Meeting Postpartum Women's Family Planning Needs through Integrated Family Planning and Immunization Services: Results of a Cluster-Randomized Controlled Trial in Rwanda

The primary objective of this study was to test the effectiveness of integrating family planning (FP) service components into infant immunisation services to increase modern contraceptive method use among postpartum women in Rwanda. Healthy timing and spacing of pregnancies (HTSP) has been shown to improve the health of both mothers and their children and yet, facility-based deliveries and postpartum care remain underutilised in Rwanda - a country that has high immunisation attendance levels. To explore the possibilities, the researchers developed an intervention using the Health Belief Model (HBM), which has been applied to sexual risk behaviours and contraceptive behaviours in a variety of populations, including populations in sub-Saharan Africa.

Specifically, the intervention, which began in July 2010, included 4 distinct yet interrelated components that were delivered by trained providers to women attending all infant immunisation services (i.e., at 6, 10, and 14 weeks and at 9 months post-delivery):

1. Concise FP messages delivered during pre-immunisation group education sessions in intervention facilities.
2. A simple brochure in the local language (Kinyarwanda) distributed during group education. It contained messages about the Lactational Amenorrhea Method (LAM), return to fertility and pregnancy risk during the postpartum period, the benefits to spacing pregnancies by at least 2 years, and contraceptive options for postpartum women.
3. Individual screening of all women attending infant immunisation services. An immunisation provider met one-on-one with each mother, during which the provider asked the mother about the 3 LAM criteria to screen her for current risk of becoming pregnant. The provider also offered a brief counseling message depending upon risk classification and referral to FP services for those currently or soon to be at-risk of pregnancy. Providers were trained on a job aid to assist the screening and counseling process.
4. Convenient offer of FP services to women attending immunisation at the same facility and on the same day as immunisation services. FP service providers received reinforcement on the safety and appropriate timing of modern contraceptive methods for use by postpartum women for both those who did breastfeed and for those who did not.

The study was a separate sample, parallel, cluster-randomized controlled trial. Fourteen randomly selected primary health facilities were equally allocated to the intervention group of 825 women (integrated FP and immunisation services) and control group of 829 women (standard immunisation services only). Baseline interviews took place May–June 2010; a separate sample of postpartum women was interviewed 16 months later.

Roughly half of women across study groups at both time points were using a modern contraceptive method. Among those women who did not initiate a contraceptive method, awaiting the return of menses was the most common reason cited for non-use of a method. Unmet contraceptive need was also high (45.6% in the control group and 39.2% in the intervention group at endline); nearly all women not currently using a modern method desired to space or limit their births.

Results showed that the intervention had a statistically significant, positive effect on modern contraceptive method use among intervention group participants compared with control group participants (regression coefficient, 0.15; 90% confidence interval [CI], 0.04 to 0.26). In other words, they observed an 8% increase in the intervention group and a 7% decrease in the control, resulting in a 15 percentage point difference between the intervention and control groups when comparing baseline to follow-up results.

Concerning the HBM concepts and contraceptive method use, a small but statistically significant change in perceived susceptibility to an unplanned pregnancy between intervention and control groups from baseline to follow-up; perceived susceptibility increased from baseline to endline in intervention facilities and decreased in control facilities.

Women in both study groups overwhelmingly supported the concept of integrating FP services components into infant immunisation services (97.9% in each group), and service data collected during the intervention period did not indicate that the intervention had any negative effect on infant immunisation service uptake.

"More efforts are needed to ensure women and their providers understand that postpartum women can become pregnant before their menses return, even while breastfeeding, and that sexually active women who desire to space or limit their pregnancies should initiate an effective modern contraceptive method as early as possible. Additional research is needed to better understand the persistence of these misperceptions and to test strategies to address them."

The researchers note that "a strong policy environment aiming to improve maternal and child health, extensive engagement of the Ministry of Health in the planning and implementation of the intervention, as well as intensive efforts to strengthen the country's health system likely played important roles in the success of the intervention. Replicating this work in settings where political or health system support is not as strong may not generate the same results." In March 2013, the Rwanda Ministry of Health held a national meeting to discuss results of this and other studies focused on improving FP services and contraceptive uptake. Participants recommended national scale-up of the intervention and initiated discussions on changes to service delivery guidelines, supervision requirements, training curricula, and data collection systems to support scale-up.