A systematic review and meta-analysis of postpartum contraceptive use among women in low- and middle-income countries

Abstract

Background: Short birth intervals increase risk for adverse maternal and infant outcomes including preterm birth, low birth weight (LBW), and infant mortality. Although postpartum family planning (PPFP) is an increasingly high priority for many countries, uptake and need for PPFP varies in low- and middle-income countries (LMIC). We performed a systematic review and meta-analysis to characterize postpartum contraceptive use, and predictors and barriers to use, among postpartum women in LMIC.

Methods: PubMed, EMBASE, CINAHL, PsycINFO, Scopus, Web of Science, and Global Health databases were searched for articles and abstracts published between January 1997 and May 2018. Studies with data on contraceptive uptake through 12 months postpartum in low- and middle-income countries were included. We used random-effects models to compute pooled estimates and confidence intervals of modern contraceptive prevalence rates (mCPR), fertility intentions (birth spacing and birth limiting), and unmet need for contraception in the postpartum period.

Results: Among 669 studies identified, 90 were selected for full-text review, and 35 met inclusion criteria. The majority of studies were from East Africa, West Africa, and South Asia/South East Asia. The overall pooled mCPR during the postpartum period across all regions was 41.2% (95% CI: 15.7-69.1%), with lower pooled mCPR in West Africa (36.3%; 95% CI: 27.0-45.5%). The pooled prevalence of unmet need was 48.5% (95% CI: 19.1-78.0%) across all regions, and highest in South Asia/South East Asia (59.4, 95% CI: 53.4-65.4%). Perceptions of low pregnancy risk due to breastfeeding and postpartum amenorrhea were commonly associated with lack of contraceptive use and use of male condoms, withdrawal, and abstinence. Women who were not using contraception were also less likely to utilize maternal and child health (MCH) services and reside in urban settings, and be more likely to have a fear of method side effects and receive inadequate FP counseling. In contrast, women who received FP counseling in antenatal and/or postnatal care were more likely to use PPFP.

Conclusions: PPFP use is low and unmet need for contraception following pregnancy in LMIC is high. Tailored counseling approaches may help overcome misconceptions and meet heterogeneous needs for PPFP.

Keywords: Barriers; Contraceptives; Low income; Middle income; Postpartum; Predictors.

Fig. 1

PRISMA flow diagram of literature search results (Search Dates: January 1997–May 2018). mCPR; modern contraceptive prevalence rate, FP; family planning. * not indexed in electronic database at the time of review ** unpublished dissertation

Fig. 2

Forest plot of modern contraceptive prevalence rate, by region. Year is start of survey year and N is sample size. mCPR; modern contraceptive prevalence rate, CI; confidence interval

Fig. 3

Forest plot of desire for birth spacing, by region. Year is start of study and N is sample size. % is pooled prevalence. CI; confidence interval

Fig. 4

Forest plot of desire for birth limiting, by region. Year is start of study and N is sample size. % is pooled prevalence. CI; confidence interval

Fig. 5

Forest plot for unmet need for contraception, by region. Year is start of study and N is sample size. % is pooled prevalence. CI; confidence interval

Fig. 6

Facilitators for postpartum contraceptive use, 0–12 months postpartum

Fig. 7

a. Forest plot of modern contraceptive prevalence rate (mCPR), by postpartum follow-up period. Year is start of study and N is sample size. mCPR; modern contraceptive prevalence rate, CI; confidence interval. b. Forest plot for unmet need for contraception, by postpartum follow-up period. Year is start of study and N is sample size. CI; confidence interval