REVIEW
Open Access

Antenatal Care Interventions to Increase Contraceptive Use Following Birth in Low- and Middle-Income Countries: Systematic Review and Narrative Synthesis

Ona L. McCarthy, Nasser Fardousi, Vandana Tripathi, Renae Stafford, Karen Levin, Farhad Khan, Maxine Pepper and Oona M.R. Campbell
Global Health: Science and Practice October 2024, 12(5):e2400059; https://doi.org/10.9745/GHSP-D-24-00059

Figures & Tables

Figures

Tables

  • TABLE 1.

    Main Characteristics of the Included Studies, by Intervention Type

    StudyCountry and SettingParticipant Characteristic at EnrollmentIntervention ComponentsTiming and Dose
    Counseling interventions
    One-to-one
    Ndegwa, 201432Kenya, HF: hospitalPregnant women: 36 weeks gestation or more, attending ANC clinic at study siteANC+: In-person intensive counseling with trained counselor was an extra effort to enhance informed decision-making.Not specified.
    Adanikin, 201339Nigeria, HF: tertiary hospital (referral center), obstetrics/gynecology department, obstetric unitsPregnant women: 28–37 weeks gestation, booked at study hospitalANC only: In-person counseling with trained senior registrar covered information on genitalia, ovulation, fertility following birth, and modern and traditional FP methods.3 sessions, third trimester.
    Camara, 201843Guinea, lower-level HF: 5 health centersPregnant women: 6 months gestation or more, attending ANC visits at study health centersANC only: In-person counseling with trained ANC provider focused on PPFP methods (modern and traditional).Once (15–20 minutes); during ANC visits.
    Ayiasi, 201546Uganda, lower-level HF: 16 health centersPregnant women: 28 weeks gestation or less attending health centers for ANCANC only: During home visits and phone consultations, CHWs discussed risk of pregnancy soon after delivery, available options for delaying next pregnancy, and importance of regular and EBF to delay pregnancy. Women also offered phone consultations with health workers for advice.Dose not specified; prenatal period.
    One-to-one plus pamphlet
    Keogh, 201540Tanzania, lower-level HF: 14 antenatal clinicsPregnant women: 3 months gestation or moreANC only: In-person counseling with HIV post-test counselors covered benefits of spacing and limiting births; postpartum fertility and LAM; suitability of LAM based on breastfeeding plans; availability and suitability of FP methods for clients; role of condoms; referral to FP clinic and pamphlet, which covered PPFP, FP methods, and their suitability for couples living with HIV.10 minutes of contraceptive advice after HIV post-test counseling session.
    One-to-one with spouse involvement
    Abdulkadir, 202038Nigeria, HF: tertiary hospital, obstetrics/gynecology department, antenatal clinicPregnant women: 15-45 years, 32-38 weeks gestation, attending ANC at study hospitalANC only: In-person antenatal counseling with principal author using a validated tool that includes information about the FP methods.2 sessions; first 1 during third trimester and second 14 weeks later.
    Mixed couple and group session
    Daniele, 201836Burkina Faso, lower-level HF: 5 (large) PHCsPregnant women and their male partners aged 15–45 years, 20–36 weeks gestation, attending routine check-ups at study health centersANC+: Private counseling sessions with auxiliary midwives or midwives covered importance of ANC and PNC, birth preparedness and signs of labor, danger signs for mother and newborn child, EBF, healthy timing and spacing of pregnancies, and PPFP. Group sessions focused on role of male partners.3 sessions (1 hour each): group discussion between 20 weeks gestation and term, first counseling session between 20 weeks gestation and term, second session before postpartum discharge.
    Digital interventions: SMS
    Unger, 201831Kenya, lower-level HF: government health center (MCH clinic)Pregnant women aged 14 years or older, less than 36 weeks gestation, attending ANC at study centerANC only: Participants classified into tracks (routine, adolescents 14–19 years, first-time mothers, women with previous cesarean delivery, and those with multiple gestations) with tailored messaging. Personalized approach that provided gestational age-appropriate educational and counseling messaging. SMS topics on ANC, FP, infant health, etc.Weekly SMS: from enrollment to 12 weeks postpartum.
    Harrington, 201933Kenya, HF: 2 public hospitalsPregnant women and their male partners aged 14 years or older, 28 weeks gestation or more, attending ANC at study hospitalsANC+: SMS covered general perinatal topics, and FP: available methods and their effectiveness, postpartum pregnancy risk, contraceptive safety during lactation, anticipatory guidance about side effects, community misperceptions, and dual protection.Once a week, from enrollment (ANC visits) to 6 months postpartum.
    Educational interventions
    Campaign
    Sebastian, 201254India, community: 1 district, 4 blocks, 48 villagesPregnant women aged 15–24 years, 4–7 months gestation, max. 1 previous childANC only: Community workers provided counseling on healthy timing and spacing of pregnancy; postpartum care, the LAM and PPFP; educational campaign for husbands and males in community on maternity care.During pregnancy; dose not specified.
    Group sessions
    Maldonado, 202035Kenya, community: 4 subcounties, 77 community health unitsPregnant women: 32 weeks gestation or less, women attending ANC at a health facilityANC+: In-person community health volunteer group educational sessions cover health and social topics relevant to antenatal, postpartum, and early childhood experiences (with an optional financial savings program).2 60–90 minute sessions per month.
    Bang, 201841Ethiopia, community: 1 district, 2 villagesWomen aged 15–49 years, pregnancy status not specified

    ANC+: In-person village-level sessions covered FP, safe delivery, and postpartum care.

    Small group classes covered FP, ANC, institutional birth, postnatal management, and neonatal/child care.

    One education session was given to male community leaders to encourage paternal participation in FP.

    Mass media was used to improve women’s awareness of maternal health.

    On-the-job training sessions for providers to improve their capacity in practice and provide quality of care to women. Education and mobilization of Health Development Army members to help women in their villages improve awareness of maternal health.

    Interventions implemented over 2.5-year study period.

    2 village-level education sessions (reaching 196 women); 39 small group classes with 3 sessions each (reaching 2,576 women).

    Lori, 201842Ghana, HF: district hospitalPregnant women aged 18 years or older, 14 weeks gestation or lessANC only: In-person educational content and group peer support. One ANC visit dedicated to FP and EBF as a LAM.Women encouraged to attend 7 ANC visits.
    Sarnquist, 201448Zimbabwe, lower-level HF: 4 public polyclinicsPregnant women: HIV-positive, aged 18–40 years, 26-38 weeks gestation, attending ANC at study clinicsANC only: In-person trainers offered sessions focused on sexual negotiation skills and empowerment, information about HIV, prevention of mother-to-child HIV transmission, FP, and communication skills related to sex and FP. Various learning techniques were used, including discussions, behavior modeling, songs/ dramatizations, and role-playing.3 90-minute group sessions; most sessions happened in antenatal period; however, 21 32% of women had at least 1 session after delivery due to late study entry or early delivery.
    Financial interventions
    Client vouchers
    McConnell, 201834Kenya, lower-level HF: 2 private maternity clinicsPregnant women aged 18-40 years, 7 months gestation or more, attending ANC at study clinicsANC+: Vouchers given in person for free modern methods or counseling on LAM valid for 1 year and a time-limited voucher that expired 8 weeks after the estimated date of delivery. Value of voucher from US$0.92– US$6.45 depending on method; SMS reminders to use vouchers.Vouchers given during ANC (7+ month gestation); SMS given at 5 weeks postpartum.
    Pay-for-performance
    Engineer, 201652Afghanistan, lower-level HF: 442 facilities offering basic package of health services

    Postpartum women: ever married, aged 12–49 years, up to 2 years postpartum

    Children: less than 5 years

    		ANC+: Facilities were given quarterly bonus payments based on MCH services provided: first ANC visits 1–4, skilled birth attendance cases, PNC visits 1–2, pentavalent 3 vaccination, and TB case detection. Additional annual payments also made based on 2 measures of equity of service provision, a balanced scorecard that addresses quality of services, and contraceptive prevalence rates in HF catchment areas.Bonus amounts paid were about 6%–11% above their base salary in 2011 and increased to about 14%–28% in 2011, depending on the health worker’s cadre.
    Package of interventions
    Digital and one-to-one
    Jiusitthipraphai, 201555Thailand, HF: teaching hospitalPregnant women aged 15–19 years, gestational age not specified, women who delivered and received antenatal/postnatal care at study hospital

    ANC+: In-person motivational lessons covering impacts of adolescent pregnancy, preventing subsequent pregnancies by taking oral contraceptive, mechanism of oral contraceptives, correct taking methods, forgetting to take the contraceptive, and sources of assistance.

    Provision of a handbook to participants.

    Nurses were meant to praise and encourage participants.

    3 sessions: antenatal, immediate postpartum, up to 6 weeks postpartum.

    Weekly phone calls (5–10 minutes) for 4 weeks in postpartum period.

    Multifaceted

    Guo, 202223

    Huber-Krum, 202024

    Pradhan, 201925

    Puri, 202126

    		Nepal, HF: 6 tertiary hospitalsPostpartum women: women delivering in study hospitals (recruited after delivery and before discharge)

    ANC+: FIGO’s PPIUD intervention: Training of providers (to improve counseling), information leaflet provision, establishing an information wall chart and video broadcast, training and supplies for PPIUD insertion/removal techniques, and complication management.

    Women received free in-person general counseling from community health volunteers on various FP methods and PPIUD-specific counseling on advantages and disadvantages, potential side effects, how to seek removal, and how long it protects from pregnancy. All counseling services, contraceptive use, and IUD removals were free.

    		Counseling occurred during routine ANC, at early labor, and after delivery but before discharge from hospital; provision of PPIUD in immediate postpartum and before discharge.
    Karra, 201927Sri Lanka, HF: 6 tertiary hospitalsPostpartum women: women delivering in study hospitals (recruited after delivery and before discharge)ANC only: FIGO’s PPIUD intervention: Training of providers (to improve counseling), information leaflet provision, establishing video broadcast, training and supplies for PPIUD insertion, monitoring and evaluating of counseling services.Counseling occurred during routine ANC or after admission for delivery; provision of PPIUD in the immediate postpartum and before discharge.
    Pearson, 202028Tanzania, HF: 6 tertiary hospitalsPostpartum women: 18 years or older, recruited after delivery and before dischargeANC+: FIGO’s PPIUD intervention: Training of providers (to improve counseling), information leaflet provision, establishing video broadcast, training and supplies for PPIUD insertion, regular monitoring, and support.Counseling occurred during routine ANC or after admission for delivery; provision of PPIUD in the immediate postpartum and before discharge.
    Tran, 201929Burkina Faso, lower-level HF: 8 PHCsPregnant women: third trimester, attended ANC at study centersANC+: 3 facility-oriented interventions (i.e., refresher training of service providers, regularly scheduled and strengthened supportive supervision of providers, enhanced availability of services 7 days a week), and 3 individual-based interventions (i.e., a PPFP counseling tool, appointment cards for women, and invitation letters for partners).Individual-based interventions delivered during third-trimester ANC visits and postnatal care follow-up visits.
    Tran, 202030DRC, lower-level HF: 8 PHCsPregnant women: third trimester, attended ANC at study centersANC+: 3 facility-oriented interventions (i.e., refresher training of service providers, regularly scheduled and strengthened supportive supervision of providers, enhanced availability of services 7 days a week), and 3 individual-based interventions (i.e., a PPFP counseling tool, appointment cards for women, and invitation letters for partners).Individual-based interventions delivered during third-trimester ANC visits and postnatal care follow-up visits.
    Jarvis, 201837DRC, HF, mixed levels: 2 hospitals, 2 maternity referral centersPregnant and postpartum women aged 18–49 years, gestational age not specified, exiting services at study hospitals (L&D, FP, ANC, PNC, child immunization)

    ANC+: In-person whole-site training for providers on quality inputs: clinical training and provision of equipment for PPIUD, training on WHO’s Medical Eligibility Criteria for Contraceptive Use, and introduction of a systematic screening and referral tool for FP (to be implemented by ANC, PNC, immunization, labor and delivery, and FP providers).

    Free contraceptives provided by labor and delivery and FP units.

    		7-day training
    Karra, 202244Malawi, community: 1 city, recruited through household visitsPregnant and postpartum women aged 18–35 years currently pregnant or up to 6m postpartum

    ANC+: FP information package and private individual counseling visits: risk assessment for clinical methods and detailed information on methods switching, side effects associated with each method, benefits of contraception, birth spacing, dual protection, and male partner involvement.

    Financial: free transportation (taxi) service to a designated high-quality FP clinic with low waiting times; Free FP services at designated clinic or financial reimbursement for any FP services received at other clinics; and reimbursement for treatment costs if woman experienced any contraindications or side effects related to use of FP.

    Free phone consultations to discuss side effects if needed.

    		1 counseling session within 1 month after administering baseline, 5 shorter follow-up sessions spaced over 2 years; sessions lasted up to 1 hour.
    Espey, 202145Rwanda, HF, mixed levels: 2 high-volume hospitals, 4 health centersPregnant and postpartum women (up to 6 weeks postpartum)ANC+: Group and individual counseling to expectant mothers (with possibility of partner involvement) on PPFP, integration of FP counseling in ANC, labor and delivery, and infant vaccination services. Provider training on PPIUD insertion/removal. Higher provider reimbursement for IUDs compared to implants. Engagement with Ministry of Health stakeholder.Antenatal period up to 6 weeks postpartum. Group sessions and individual counseling lasted 20 minutes each.
    Wu, 202051Nepal, community: 1 rural municipalityPostpartum women: married, aged 15–49 years, up to 1 year postpartumANC+: In-person home-based ANC and PNC counseling by CHW on clinical topics included recommendations and reasons for birth spacing, contraceptive efficacy, contraindications, timing for initiation of PPFP, and facilities where each method; training materials emphasized best practices for contraceptive counseling, such as shared decision-making, respect for patient autonomy, and anticipatory guidance on potential side effects, and home-based childcare and counseling.General contraceptive counseling occurred at the eighth month ANC home visit, and patient-centered contraceptive counseling was offered at PNC months 1, 5, and 10.
    Ahmed, 201553Bangladesh, community: 4 rural unionsPregnant women: gestational age not specified (recruitment must have happened <32 weeks)ANC+: CHWs discussed the importance of pregnancy spacing, effective LAM use, and LAM transition (+ flyers summarizing information). In addition, CHWs provided oral contraceptives, condoms, and injectables. Community-based monthly meetings to discuss importance of pregnancy spacing and PPFP, including LAM.Household visits every 2 months (antenatal and postnatal period; pregnancy-surveillance visits) and community-based meetings every month.
    Cooper, 201656Egypt, community: households, 6 governoratesPostpartum women: women with a child aged 24 months or younger

    ANC only: Home visits and community-based group discussion counseling covered benefits of FP, healthy timing and spacing of pregnancies, postpartum return to fecundity, and risk of pregnancy after childbirth, LAM, and gender roles.

    Mobile clinics offered free medical care, including FP.

    Cooperation with health directors and pharmacists to improve access to FP methods.

    		During pregnancy and up to 24 months postpartum
    Systems strengthening
    Buser, 202147Zambia, lower-level HF: 40 HFsPostpartum women aged 15 years or older, women who gave birth in one of the study facilities in the previous 13mANC+: Improving MWHs through infrastructure, equipment, and supplies to address the need for higher quality, safer MWHs; policies, management, and financial structures; and linkages to health systems with skilled midwives (incl. participation of women living in MWH in maternal and child education courses at HF)Around births (women in MWH could attend ANC and PNC)
    Maru, 201749Nepal, mixed HF and community: hospital and community (CHWs in 14 community clusters)Pregnant women aged 15–49 years, gestational age not specifiedUnclear: Evaluated improvements to existing public-private partnership program: strengthening CHW active surveillance, integrating digital health information, and increasing monitoring and supervision capabilities. CHWs continuously survey population for new pregnancies, assist in attaining laboratory and ultrasound testing to identify high-risk pregnancies, and follow those pregnancies through postpartum period. Patient data are collected in an open-source electronic health records platform, and key performance measures are tracked and incorporated into the financial contract.Not specified
    Training intervention
    Providers
    Dhital, 202150Nepal, Mixed, HF and community: 2 major referral hospitals and catchment area of 23 peripheral HFsFemale community health volunteers and postpartum womenANC only: Training for providers covered different PPFP methods and advantages and disadvantages of each and PPIUD in more detail as it was only long-acting reversible method available in immediate postpartum period in Nepal.Not specified

    • Abbreviations: ANC, antenatal care; ANC+, antenatal period and other periods; CHW, community health worker; DRC, Democratic Republic of the Congo; EBF, exclusive breastfeeding; FIGO, Federation of International Gynaecology and Obstetrics; FP, family planning; HF, health facility; IUD, intrauterine device; LAM, lactational amenorrhea method; MCH, maternal and child health; MWH, maternity waiting home; PHC, primary health center; PNC, postnatal care; PPFP, postpartum family planning; PPIUD, postpartum intrauterine device; SMS, short messages service; WHO, World Health Organization.

  • TABLE 2.

    Summary of Main Effect Sizes, by Outcome Typea

    StudyPostpartum Contraceptive Use Within 1 Year of BirthUse of Specific Methods of ContraceptionOther Outcomes
    Counseling interventions
    Ndegwa, 201432Post-placental IUD insertion: 63.3% intensive vs. 64.3% routine P=.23
    Adanikin, 2013396 months: intervention group reported higher modern contraceptive use (57.4% vs. 35.4%; P=.002) and less use of traditional methods (19.8% vs. 32.3%; P=.044)

    Precise method used postpartum (P=.061):Condom: 30.7% vs. 18.2%IUD: 12.9% vs. 11.1%POP/COC: 6.9% vs. 4.0%Injectables: 5.0% vs. 2.0%Implants: 0 vs. 0Sterilization: 2.0% vs. 0LAM: 13.9% vs. 21.2%Calendar: 4.0% vs. 2.0%Withdrawal: 2.0% vs. 9.1%

    Camara, 201843

    6 months: no difference in use of any FP method (4.8% vs. 5.7 in intervention; P=.708);No difference in use of modern FP method (3.2% vs. 4.6% in intervention; P=.473)9 months: no difference in use of any FP method (2.7% vs. 6.7% in intervention; P=.064);Higher uptake of modern FP methods in intervention group (1.1% vs. 5.7% in intervention; P=.024)

    6 months: no difference in choice of FP method (P=.282): condoms (2.1% vs. 2.1%), pills (0.0% vs. 2.1%), IUD (0.0% vs. 0.0%), injectable (0.0% vs. 0.0%), traditional methods (1.6% vs. 1.0%)At 9 months: no difference in choice of FP method (P=.058): pills (0.0% vs. 0.5%), injectable (0.5% vs. 5.2%), implant (0.5% vs. 0.0%), traditional methods (1.6% vs. 1.0%).The authors intended to group LAM with modern methods but could not verify its accurate measurement.

    At 9 months, women cited more FP methods in intervention group.More women with postpartum FP intention in the intervention group at 6 months (88% vs. 69%, P<.01), as well as at 9 m months (78% vs. 54%, P<.001). However, these proportions were similar at time of inclusion just after counseling session.Also asked for reasons for not using FP methods; common ones: preference to abstain from sexual intercourse till child walks, unavailability of desired FP method, husband does not want it.

    Ayiasi, 20154612 months: Only 28.2% (control) and 31.6% (intervention) of mothers were current users of modern contraceptives. Although there was slightly higher proportion of current users in the intervention arm, this difference was not statistically significant (aRR: 1.10; 95% CI=0.51, 1.82; P=.810).

    About half of postpartum women, 47.1% (control) and 49% (intervention) arm had considered delaying the next pregnancy among the current noncontraceptive users, signifying unmet needs for contraceptive use. Of these, 71.4% in control and 87% in intervention had considered using a modern FP method. In preliminary analysis, risk of being willing to use was 1.5 times higher among intervention group, but this difference was not statistically significant after adjustment (aRR: 0.98; 95% CI=0.53, 1.82; P=.955).Pregnancy: Intervention arm (3.3% vs. 5.7%; P=.302)No difference in breastfeeding practices.

    Keogh, 201540At 6–15 months (median 10.5 months): No evidence of an association between antenatal counseling and starting FP

    At 6–15 months (median 10.5 months):No evidence of an association between antenatal counseling and stopping FP, unmet need, and repeat pregnancy.

    Abdulkadir, 20203812–20 weeks (2.8–4.6 months): intervention group reported higher contraceptive use (48.5% vs. 31.0%, P=.0001 based on Mc Nemar’s X2)Significant predictors of uptake: occupation, education, husbands’ participation
    Daniele, 201836

    3 months: Positive effect on use of any contraceptive method (57.0% vs. 49.3% in control, RD=7.7 [1.2 to 13.6], RR=1.16 95% CI=1.04, 1.30)8 months: Positive effect on use of any contraceptive method (70.6% vs. 64.4% in control, RD=6.5 95% CI=1.0, 12.1; RR=1.10 95% CI=1.02, 1.20)Positive effect on use of effective modern contraceptive methods (59.6% vs. 53.1% in control, RD=6.4, RR=1.12 95% CI=1.01, 1.24).

    		8 months: positive effect on use of long-acting or permanent contraception (30.7% vs. 22.9% in control, RD=8.1, RR=1.33 95% CI=1.09, 1.62)

    Intervention was associated with reduction of unmet need for contraception 8 months postpartum (14.2% vs. 18.7% in control, RD= −4.8, RR=0.75; 95% CI=0.57, 0.98Also looked at timely initiation of effective modern contraception, Unmet need for contraception 8 months postpartum.

    Digital interventions
    Unger, 201831

    16 weeks (3.7 months): Contraceptive use was significantly higher in both intervention arms (1-way SMS: 72% and 2-way SMS: 73%; P=.03 and 0.02 versus 57% control, respectively). However, this difference was not significant when correcting for multiple comparisons.At 10 and 24 weeks (2.3 months and 5.5 months): No difference in contraceptive uptake between groups.

    LARCs use similar across arms:One-way versus control, RR 1.16, 95% CI=0.44, 3.03; P=0.772-way versus control, RR 1.41 95% CI=0.57, 3.51; P=0.46) with only 25 (11%) of all contraceptive users using long-acting, reversible contraception methods (intrauterine devices and implants), the majority implants.Women in both intervention arms were significantly more likely to EBF at 10 weeks and 16 weeks than women in the control arm. The probability of EBF to 24 weeks postpartum was higher in both intervention groups than in the control, but only statistically significant in the 2-way messaging group [0.49 in 1-way, 0.62 in 2-way, and 0.41 in control, (P=.30 and .005 for 1-way and 2-way vs. control, respectively)]

    		Contraceptive continuation high among women starting contraception at 10 weeks; however, 44 (30%) of contraceptive users across all arms switched methods between 10 and 24 weeks.
    Harrington, 2019336 months: use of any contraceptive method higher among women in the SMS group (aRR=1.19; 95% CI=1.01, 1.41)

    6 months: use of highly effective methods higher among women in the SMS group (aRR=1.26; 95% CI=1.04, 1.52). No difference observed in use of LARC/permanent contraception (aRR=0.96; 95% CI=0.91, 1.02).At 6 months, 31.7% of all attendees were using injection. Implant users made up 25.4% of participants at 6 months. No participants reported LAM as their method of contraception at the 6 months visit.

    		Contraceptive discontinuation at 6 months was comparable in the SMS and control groups at 1.6% (P=.96).
    Educational interventions
    Sebastian, 2012549 months: higher proportion of women in the intervention group than of those in the comparison group reported modern contraceptive use (57.0% vs. 30.1%, P≤.01)

    9 months – choice of methods:Pill: 13.8% (intervention) vs. 7.1% (control)Condoms: 40.9% (intervention) vs. 22.6% (control)IUD: 1.9% (intervention) vs. 0.2% (control)Sterilization: 0.4% (intervention) vs. 0.2% (control)Traditional method: 18.9% (intervention) vs. 25.3 (control); P≤.014 months – LAM:23% (intervention) vs. 13% (control)

    		Knowledge of the various contraceptive methods (including LAM) was significantly higher in the intervention group compared with the comparison group at 4 months postpartum; these differences were even greater at the 9-month postpartum survey.
    Maldonado, 20203512 months: increased contraceptive adoption in intervention clusters (RD 7.2%, 95% CI=2.6, 12.9, P=.034)

    12 months: increased EBF in intervention clusters (11.9% 95% CI=7.2%, 16.9%; P=.14).No statistically significant effect on adoption of LARCs (RD=7.1% 95% CI=0.9%, 13.3%; P=.099).

    Bang, 20184118-19 months after the baseline survey: In intervention group, contraceptive prevalence increased from 31.3% to 61.8% (in comparison group: from 33% to 35.5%) (P=.065)The intervention group showed significantly greater increases in knowledge about FP compared to the comparison group (P<.038).
    Lori, 20184212 months: Women who participated in group ANC had higher odds of using a modern or non-modern method of contraception (aOR= 6.690, 95% CI=2.724, 16.420)

    12 months: Women who participated in group ANC had higher odds of using a modern FP method than those in individual care (aOR=8.063, 95% CI=2.887, 22.524).Women enrolled in group ANC had nearly three-fold odds of EBF for more than 6 months compared with women in individual care (aOR=2.84, 95% CI= 1.298, 6.216).

    		Women who participated in group ANC were more likely to demonstrate intention to use FP immediately postpartum than those who were in individual care (63.0% vs. 31.6%, X2=16.49, P<.001)
    Sarnquist, 2014483 months: uptake of LARCs in intervention (87.1%) and standard of care (81.8%) group (P=.34). Uptake of other modern FP methods in intervention (9.7%) and standard of care (9.1%) group (P=.12).

    Use at 3 months PP (Intervention v control)IUD: 1.6% v 9.1%, P=.12Implant: 85.5% v 72.7%, P=.11

    Identified IUD as effective at preventing pregnancy, 3 months PP (Intervention vs. control)85.5% v 56.3%, .002

    Financial interventions
    McConnell, 20183422 weeks (after estimated date of delivery; 5.1 months): increased probability of using modern contraception among those with standard voucher + SMS (RD=25% [6%, 44%]). None of the other treatment arms were estimated to statistically significantly increase the likelihood of modern contraceptive use22 weeks (after estimated date of delivery): increased probability of using LARCs among those with standard voucher + SMS (RD=20% [0%, 41%]). None of the other treatment arms were estimated to statistically significantly increase the likelihood of LARC use.
    Engineer, 20165223-25 months after P4P rollout- current use of modern FP methods: 10.7% vs 11.2% (P-value: 0.90)
    Package of interventions
    Jiusitthipraphai, 20155512 weeks (2.8 months): mean scores on oral contraceptive self-efficacy (OCSE) and oral contraceptive used behavior (OCUB) of study group were higher than control group with a statistical significance (P<.001)

    Guo, 202223Huber-Krum, 202024Pradhan, 201925Puri, 202126

    		12 months: use of modern contraception (0.04; 95% CI=0.00, 0.10)(Huber-Krum)

    IUD insertion in immediate postpartum period:Intervention increased PPIUD uptake by 4.4% (95% CI=2.8%, 6.4%]). The adherence-adjusted estimate implies that receiving counseling due to the intervention increases uptake of PPIUD by around 17% (95% CI=4%, 40%).(Pradhan)At 1 year:Short-acting contraception: Y1 (0.02, 95% CI=−0.02, 0.07, P>.05)Long-acting contraception: Y1 (0.03, 95% CI=0.01, 0.05, P<.05)PPIUD: Y1 (0.03, 95% CI=0.02, 0.04, P<.05)Non-postpartum IUD LARC: Y1 (−0.00, 95% CI=−0.01, 0.01, P>.05)Sterilization: Y1 (−0.01, 95% CI=−0.02, −0.00, P<.05)24 months:Short-acting contraception: Y2 (−0.01, 95% CI=−0.04,0.02), P>.05)Long-acting contraception: Y2 (0.02, 95% CI=−0.00, 0.04), P>.05)PPUID: Y2 (0.02, 95% CI=0.01, 0.03,P<.05)Non-PPIUD LARC: Y2 (−0.01, 95 %CI=−0.02, 0.01, P>.05)Sterilization: Y2 (−0.01, 95% CI=−0.02, 0.00, P>.05)(Huber-Krum)

    At 24 months: use of modern contraception (0.00; 95% CI=−0.04, 0.4) (Huber-Krum)Women counseled in either the pre-discharge period (aOR 0.86; 95% CI=0.80, 0.93) or in the post-discharge period (aOR 0.86; 95% CI=0.79, 0.93) were less likely to have an unmet need in the postpartum period compared to women with no counselinga; women who received counseling in both the pre- and post-discharge period were 27% less likely than women who had not received counseling to have unmet need (aOR 0.73; 95% CI=0.67, 0.80). (Puri)The adjusted probability of having incident pregnancy was 0.7 percentage points (95% CI=−3.0, 1.4) lower among women in the intervention group than among women in the control group. (Guo)

    Karra, 201927

    Assessed choice not insertion: 4.1% of women choosing PPIUD prior to the intervention compared to 9.8% of women choosing PPIUD after the rollout of the intervention (0.027; 95% CI=0.000, 0.054).The adherence-adjusted estimate implies that receiving counseling due to the intervention increases uptake of PPIUD by around 8.9% [95% CI=2.7%, 15%].

    Pearson, 202028

    Assessed choice not insertion: Increased choice of PPIUD by 6.3% (95% CI=2.3%, 8.0%).The adherence-adjusted estimate implies that receiving counseling due to the intervention increases uptake of PPIUD by around 31.6% (95% CI=24.3%, 35.8%).

    Tran, 20192912 months: prevalence of modern contraceptive methods in the intervention arm was about twice that of the control arm (55% vs 29%, aPR: 1.79, 95% CI=1.30, 2.47). Also, significant changes in modern contraceptive use were observed at 6 weeks and 6 months.

    At 12 months: In the intervention group, increased use of LARCs (aPR: 1.66; 95% CI=1.17, 2.35) and short-acting methods (aPR: 2.01; 95% CI=1.18, 3.43) was observed.Also, significant changes were observed in LARC use at 6 months and in use of short-acting methods at 6 weeks and 6 months.

    Tran, 202030

    12 months: prevalence of modern contraceptive methods in the intervention arm was not significantly different from the control group (aPR: 1.58; 95% CI=0.74, 3.38).No difference was observed also at 48 hours, 1 week, 6 weeks, 6 months.

    		Significant change was observed in use of implants (long-acting) at 6 weeks, 6 months, 12 months.
    Jarvis, 201837

    Within 12 months (timing unclear): FP use among all nonpregnant womenModern FP Use OR (95% CI)/aOR(95% CI)Arm 1 (quality): 0.4(0.2,0.8)/0.4(0.2,0.9) P<.05 for bothArm 2 (free): 1.2(0.7,2.0)/0.9(0.5,1.8)Arm 3 (free/quality): 2.3(1.4,3.9) P<.005/2.3(1.2,4.3) P<.05Control=reference

    Among all nonpregnant women:Modern FP use, excluding condomsArm 1: 0.8(0.4,1.7)/1.4(0.6,3.2)Arm 2: 3.2(1.8,5.8) P<.001/3.2(1.4,7.2) P<.005Arm 3: 6(3.4,10.7)/8.6(3.9,19.0) P<.001 for bothLARC UseArm 1: 2.1(0.8,5.4)/2.9(1.1,7.9)Arm 2: 6.3(2.8,14.2)/5.6(2.3,13.7) P<.001 for bothArm 3: 8.2(3.7,18.4)/8.4(3.4,20.6) P<.001 for bothImplant useArm 1: 1.7(0.6,4.8)/2.3(0.8,6.9)Arm 2: 7.0(3.0,16.4)/5.7(2.2,14.4) P<.001 for bothArm 3: 6.8(2.9,16.0)/5.6(2.2/14.4) P<.001 for both

    Karra, 202244At 24 months: Use of long-acting methods increased by 5.4% (95% CI=0.020, 0.089). Use of implants increased by 4.3% (95% CI=0.011, 0.075). No change in use of injectables (0.00088 (95% CI=−0.039, 0.040).

    At 24 months: contraceptive use increased in intervention group by 5.9% (95% CI=0.024, 0.094).Intervention group’s hazard of pregnancy was 43.5% lower 24 months after the index birth (based on a hazard rate of 0.565 (95% CI=0.387, 0.824).

    Espey, 202145Over the 15-month intervention period, providers at our intervention facilities inserted 83.5 PP implants per month (SD=51.9) and 224.8 PPIUDs per month (SD=75.3). Notably, prior to our intervention, only 30 PP implant insertions per month and 8 PPIUD insertions per month occurred in our selected facilities.Receiving more promotions was associated with client uptake for PP implants (test for trend, X2=65.8, P<.0001) and PPIUDs (test for trend, X2=26.9, P<.0001). Of the 12,068 women who received our intervention and delivered at a study facility, 1252 chose a PP implant (10.4% uptake), 3372 chose a PPIUD (27.9% uptake), and 7444 declined a postpartum LARC method (61.7% non-uptake)
    Wu, 202051

    Within 12 months: Use of any modern contraceptive method increased from 29% pre-intervention to 46% post-intervention (P<.0001).The adjusted OR for any modern contraceptive use of women in the post-intervention group as compared to pre-intervention group was 2.3 (95% CI=1.7, 3.1; P<.0001).

    		With respect to method mix, use of LAM, injectables, and implant increased significantly. Condom use decreased significantly from 4.5% to 1.6% (P=.01).
    Ahmed, 201553

    12 months: cumulative probability of adopting any modern contraceptive method=65.9% in intervention and 39.1% in comparison arm.CPR=42% in intervention and 27% in comparison (P<.001).

    In intervention arm, higher acceptance of oral contraceptives (aHR=1.33, P<.001), condoms (aHR=3.39, P<.001), and reduced acceptance of traditional methods (aHR=0.59, P=.001).No difference in adoption of injectables and female sterilization. Low acceptance of IUDs in both groups (0.6% in intervention vs. 1.3% in control)Higher use of LAM in intervention arm: 3 months – 23% vs. 0%; 6 months – 12% vs. 0%; no use in either arm at 12 months or 24 months (not reported in article table).

    24 months:Cumulative probability of adopting any modern contraceptive method=76.6% in intervention and 54.5% in comparison armThe hazard of all-method adoption was higher in the intervention arm than in the comparison arm (adjusted hazard ratio=2.57, P<.001; excluding LAM: aHR=1.51, P<.001).CPR=46% in intervention and 35% in comparison (P<.001).Continuation rates for first 12 months after adoption show that continuation of oral contraceptives was not significantly (in multivariate analysis) higher in intervention arm [aHR=0.81]; continuation rate of IUDs/implants was higher in intervention arm (85.3%) than in the control arm (59.0%) but was not significantly different in the multivariable model [aHR:0.32). Continuation rates of other methods were not statistically significant.After discontinuation (n=745), 34% of LAM users switched to oral contraceptives, 21% to condoms, 12% to injectables, 1% to IUDs/implants, and 2% to sterilization; 26% remained nonusers at 24 months

    Cooper, 201656

    Up to 11 months: Effect statistically insignificant for mothers with children 11 months or younger.Up to 24 months: overall, there was a decline in modern contraceptive use over the study period. However, intervention might still have positive effect (In Upper Egypt: OR=1.45, P<.001; in Lower Egypt: OR=1.29, P<.05).

    		Use of LARCs generally decreased in intervention and comparison sites over the study period. Measured LAM incorrectly as a breastfeeding method, limiting the ability to interpret this indicator.

    When stratifying by children’s age, effect only statistically significant in women with children 12-24m (these are the women that were hardly exposed to antenatal visits)Positive effect on (lower) risk of pregnancy in both Lower (OR=0.40, P<.001) and Upper Egypt (OR=0.67, P<.001)The intervention appears to have had a positive effect on knowledge of optimal birth spacing in Upper Egypt (OR=1.68, P<.001); negative effect on same outcome in Lower Egypt (OR=0.55, P<.001)Positive effect on joint contraceptive decision making in both Lower and Upper Egypt

    Buser, 202147Women who gave birth in the last 13 months: aOR contraceptive use (also referred to as avoiding pregnancy/actively avoiding pregnancy) among those who used the Core MWH Model compared to those who did not: 1.33 (1.08–1.63, P<.05)
    Maru, 20174912 months: postpartum contraceptive prevalence increased from 19.0% to 46.5% (difference=27.5%, 95% CI=20.8% to 34.2%, P<.001).
    Training intervention
    Dhital, 202150In the adjusted model, a 25-fold increase in FCHV knowledge had been observed at the post-test [aOR=25.4 (CI=12.6, 50.2), P<.001], and at 1-year post-intervention, it remained approximately 11-fold higher [aOR=10.7(CI=6.3, 18.1), P<.001] as compared to the pre-intervention phase.

    • Abbreviations: aHR, adjusted hazard ratio; ANC, antenatal care; aOR, adjusted odds ratio; aPR, adjusted prevalence ratio; aRR, adjusted relative risk; CI, confidence interval; CPR, contraceptive prevalence rate; FCHV, female community health volunteer; FP, family planning; IUD, intrauterine device; LAM, lactational amenorrhea method; LARC, long-acting reversible contraceptive; MWH, maternity waiting home; OR, odds ratio; PP, postpartum; PPIUD, postpartum intrauterine device; RD, risk difference; RR, relative risk; SD, standard deviation; SMS, short message service.

    • ↵a Information regarding outcomes largely taken verbatim from the text.

  • TABLE 3.

    Quality Appraisal

    AuthorQuasi/RCTWell-Described Source Population?Eligible Population Representative of Source Populations?Well-Described Intervention(s)?Well-Described Comparator(s)?Random Sequence Generation Risk of Bias?Baseline (or Group) Characteristics Similar Risk of Bias?Outcome Data Completeness Risk of Bias?Adequate Analytical Methods?
    Counseling interventions
    Ndegwa32QuasiUnclearUnclearNoYesUnclearHighLowNo
    Adanikin39RCTYesYesYesYesLowLowLowYes
    Camara43QuasiYesYesYesYesUnclearLowLowNo
    Ayiasi46cRCTYesYesYesYesHighHighUnclearNo
    Keogh40QuasiYesYesYesYesNAHighHighYes
    Abdulkadir38RCTYesYesYesYesHighLowLowYes
    Daniele36RCTYesYesYesYesUnclearLowLowYes
    Digital interventions
    Unger31RCTUnclearUnclearYesYesLowLowLowYes
    Harrington33RCTYesYesYesYesUnclearHighLowYes
    Educational interventions
    Sebastian54QuasiYesYesYesYesUnclearLowLowYes
    Maldonado35cRCTYesYesYesYesLowLowLowYes
    Bang41QuasiYesYesYesYesNAHighUnclearYes
    Lori42QuasiYesYesYesYesNALowHighYes
    Sarnquist48QuasiYesYesYesYesNALowLowYes
    Financial interventions
    McConnell34RCTYesYesYesYesUnclearLowHighYes
    Engineer52cRCTYesYesYesYesUnclearLowUnclearYes
    Package of interventions
    Jiusitthipraphai55QuasiYesYesYesYesNAHighLowYes

    Guo23Huber-Krum24Pradhan25Puri26

    		cRSWDYesYesYesYesUnclearLowLowYes
    Karra27cRSWDYesYesYesYesUnclearLowLowYes
    Pearson28cRSWDYesYesYesYesUnclearLowLowYes
    TrancRCTYesYesYesYesUnclearHighLowYes
    TrancRCTYesYesYesYesLowLowLowYes
    JarvisQuasiYesYesYesYesNAHighHighYes
    KarraRCTYesYesYesYesLowLowHighYes
    EspeyQuasiNRNRYesNANANANAUnclear
    WuQuasiYesYesYesYesNALowLowYes
    AhmedQuasiYesUnclearYesYesNAHighUnclearYes
    CooperQuasiYesYesYesYesNALowUnclearYes
    BuserQuasiYesYesYesNANANANAYes
    MaruQuasiUnclearUnclearUnclearNANANANAYes
    Training intervention
    DhitalQuasiYesYesUnclearNANANALowYes

    • Abbreviations: cRCT, cluster randomized controlled trial; cRSWD, cluster-randomized stepped-wedge design; NA, not applicable; NR, not reported; RCT, randomized controlled trial.

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Antenatal Care Interventions to Increase Contraceptive Use Following Birth in Low- and Middle-Income Countries: Systematic Review and Narrative Synthesis
Ona L. McCarthy, Nasser Fardousi, Vandana Tripathi, Renae Stafford, Karen Levin, Farhad Khan, Maxine Pepper, Oona M.R. Campbell
Global Health: Science and Practice Oct 2024, 12 (5) e2400059; DOI: 10.9745/GHSP-D-24-00059
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