Outcomes of a Pragmatic Cluster-Randomized Trial of Home-Based Postpartum Contraceptive Delivery in Southwest Trifinio, Guatemala

MARGO S. HARRISON
Assistant Professor, University of Colorado

Postpartum contraception is important to prevent unintended, undesired, and closely-spaced pregnancies.1 If women receive comprehensive contraceptive education, around 11% will choose to use the contraceptive implant.3 Prior research from our community has found barriers to the use of long-acting reversible contraceptives (LARC) include lack of spousal approval, difficulty accessing methods, lack of knowledge, and fear of adverse effects.4 We hypothesized addressing access by bringing contraceptives to women’s homes would result in increased implant uptake.

In our study population of interest in the Southwest Trifinio, analysis of historical unpublished data suggests that about 88% of women in the region are using or are interested in using contraception by forty days postpartum. Of these users, 0.5% used condoms, 0.5% pills, 0.5% lactational amenorrhea, 1.5% natural family planning, almost 4% long-acting reversible contraceptives (around 3% using the implant), 21% sterilization, and 72% opted for injectable contraception.

Our study was a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with implant utilization rates at 3 months post-enrollment.

In a region of rural Guatemala referred to as the Southwest Trifinio, twelve communities are served by a community-based antenatal and postnatal care program. The communities were combined into eight clusters based on 2017 birth rates and randomized to receive the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit. All participants receive comprehensive contraceptive counseling beginning at the first antenatal visit, so control clusters received this as part of routine care; this education preceded the study intervention.

Of 208 women enrolled in the study, 108 were in four intervention and 100 in four control clusters. Three-month contraceptive initiation rates were 56.0% in the control clusters compared to 76.8% in the intervention clusters, p < 0.001. Women in control clusters overwhelmingly opted for the injectable contraceptive (94.6%) while women in intervention clusters chose both the injection (61.5%) and the implant (33.7%), p < 0.001. Implant use by 3 months, the primary outcome of the study, was significantly higher in the intervention arm (25.9%) compared to the control arm (2.0%), p < 0.001, OR 18.8 CI [4.3, 81.4].

Our study was designed to respond to previously identified barriers to contraceptive uptake, and it was successful. It increased overall use of contraception by 3 months, by shifting use away from short- in favor of long-acting methods, with high continuation and satisfaction rates and no adverse outcomes reported.