Systematic Review of RCTs

10 studies (8 in high income countries not listed here due to differences in context)

Educational strategies to improve postpartum contraceptive use

Immediate postpartum women

Systematic Review of NRS

Educational strategies to improve postpartum contraceptive use

Immediate postpartum women

Institutionalize immediate postpartum IUD (PPIUD) services as a routine part of antenatal counseling and delivery room services. Health professionals from study hospitals and surrounding MOH clinics who oversaw maternal and child health care were trained to provide counseling services during antenatal visits. Doctors who provided obstetric services in maternity wards were trained on PPIUD insertion and removal using the Kelley’s forceps and thread retrievers. Each workshop was one day long and covered topics related to counseling along with lectures and videos on the PPIUD and PPFP, more generally. Obstetric trainees were given opportunities to practice IUD insertion and removal on MAMA-U mannequin models for vaginal and intra-Caesarean procedures and were trained on infection prevention, side effects, and complication management. Pre-training and mid-training knowledge assessments were conducted along with role-plays and group discussions to facilitate the training. Finally, providers were also trained on how to disseminate PPFP leaflets, which include information about the benefits of birth spacing and contraceptive methods, during counseling with women.

Choice to have a PPIUD inserted following her delivery measured right after exiting the facility based on consent form for an IUD insertion.

Effect 100% measured as IUD uptake

They were questioned regarding the source and depth of their contraceptive knowledge and their past contraceptive practice by completing a pro forma (form). The interactive questions were itemized, and the physician posed each item to the patient and marked the box as appropriate. To have consistency in the interviewing system, all interviewers had a 40-min training session on the pro forma and the counseling leaflet beforehand. After completing the baseline pro forma, intervention offered to Group A was in the form of a 20-min informal counseling session in the presence of husband (preferably) or some close relative (mother/mother-in-law) regarding methods of contraception. A didactic approach was adopted, and the woman and her husband were allowed to ask questions and discuss their concerns. Afterward, a simple one-page leaflet containing the basic knowledge regarding various contraceptive methods was given to the couple at the time of discharge to take home for discussion.

Only one session after delivery

Use of any contraceptive at 8 to 12 weeks postpartum

19.56 [11.65, 32.83]

Effect driven by IUCD (+10pp) and tubal litigation (+3.5pp) and pill (+16pp)

DRC (Kinshasa)

519 in 8 clinics

Prenantal and postnatal counseling multicomponent: facility-based interventions (ie, refresher training of service providers, regularly scheduled and strengthened supportive supervision of providers, and enhanced availability of contraceptive services 7 days a week), and three individual-based interventions (ie, a post-partum family planning counselling tool, appointment cards for women, and invitation letters for partners to attend appointments)

Prenatal + after delivery + extended postpartum

3 months (trial exited at 12 months postpartum and pts received intervention up until the 9th months postpartum: "24–48 h after delivery, then at 1 week, 6 weeks, then at months 6 and 9 postpartum")

Prevalence of use of modern contraceptives at month 12 post partum

PR 1·58, 95% CI 0·74−3·38

SS and large increase in LARCs OR 4·47 (2·05–9·74)

850 in 14 facilities

Integrating family planning messages into immunization services: After baseline data were collected, intervention group immunization and family planning providers attended a 3-day training on postpartum family planning and the use of a screening tool to assess pregnancy risk among postpartum women.

Integration immunization and FP services

1-2 months on average Follow up of maximum 4 months post intervention as the last opportunity to get counseled is 9 months postpartum and women were between 6-12 months postpartum. Women post intervention were women who brought their own infants between 6 and 12 months of age to immunization services. We sampled women who were 6 to 12 months postpartum so that all women in the sample who desired to initiate a modern contraceptive method to delay or limit a new pregnancy should have done so by that point, if they followed the information and counseling being offered through the intervention.

% of women attending an IMZ clinic who received a modern method

Effect driven by injectables 85%, other short terms 10%, LARCs 5% and

1385 in 16 health centres

Home visits and provided prenatal and postnatal contraceptive advice and made telephone consultations with health workers for advice. CHWs (VHTs) provided counselling on the risk of pregnancy soon after delivery; available options for delaying the next pregnancy and emphasised the importance of regular and exclusive breastfeeding as a means to delay pregnancy.

Prenatal + after delivery + extended postpartum

Same as Rwanda Unclear - outcomes were measured at 12-14 months postpartum but the visits were before and throughout the postpartum period.

Use of contraceptive

(aRR: 1.10; 95%CI: (0.51-1.82); p= 0.810)

not reported apart from LAM which was not different across groups

3.3% and 5.7% of the women were found to be pregnant in the control and intervention arms respectively. The risk of being pregnant was higher among the intervention women compared with the control arm but this difference was not statistically significant (aRR: 0.50; 95%CI: 0.13-1.87; p-value 0.032)

~1100 in 10 health facilities

2009-2010

Integrating family planning messages into immunization services. One time training with little support:vaccinators were trained to screen women for pregnancy risk, deliver a birth spacing message and refer mothers interested in preventing pregnancy to co-located FP services during their child’s immunization visit.

Integration immunization and FP services

Same as Rwanda study but slightly higher average follow up since mothers of children aged 9–12 months were eligible to participate in this study (meaning the endline survey)

Use of a non-condom modern family planning method

not reported but main outcome excludes condoms

2009-2010

Integrating family planning messages into immunization services. One time training with little support:vaccinators were trained to screen women for pregnancy risk, deliver a birth spacing message and refer mothers interested in preventing pregnancy to co-located FP services during their child’s immunization visit.

Integration immunization and FP services

Same as Rwanda study but slightly higher average follow up since mothers of children aged 9–12 months were eligible to participate in this study (meaning the endline survey)

Use of a non-condom modern family planning method

not reported but main outcome excludes condoms

One-to-one 20-minute health education session, interactive and supportive covering infant feeding, treatment of diarrhea, management of acute respiratory infection in infants, immunization, and contraception. The intervention was provided before discharge from hospital. The health educators were monitored weekly during the trial by two principal investigators to check the quality of the intervention with regards to the content and the style of delivery, especially the level of interaction, and constructive critical feedback was given.

Only one session after delivery

Use of contraception at 6 months

Educational campaign for enrolled pregnant women and mother-in-law or oldest female family member. Included healthy timing and spacing of pregnancy, LAM, postpartum contraception; provided in home. According to investigator, community workers continued with messages postpartum, during routine monthly home visits.

Prenatal + after delivery + extended postpartum

Use of modern contraceptive method

Pregnancy at 9months 0.60 [0.41, 0.87]

Health services model (HSM): birth spacing messages communicated through services by health workers to women during prenatal and postpartum periods. Included effective use of lactational amenorrhea method (LAM). Educational materials were also used (information, education, and communication (IEC)).

Prenatal + after delivery + extended postpartum

Contraceptive use

Only one session after delivery

Use of non-condom modern contraceptive

OR=3.2; 95% CI, 1.4 to 7.2

Use of LARC: Free arm: OR=5.6; 95% CI, 2.3 to 13.7.

Combination of the two above

Only one session after delivery

Use of non-condom modern contraceptive

OR=8.6; 95% CI, 3.9 to 19.0

Use of LARC: Free/quality arm: OR=8.5; 95% CI, 3.4 to 20.6

early 1990s

Introduce lactational amenorrhea method (LAM) to postpartum care

No contraceptive use at 12months

Pregnancy at 12months 0.48[0.27,0.87]

Same as above plus another session later

After delivery + extended postpartum

Use of contraception at 6 months

Community awareness model (CAM): communicating messages in HSM plus awareness component through community 'influentials' trained to communicate messages to men.

Prenatal + after delivery + extended postpartum

Contraceptive use

UHI: counselling during prenatal and postpartum visits

Prenatal + after delivery + extended postpartum

Modern contraceptive use during the postpartum period

1.85*** (1.32–2.60)

UHI: counselling during prenatal and postpartum visits

Prenatal + after delivery + extended postpartum

Modern contraceptive use during the postpartum period

1.71* (1.04–2.79)

UHI: counselling during prenatal and postpartum visits

Prenatal + after delivery + extended postpartum

Modern contraceptive use during the postpartum period

2.03** (1.43–3.08)

Several home visits with information and support on various maternal and child health advice

After delivery + extended postpartum

Use of contraceptive at 4months

LAM increase (20control >29%treatment)

Single home visit information and support on various maternal and child health advice

Only one session after delivery

Use of contraceptive at 4months

LAM increase (20control >29%treatment)

Quality inputs intervention involving systematic screening, referral, and immediate provision of long-acting reversible contraceptives (LARCs) after labor and delivery

Use of non-condom modern contraceptive

OR=0.4; 95% CI, 0.2 to 0.9

Use of LARC: Quality arm: OR=2.9; 95% CI, 1.1 to 7.9.

Health facility quality improvement and integration of FP counselling as part of routine postpartum care

Health facility improvement + Postpartum family planning

Women discharged with a modern FP method

1999-2000

20-minute educational session on postpartum family planning, lactation-contraception relationship, and contraceptive options during this period. Each woman given brochure on 'Postpartum Family Planning.'

Only one session after delivery

Use of modern method

1996-1999

Systematic offering of counseling and family planning services to women in the postpartum or postabortion periods

Integration immunization and FP services

Posttest evaluation showed also that final rate of FP use was still statistically significantly higher in IG (73%), than in CG (9%) (p<0.0001). The most common FP methods used in IG were OCP& Depo-Provera injection (54%), followed by IUDs (19%). Twelve clients were finally dropped out in IG due to desire of pregnancy or occurrence of pregnancy (n=9) and side effects (n=3)) compared to 14 clients (10 due to occurrence and desire of pregnancy, and 4 due to side effects) in CG (p <0.0001). In IG, drop out of FP use occurred in 4 clients due to pregnancy and 5 due to desire of pregnancy. On the other hand, in CG, drop out occurred in 7 clients due to pregnancy, and 3 due to desire of pregnancy.