title: Operations research to add postpartum family planning to maternal and neonatal health to improve birth spacing in Sylhet District, Bangladesh.
abstract: BACKGROUND
  Short birth intervals are associated with increased risk of adverse maternal and neonatal health (MNH) outcomes. Improving postpartum contraceptive use is an important programmatic strategy to improve the health and well-being of women, newborns, and children. This article documents the intervention package and evaluation design of a study conducted in a rural district of Bangladesh to evaluate the effects of an integrated, community-based MNH and postpartum family planning program on contraceptive use and birth-interval lengths.
  
  
  METHODS
  The study integrated family planning counseling within 5 community health worker (CHW)-household visits to pregnant and postpartum women, while a community mobilizer (CM) led community meetings on the importance of postpartum family planning and pregnancy spacing for maternal and child health. The CM and the CHWs emphasized 3 messages: (1) Use of the Lactational Amenorrhea Method (LAM) during the first 6 months postpartum and transition to another modern contraceptive method; (2) Exclusive, rather than fully or nearly fully, breastfeeding to support LAM effectiveness and good infant breastfeeding practices; (3) Use of a modern contraceptive method after a live birth for at least 24 months before attempting another pregnancy (a birth-to-birth interval of about 3 years) to support improved infant health and nutrition. CHWs provided only family planning counseling in the original study design, but we later added community-based distribution of methods, and referrals for clinical methods, to meet women's demand.
  
  
  METHODS
  Using a quasi-experimental design, and relying primarily on pre/post-household surveys, we selected pregnant women from 4 unions to receive the intervention (n = 2,280) and pregnant women from 4 other unions (n = 2,290) to serve as the comparison group. Enrollment occurred between 2007 and 2009, and data collection ended in January 2013.
  
  
  RESULTS
  Formative research showed that women and their family members generally did not perceive birth spacing as a priority, and most recently delivered women were not using contraception. At baseline, women in the intervention and comparison groups were similar in terms of age, husband's education, religion, and parity. CHWs visited over 90% of women in both intervention and comparison groups during pregnancy and the first 3 months postpartum.
  
  
  CONCLUSIONS
  This article provides helpful intervention-design details for program managers intending to add postpartum family planning services to community-based MNH programs. Outcomes of the intervention will be reported in a future paper. Preliminary findings indicate that the package of 5 CHW visits was feasible and did not compromise worker performance. Adding doorstep delivery of contraceptives to the intervention package may enhance impact.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA ; Jhpiego , Baltimore, MD , USA.
authors.forename: Salahuddin
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: U.S. Agency for International Development , Washington, DC , USA.
authors.forename: Maureen
authors.initials: M
authors.lastname: Norton
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Emma
authors.initials: E
authors.lastname: Williams
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Saifuddin
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Rasheduzzaman
authors.initials: R
authors.lastname: Shah
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Nazma
authors.initials: N
authors.lastname: Begum
authors.affiliation: Jhpiego , Baltimore, MD , USA.
authors.forename: Jaime
authors.initials: J
authors.lastname: Mungia
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Amnesty
authors.initials: A
authors.lastname: Lefevre
authors.affiliation: Research, Training and Management (RTM) International , Dhaka, Bangladesh.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Al-Kabir
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Winch
authors.affiliation: Jhpiego , Baltimore, MD , USA.
authors.forename: Catharine
authors.initials: C
authors.lastname: McKaig
authors.affiliation: Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA.
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui