Home-based Delivery of the Contraceptive Implant in Postpartum Guatemalan Women: a Cluster-randomized Trial

Background and Rationale: Postpartum contraception is important to prevent unintended and closely spaced pregnancies following childbirth as well as to avoid future pregnancy in mothers who have achieved their desired family size. Proper pregnancy spacing can prevent maternal and perinatal morbidity and mortality. Globally, there is significant unmet need for postpartum contraception.

Historically, in the community of interest, which is in the rural Southwest corner of Guatemala bordering Mexico, a large majority (88%) of a convenience sample of women in the community-based care program self-reported postpartum contraceptive use. However, 72% of these women were using injectable contraceptives, which are considered short-acting, and are less effective at preventing unintended and closely spaced pregnancies; the second most common method was sterilization (21%). For the remaining women who did not seek sterilization or injectable contraceptives, 0.5% of them reportedly used contraceptive pills, 0.5% condoms, 0.5% lactational amenorrhea, and 1.6% reportedly relied on natural family planning. Less than 4% of women were using long-acting reversible contraceptives (intrauterine devices or implants), which are more effective at preventing unintended and closely spaced pregnancies than injectables. The providers in the community had not been trained in implant and intrauterine device placement, so the closest place to have a device placed was the most proximate town to the communities, which is an hour away by vehicle. Additional barriers discovered through qualitative research in the study communities found that barriers to family planning use historically included knowledge, access to methods, fear of adverse events, and a woman garnering her partner's approval. Community women's ideas for future educational programming included teaching about how birth control methods work, how to talk to partners about birth spacing, and myth debunking, and they requested the location and time of teaching to occur at peripartum and pediatric visits.

Therefore, based on this preliminary data, the prospective research question is: if community-based nurses are trained to place contraceptive implants, and they offer women placement in the home at their postpartum visit (among other routinely available contraceptive methods), will the ability to provide this service increase the uptake of contraceptive implants in our communities of interest?

Specific Objectives or Hypotheses: The specific objective of the study is to observe in this population where use of postpartum contraception is historically common among women, does home delivery of the contraceptive implant increase utilization of the device above the baseline rate of 3.2%. The investigators hypothesize, based on published data from other settings, that if women receive proper counseling about all contraceptive methods, uptake of long-acting reversible contraceptives, which in this study includes only the contraceptive implant, is about 50%.

The secondary objectives are to observe if the home-based contraceptive delivery intervention featured in this study is associated with overall increased contraceptive uptake, continuation, and satisfaction in the intervention compared to the control clusters. The hypothesis is that with increased uptake of the implant there will be longer continuation rates and more satisfaction in the intervention clusters. The investigators also hypothesize that increased contraceptive uptake, continuation, and satisfaction may be associated with reduced short interval repeat pregnancy rates so the study also aims to survey participants on their pregnancy status at enrollment, and three- and twelve-months after enrollment.