Antenatal Care Interventions to Increase Contraceptive Use Following Birth in Low- and Middle-Income Countries: Systematic Review and Narrative Synthesis

"Although the studies in this systematic review were heterogeneous, the findings suggest that the interventions that included a multifaceted package of initiatives appeared to be more likely to have a positive effect. By contrast, interventions with minimal counseling did not appear to be as effective."

Health risks associated with short interpregnancy intervals, coupled with women's desires to avoid pregnancy following childbirth, underscore the need for effective postpartum family planning (PPFP) programmes. The antenatal period provides an opportunity to intervene. This article summarises the methods and results from a systematic review of interventions in low- and middle-income countries (LMICs) that attempted to increase voluntary postpartum contraceptive use through antenatal care (ANC) contacts with pregnant women. This review aimed to describe the interventions identified and assess their effectiveness on postpartum contraceptive use within the first year postpartum and other related outcomes.

Studies published from January 2012 to July 2022 were considered if they were conducted in LMICs, evaluated an intervention delivered during the antenatal period, were designed to affect postpartum contraceptive use, were experimental or quasi-experimental, and were published in French or English. The main outcome of interest was postpartum contraceptive use within 1 year after birth, defined as the use of any method of contraception at the time of data collection. A search of EMBASE, Global Health, and Medline, along with a manual search of the reference lists from studies included in the full-text screening, ultimately led to 34 reports on 31 unique interventions.

Twenty-three studies were published from 2018 on, with 21 studies conducted in sub-Saharan Africa. Approximately half of the study designs (n=16) were randomised controlled trials, and half (n=15) were quasi-experimental. Interventions were heterogeneous, but the researchers categorised them into 6 main types: counseling (23%, n=7), digital (6%, n=2), educational (16%, n=5), financial (6%, n=2), package (45%, n=14), and training of providers (without an explicit follow-up intervention with pregnant women) (3%, n=1). They further categorised the types into 13 subtypes: counseling: one-to-one (13%, n=4); counseling: one-to-one plus pamphlet (3%, n=1); counseling: one-to-one with spouse involvement (3%, n=1); counseling: mixed couple and group sessions (3%, n=1); digital: SMS (6%, n=2); educational: campaign (3%, n=1); educational: group sessions (13%, n=4); financial: client vouchers (3%, n=1); financial: provider pay-for-performance (3%, n=1); package: multifaceted (35%, n=11); package: digital and one-to-one education and counseling (3%, n=1); package: systems strengthening (6%, n=2); and training: providers (3%, n=1).

Of the 24 studies (77%) that reported on voluntary postpartum contraceptive use within 1 year after birth, 18 reported a positive intervention effect (75%). Of these 18, 9 (50%) were package interventions, 4 (22%) were counseling interventions, 3 (17%) were educational interventions, 1 (6%) was digital, and 1 (6%) was financial. The largest, most consistent effects were seen in the package interventions. Four studies reported on postpartum contraceptive use beyond 1 year after birth; 3 of these reported a statistically significant intervention effect.

Here is just one example of the impact reported in one study, which evaluated a package intervention in Egypt called the SMART project, using a controlled before-after design. SMART aimed to decrease child malnutrition through an "integrated, community-based reproductive and maternal and child health intervention package". SMART was implemented during a political transition in Egypt and, as such, family planning (FP) was deemphasised in the beginning to respond to the political and social climate. The intervention consisted of 3 overarching components, within which existed various activities: one-to-one and group counseling, training of healthcare workers, and mobile clinics. The counseling covered the benefits of FP, healthy timing and spacing of pregnancies, postpartum return to fertility and pregnancy risk after childbirth, and transition to modern contraceptive methods. The project coordinated with local health directors to advocate for the availability of FP commodities at government health facilities and mobile clinics. Women in the intervention group were more likely to use a modern method of contraception (Upper Egypt: odds ratio (OR)=1.45, P<.001; Lower Egypt: OR=1.29, P<.05). However, the difference was not statistically significant for mothers with children aged 11 months or younger.

In conclusion: "To help avert short interpregnancy intervals and improve health outcomes for mothers and babies, funders, policymakers, and providers may consider strengthening their support for multifaceted ANC interventions delivered over multiple time points that promote voluntary informed choice regarding postpartum contraception."