Effectiveness of a package of postpartum family planning interventions on the uptake of contraceptive methods until twelve months postpartum in Burkina Faso and the Democratic Republic of Congo: the YAM DAABO study protocol

Ignoring the contraceptive needs of postpartum women are missed opportunities in health service delivery to ensure that every woman and her family can enjoy the health, social, and economic benefits of family planning (FP).

By spacing the birth-to-pregnancy interval by at least two years and the inter-birth interval by at least three years, the use of effective postpartum contraceptive methods in less developed countries could prevent poor maternal, perinatal, and neonatal health outcomes, including stillbirth, prematurity, low birth weight, neonatal and maternal mortality [1‐3]. However, among women in developed countries, the impact of short birth-to-pregnancy intervals is mixed considering recent studies [4‐6]. PPFP can be therefore defined as the prevention of unwanted pregnancies and closely spaced pregnancies during the first 12 months after delivery – during this period, pregnancy poses the greatest risks to both the mother and baby [7].

Despite the importance given by the International Conference on Population and Development to FP and timely birth spacing (“that all couples and individuals have the basic right to determine freely and responsibly the number and spacing of their children and to have the information, education and means to do so”), unmet need for FP in the postpartum period remains unacceptably high and far exceeds the FP unmet need of other women. Birth-to-pregnancy intervals in 50% or more of pregnancies in low- and middle-income countries are too short – at less than 23 months [8]. Depending on the definitions of unmet need for PPFP and according to estimates derived from Demographic Health Survey (DHS) data analysis from 57 countries during 2005–2013, the proportion of postpartum women who no longer wanted children or wanted to postpone another child for at least two years but were not using a contraceptive method ranged from 32% (at the end of amenorrhea) to 62% (soon after birth and before the sixth week postpartum; this prospective definition assumes that women should be offered a contraceptive method even while they are still amenorrheic and does not take into account the protection offered by amenorrhea and abstinence) [9]. The unmet need soon after birth even reaches 75% for the West and Central Africa region. The overall goal of our study is to address this high unmet need for PPFP.

Routine reproductive, maternal, newborn and child health (RMNCH) services offer frequent points of contact for providers and women and are key opportunities to address the contraceptive needs of postpartum women and couples [10]. PPFP should therefore be an integral part of RMNCH services. Despite observed advances in access to RMNCH services in many Sub-Saharan African countries in recent decades, progress is weak regarding effective postpartum contraceptive use [8, 11, 12]. There are multiple factors that can be examined from the perspective of the demand side on the one hand (factors related to the demand of health services by women), and supply side on the other (factors related to the provision of health services).

From the demand side: first, abstinence from sex for long periods after childbirth. Second, reliance on amenorrhea are common traditional PPFP methods, especially in Sub-Saharan Africa, where women generally breastfeed their babies up to two years, although not exclusively [13]: among children younger than six months in low- and middle-income countries, 63% are not exclusively breastfed [14]. The length of postpartum amenorrhea depends on the breastfeeding practices. Women often rely on these methods without knowing their limitations. For women who are not breastfeeding, pregnancy can occur within 45 days postpartum even before the return of menses, and among women who are exclusively or almost exclusively breastfeeding, around a quarter (28%) are at risk of pregnancy before six months postpartum [15, 16]. Third, women tend to adopt modern contraceptives only after the resumption of sexual activity or menses [17]. These trends differ between rural and urban areas, as suggested by qualitative research in the urban setting of Ouagadougou, Burkina Faso, where women interviewed did not consider amenorrhea as a protection against pregnancy and all had adopted a contraceptive method or had the intention to do so just before the resumption of sexual activity [18]. Fourth, opposition from partners or others, including for religious reasons, can prevent women from practicing contraception after birth. In West and Central Africa, one in five women reported this barrier [9].

From the supply side: first, contraceptive services may be limited to certain days of the week and only offered once during the six-week postpartum period. Second, service providers sometimes require amenorrheic postpartum women, who missed their 6-week postpartum visit, to wait for the return of their menses or take a pregnancy test before they can receive a contraceptive method.

Several reviews of the literature and of PPFP interventions in less developed countries were recently published [19‐22]. The World Health Organization (WHO) and key partners published in 2013 programmatic strategies for PPFP to support program managers in their efforts to integrate PPFP into national and local health strategies [23]. This document reviews the evidence according to the RMNCH continuum as it offers convenient entry points for PPFP interventions: antenatal care (ANC), labor and delivery, postnatal care (PNC), immunization, and child health. The following interventions may have a positive effect on postpartum contraceptive uptake: (1) counseling activities in ANC [24‐28]; (2) provision of PPFP information, education, and counseling materials before the woman is discharged home from the health facility, including the provision of emergency contraception backup for lactational amenorrhea method (LAM) users [29‐32]; (3) exclusive breastfeeding promotion by community-based counsellors on exclusive breastfeeding practices before five to six months postpartum [33, 34]; (4) access to contraceptive methods (including intrauterine devices (IUD)) immediately after childbirth [35‐37]; (5) provider competencies in quality counseling and the provision of quality services with a range of readily available products [38‐40]; (6) longer programs with several contact points between providers and clients across the continuum of care versus short ANC interventions [41‐43]. While integration of PPFP into immunization and child health services may yield positive results, programmatic challenges (e.g., provider competencies, time pressure, and competition with other priority interventions) and policy barriers remain [44‐48]. This said, the evidence is often weak or incomplete and there are still knowledge gaps, particularly regarding studies that explore the desires, intentions, and priorities of women or couples related to PPFP, which may differ across settings, and that look at operationally-feasible ways to integrate PPFP into existing ANC and PNC services. Further, there is a limited number of methodologically rigorous trials that give a detailed description of tested interventions and of how these were implemented.

Despite the proven benefits of modern contraceptive use, the unmet need for postpartum family planning remains unacceptably high. This is puzzling as survey findings continue reporting that most couples wish to space their children by at least two years [60], and women access health services more often during pregnancy, delivery, and the first year of their child’s life than other periods. During the multiple opportunities given by this heightened contact with health services, we would expect an increase in demand for and supply of contraceptive information and services.

Given the known reliance on amenorrhea from breastfeeding and abstinence for protection from pregnancy for up to a year postpartum, is it then worth investing energy and resources into PPFP programming during the first year postpartum? Despite these practices, DHS data show that the unmet need for PPFP in Burkina Faso and the DRC, as well as in Sub-Saharan Africa in general, remains critically high and it is important to explore the optimal programmatic approaches to address and resolve it. To this end, different strategies have been explored:

First, there has been a renewed interest on highly effective long-acting and reversible methods, such as immediate postpartum IUD. These programs have shown promising results, although they require major undertaking in terms of logistics, competency training of health staff, and demand creation [37]. Burkina Faso and the DRC have recently given commitments to piloting such programs.

Second, targeted investment to promote LAM for up to six months and switching to another method appears justified from the RMNCH perspective. Tabulations of DHS data on exclusive breastfeeding from Burkina Faso and the DRC are not encouraging and reflect the situation in other low-income countries [61]. The median duration of exclusive breastfeeding changed minimally in Burkina Faso between 1993 and 2010 (0.4 and 0.6 month respectively), and in the DRC between 2007 and 2013–14 (1.4 and 2.2 months respectively). This may be due to widespread early supplementation practices that are entrenched by traditions and hard to influence. The median duration of amenorrhea is twelve months in both countries and suggests that breastfeeding, although not exclusive, must be frequent enough to induce an amenorrheic state. Therefore, having health staff promoting LAM at length may not be an efficient use of limited resources.

Third, with a median duration of postpartum abstinence close to eight months in both study countries, it appears that the immediate postpartum or the six-week postpartum visit dedicated to contraceptive services may not respond to women’s demand. Instead of the targeted “high-dose, low-frequency” strategies that promote a method over another and restrict services to a narrow window period, a “low-dose, high frequency” approach during the end of pregnancy and the first year postpartum to deliver contraceptive information and services may be a more appropriate pathway to respond to the wishes and situations of each postpartum woman and couple: giving information to women and couples, including on benefits and limitations of PPFP and of available contraceptive methods, and letting them choose.

The latter choice-based strategy underpins our health service trial, which also stands out for other reasons. First, given the growing availability of ANC, delivery, and PNC services in primary health centers in low-resource countries, we believe that there is an urgent need to design, test, and scale up effective, affordable, and sustainable PPFP interventions that are not only respectful of the intentions, decisions, and situations of clients but that can also reinforce the existing RMNCH continuum of care. This will allow to minimize missed health services opportunities to address the contraceptive needs of postpartum women and couples. Second, due to the complex social, cultural and religious challenges and opportunities surrounding contraceptive use, our research assumes that this can only be accomplished by following participatory action research principles. Engaged stakeholders include adolescents, women, men, key community members, health staff, policy-makers, and researchers, whose views and inputs will contribute to shaping the PPFP intervention package.

Several changes may happen as a consequence of the study. At the individual level, knowledge, attitudes, and behaviors of women and couples toward PPFP will likely be influenced by a set of inexpensive interventions. At the health service delivery level, implementation of the intervention phase will probably require a shift in behavior and accountability of service providers with regard to the systematic integration of PPFP into their clinical practice, and optimization of health service organization to ensure a reliable availability of competent staff and contraceptive methods and supplies when they are needed.