The effect of a prenatal family planning counseling intervention led by community health workers on postpartum contraceptive uptake in the West Bank
Awarded 2013
Complex Family Planning Fellowship Research
Rasha Khoury, MD
Planned Parenthood League of Massachusetts

Little is known about contraception use among postpartum women in the West Bank. Survey data shows that 27% of birth intervals are under 18 months and 40% of pregnancies are mistimed or unwanted (Family Health Survey, Palestinian Central Bureau of Statistics 2007). While 40% of women report using modern contraceptive methods, they are predominantly older women who have completed desired childbearing. The extended postpartum period likely represents a time of under-addressed contraceptive need in the reproductive life cycle of Palestinian women.
In this study, we investigated whether a community health worker (CHW) family planning counseling intervention administered during prenatal care can increase contraceptive use among postpartum women in the West Bank. Women were enrolled in two Palestinian (governmental) maternal child health clinics in the towns of Ramallah and Al-Bireh. Women enrolled at the Ramallah clinic received standard care (target N: 79) while women enrolled in the Al-Bireh clinic received the study intervention (target N: 79). Our intervention was led by community health workers to both highlight the need for dedicated family planning counseling during prenatal care as well as the need to expand family planning service provision beyond medical facilities and biomedical providers and into communities and homes (future research).  Follow-up data collection included 3- and 6-month follow-up surveys administered over the phone. The main outcome was self-reported contraceptive use. Secondary outcomes included intent to use contraception in the future and non-desire to use contraception.
We approached 202 women about study participation. Of those women, 176 women enrolled, 80 from the Ramallah clinic (standard care) and 96 from the Al-Bireh clinic (intervention).  Seventeen women who enrolled at the Al-Bireh clinic did not complete the study intervention (primarily due to delivery before scheduled intervention date), so enrollment at the Al-Bireh clinic continued until we reached our target of 79 women having received the study intervention. In the group enrolled at the Ramallah clinic, 74 completed the 3- and 6-month follow-up surveys. In the group enrolled at the Al-Bireh clinic, 78 completed the 3-month follow-up (65 who received the intervention and 13 who did not) and 76 completed the 6-month follow-up (64 who received the intervention and 12 who did not).
Demographically the women in both groups were similar in age, parity, gestational age at enrollment, number of years married, husbands’ level of education and differed in residence locality (city, village, refugee camp) –more urban dwellers in the control group, education level –more post secondary degrees in the intervention group, household size and whether or not they received additional antenatal care elsewhere (often in their local community clinic). There was no difference in reported use of modern contraceptives among participants from the Ramallah clinic compared to participants from the Al-Bireh clinic at 3-months (38 vs. 40 participants respectively, p=0.4379) or at 6-months (39 vs. 50 participants respectively, p=0.6596).  These results did not change when the analysis excluded participants who withdrew from the study, were lost to follow-up, or did not complete one of the follow-up surveys.
That said the CHWs were allowed into Ministry of Health clinics for the first time, welcomed by clinic staff and study participants alike. Demonstrating that the the family planning counseling intervention was both acceptable and feasible has allowed me access to future collaboration with the Palestinian Ministry of Health primary care services. I have now relocated back to East Jerusalem and am establishing myself as a women’s health clinician and researcher. I have strengthened my relationship with the CHW association in the West Bank and continue to support their efforts to integrate into mainstream primary health care services with a specific interest in decentralizing family planning service provision in the West Bank.