Education for contraceptive use by women after childbirth.
BACKGROUND
Providing contraceptive education is now considered a standard component of postpartum care. The effectiveness is seldom examined. Questions have been raised about the assumptions on which such programs are based, e.g., that postpartum women are motivated to use contraception and that they will not return to a health center for family planning advice. Surveys indicate that women may wish to discuss contraception both prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women may have unmet needs for contraception. In the USA, many adolescents become pregnant again within a year a giving birth.


OBJECTIVE
Assess the effects of educational interventions for postpartum mothers about contraceptive use


METHODS
In May 2012, we searched the computerized databases of MEDLINE, CENTRAL, CINAHL, PsycINFO, and POPLINE. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. In addition, we examined reference lists of relevant articles, and contacted subject experts to locate additional reports.


METHODS
Randomized controlled trials were considered if they evaluated the effectiveness of postpartum education about contraceptive use. The intervention must have started postpartum and have occurred within one month of delivery.


METHODS
We assessed for inclusion all titles and abstracts identified during the literature searches with no language limitations. The data were abstracted and entered into RevMan. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI) was calculated. For continuous variables, we computed the mean difference (MD) with 95% CI. Due to varied study designs, we did not conduct meta-analysis.


RESULTS
Ten trials met the inclusion criteria. Of four trials that provided one or two counseling sessions, two showed some evidence of effectiveness. In a study from Nepal, women with an immediate postpartum and a session three months later were more likely to use contraception at six months than those with only the later session (OR 1.62; 95% CI 1.06 to 2.50). However, most comparisons did not show evidence of effectiveness. In a trial conducted in Pakistan, women in the counseling group were more likely than those without counseling to use contraception at 8 to 12 weeks postpartum (OR 19.56; 95% CI 11.65 to 32.83). The assessments were short-term. The remaining two studies were from the USA; one did not provided sufficient data and one had too small a sample to detect differences.Six trials provided multifaceted programs with many contacts. Three showed evidence of effectiveness. Of those, two USA studies focused on adolescents. Adolescents in a home-visiting program were less likely to have a second birth in two years compared to adolescents who received usual care (OR 0.41; 95% CI 0.17 to 1.00). In the other trial, adolescents receiving enhanced well-baby care were less likely to have a repeat pregnancy by 18 months compared to those with usual well-baby care (OR 0.35; 95% CI 0.17 to 0.70). In an Australian study, teenagers in a structured home-visiting program were more likely to use contraception at six months than those who had standard home visits (OR 3.24; 95% CI 1.35 to 7.79). The trials without evidence of effectiveness included two for adolescents in the USA (computer-assisted motivational interviewing and cell phone counseling) and a home-visiting program for women in Syria.


CONCLUSIONS
The overall quality of evidence was moderate. Half of these postpartum interventions led to fewer repeat pregnancies or births or more contraceptive use. However, the evidence of intervention effectiveness was of low to moderate quality. Trials with evidence of effectiveness included two that provided one or two sessions and three that had multiple contacts. The former had limitations, such as self-reported outcomes and showing no effect for many comparisons. The interventions with multiple sessions were promising but would have to be adapted for other locations and then retested. Researchers and health care providers will have to determine which intervention might be appropriate for their setting and level of resources.
Clinical Sciences, FHI 360, P.O. Box 13950, Research Triangle Park, North Carolina, USA. llopez@fhi360.org.
Laureen M
LM
Lopez
Janet E
JE
Hiller
David A
DA
Grimes
Mario
M
Chen
D000293:Adolescent; D000328:Adult; D003267:Contraception; D005260:Female; D006801:Humans; D010353:Patient Education as Topic; D049590:Postpartum Period; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic; D055815:Young Adult