou, the largest city of Benin. Data comes from the 2017-2018 Benin Demographic and Health Survey (DHS) of women aged 15-49. Estimates from exponential regression models with episode-splitting were compared to estimates from exponential regression models without episode-splitting approach. Sensitivity analysis was also conducted to determine the robustness of the comparison between the two methods. Akaike Information Criteria (AIC) and Bayesian Information Criteria (BIC) were used to identify the method that provides models with best fit.

RESULTS

The results from (standard) exponential regression models without episode-splitting show that there is no significant association between migration and interbirth transition rate. However, significant associations between migration and interbirth transition rate emerge after applying the episode splitting method. The hazard ratios (HR) of the transition to the next live birth are higher among migrant women than among nonmigrant women. This trend is persistent even after 10 years spent in Cotonou by migrant women.

CONCLUSION

Exponential regression models with episode-splitting were of better fit than exponential regression models without episode-splitting. Sensitivity analysis conducted seems to confirm that models with episode-splitting produce estimates that are accurate, reliable and superior to models without episode-splitting. The results suggest a long-run process adaptation of migrants to lower fertility behaviours in Cotonou and are therefore consistent with the socialization hypothesis.

User-Centered Counseling and Male Involvement in Contraceptive Decision Making: Protocol for a Randomized Controlled Trial

Background

To achieve informed choice within the framework of reproductive autonomy, family planning programs have begun to adopt user-centered approaches to service provision, which highlight the individual client as the focal point of interaction and key decision maker. However, little is known about how user-centered approaches to family planning, particularly family planning counseling, shape contraceptive preferences and choices.

Objective

We conducted a multiarmed randomized controlled trial to identify the causal impact of user-centered approaches to family planning counseling on women’s contraceptive decision making in urban Malawi. This study aims to determine how a tailored, preference-driven approach to family planning counseling and the involvement of male partners during the counseling process may contribute to shaping women’s contraceptive preferences and choices.

Methods

Married women aged 18-35 years were recruited and randomly assigned to 1 of the 3 intervention arms or a control arm characterized by the following two interventions: an intervention arm in which women were encouraged to invite their husbands to family planning counseling (husband invitation arm) and an intervention arm in which women received targeted, tailored counseling on up to five contraceptive methods (as opposed to up to 13 contraceptive methods) that reflected women’s stated preferences for contraceptive methods. Women were randomized into a control arm, T0 (no husband invitation, standard counseling); T1 (husband invitation, standard counseling); T2 (no husband invitation, targeted counseling); and T3 (husband invitation, targeted counseling). Following counseling, all women received a package of family planning services, which included free transportation to a local family planning clinic and financial reimbursement for family planning services. Follow-up surveys were conducted with women 1 month after counseling.

Results

A total of 785 women completed the baseline survey, and 782 eligible respondents were randomized to 1 of the 3 intervention groups or the control group (T1, n=223; T2, n=225; T3, n=228; T0, n=108). Furthermore, 98.1% (767/782) of women were contacted for follow-up. Among the 767 women who were contacted, 95.3% (731/767) completed the follow-up survey. The analysis of the primary outcomes is ongoing and is expected to be completed by the end of 2021.

Conclusions

The results from this trial will fill knowledge gaps on the effectiveness of tailored family planning counseling and male involvement in family planning on women’s stated and realized contraceptive preferences. More generally, the study will provide evidence on how user-centered counseling may affect women’s willingness to use and continue contraception to realize their contraceptive preferences.

Trial Registration

American Economics Association’s Registry for Randomized Controlled Trials AEARCTR-0004194; https://www.socialscienceregistry.org/trials/4194/history/46808. Registry for International Development Impact Evaluations RIDIE-STUDY-ID-5ce4f42bbc2bf; https://ridie.3ieimpact.org/index.php?r=search/detailView&id=823.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24884