Evaluating two models of postpartum family planning counseling on contraceptive uptake: evidence from a repeated cross-sectional study in Ghana

doi:10.21203/rs.3.rs-4818121/v1

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Research Article

Evaluating two models of postpartum family planning counseling on contraceptive uptake: evidence from a repeated cross-sectional study in Ghana

https://doi.org/10.21203/rs.3.rs-4818121/v1

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Background

Integrating family planning programming into postpartum care is widely established as an effective approach to improve access to family planning. We conducted a pilot in 6 hospitals in northern Ghana to evaluate the effectiveness of two approaches at improving contraceptive uptake. These approaches were: 1) family planning counseling during postnatal care (PNC) appointments and; 2) family planning messaging and referrals during immunization/child welfare clinic (CWC) sessions in the first year postpartum.

Methods

This study used a two-arm non-randomized repeated cross-sectional design. We surveyed 205 women pre-intervention and 226 women post-intervention.

Results

We observed no statistically significant effects on actual or intended contraceptive use in either arm at immediate surveying. Results from two-week phone surveying (n = 202) suggest a 22% increase in contraceptive use (p< .01) and a 25.3% increase in intended use (p <.05) post-intervention in the PNC arm and no statistically significant effects in the CWC arm; however, this data is only suggestive due to its small sample size. High rates of breastfeeding and prolonged postpartum abstinence suggest that the majority surveyed were not at high risk of pregnancy irrespective of modern contraceptive use.

Conclusions

While the relatively small sample size and non-randomized study design limit the generalizability of the findings, the results suggest that contraceptive counseling at CWC may have limited effect on contraceptive uptake, while counseling at PNC is more promising yet still mixed. High rates of breastfeeding and prolonged postpartum abstinence suggest that changes in contraceptive uptake in the first year postpartum in similar contexts may have a reduced effect on unintended pregnancies; this supports similar recent findings in the literature.

Trial registration

Not applicable.

postpartum family planning

contraception

family planning access

postnatal care

The Case for Family Planning Interventions

Pregnancy-related health outcomes are a leading cause of preventable death among both mothers and children. In 2020, 287,000 women and girls died due to either pregnancy or childbirth (1). While a variety of approaches are necessary to combat this issue, comprehensive access to contraception could avert more than 30% of maternal deaths and 10% of child mortality globally (2, 3).

Contraceptive access provides a wide range of other potential benefits. The most significant of these may be increasing reproductive autonomy for women who want to space or limit births and currently have limited options for doing so. Increasing women’s reproductive autonomy has been linked to increased income, educational attainment, and subjective well-being (4, 5). More than this, increasing autonomy represents a worthy and important goal in and of itself (6).

The maternal and infant mortality risks from short birth spacing make the postpartum period potentially a particularly valuable time for increased contraceptive access (7–9). Kozuki and Walker’s analysis of Demographic and Health Service (DHS) data across 47 countries suggests an 18% increase in neonatal mortality and a 21% increase in child mortality from short-spaced births (10). Changes in maternal mortality are more difficult to measure due to the lower incidence of maternal deaths but may be as significant as a 32% increase in mortality risk (11).

Programming targeting Sub-Saharan Africa may be particularly worthwhile given that contraceptive rates across the region are less than half of the global average while over half of young women with unmet need for family planning will live in the region by 2030 (12, 13). Additionally, the risks of short birth spacing are likely intensified in the region due to more fragile healthcare systems and additional financial and location constraints on accessing care (14, 15).

Previous studies in other contexts have shown that integrating family planning guidance into postnatal care or child immunization appointments can be an effective way of increasing contraceptive uptake and reducing unmet need (16–21).

These studies have adopted a variety of approaches to increasing contraceptive uptake in the postpartum period. The strongest increases in uptake appear to be associated with immediate postpartum family planning, particularly in programs with a focus on long-acting reversible contraception (LARC) delivery in the first 48 hours after birth. This model of programming was not selected for this study due to concerns about freedom of choice and reproductive decision-making when information on certain methods is prioritized. Concerns around “LARC-first” programming have been discussed extensively, but nevertheless appear relatively under-addressed (22–25). These concerns are supported by studies highlighting broader issues with unintentional coercion in family planning programming due to biased counseling, provider reluctance to remove LARCs, and an excess emphasis on uptake targets (26–28). In response to these concerns, the design of counseling materials and counseling approach in this study avoided any prioritization of methods and focused on centering client preferences when selecting methods.

Intervention Rationale

This study was delivered in Ghana, one of several countries in West Africa where increases in contraceptive uptake have lagged behind global trends. Ghana had an average contraceptive uptake of 27% in 2018 (29), significantly lower than the global average of 48.5% (30). In addition, recent data suggests that 30% of women in Ghana have an unmet need for contraception, meaning many women would like to space or limit their births but are not using contraception (31). This study took place in the Northern region of Ghana, which has among the lowest uptake of modern contraceptives in the country, at 17% (32).

One potential barrier to higher rates of family planning is insufficient counseling quality (33). It is the official policy of the Ghana Health Service that all postnatal care should include family planning counseling and services (34). However, prior research has indicated that the consistency and quality of family planning services in the postpartum period varies in practice (35).

Based on this perceived gap, our study aimed to test the impact on family planning acceptor rates in the Northern Region of two models integrating consistent, high-quality family planning counseling into routine care.

These models were: 1) the provision of one-to-one family planning counseling during routine postnatal care (PNC) appointments; 2) the implementation of short family planning messaging and a referral system as part of normal child welfare clinic (CWC) sessions. In Ghana, postnatal care sessions are one-to-one appointments between a provider and the mother delivered from 0–6 weeks post-birth. Child welfare clinics are group sessions focused on child weighing and immunization delivered from 6 weeks to 2 years after birth. See Fig. 1.

This study provided high-quality training to frontline staff who deliver either postnatal care appointments or child immunization sessions. In doing so, the study sought to replicate results from Asah-Opoku et al. and Dulli et al. (21, 31). These studies showed increased consistency of family planning counseling and increased contraceptive uptake after training public healthcare staff in integrating counseling into routine care. As part of the training, providers were given materials and instruction on a system of counseling designed to be integrated into the routine care offered during Ghana Health Service appointments.

Evidence for Intervention Models

The two intervention models were selected based on an extensive review of the evidence supporting different approaches to increasing contraceptive knowledge and uptake. Both approaches are supported by numerous randomized control trials.

In a prior study in Ghana, Asah-Opoku et al. found that contraceptive uptake was 12.6% for clients who received group counseling and 51% for those who received individual counseling in postnatal care (31). We based the design of the PNC intervention package in this study on Asah-Opoku et al.’s work. We aimed to reproduce their results through a streamlined intervention package suitable for scale-up through the Ghana Health Service.

Dulli et al. delivered a randomized control trial in Rwanda that integrated family planning into child immunization services (21). This study found a 15% greater uptake of contraception in the intervention group in comparison to the control group, without any negative impact on child immunization rates. Similar models in Egypt, Malawi, and Liberia have also reported positive outcomes (36–38). However, a previous study that attempted to integrate family planning into immunizations in Ghana encountered significant implementation challenges and did not find any increases in uptake (39). We designed the CWC intervention package for this study to replicate the work of Dulli et al. in a manner that would overcome the implementation challenges encountered by Vance et al. (21, 39).

Study Design and Sampling

This study used a two-arm non-randomized repeated cross-sectional design to evaluate the two intervention packages. We surveyed 205 women receiving routine care prior to the implementation of the intervention: 100 in the PNC arm and 105 in the CWC arm. We subsequently surveyed 226 women receiving the intervention package post-intervention: 106 in the PNC arm and 120 in the CWC arm. See Figure 2. This study design was selected to reduce the possibility of contamination between the control and treatment groups; furthermore, as only approximately 3 months elapsed between the collection of treatment and control data, changes in contraceptive uptake due to exogenous factors were minimized.

This study took place at six hospitals in the Northern Region of Ghana. At the time of the study, there were 15 district hospitals across the Northern Region of Ghana. The sample of six

facilities selected across six districts - with a mix of urban, peri-urban and more rural hospitals - aimed to provide a representative sample of care at hospitals across the Northern Region.

District hospitals were selected as the primary sampling unit due to higher anticipated client flow that would ease data collection and maximize the number of clients reached by each trained provider. Facilities were divided between the two intervention packages to ensure a comparable geographic spread. The following hospitals were allocated to the postnatal care package: Bimbilla, Gushegu, and Yendi Hospital. The following hospitals were allocated to the child immunization package: Karaga, Kpandai, and Zabzugu.

Sampling

The sample size for clients was selected to exceed the baseline number of participants

needed to do a regression analysis according to the principles set forth by (40). See Table 1.

The inclusion criteria for clients participating in the study were that they had:

Delivered a live birth in the last 12 months
Attended a child immunization or postnatal care at one of the targeted facilities on the day of surveying

Clients were sampled while exiting appointments from the six facilities. The implementation team approached clients, explained the study, and asked if they met the selection criteria. If clients met the criteria, they were offered a stipend of 20 cedis to participate.

Table 1. Sample Sizes

Allocation	Clients
Allocation	Baseline	Endline
Intervention 1: Postnatal care package	100	106
Intervention 2: Child welfare clinic package	105	120
Total	205	226

Timeline of Activities

This study was split into three phases of programming. Phases 1 and 3 were the same for both intervention arms. During Phase 2, three facilities received the postnatal care package and three received the child welfare clinic package.

Phase 1: Formative Research

To begin, the study team engaged facility-level stakeholders to understand the feasibility of implementing the intervention packages at the selected facilities. Previous research has indicated the importance of designing interventions in a participatory manner, including incorporating input from service providers and other stakeholders (18). Speaking to facility directors highlighted the need for an adaptable program with the structure of care differing between facilities. It also emphasized the importance of making the materials self-explanatory to better account for likely staff turnover or rotation around the facilities.

From here, the team conducted baseline data collection through structured questionnaires delivered in person to clients who met the inclusion criteria at the target facilities. A follow-up questionnaire was delivered by mobile phone 14 days after in-person surveying to assess contraceptive uptake.

Phase 2: Implementation of Intervention Packages

Both intervention packages included the following activities:

1. Training for providers on 1:1 family planning counseling

A single one-day training session was held for each intervention package with providers selected from the target facilities. While the project team intended to only invite providers from the intervention units (PNC or CWC), hospital administrators selected providers from multiple departments for attendance. This included staff who provided immediate postpartum services at the maternity ward but were not part of the Reproductive and Child Health team.

The sessions were tailored to the postpartum period. They focused on guidance and practice in a model of counseling designed to be feasible for providers to consistently deliver in a way that would increase the quality of routine postnatal contraceptive counseling. Providers’ knowledge and attitudes were tested after the training to assess its effectiveness and potential barriers to implementation, with questions such as ‘Which methods can be safely used by breastfeeding mothers at one month post-delivery?’.

2. Program champions

One provider was selected from each target facility to act as a ‘Program Champion’. These were selected by the facility director, with their name and contact details passed onto the project team. Program Champions were responsible for ensuring the program was consistently implemented at their facility, and for highlighting any barriers to implementation promptly so that the project team could coordinate with the facility to address these. These aims were achieved in part by collecting and submitting routine data on referral and counseling rates to the project team. They were also responsible for ensuring that all relevant providers - including those unable to attend the in-person training - were given clear guidance on the intervention and how to use the materials.

Each Program Champion had to pass a knowledge test to be accepted into the role. They received a small stipend every two weeks upon submission of short observation, client, and facility data surveys, as well as a weekly WhatsApp check-in.

3. Ongoing monitoring activities through implementation

Previous investigations of postpartum contraceptive counseling have been undermined by significant implementation challenges (39). As such, the project team implemented multiple further monitoring activities in addition to recruiting Program Champions.

The team conducted phone surveys of a small sample (n=54) of clients to assess the quality of implementation at the midpoint of the intervention period. These surveys focused on assessing the frequency with which healthcare staff at the facilities used the counseling materials during the appropriate appointments. Phone numbers for clients were provided by each facility’s Program Champion.

An experimental WhatsApp tool was also developed. This aimed to increase providers’ retention of training knowledge while engaging them in direct monitoring to maximize their adherence to the counseling model. This system allowed the project team to send an automated program of interactive content to every healthcare provider who participated in the training. Program Champions collected the phone numbers of any providers at the target facilities who were not able to attend the in-person training so that they could receive the key messages of the training through this WhatsApp system. For the postnatal care program, we sent a weekly survey of around five questions. For the child welfare clinic program, we sent a fortnightly survey of around 10-15 questions with the provision of a small airtime incentive as compensation for the time this took. Completion of the questionnaires was significant, particularly for those receiving the airtime incentive, suggesting that this is a viable strategy for direct provider engagement.

Phase 3: Evaluation

Endline surveying took place six weeks after the training sessions and initiation of the intervention packages. Client and provider surveys were delivered to assess provisional changes in knowledge, attitudes and contraceptive uptake rate. While a longer assessment period may have been beneficial, we believe that six weeks was more than sufficient time for quality implementation to occur that would allow for a robust indication of each program’s value based on the pre-post assessment model.

Sample size and data collection questions were kept the same at the endline as for the baseline, with the addition of a few other questions to improve the contextual understanding of implementation quality and program value. With permission from the Regional Health Directorate and each facility, the project team collected government facility data capturing the monthly facility records for key metrics. However, some records were missing from the datasets and there were issues with the consistency and reliability of data received. As such, we have excluded this data from our assessment of program results.

Timeline of Activity

See Table 2.

Table 2. Timeline of Activity

August-September 2023

Phase 1 - Formative Research

We refined the program design through engagement with facility stakeholders and baseline data collection. We completed baseline data collection by administering structured questionnaires to postpartum women at facilities alongside a questionnaire for facility directors. We then followed up with clients 14 days after the initial questionnaires via mobile phone to assess contraceptive uptake.

October - November 2023

Phase 2 - Implementation of Intervention Packages

We delivered training sessions in October 2023, including an assessment of providers’ contraceptive knowledge and attitudes towards contraceptive use. We commenced implementation at the facilities immediately post-training, pairing this with ongoing monitoring work to ascertain the quality of implementation.

November 2023 - January 2024

Phase 3 - Evaluation

We conducted endline data collection six weeks post-training through structured questionnaires with postpartum women at the intervention facilities. We supplemented this with mobile phone surveying 14 days later. We held the questions used for data analysis and the structure of surveying constant between the baseline and endline surveying.

Limitations

As data was only collected from mothers on a handful of days, the data represents only a snapshot of the care provided at facilities pre- and post-intervention. As a result, any differences to care provided on days when surveyors were present could have a disproportionate effect on the results. Additionally, data on contraceptive use was self-reported; hence, it may be vulnerable to issues such as social desirability bias. While the sample was sufficiently large to draw overall conclusions, the conclusions for particular subgroups are less robust due to the smaller sample size. Finally, we were unable to use facility data to examine the effect of programming on longer-run trends in contraceptive uptake due to issues with the consistency and reliability of the facility data we received.

Intervention Package

Intervention Arm 1: Postnatal Care (PNC)

This intervention package was implemented at Yendi, Gushegu and Bimbilla hospitals. Counseling materials were provided to every training attendee, with additional copies for relevant providers at each facility who were unable to attend the training day. Providers at the PNC session were given a counseling guide, method cards, and a ‘Method Information Booklet’.

The focus of this intervention was to increase the frequency and quality with which family planning counseling is included in one-to-one counseling sessions. The intervention package had three main aims:

Include family planning counseling as part of every 1:1 postnatal appointment.
Use MHI’s Counseling Guide as a framework for this discussion, with the Method Cards and Method Information Booklet used as key resources in this framework. The discussion should take around 20 minutes, depending on the number of questions from the client.
Offer a method directly, or a referral to the family planning unit, for women who express an interest in taking up a method of birth spacing at the end of the counseling discussion.

A novel counseling guide was designed for the intervention. This was targeted specifically at the postnatal period and designed to integrate into the existing structure of appointments at Ghana Health Service facilities. The counseling guide provided an overall structure for the counseling session and acted as a job aid for remembering the training while delivering counseling. The counseling guide was supplemented with method cards that aimed to make appointments interactive and client-centered, two markers of improved quality of care identified in prior literature (41). These acted as a visual tool for clients to indicate their key preferences and which kinds of methods they were most interested in.

All attendees also received a ‘Method Information Booklet’ with an extensive explanation of family planning methods. This acted as a reference tool for providers to look up more complex or detailed information about different methods, including side effect profiles, effectiveness in preventing pregnancy, risk factors to screen for before method provision, and the mechanism for taking the method. Finally, the referral card acted as a practical reminder to clients who expressed interest in a method that was not available for provision during the routine appointment, either due to stock shortages or the need for insertion by a trained specialist.

Intervention Arm 2: Child Welfare Clinics (CWC)

This intervention package was implemented at Zabzugu, Karaga, and Kpandai hospitals. Counseling materials were provided to every training attendee, with additional copies for relevant providers at each facility who were unable to attend the training day.

At the CWC session, providers were given a group talk flipchart, 1:1 counseling card, and referral cards for directing people to the Family Planning Unit. Similarly, all materials were designed specifically for this intervention to ensure their relevance to postpartum counseling and their ability to integrate into existing systems of care at public health facilities in Ghana.

The child welfare clinic intervention was designed to consist of three key components. These were a group talk, one-to-one messaging, and a referral system. The intended process for delivering these is described below:

Providers include family planning messaging in every group talk given while women wait for their child to be called up for weighing and immunization, using MHI’s streamlined ‘Birth Spacing Group Talk’ flipchart as a guide.
Providers offering immunizations have a very short one-to-one family planning discussion with each woman as her child is vaccinated using the ‘Birth Spacing Card’.
Providers offer women the option of a streamlined referral for family planning at the end of this one-to-one engagement, using a system of referral cards to make it simple for women to receive a method that day should they choose to do so.

The ‘Birth Spacing Group Talk’ flipchart was designed so that the group talk would take no more than 10 minutes and be feasible to implement even at busy CWC sessions. The flipchart leads providers and clients through a discussion of the range of methods available to clients, how to safely take methods and manage their side effects, and the benefits of receiving family planning counseling while at the facility.

The ‘Birth Spacing Card’ was designed for use by providers directly administering immunizations to children after they have been weighed and their health records have been recorded. Providers were asked to counsel every woman whose child they immunized. The card was designed so that the engagement would last 1-2 minutes at a maximum to ensure feasible implementation. This model was chosen to mirror the approach of (21).

A referral card system was paired with the ‘Birth Spacing Card’. All women who expressed interest in discussing family planning further received a referral card to take to the Family Planning Unit. These were designed to be discreet to pass between provider and client to maintain confidentiality. Referral cards acted as a physical reminder to the client to follow up on their family planning interest. They also indicated to providers at the Family Planning Unit of the hospital that the client had already received some family planning guidance and could receive a streamlined version of standard counseling.

Finally, all providers received a ‘Method Information Booklet’ as a reference tool to answer more complex questions about contraceptive method use and provision.

Data Collection

The surveying team obtained written, informed consent to participate from all clients and providers who participated in the study. All data was collected using the SurveyCTO system unless otherwise stated. All surveys and tests took place in private areas of the facilities where clients and providers could not be overheard, or via mobile phone.

Surveying Approach

Clients

The implementation team used the SurveyCTO platform to deliver structured questionnaires to clients at each of the target facilities. Clients were surveyed after they had received care, but before they left that unit of the hospital. At the end of these questionnaires, clients were asked if they would be willing to share their mobile phone number and answer a short follow-up call 14 days later. Follow-up phone surveying was included based on feedback received from local stakeholders during the intervention design. Stakeholders shared that women often take time to consult with their husbands or other family members before beginning a family planning method, and that delayed surveying would capture such uptake.

Questions at baseline and endline day-of surveying focused on assessing the following: demographic characteristics; current contraceptive use and attitudes; quality and structure of family planning counseling as part of routine care; and plans and preferences for contraceptive uptake. Surveys delivered via phone at the 14-day phone follow-up were substantially briefer. These focused on current and intended contraceptive use alongside reasons for non-use.

Due to issues with client flow at some of the intervention facilities, some baseline surveying was delivered over the phone rather than in person. These phone surveys used the same questionnaire structure and approach as the in-person surveying.

Data analysis

We used Pearson’s chi-squared test to evaluate our primary hypothesis: postpartum women in the post-intervention group will have a higher level of current and intended modern contraceptive use than postpartum women in the pre-intervention group across both intervention packages. When samples were small, Fisher’s exact test was used.

Pearson’s chi-squared test was also used to evaluate the knowledge differences between pre- and post-intervention groups across the two arms.

Analyses were completed in R (version 4.3.2).

Ethics approval and consent to participate

The study’s authors received ethical approval from the Navrongo Health Research Centre Institutional Review Board to undertake this research. The project team also engaged the Regional Health Directorate of the Ghana Health Service in the design and delivery of the intervention. The study was conducted in accordance with the ethical standards set forth in the Belmont Report. Participants were informed of their voluntary participation in the study and were free to withhold answers at any time. They were also free to withdraw at any time without any consequences. Their consent was obtained before the commencement of the interviews and any data collection.

Table 3 presents the personal and socio-demographic characteristics of women in the two groups (pre-intervention and post-intervention) across the two arms. The pre- and post-intervention groups were similar within the two arms: most respondents were Muslim, currently married, and had an average age of 27-28. Education levels were similar between pre- and post-intervention groups, with median educational outcomes of elementary to junior secondary. Most respondents had previously used modern contraception and were currently abstinent. Breastfeeding was almost universal across the two arms, with a substantial fraction breastfeeding exclusively (86% and 92.5% pre- and post-intervention at PNC and 42.8% and 50.8% pre- and post-intervention at CWC). The two metrics with significant differences between the pre- and post-intervention groups were the number of days post-birth and sexual activity for the CWC arm: in the post-intervention group, the average duration postpartum was 16.8% shorter and 14.4% fewer respondents were sexually active. Generally speaking, the pre- and post-intervention groups within each arm were similar, allowing for robust comparison between the two.

Table 3. Background Characteristics of Study Participants by Arm

	PNC		CWC
	Baseline (n= 100)	Endline (n=106)	Baseline (n= 105)	Endline (n=120)
Age (mean)	27.6	27.5	27.2	27.8
Marital status
Married	83.0%	84.0%	88.6%	87.5%
Unmarried	17.0%	16.0%	11.4%	12.5%
Religion
Muslim	86.0%	89.6%	69.5%	69.2%
Christian	13.0%	10.4%	28.6%	30.8%
Traditional/Spiritual	0.0%	0.0%	1.0%	0.0%
Other	1.0%	0.0%	1.0%	0.0%
Level of education
None	31.0%	33.0%	32.4%	35.0%
Elementary	10.0%	8.5%	17.1%	19.2%
Junior secondary	23.0%	17.9%	21.9%	19.2%
High school	26.0%	32.1%	21.9%	17.5%
University	10.0%	8.5%	6.7%	9.2%
Number of days post-birth (mean)	21.1	17.2	180.2	149.9
Abstinent	96.00%	98.11%	67.6%	81.7%
Breastfeeding	100.0%	100.0%	100.0%	99.2%
Exclusively breastfeeding	86.0%	92.5%	42.8%	50.8%
Past use of modern contraception	68.0%	67.0%	67.6%	68.3%

Table 4 presents data on implementation across the two arms. In the PNC arm, there was a moderate increase in the frequency of 1:1 family planning counseling from pre- to post-intervention. In the CWC arm, there was a significant increase in the incidence of the family planning group talk and 1:1 family planning counseling from baseline to endline. Substantial variation between facilities was observed. In the PNC arm, 1:1 counseling was significantly more common at Yendi than the other two hospitals, while in the CWC arm, 1:1 family planning counseling was moderately less common at Zabzugu than the other two hospitals.

In the PNC arm, the overall increase in 1:1 family planning guidance was largely driven by substantial increases at Yendi Hospital, where 1:1 counseling was received by 81% of clients at endline. Lower implementation at the other facilities was associated with low engagement from providers and facility leadership throughout the project and a change in Program Champion in the case of Bimbilla.

Implementation data is only suggestive, given that data was collected from clients at only a few days for each facility. There is limited evidence to suggest surveyor presence may have affected the reliability of results by increasing provider compliance, particularly in the case of 1:1 messaging at immunization. While formal surveying elicited nearly universally positive feedback from providers and clients, providers expressed frustration with the 1:1 messaging at immunization in informal conversations. Concerns centered on time pressures for both clients and providers that made the 1:1 engagements frustrating to implement.

Table 4. Implementation by Arm

	PNC				CWC
		Baseline (n= 100)	Endline (n=106)	Difference (percentage points)		Baseline (n= 105)	Endline (n=120)	Difference (percentage points)
1:1 Family Planning Counseling	Bimbilla	2.27%	28.57%	26.30%	Karaga	20.00%	62.86%	42.86%
	Gushegu	28.57%	46.67%	18.10%	Kpandai	2.86%	68.57%	65.71%
	Yendi	31.43%	80.95%	49.52%	Zabzugu	2.86%	42.00%	39.14%
	Overall	18.0%	39.6%	21.60%	Overall	28.10%	55.80%	27.70%
Group Talk on Family Planning	N/A				Karaga	37.14%	68.57%	31.43%
					Kpandai	2.86%	77.14%	74.28%
					Zabzugu	5.71%	74.00%	68.29%
					Overall	15.20%	72.50%	57.30%

Tables 5 and 6 present data on self-reported change in actual and intended contraceptive use across the two arms between pre- and post-intervention. Table 5 includes data collected on the day of surveying (or, in several cases, on the day immediately following), while Table 6 includes data collected at the 2-week phone follow-up. While phone follow-up was attempted for all respondents, attrition was high due to phone non-use and unavailability.

No statistically significant effects on actual or intended contraceptive use in either arm were observed at immediate surveying. In the PNC arm, contraceptive use increased from 2% to 5% and intended use decreased from 67.4% to 67.3% from baseline to endline; in the CWC arm, contraceptive use decreased from 15.2% to 14.2% and intended use increased from 65.9% to 74.8% from baseline to endline.

Data from 2-week phone surveying suggests a statistically significant 22 percentage point increase in contraceptive use (p = 0.000447) and a 25.3 percentage point increase in intended use (p = .0187) in the PNC arm from baseline to endline and no statistically significant effects in the CWC arm. In the CWC arm, contraceptive use decreased from 15.4% to 13.6% and intended use increased from 59.1% to 70.6%.

Table 5. Difference in Actual and Intended Contraceptive Use by Arm (Immediate surveying)

	PNC				CWC
	Baseline	Endline	Difference (percentage points)	p value	Baseline	Endline	Difference (percentage points)	p value
	n=100	n=106			n=105	n=120
Use of modern contraception	2.00%	5.00%	3.00%	0.446^☨	15.20%	14.20%	-1.00%	0.821
	n = 98	n = 101			n = 88	n = 103
Intended use of modern contraception	67.40%	67.30%	-0.10%	0.998	65.90%	74.80%	8.90%	0.181

Note: p-values calculated using Pearson's chi-squared unless indicated otherwise

☨ = Fisher's exact test, used due to small sample size

Sample sizes for current and intended use differ due to the fact that current users of modern contraception were not asked about intended use

Table 6. Difference in Actual and Intended Contraceptive Use by Arm (2 week phone follow-up)

	PNC				CWC
	Baseline	Endline	Difference (percentage points)	p value	Baseline	Endline	Difference (percentage points)	p value
	(n= 50)	(n=41)			(n= 52)	(n=59)
Use of modern contraception	0%	22.00%	22.00%	0.000447^☨**	15.40%	13.60%	-1.80%	0.794^☨
	(n=50)	(n=32)			(n=44)	(n=51)
Intended use of modern contraception	56.00%	81.30%	25.30%	0.0187*	59.10%	70.60%	11.50%	0.241

Note: p-values calculated using Pearson's chi-squared unless indicated otherwise

☨ Fisher's exact test, used due to small sample size

* p < .05

** p < .01

Sample sizes for current and intended use differ due to the fact that current users of modern contraception were not asked about intended use.

There was significant attrition in both arms of the phone surveying, with only 46.9% of respondents reached; additionally, levels of attrition were higher at endline than baseline. This substantially reduces the sample size and therefore the robustness of these results. However, the demographics of both groups are generally similar; see Table 7.

Table 7. Background Characteristics for Phone Respondents and Non-Respondents

	Phone Respondents (n=196)	Phone Non-Respondents (n=216)
Religion
Muslim	80.61%	74.07%
Christian	19.39%	24.54%
Traditional/Spiritual	0.00%	0.46%
Other	0.00%	0.93%
Level of education
None	31.12%	34.72%
Elementary	11.73%	15.28%
Junior secondary	20.41%	19.91%
High school	27.55%	21.76%
University	9.18%	8.33%
Sexually active	11.73%	16.67%
Past use of modern contraception	55.61%	57.41%
Current use of modern contraception*	8.67%	9.72%

* according to in-person surveying

Due to inconsistencies in one step of data collection, data on background characteristics is unavailable for 6 phone respondents and 13 non-respondents and thus omitted from the table above.

Table 8 presents data on knowledge differences among respondents. The data indicates a moderate increase in knowledge regarding the duration of LAM in both arms, suggesting that there was some knowledge transmission from providers to clients associated with the intervention. In the PNC arm, there was a moderate decrease in correct answers regarding side effects, raising concerns about misinformation provided in individual counseling sessions; however, there was only minimal change on this metric in the CWC arm.

The data also indicates high levels of baseline knowledge regarding the importance of healthy birth intervals in both arms, suggesting that education on this topic may be less valuable for the respondents targeted in this study. Additionally, there was a moderate increase in knowledge concerning return to fertility in the CWC arm but only minimal change in the PNC arm, suggesting that this topic may have been addressed in group but not individual sessions.

Table 8. Knowledge Differences by Arm

	PNC			CWC
	Baseline (n= 100)	Endline (n=106)	Difference (percentage points)	Baseline (n= 105)	Endline (n=120)	Difference (percentage points)
Timing of Return to Fertility	13.0%	11.5%	-1.5%	9.5%	23.3%	13.8%**
Healthy Birth Intervals	95.0%	96.2%	1.2%	95.2%	97.5%	2.3%
Duration of LAM	68.0%	82.1%	14.1%*	65.7%	88.3%	22.6%**
Side Effects	25.0%	10.4%	-14.6%**	21.0%	24.2%	3.2%

Note: p-values calculated using Pearson's chi-squared unless indicated otherwise

* p < .05

** p < .01

Table 9 presents data on reasons for non-use, according to post-intervention phone surveying. Responses were similar between the two arms, with some variation: the most common reasons provided include breastfeeding, abstinence, and attitude of husband/partner. 21.6% of respondents in the CWC arm selected “other,” among whom most disclosed that they were waiting for their period to return. A substantial minority chose not to disclose a reason. Less commonly cited reasons included concerns about side effects and not wanting to use contraception. No respondents stated that they were unable to access contraception or willing to become pregnant.

Table 9. Reasons for Non-Use by Arm (2 week phone follow-up, endline)

	PNC	CWC
	Endline (n= 32)	Endline (n= 51)
Breastfeeding	37.5%	23.5%
Abstinence	15.6%	25.5%
Husband/partner attitude	25%	25.5%
Do not want to answer	28.1%	23.5%
Other	0%	21.5%
Concerns about side effects	9.4%	7.8%
Do not want to use contraception	6.3%	7.8%
Unable to access	0%	0%
Willing to become pregnant	0%	0%

Note that respondents could select multiple responses

Immediate surveying indicated no statistically significant changes to actual or intended contraceptive use in either arm associated with the intervention. Results from two-week phone surveying, however, suggest a 22% increase in contraceptive use (p = 0.000447) and a 25.3% increase in intended use (p = 0.0187) post-intervention in the PNC arm, and a non-significant 1.8% decrease in contraceptive use (p = 0.794) and non-significant 11.5% increase in intended use (p = 0.24) in the CWC arm. As many women consult with their husbands before starting a method, we expected higher rates of contraceptive use at follow-up surveys; however, it is surprising that no changes to intended use were present at immediate surveying. While there was a high rate of attrition between the in-person and phone follow-up, the background characteristics of respondents and non-respondents were similar, which suggests that differences in responses by phone likely result from the intervention rather than differences in the groups sampled. However, given that the sample size for the phone survey was substantially smaller, its results should be taken as suggestive rather than decisive. Taken together, the results suggest that the CWC arm had no effects on contraceptive use and a small, non-significant increase in intended use, while the PNC arm likely led to a moderate increase in actual and intended contraceptive use.

While the relatively small sample size and lack of randomization limit the generalizability of the findings, the study contributes to the evidence base for postpartum family planning programming, suggesting that lighter-touch family planning programming in the postpartum period may be more likely to produce only limited changes to contraceptive uptake in some contexts. The lack of change in uptake in the CWC arm aligns with previous findings by Vance et al. in Ghana and Zambia, but contrasts with more successful results in Rwanda (21,39). The mixed findings in the PNC arm stand in contrast with several more successful studies; however, a significant proportion of studies evaluating facility-based programming involved a heavier-touch approach or emphasized LARCs such as intrauterine devices (IUDs) (18–20,42). The lighter touch approach we took in the PNC arm, involving adding family planning into only postnatal appointments in the first 6 weeks postpartum, may account for the less successful results.

Other aspects of the results cast doubt on the usefulness of the uptake associated with the intervention, regardless of its magnitude. High rates of breastfeeding and prolonged postpartum abstinence reported by respondents in both arms suggest that the reported changes in contraceptive uptake may have limited short-term effects in reducing unintended pregnancies. These results, considered alongside previous studies finding limited to no effects on pregnancy rates from facility-based postpartum programming in areas with high levels of postpartum insusceptibility, cast doubt on the usefulness and efficacy of family planning programming focused on the postpartum period in such regions (43–45).

High levels of abstinence reported in this study – 96% at baseline and 98.1% at endline in the PNC arm and 67.6% at baseline and 81.7% at endline in the CWC arm – suggest a high level of existing protection against pregnancy, which reduces interest in contraceptive uptake as well as its impact. Near-universal levels of breastfeeding reported here also reduce the usefulness of contraceptive uptake. DHS data substantiates that postpartum abstinence and breastfeeding are both long-duration in the Northern region, with median durations of 4.7 and 20.5 months, respectively; note, however, that levels of postpartum abstinence in the CWC arm were higher than those reflected in DHS data (32).

Breastfeeding – particularly exclusive breastfeeding – has been shown to delay the return of ovulation, a biological necessity for pregnancy (46). While the WHO defines LAM in strict, time-limited terms, numerous studies indicate that breastfeeding, amenorrheic women are at significantly reduced risk of pregnancy at one year postpartum and beyond than their non-breastfeeding, menstruating peers (47–50). Due to the combined effects of prolonged postpartum abstinence and high rates of breastfeeding, most African countries report long durations of postpartum insusceptibility, the inability to become pregnant due to amenorrhea. DHS data reflecting 44 African countries indicates a mean of 14.2 months of postpartum insusceptibility across the continent (51).

Long-lasting postpartum insusceptibility significantly reduces the impact of family planning uptake in the first year postpartum. New users of contraception who are already protected by abstinence and/or breastfeeding will not incur additional benefits from modern forms of contraception; indeed, they may merely incur the burden of side effects (52,53). Increases in family planning uptake are primarily valuable insofar as they allow women to avert mistimed or unintended pregnancies. If most users of postpartum programming are already protected, few mistimed or unintended pregnancies will be averted. While some pregnancies are likely still averted - due to shifts in attitude that lead to subsequent uptake or immediate contraceptive uptake that lasts beyond the period of postpartum insusceptibility – high rates of contraceptive discontinuation diminish these effects (54,55).

Indeed, multiple recent studies suggest that facility-based postpartum programming may have limited to no effect on rates of unintended or short-spaced pregnancies in regions with prolonged postpartum insusceptibility. Of the three studies we identified that measure the effects of facility-based postpartum family planning programming on pregnancy rates, studies in Tanzania and Burkina Faso found no effect (43,44), while one in Nepal found only a 0.7% absolute decrease in short-spaced pregnancies (45). More research investigating this area is needed, but these results tentatively suggest that prolonged postpartum insusceptibility may significantly reduce the effects of postpartum programming on pregnancy rates. High rates of prolonged abstinence and amenorrhea among postpartum women – as found in our study – may substantially reduce the level of additional protection against pregnancy conferred by modern contraceptive methods. While community-based programs in Bangladesh and Malawi have shown more promising results regarding short-spaced pregnancies, these programs were significantly heavier-touch and not geographically representative (56,57). Further research is needed, but one possibility is that such programs more successfully reach women at high risk of short-spaced pregnancies than their lighter-touch counterparts at facilities.

Abstinence and breastfeeding were key drivers of non-use among those surveyed, cited by more than half of respondents as a reason for non-use of contraceptives. Respondents demonstrated strong knowledge of the importance of healthy birth spacing. This suggests that a lack of knowledge regarding the benefits of birth spacing is not a key barrier to increased postpartum contraceptive uptake. This aligns with the literature more broadly. Gahungu et al., a systematic review of the drivers of unmet need in the postpartum period, found that amenorrhea, abstinence, and low perceived pregnancy risk were key drivers of non-use, alongside fear of side effects and husband opposition (13). Dulli et al. – which evaluated immunization integration in Rwanda – similarly identified amenorrhea and breastfeeding as among the most significant factors cited among non-users (21). Lowered interest in contraceptives due to abstinence and breastfeeding may contribute to the lower-than-expected implementation levels observed in this study: if providers do not feel that clients will be interested in or benefit from a service, it is understandable that they may decide not to provide it.

Postpartum family planning is widely recommended, having been identified as a “proven high-impact practice” and endorsed by major institutions in the sexual and reproductive health space (58,59). These recommendations rest on an impressive number of studies indicating short-term increases in contraceptive use due to postpartum programming (17,18,21). However, these recommendations do not take into account recent studies showing minimal to no effects on rates of pregnancy from this programming. High rates of abstinence and breastfeeding suggest that the increases in contraceptive use found in these studies may have a significantly reduced effect on endline outcomes in comparison to family planning programming that targets other touchpoints, and hence significantly reduced value.

Given the limited resources available for these interventions, our results suggest that postpartum family planning programming may be significantly less effective than currently considered in contexts with long-duration postpartum insusceptibility. The fact that many studies continue to find modest improvements in uptake during the postpartum period despite this reduced interest suggests that increased family planning messaging at a time when women have higher levels of interest and risk could be highly promising. Furthermore, investment in interventions that engage women and their broader communities outside of the first year postpartum appears promising.

The intervention packages increased the rate of counseling on family planning and knowledge of family planning by women, but only produced suggestive increases in contraceptive uptake rates in the PNC arm and no statistically significant effects in the CWC arm. Implementation was imperfect but sufficient to suggest that postpartum family planning counseling through lighter-touch models that emphasize broad method choice may be less effective in increasing contraceptive uptake than other interventions. High rates of abstinence and breastfeeding indicate a minimal risk of unwanted pregnancy for many clients in the first year after birth. This level of postpartum insusceptibility appears prevalent across much of Sub-Saharan Africa and may be a driver behind recent research suggesting that facility-based postpartum family planning programming produces minimal changes in pregnancy rates in some regions. This conclusion warrants further investigation given its implication that facility-based postpartum family planning work may be significantly less valuable than widely considered at this time in regions with prolonged postpartum insusceptibility.

CWC

child welfare clinic

DHS

Demographic and Health Service

IUD

intrauterine device

LARC

long-acting reversible contraception

PNC

postnatal care

Ethics approval and consent to participate

The study’s authors received ethical approval from the Navrongo Health Research Centre Institutional Review Board to undertake this research. The project team also engaged the Regional Health Directorate of the Ghana Health Service in the design and delivery of the intervention. Participants were informed of their voluntary participation in the study and were free to withhold answers at any time. They were also free to withdraw at any time without any consequences. Their consent was obtained before the commencement of the interviews and any data collection.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated by the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was funded by a collection of anonymous individual donors. Funders had no role in the design or implementation of this study.

Author’s contributions

SE and BW designed the study protocol and instruments. CF contributed to the study protocol. BW, SE, ASA, ARI, AMA, and SMG coordinated the data collection and field implementation. BW and SE wrote the first draft of the manuscript. All authors contributed toward data analysis, drafting, and revision and agreed to be accountable for all aspects of the work.

Acknowledgements

We are grateful for the hard work of Enoch Weikem Weyori and the rest of the Norsaac team in delivering the surveying work. We thank Sulemana Hikimatu Tibangtaba for her skilful facilitation of the training sessions. We also thank the management staff of the Ghana Health Service Regional Health Directorate, as well as the staff for each of the intervention facilities, for their assistance in implementing this research.

Additionally, we are grateful to Jemima Jones and Wan Yun Tan for their assistance in analyzing the results of this study, as well as Marshall Thomas for his feedback on the data analysis and manuscript. Finally, thank you to the healthcare providers and clients who participated in this study.

Author Information

Maternal Health Initiative – Sarah Eustis-Guthrie, Ben Williamson, Catherine Fist, and Sofía Martínez Gálvez

Norsaac – Alhassan Mohammed Awal, Anthony Suguru Abako, and Abdul Rahman Issah

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No competing interests reported.

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Evaluating two models of postpartum family planning counseling on contraceptive uptake: evidence from a repeated cross-sectional study in Ghana

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Abstract

Figures

Background

The Case for Family Planning Interventions

Intervention Rationale

Evidence for Intervention Models

Methods

Study Design and Sampling

Sampling

Timeline of Activities

Phase 1: Formative Research

Phase 2: Implementation of Intervention Packages

Phase 3: Evaluation

Timeline of Activity

Limitations

Intervention Package

Intervention Arm 1: Postnatal Care (PNC)

Intervention Arm 2: Child Welfare Clinics (CWC)

Data Collection

Surveying Approach

Data analysis

Ethics approval and consent to participate

Results

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Author’s contributions

Acknowledgements

Author Information

References

Additional Declarations

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