Study protocol for Post Pregnancy Family Planning Choices, an operations research study examining the effectiveness of interventions in the public and private sectors in Indonesia and Kenya.

Background: Global evidence suggests many postpartum and postabortion women have an unmet need for family planning (FP) after delivery or receiving care following loss of a pregnancy. Post Pregnancy Family Planning Choices, an operations research study, aims to examine the effectiveness of a package of postpregnancy FP interventions, inclusive of postpartum and postabortion FP. The interventions are being implemented in selected public and private facilities in Indonesia and Kenya and focus on quality FP counseling and service provision prior to discharge. This manuscript presents the study protocol, documenting how the study team intends to determine key factors that influence uptake of postpregnancy FP. Methods: This is a multi-country, quasi-experimental three-year operations research study in Brebes and Batang Districts of Indonesia and Meru and Kilifi Counties of Kenya. Quantitative and qualitative data is collected longitudinally through interviews and health facility assessments at multiple time points. Data is gathered from 22 health facilities; 8,796 antenatal, postpartum, and postabortion clients; and key informants at national, subnational, facility, and community levels. Quantitative study data is collected and managed using REDCap (Research Electronic Data Capture). Once data are thoroughly cleaned and reviewed, regression models and multilevel analyses will explore quantitative data. Qualitative study data is collected using audio recordings and transcribed to Microsoft Word, then analyzed using ATLAS.ti. Qualitative datasets will be analyzed using grounded theory methods. Discussion: The ultimate goals of the study are to generate and disseminate actionable evidence of positive drivers, barriers, and activities that do not yield results with regard to increasing postpregnancy FP programmatic activities, and to institutionalize postpregnancy FP in the public and private sectors in Indonesia and Kenya. We hope these learnings and experience will contribute to global efforts to advance and scale up postpregnancy FP in similar settings beyond these two countries. Trial registration: ClinicalTrials.gov NCT03333473.

Quasi-experimental Study of Systematic Screening for Family Planning Services among Postpartum Women Attending Village Health and Nutrition Days in Jharkhand, India.

BACKGROUND: Systematic screening helps increase family planning uptake through integration with other services, including immunization. Though successfully demonstrated at health facilities, this strategy has not been demonstrated in communities. This study assessed the effectiveness of systematic screening to increase postpartum family planning use during community health days in India without adversely affecting immunization services. METHODS: The study was conducted during 180 individual Village Health and Nutrition Days in Jharkhand, India. All health workers were trained in postpartum family planning counseling. Intervention providers were also trained in systematic screening. 217 postpartum women aged 15-49 years participated in baseline and endline exit interviews and routine service statistics were analyzed from 2,485 facility visits at affiliated health centers. RESULTS: No difference in family planning service use was found in the intervention group, but significantly fewer interviewed women reported receiving family planning services at endline in the comparison group (p = 0.014). Family planning acceptance at affiliated health centers increased significantly in intervention areas (p < 0.001) but not in comparison areas, while immunization service use increased in both groups (p = 0.002 intervention, p < 0.001 comparison). CONCLUSIONS: The use of the postpartum systematic screening tool appears to increase acceptance of family planning services when integrated with community-based services in Jharkhand.

Postpartum Family Planning During Sociopolitical Transition: Findings from an Integrated Community-Based Program in Egypt.

CONTEXT: Limited information exists on postpartum family planning and implementation of integrated reproductive and maternal and child health programs in countries experiencing sociopolitical transition. METHODS: A quasi-experimental evaluation of an integrated reproductive and maternal and child health program implemented in selected sites in Upper and Lower Egypt was conducted between 2012 and 2014. Preintervention and postintervention household surveys were conducted among 12,454 women in intervention sites and nonintervention comparison sites who at survey had a child younger than 24 months. Bivariate and multivariate analyses estimated the intervention's effects on postpartum family planning-related outcomes, including contraceptive use, knowledge of optimal birthspacing, reproductive intentions and decision making about contraceptive use. RESULTS: In Upper Egypt, modern contraceptive use decreased over the study period in both intervention and comparison sites (by six and 15 percentage points, respectively), and in Lower Egypt, contraceptive use remained unchanged in intervention sites and decreased slightly (by three points) in comparison sites; in both regions, the intervention was positively associated with the difference in differences between groups (odds ratios, 1.5 for Upper Egypt and 1.3 for Lower Egypt). The intervention appears to have had a positive effect on knowledge of optimal birthspacing in Upper Egypt, on wanting to delay the next pregnancy in Lower Egypt, and on pregnancy risk and joint decision making in both regions. DISCUSSION: Study findings demonstrate the feasibility and effectiveness of an integrated reproductive and maternal and child health program implemented in a changing sociopolitical context. Revitalized efforts to bolster family planning within the country are needed to avert further losses and spark a return to positive trends.

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.

Women's experience with postpartum intrauterine contraceptive device use in India.

BACKGROUND: Postpartum intrauterine contraceptive devices (PPIUCD) are increasingly included in many national postpartum family planning (PPFP) programs, but satisfaction of women who have adopted PPIUCD and complication rates need further characterization. Our specific aims were to describe women who accepted PPIUCD, their experience and satisfaction with their choice, and complication of expulsion or infection. METHODS: We studied 2,733 married women, aged 15-49 years, who received PPIUCD in sixteen health facilities, located in eight states and the national capital territory of India, at the time of IUCD insertion and six weeks later. The satisfaction of women who received IUCD during the postpartum period and problems and complications following insertion were assessed using standardized questionnaires. RESULTS: Mean (SD) age of women accepting PPIUCD was 24 (4) years. Over half of women had parity of one, and nearly one-quarter had no formal schooling. Nearly all women (99.6%) reported that they were satisfied with IUCD at the time of insertion and 92% reported satisfaction at the six-week follow-up visit. The rate of expulsion of IUCD was 3.6% by six weeks of follow-up. There were large variations in rates of problems and complications that were largely attributable to the individual hospitals implementing the study. CONCLUSIONS: Women who receive PPIUCD show a high level of satisfaction with this choice of contraception, and the rates of expulsion were low enough such that the benefits of contraceptive protection outweigh the potential inconvenience of needing to return for care for that subset of women.

Cervical cancer screening using visual inspection with acetic acid: operational experiences from Ghana and Thailand.

Thailand in 2000 and Ghana in 2001 initiated cervical cancer prevention programmes using a single-visit approach with visual inspection with acetic acid (VIA) with cryotherapy for pre-cancerous lesions. This service was integrated into existing reproductive health services, provided by trained nurses. The providers maintained a high level of competence and performance, including after the withdrawal of external funding. In Ghana, independent co-assessments revealed a high level of agreement in diagnosis between providers and a Master Trainer. In Thailand, high quality performance was associated with quality assurance mechanisms such as peer feedback and review of charts and service statistics. Provider performance was maintained at a high level in both countries: an average of 74% of providers from both countries met 85% or more of performance standards. The successful transition from a demonstration project to a national programme in Thailand was dependent on a strong commitment from government health bodies and health professionals. In contrast, the lack of health infrastructure and political will has prevented scale-up to a national programme in Ghana. However, this study shows that a single-visit approach with VIA and cryotherapy is programmatically feasible and sustainable and should be considered in national investments to control cervical cancer.