Education for contraceptive use by women after childbirth.
BACKGROUND
n 1966, the Population Council (a non-profit, non-government organisation which aims to foster reproductive health around the world) sponsored demonstration projects (known as the 'International Postpartum Program') on postpartum family planning, focussing primarily on developing countries and including 25 hospitals in 14 countries (Zatuchni 1970). These projects were based on the assumptions that women are receptive to family planning education in the postpartum period, and that they will not return to health centres for contraception once they have been discharged from hospital. The demonstration projects were declared a success given their ability to reach large numbers of women, and they were expanded to include hospitals in 21 countries (Winikoff et al 1991). Randomised controlled trials were not used to assess the effectiveness of the program. The provision of education on contraceptive use to postpartum mothers has come to be considered a standard component of postnatal care, with up to 84% of women noting that a discussion on contraception took place with a midwife on the postnatal floor (Glasier et al 1996). Although education frequently is provided as an integral component of discharge planning, many women experience this as a perfunctory discussion included as part of a checklist of topics (Glasier et al 1996). Midwifery and obstetric texts routinely refer to the provision of such education as a responsibility in the provision of postpartum care; however, the effectiveness of this intervention is seldom questioned (Keith et al 1980; Semeraro 1996). Questions have been raised about the assumptions that are the basis for such programs, e.g. that postpartum women are motivated to use contraception and that they will not return to a health centre for family planning advice (Winikoff et al 1991). In addition surveys conducted postpartum indicate that women may wish to discuss contraception antenatally and post hospital discharge, preferably in the context of general education about maternal and child health (Ozvaris 1997).


OBJECTIVE
Postpartum education on contraceptive use is a routine component of discharge planning in many different countries with a wide variety of health care systems. This education is based on assumptions concerning women's receptivity to contraceptive education during the postpartum period and their presumed lack of access to such education after that time. The objective of this review is to assess the effects of education about contraceptive use to postpartum mothers.


METHODS
We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, Psychlit, Popline, citations indexes and reference lists of relevant articles. We contacted subject experts to locate additional research, in addition to the Group's Specialised Register of Controlled Trials. Date of the most recent search: March 2001.


METHODS
Trials using random or quasi-random methods of allocation which evaluated the effectiveness of postpartum education about contraceptive use.


METHODS
Two independent reviewers abstracted data on trial characteristics and results.


RESULTS
No new trials were identified since this review was updated in 1999. Three trials were identified with 5438 women. These trials were conducted in Lebanon, Peru and Nepal. None of the trials examined all major prespecified endpoints. Postpartum education about contraceptive use influenced short-term use assessed between 40 days and three months post-partum. Women in the intervention groups were less likely to be non-users than women in the comparison groups (Odds Ratio (OR) = 0.47, 95% Confidence Interval (CI) 0.39 to 0.58). This benefit was not apparent following analysis of data from better quality studies (OR = 0.67, 95% CI 0.41 to 1.13). An apparent benefit on contraceptive use at six months post-partum (OR = 0.52, 95% CI 0.37 to 0.74) was not apparent following sensitivity analyses (OR = 0.59, 95% CI 0.33 to 1.06). Data are inadequate to assess the impact on cessation of breast feeding and non-attendance at family planning clinics. Unplanned pregnancies, knowledge about contraception and satisfaction with care were not assessed in any trial.


CONCLUSIONS
The effectiveness of postpartum education about contraceptive use has not yet been established in randomised controlled trials. Such education may be effective in increasing the short-term use of contraception. However, there are only limited data examining a more-important longer-term effect on the prevention of unplanned pregnancies. Research needs to be undertaken to assess the effectiveness of the minimalist education provided in more developed countries and the variety of programs provided in less developed regions. Such research should examine the content, timing, range and organisation of postpartum education on contraceptive use including lactational amenorrhea, as well as its impact on breast feeding rates.
Public Health, University of Adelaide, Adelaide, South Australia, Australia. jhiller@medicine.adelaide.edu.au
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D003267:Contraception; D005260:Female; D006801:Humans; D010353:Patient Education as Topic; D049590:Postpartum Period; D015397:Program Evaluation