Does family planning counseling reduce unmet need for modern contraception among postpartum women: Evidence from a stepped-wedge cluster randomized trial in Nepal

BACKGROUND: Postpartum women have high rates of unmet need for modern contraception in the two years following birth in Nepal. We assessed whether providing contraceptive counseling during pregnancy and/or prior to discharge from the hospital for birth or after discharge from the hospital for birth was associated with reduced postpartum unmet need in Nepal. METHODS: We used data from a larger a stepped-wedge, cluster randomized trial, including contraceptive counselling in six tertiary hospitals. Group 1 hospitals (three hospitals) initiated the intervention after three months of baseline data collection, while Group 2 hospitals (three hospitals) initiated the same intervention after nine months. We have enrolled 21,280 women in the baseline interviews and conducted two follow-up interviews with them, one and two years after they had delivered in one of our study hospitals. We estimated the effect of counseling and its timing (pre-discharge, post- discharge, both, or neither) on unmet need for modern contraception in the postpartum period, using random-effects logistic regressions. RESULTS: Unmet need for modern contraception was high (54% at one year and 50% at two years). Women counseled in either the pre-discharge period (Odds ratio [OR] 0·86; 95% CI: 0·80, 0·93) or in the post-discharge period (OR 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 counseling. However, 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 (OR 0.73; 95% CI: 0·67, 0·80). CONCLUSIONS: Counseling women either before or after discharge reduces unmet need for postpartum contraception but counseling in both periods is most effective.