Sex, Lives and Red Tape

Promoting postpartum birth spacing – what works?

fpThe Sexual and Reproductive Health (SRH) team monthly journal club discussed the following paper:

Sonalkar S, Mody S and Gaffield M E (2013) Outreach and integration programs to promote family planning in the extended postpartum period, International Journal of Gynecology and Obstetrics 124 (2014) 193–197 – not open access


Family planning is an unfinished agenda [1]. Globally it is estimated that 222 million women have an unmet need for family planning; the consequences of which include 104,000 avoidable maternal deaths and 18 million abortions taking place in low income countries [2].

The WHO recommends a minimum spacing of 24 months between births, and acknowledge the benefits to both mothers and babies [3]. Provision of family planning information is essential to meeting this recommendation.

This paper was chosen by Dr Sue Mann because it aligns closely to the current research strands of the SRH team in Africa.

Study Summary

  • AIM: Sonalker et al’s paper aimed to conduct a systematic review of published literature to find out  a) what interventions are effective at promoting birth spacing and b) what gaps in knowledge remain.
  • METHOD:The review was limited to study designs which included either interventions to prevent short birth-spacing or interventions promoting postpartum contraception use. Papers were only included if studies included a control/comparison group and interventions took place within the 12 months postpartum period. Outcomes of interest included interpregnancy interval and contraception use.
  • RESULTS: 34 articles were included and reviewed. The authors reported:

“Prenatal care, home visitation programs, and educational interventions were associated with improved family-planning outcomes, but should be further studied in low-resource settings. Mother–infant care integration, multidisciplinary interventions, and cash transfer/microfinance interventions need further investigation”

Overall the authors concluded that programmatic interventions may improve birth-spacing and postpartum contraception uptake. They also identified a need for large well-designed international studies to determine what would work best in low income settings.

Discussion Summary

Our discussion was guided by the CASP framework for systematic review

The paper’s aim was clear, however it was far from being focused. The authors included all geographical settings and all interventions, which makes it difficult to assess the generalisability of any findings. This unfocused approach may have been due to the limited knowledge about this topic. In which case this review may have served as a scoping review to identify what is out there (however this was not stated by the authors).

The authors restricted their search to pubmed and Cochrane, which seems very limited. Compounded with a very broad search aim, the group agreed that this search strategy was a little odd. It would have been preferable to have a more specific enquiry with more detailed search strategy (rather than a broad enquiry and a brief search strategy which this paper has used). In addition, such a brief search strategy was probably biased towards high income countries.

The group also noted their surprise at the small number of papers included in the review. Information regarding the inclusion/exclusion criteria was amiss and would have been helpful.

We discussed that based on the information provided in the paper it would be impossible to fully replicate this study. Although information was provided regarding the search terms used for pubmed, the authors did not provide enough information regarding how they identified the “abstracts of conference presentations, dissertations, and unpublished studies” …which conferences? how did they access unpublished studies? Without this information it is difficult to be confident in the systematic approach of the authors.

fp2We noted that all included studies had been ranked according to a checklist used to grade quality. On a side note, we did have some discussion as to how useful this process was in reality. In particular, the categories of fair, average or good quality are very subjective.

It is difficult to say whether the results could be applied to our local population, as the review included all possible populations. The group didn’t feel this was useful as the settings of high and low income regions are so vastly different.

Were all important outcomes considered? Contraceptive outcomes were not explained in great detail and are therefore hard to assess. However the primary outcome measure of repeat pregnancies was appropriate.

Are the benefits worth the harms and costs?  Harms occurring from intervention are likely to be minimal, especially as the benefits of family planning are very well established.

We felt the conclusion was weak, and could’ve been written before the review took place. This again highlights another benefit of having a focused question in enabling more informative conclusions to be made! Furthermore, it would’ve been more informative to present the findings separating the high quality papers from the low quality papers, in order to identify what is known to not work.


[1] Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A and Innis J (2006) ” Family planning: the unfinished agenda”, The Lancet, 368: 1810–27, available online

[2] Singh S and Darroch J E (2012) “Adding It Up: Costs and Benefits of Contraceptive Services: Estimates for 2012”, Guttmacher Institute, available online

[3] World Health Organization (2006) “Report of a WHO Technical Consultation on BirthSpacing: Geneva, Switzerland 13–15 June 2005”, available online


Thank you to Dr Sue Mann, Dr Jenny Hall, Dr Hannat Akintomide and Professor Judith Stephenson for contributing to the journal club discussion.


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This entry was posted on October 7, 2014 by in Critical Appraisal, Sexual Health and tagged , , , , , , .