Group antenatal care versus standard antenatal care and effect on mean gestational age at birth in Rwanda: protocol for a cluster randomized controlled trial.

Background: Group antenatal care has demonstrated promise as a service delivery model that may result in improved outcomes compared to standard antenatal care in socio-demographic populations at disparately high risk for poor perinatal outcomes. Intrigued by results from the United States showing lower preterm birth rates among high-risk women who participate in group antenatal care, partners working together as the Preterm Birth Initiative - Rwanda designed a trial to assess the impact of group antenatal care on gestational age at birth. Methods: This study is a pair-matched cluster randomized controlled trial with four arms. Pairs randomized to group or standard care were further matched with other pairs into quadruples, within which one pair was assigned to implement basic obstetric ultrasound at the health center and early pregnancy testing at the community. At facilities randomized to group care, this will follow the opt-out model of service delivery and individual visits will always be available for those who need or prefer them. The primary outcome of interest is mean gestational age at birth among women who presented for antenatal care before 24 completed weeks of pregnancy and attended more than one antenatal care visit. Secondary outcomes of interest include attendance at antenatal and postnatal care, preterm birth rates, satisfaction of mothers and providers, and feasibility. A convenience sample of women will be recruited to participate in a longitudinal survey in which they will report such indicators as self-reported health-related behaviors and depressive symptoms. Providers will be surveyed about satisfaction and stress. Discussion: This is the largest cluster randomized controlled trial of group antenatal and postnatal care ever conducted, and the first in a low- or middle-income country to examine the effect of this model on gestational age at birth. Trial registration: This study is registered on ClinicalTrials.gov as NCT03154177 May 16, 2017.

[Unwanted adolescent pregnancy and post-partum utilization of contraceptive methods]. / Embarazo no deseado en adolescentes, y utilización de métodos anticonceptivos posparto.

OBJECTIVE: To describe the proportion of unwanted pregnancies among all pregnant adolescents, its association with sociodemographic characteristics, and the use of post-partum contraceptive methods. MATERIAL AND METHODS: A cross-sectional study was conducted among 220 women between 13 and 19 years of age, in two semi-urban municipalities of the State of Morelos, Mexico, interviewed between 1992 and 1994. Women were interviewed at home, six to twelve weeks after their delivery date. Women were asked whether they had wanted their last pregnancy, and about knowledge and use of contraceptive methods after delivery. RESULTS: Adolescent pregnancies accounted for 17% of all births registered in these two municipalities. Among all adolescent mother 22.73% reported that their pregnancy had not been wanted. A positive association was found between the lack of access to health services provided by public medical insurance systems (Instituto Mexicano del Seguro Social IMSS and Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado ISSSTE) and unwanted pregnancy (adjusted OR = 3.03, 95% CI (1.31, 7.) An association was also found between living in an urban community (adjusted OR = 2.16, 95% CI (1.08, 4.33) and an unwanted pregnancy. Among all adolescent mothers, 91.3% were familiar with "the pill" as a contraceptive method; 84.72% knew about the IUD, and 63.68% knew about the condom. However, only 35% of them were actually using an effective contraceptive method six weeks after delivery. No difference in frequency of contraceptive use was found among the adolescent mothers, according to whether they wanted their last pregnancy. Only 43.39% of mothers who delivered at hospitals or health centers were using an effective contraceptive method. CONCLUSIONS: These findings suggest that there is a great potential for family planning programs to target adolescents, and that the use of contraceptive methods after delivery should be promoted among adolescent mothers, especially those lacking access to public medical insurance and those living in semi-urban settings. It is also recommended to conduct studies on family planning education programs that can be introduced earlier in the school system in Mexico.

Embarazo no deseado en adolescentes, y utilización de métodos anticonceptivos posparto / Unwanted adolescent pregnancy and post-partum utilization of contraceptive methods

OBJETIVO: Describir la proporción de embarazo no deseado en adolescentes, su asociación con características sociodemográficas y la utilización de anticonceptivos posparto. MATERIAL Y MÉTODOS: Se trata de un estudio transversal con una muestra de 220 mujeres adolescentes entre 13 y 19 años de edad, de dos municipios semiurbanos del estado de Morelos, México, entrevistadas entre 1992 y 1994. Las mujeres fueron entrevistadas en su casa entre seis y 12 semanas después del parto. Se les preguntó si antes de embarazarse desearon el último embarazo. Además, se indagó sobre conocimientos y uso de métodos anticonceptivos posparto. RESULTADOS: Un 17 por ciento de todos los nacimientos registrados en la población total en ese periodo fueron producto de madres adolescentes. De éstas, 22.73 por ciento declararon que su embarazo no fue deseado. Se encontró una asociación positiva entre no tener derecho de acceso a los servicios de salud de las instituciones del sistema de seguridad social -Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE)- y embarazo no deseado (RM ajustada=3.03, IC 95 por ciento 1.31, 7). Asimismo, las adolescentes de comunidades urbanas manifestaron no deseo del embarazo con mayor frecuencia que las mujeres de comunidades rurales (RM ajustada=2.16, IC 95 por ciento 1.08, 4.33). Un 91.3 por ciento de las madres adolescentes enunció la píldora anticonceptiva entre los métodos que conocía. Un 84.72 por ciento conocía el DIU y 63.68 por ciento el condón. Sin embargo, sólo 35 por ciento estaba utilizando algún método anticonceptivo efectivo después de las seis semanas posparto. No se encontró diferencia en la frecuencia de uso de anticonceptivos según deseo del último embarazo. Entre quienes se atendieron el parto en centros de salud u hospital sólo 43.39 por ciento estaba utilizando algún método efectivo de planificación familiar. CONCLUSIONES: Estos hallazgos sugieren que los programas de planificación familiar tienen un potencial de cobertura aún no alcanzado entre el grupo de adolescentes, especialmente entre las que viven en áreas suburbanas y entre las no derechohabientes de la seguridad social. Asimismo, sugiere la necesidad de insistir en la promoción de la utilización de métodos anticonceptivos posparto en este grupo considerado de alto riesgo reproductivo...