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International Health

August 3, 2018

Integrating postpartum family planning into an existing community-based health program significantly reduces risk of preterm birth and improves birth spacing

The study, conducted in a rural area of Bangladesh, provides some of the strongest evidence yet that integrating family planning services with maternal and newborn health programs is feasible and effective in low-resources settings

Women who give birth more than once within 24 months are at substantially higher risk of facing a wide range of serious health issues. They are also more likely to have a preterm birth, which puts the child at risk. The risks are especially high for both mother and child in low-resource areas where adequate health care is often not available.

Recent studies show that the vast majority of women in low-and middle-income countries want to delay their next pregnancy for at least 2 years. Unmet need for contraception remains high, stagnant at levels from a decade ago. As a result, around half of non-first pregnancies in these countries occur at intervals that are too short. To address these challenges, governments and public health organizations are more and more looking to integrating family planning services into existing community-based maternal, newborn health (MNH) care programs. Despite this, there is little evidence about the feasibility and effectiveness of such integration. It is widely recognized that well-designed evaluation research is still urgently needed.

A community health worker visiting a mother and her newborn in Bangladesh
Community health worker mother and child

A new study led by researchers at the Johns Hopkins Bloomberg School of Public Health found that adding postpartum family planning services to existing maternal, antenatal and newborn community health programs significantly decreased the risk of a subsequent birth within two years and reduced the risk of preterm birth. The study also showed community health care workers were able to add family planning to their package of care without undermining the effectiveness of the services they already offered.

The study was published in the July issue of the Journal of Global Health. It was conducted in Sylhet Bangladesh, a rural area where the majority of births occur at home.

The quasi-experimental study was broken into 2 arms: control and intervention. In the entire study site, community health workers (CHWs) had been providing a platform of MNH services. Both the control and intervention arms continued receiving these. Women in the intervention arm also received a family planning package of care. CHWs provided family planning information, promoted exclusive breast-feeding for 6 months, distributed short-term contraception, made referrals for long-term contraception, and made two additional home visits in the 6-month postpartum period to provide contraception and check on satisfaction with the method being used. 

The study enrolled a total of 4,504 pregnant women. The analysis showed the risk of short birth interval was 19% lower in the intervention arm. It also found the risk of preterm births was 21% lower in the intervention arm.

A concern related to family planning integration activities is that while adding family planning may improve family planning outcomes, the addition of new tasks and activities may undermine MNH service delivery performance and affect outcomes. Across all measurements, researchers found no significant differences between the two arms of the study.

The findings lead researchers to conclude that this integration program, which was designed by the Healthy Fertility Study, is scalable because it reflects WHO recommendations for integrating family planning counseling, services and referrals into multiple MNCH service contact points in the health system.

“MNH programs should consider systematically integrating postpartum family planning,” says Abdullah Baqui, MBBS, DrPH ’90, MPH ’85 a professor of International Health at the Bloomberg School and lead author of the study. “These programs would benefit from early & sustained family planning use, including exclusive breastfeeding, reducing the risk of short birth intervals and preterm birth.”

Impact of integrating a postpartum family planning program into a community-based maternal and newborn health program on birth spacing and preterm birth in rural Bangladesh was written by Abdullah H Baqui, Salahuddin Ahmed, Nazma Begum, Rasheda Khanam, Diwakar Mohan, Meagan Harrison, Ahmed al Kabir, Catharine McKaig, Neal Brandes, Maureen Norton, Saifuddin Ahmed, and for the Projahnmo Study Group in Bangladesh

This study was funded by US Agency for International Development under the terms of Award No GHS-A-00-08-00002-00 (Maternal and Child Health Integrated Program (MCHIP), No. GPO-AA-05-00025-00 (Associate Cooperative Agreement with the Access Program), No.GHS-A-00-04-00002-00 (Cooperative Agreement with the Access Program), and No. GHS-A-00-03-00019-00 (Global Research Activity Cooperative Agreement with the Johns Hopkins Bloomberg School of Public Health).