Couples-based interventions and postpartum contraceptive uptake: A systematic review

  • Daniel E. Sack
    Corresponding author.
    Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States

    Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States
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  • Lauren S. Peetluk
    Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States

    Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
    Search for articles by this author
  • Carolyn M. Audet
    Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States

    Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States
    Search for articles by this author



      Systematically review the existing evidence about couples-based interventions and postpartum contraceptive uptake and generate recommendations for future research.

      Data sources

      PubMed, Web of Science, PsycINFO, Embase, and CINAHL through June 7, 2021.

      Study selection and data extraction

      Studies with a couples-based intervention assessing postpartum contraceptive uptake. Two independent reviewers screened studies, extracted data, and assessed risk of bias with RoB-2 (Cochrane Risk of Bias 2) for randomized and ROBINS-I (Risk of Bias in Non-Randomized Studies – Interventions) for observational studies. Data were synthesized in tables, figures, and a narrative review.


      A total of 925 papers were identified, 66 underwent full text review, and 17 articles, which included 18 studies – 16 randomized, 2 observational – were included. The lack of intervention and outcome homogeneity precluded meta-analysis and isolating the effect of partner involvement. Four studies were partner-required, where partner involvement was a required component of the intervention, and 14 were partner-optional. Unadjusted risk differences ranged from 0.01 to 0.51 in favor of couples-based interventions increasing postpartum contraceptive uptake versus standard of care. Bias assessment of the 16 randomized studies classified 8, 3, and 5 studies as at a high, some concern, and low risk of bias. Common sources of bias included intervention non-adherence and missing outcome data. One observational study was at a high and the other at a low risk of bias.


      Future studies that assess couples-based interventions must clearly define and measure how partners are involved in the intervention and assess how intervention adherence impacts postpartum contraceptive uptake.


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        • Conde-Agudelo A
        • Rosas-Bermúdez A
        • Kafury-Goeta AC.
        Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.
        JAMA. 2006; 295: 1809-1823
        • Conde-Agudelo A
        • Rosas-Bermúdez A
        • Kafury-Goeta AC.
        Effects of birth spacing on maternal health: a systematic review.
        Am J Obstet Gynecol. 2007; 196: 297-308
        • Cleland J
        • Conde-Agudelo A
        • Peterson H
        • Ross J
        • Tsui A.
        Contraception and health.
        Lancet Lond Engl. 2012; 380: 149-156
      1. World Health Organization. Report of a WHO technical consultation on birth spacing: Geneva, Switzerland 13-15 June 2005 2007.

        • Louis JM
        • Bryant A
        • Ramos D
        • Stuebe A
        • et al.
        • American College of Nurse-Midwives and the National Association of Nurse Practitioners in Women's Health, American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine
        Interpregnancy care.
        Am J Obstet Gynecol. 2019; 220: B2-18
        • RamaRao S
        • Townsend J
        • Askew I.
        Correlates of inter-birth intervals: Implications of optimal birth spacing strategies in Mozambique.
        Reprod Health. 2006;
        • van Eijsden M
        • Smits LJM
        • van der Wal MF
        • Bonsel GJ.
        Association between short interpregnancy intervals and term birth weight: the role of folate depletion.
        Am J Clin Nutr. 2008; 88: 147-153
        • Feyissa TR
        • Harris ML
        • Melka AS
        • Loxton D.
        Unintended pregnancy in women living with HIV in Sub-Saharan Africa: a systematic review and meta-analysis.
        AIDS Behav. 2019; 23: 1431-1451
        • Audet CM
        • Chire YM
        • Vaz LM
        • Bechtel R
        • Carlson-Bremer D
        • Wester CW
        • et al.
        Barriers to male involvement in antenatal care in rural Mozambique.
        Qual Health Res. 2016; 26: 1721-1731
        • Kraft JM
        • Wilkins KG
        • Morales GJ
        • Widyono M
        • Middlestadt SE.
        An evidence review of gender-integrated interventions in reproductive and maternal-child health.
        J Health Commun. 2014; 19: 122-141
        • Eliason S
        • Baiden F
        • Quansah-Asare G
        • Graham-Hayfron Y
        • Bonsu D
        • Phillips J
        • et al.
        Factors influencing the intention of women in rural Ghana to adopt postpartum family planning.
        Reprod Health. 2013; 10: 34
        • Hartmann M
        • Gilles K
        • Shattuck D
        • Kerner B
        • Guest G.
        Changes in couples’ communication as a result of a male-involvement family planning intervention.
        J Health Commun. 2012; 17: 802-819
        • Mboane R
        • Bhatta MP.
        Influence of a husband's healthcare decision making role on a woman's intention to use contraceptives among Mozambican women.
        Reprod Health. 2015; 12: 36
        • Olakunde BO
        • Sam-Agudu NA
        • Patel TY
        • Hunt AT
        • Buffington AM
        • Phebus TD
        • et al.
        Uptake of permanent contraception among women in Sub-Saharan Africa: a literature review of barriers and facilitators.
        Contraception. 2019;
        • Harrington EK
        • McCoy EE
        • Drake AL
        • Matemo D
        • John-Stewart G
        • Kinuthia J
        • et al.
        Engaging men in an mHealth approach to support postpartum family planning among couples in Kenya: a qualitative study.
        Reprod Health. 2019; 16: 17
        • Akaba G
        • Ketare N
        • Tile W.
        A community-based, mixed-methods study of the attitudes and behaviors of men regarding modern family planning in Nigeria.
        Int J Gynecol Obstet. 2016; 135: 86-90
        • Blackstone SR
        • Nwaozuru U
        • Iwelunmor J.
        Factors influencing contraceptive use in Sub-Saharan Africa: a systematic review.
        Int Q Community Health Educ. 2017; 37: 79-91
        • Blazer C
        • Prata N.
        Postpartum family planning: current evidence on successful interventions.
        Open Access J Contracept. 2016; 7: 53-67
        • Daniele MA
        • Ganaba R
        • Sarrassat S
        • Cousens S
        • Rossier C
        • Drabo S
        • et al.
        Involving male partners in maternity care in Burkina Faso: a randomized controlled trial.
        Bull World Health Organ. 2018; 96: 450-461
        • Chinaeke EE
        • Fan-Osuala C
        • Bathnna M
        • Ozigbu CE
        • Olakunde B
        • Ramadhani HO
        • et al.
        Correlates of reported modern contraceptive use among postpartum HIV-positive women in rural Nigeria: an analysis from the MoMent prospective cohort study.
        Reprod Health. 2019; 16: 2
        • Yargawa J
        • Leonardi-Bee J.
        Male involvement and maternal health outcomes: systematic review and meta-analysis.
        J Epidemiol Community Health. 2015; 69: 604-612
        • Atukunda EC
        • Mugyenyi GR
        • Atuhumuza EB
        • Kaida A
        • Boatin A
        • Agaba AG
        • et al.
        Factors associated with pregnancy intentions amongst postpartum women living with HIV in Rural Southwestern Uganda.
        AIDS Behav. 2019; 23: 1552-1560
        • Huang Y
        • Merkatz R
        • Zhu H
        • Roberts K
        • Sitruk-Ware R
        • Cheng L
        • et al.
        The free perinatal/postpartum contraceptive services project for migrant women in Shanghai: effects on the incidence of unintended pregnancy.
        Contraception. 2014; 89: 521-527
        • Saeed GA
        • Fakhar S
        • Rahim F
        • Tabassum S.
        Change in trend of contraceptive uptake–effect of educational leaflets and counseling.
        Contraception. 2008; 77: 377-381
        • Sebastian MP
        • Khan ME
        • Kumari K
        • Idnani R.
        Increasing postpartum contraception in rural India: evaluation of a community-based behavior change communication intervention.
        Int Perspect Sex Reprod Health. 2012; 38: 68-77
        • Ahmed S
        • Ahmed S
        • McKaig C
        • Begum N
        • Mungia J
        • Norton M
        • et al.
        The effect of integrating family planning with a maternal and newborn health program on postpartum contraceptive use and optimal birth spacing in rural Bangladesh.
        Stud Fam Plann. 2015; 46: 297-312
        • Abdel-Tawab N
        • Loza S
        • Zaki A.
        Helping Egyptian women achieve optimal birth spacing intervals through fostering linkages between family planning and maternal/child health services.
        Reprod Health. 2008;
        • Koenig LJ
        • Whitaker DJ
        • Royce RA
        • Wilson TE
        • Ethier K
        • Fernandez MI.
        Physical and sexual violence during pregnancy and after delivery: a prospective multistate study of women with or at risk for HIV infection.
        Am J Public Health. 2006; 96: 1052-1059
        • Jiwatram-Negrón T
        • El-Bassel N.
        Systematic review of couple-based HIV intervention and prevention studies: advantages, gaps, and future directions.
        AIDS Behav. 2014; 18: 1864-1887
        • Choi J
        • Fukuoka Y.
        Spousal influence on physical activity in physically inactive pregnant women: a cross-sectional study.
        Health Care Women Int. 2018; 39: 263-274
        • Audet CM
        • Blevins M
        • Chire YM
        • Aliyu MH
        • Vaz LM
        • Antonio E
        • et al.
        Engagement of men in antenatal care services: increased HIV testing and treatment uptake in a community participatory action program in Mozambique.
        AIDS Behav. 2016; 20: 2090-2100
        • Crepaz N
        • Tungol-Ashmon MV
        • Vosburgh HW
        • Baack BN
        • Mullins MM.
        Are couple-based interventions more effective than interventions delivered to individuals in promoting HIV protective behaviors? A meta-analysis.
        AIDS Care. 2015; 27: 1361-1366
        • Arden-Close E
        • McGrath N.
        Health behaviour change interventions for couples: a systematic review.
        Br J Health Psychol. 2017; 22: 215-237
        • Page MJ
        • McKenzie JE
        • Bossuyt PM
        • Boutron I
        • Hoffmann TC
        • Mulrow CD
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71
        • Sundermann AC
        • Hartmann KE
        • Jones SH
        • Torstenson ES
        • Velez Edwards DR
        Interpregnancy interval after pregnancy loss and risk of repeat miscarriage.
        Obstet Gynecol. 2017; 130: 1312-1318
        • Ouzzani M
        • Hammady H
        • Fedorowicz Z
        • Elmagarmid A.
        Rayyan—a web and mobile app for systematic reviews.
        Syst Rev. 2016; 5: 210
        • Khabsa M
        • Elmagarmid A
        • Ilyas I
        • Hammady H
        • Ouzzani M.
        Learning to identify relevant studies for systematic reviews using random forest and external information.
        Mach Learn. 2015; : 1-18
        • Harrison H
        • Griffin SJ
        • Kuhn I
        • Usher-Smith JA.
        Software tools to support title and abstract screening for systematic reviews in healthcare: an evaluation.
        BMC Med Res Methodol. 2020; 20: 7
        • Peetluk LS
        • Ridolfi FM
        • Rebeiro PF
        • Liu D
        • Rolla VC
        • Sterling TR.
        Systematic review of prediction models for pulmonary tuberculosis treatment outcomes in adults.
        BMJ Open. 2021; 11e044687
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG.
        Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inf. 2009; 42: 377-381
      2. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al., editors. Cochrane handbook for systematic reviews of interventions version 6.2 (updated February 2021). Chichester, United Kingdom: Cochrane: 2021.

        • Hubacher D
        • Trussell J.
        A definition of modern contraceptive methods.
        Contraception. 2015; 92: 420-421
        • Sterne JAC
        • Savović J
        • Page MJ
        • Elbers RG
        • Blencowe NS
        • Boutron I
        • et al.
        RoB 2: a revised tool for assessing risk of bias in randomised trials.
        BMJ. 2019; 366: l4898
        • Sterne JA
        • Hernán MA
        • Reeves BC
        • Savović J
        • Berkman ND
        • Viswanathan M
        • et al.
        ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
        BMJ. 2016; 355: i4919
        • Hernán MA
        • Hernández-Díaz S.
        Beyond the intention-to-treat in comparative effectiveness research.
        Clin Trials. 2012; 9: 48-55
        • Hernán MA
        • Alonso A
        • Logan R
        • Grodstein F
        • Michels KB
        • Stampfer MJ
        • et al.
        Observational studies analyzed like randomized experiments: an application to postmenopausal hormone therapy and coronary heart disease.
        Epidemiol Camb Mass. 2008; 19: 766-779
        • Hernán MA
        • Robins JM.
        Per-protocol analyses of pragmatic trials.
        N Engl J Med. 2017; 377: 1391-1398
      3. Confidence Interval for Two Independent Samples, Dichotomous Outcome n.d. (accessed September 10, 2021).

        • Guyatt GH
        • Oxman AD
        • Vist GE
        • Kunz R
        • Falck-Ytter Y
        • Alonso-Coello P
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Soliman MH.
        Impact of antenatal counselling on couples’ knowledge and practice of contraception in Mansoura, Egypt.
        East Mediterr Health J Rev Sante Mediterr Orient Al-Majallah Al-Sihhiyah Li-Sharq Al-Mutawassit. 1999; 5: 1002-1013
        • Turan JM
        • Nalbant H
        • Bulut A
        • Sahip Y.
        Including expectant fathers in antenatal education programmes in Istanbul, Turkey.
        Reprod Health Matters. 2001; 9: 114-125
        • Kunene B
        • Beksinska M
        • Zondi S
        • Mthembu N
        • Mullick S
        • Ottolenghi E
        • et al.
        Involving men in maternity care: South Africa.
        Reprod Health. 2004;
        • Caleb-Varkey L
        • Mishra A
        • Das A
        • Ottolenghi E
        • Huntington D
        • Adamchak S
        • et al.
        Involving men in maternity care in India.
        Reprod Health. 2004;
        • Villar-Loubet OM
        • Cook R
        • Chakhtoura N
        • Peltzer K
        • Weiss SM
        • Shikwane ME
        • et al.
        HIV knowledge and sexual risk behavior among pregnant couples in South Africa: the PartnerPlus project.
        AIDS Behav. 2013; 17: 479-487
        • Tran NT
        • Seuc A
        • Coulibaly A
        • Landoulsi S
        • Millogo T
        • Sissoko F
        • et al.
        Post-partum family planning in Burkina Faso (Yam Daabo): a two group, multi-intervention, single-blinded, cluster-randomised controlled trial.
        Lancet Glob Health. 2019; 7: e1109-e1117
        • Abdulkadir Z
        • Grema BA
        • Michael GC
        • Omeiza SY.
        Effect of antenatal couple counselling on postpartum uptake of contraception among antenatal clients and their spouses attending antenatal clinic of a Northern Nigeria tertiary hospital: a randomized controlled trial.
        West Afr J Med. 2020; 37: 695-702
        • Whiting-Collins LJ.
        Postpartum family planning among women attending group-based antenatal and postnatal care in Kenya and Nigeria: A cluster randomized control trial.
        The Johns Hopkins University, Baltimore, Maryland2020
        • Tran NT
        • Seuc A
        • Tshikaya B
        • Mutuale M
        • Landoulsi S
        • Kini B
        • et al.
        Effectiveness of post-partum family planning interventions on contraceptive use and method mix at 1 year after childbirth in Kinshasa, DR Congo (Yam Daabo): a single-blind, cluster-randomised controlled trial.
        Lancet Glob Health. 2020; 8: e399-e410
        • Coulibaly A
        • Baguiya A
        • Garanet F
        • Tran NT
        • Millogo T
        • Yaméogo WME
        • et al.
        Yam Daabo interventions’ effects on postpartum family planning use in Burkina Faso at 24 months after childbirth.
        BMC Public Health. 2021; 21: 1-7
        • Atukunda EC
        • Mugyenyi GR
        • Musiimenta A
        • Kaida A
        • Atuhumuza EB
        • Lukyamuzi EJ
        • et al.
        Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial.
        J Glob Health. 2021; 11: 04034
        • Turner EL
        • Li F
        • Gallis JA
        • Prague M
        • Murray DM.
        Review of recent methodological developments in group-randomized trials: Part 1-Design.
        Am J Public Health. 2017; 107: 907-915
        • Turner EL
        • Prague M
        • Gallis JA
        • Li F
        • Murray DM.
        Review of recent methodological developments in group-randomized trials: Part 2-Analysis.
        Am J Public Health. 2017; 107: 1078-1086
        • Bie R
        • Haneuse S
        • Huey N
        • Schildcrout J
        • McGee G.
        Fitting marginal models in small samples: a simulation study of marginalized multilevel models and generalized estimating equations.
        Stat Med. 2021; (n/a)
        • Toh S
        • Hernán MA.
        Causal inference from longitudinal studies with baseline randomization.
        Int J Biostat. 2008; 4: 22
        • O'Cathain A
        • Croot L
        • Duncan E
        • Rousseau N
        • Sworn K
        • Turner KM
        • et al.
        Guidance on how to develop complex interventions to improve health and healthcare.
        BMJ Open. 2019; 9e029954
        • Aliyu MH
        • Sam-Agudu NA
        • Shenoi S
        • Goga AE
        • Ramraj T
        • Vermund SH
        • et al.
        Increasing male engagement in the prevention of vertical transmission of HIV: what works in sub-Saharan Africa?.
        BMJ. 2019; 365: l1965
        • Peneza AK
        • Maluka SO.
        Unless you come with your partner you will be sent back home”: strategies used to promote male involvement in antenatal care in Southern Tanzania.
        Glob Health Action. 2018; 111449724
        • Turan B
        • Hatcher AM
        • Weiser SD
        • Johnson MO
        • Rice WS
        • Turan JM
        Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes.
        Am J Public Health. 2017; 107: 863-869
        • Harrington EK
        • Drake AL
        • Matemo D
        • Ronen K
        • Osoti AO
        • John-Stewart G
        • et al.
        An mHealth SMS intervention on postpartum contraceptive use among women and couples in Kenya: a randomized controlled trial.
        Am J Public Health. 2019; 109: 934-941