Hiller J E, Griffith E, Jenner F
Public Health, University of Adelaide, Adelaide, South Australia, Australia.
Cochrane Database Syst Rev. 2002(3):CD001863. doi: 10.1002/14651858.CD001863.
n 1966, the Population Council (a non-profit, non-government organisation which aims to foster reproductive health around the world) sponsored demonstration projects (known as the 'International Postpartum Program') on postpartum family planning, focussing primarily on developing countries and including 25 hospitals in 14 countries (Zatuchni 1970). These projects were based on the assumptions that women are receptive to family planning education in the postpartum period, and that they will not return to health centres for contraception once they have been discharged from hospital. The demonstration projects were declared a success given their ability to reach large numbers of women, and they were expanded to include hospitals in 21 countries (Winikoff et al 1991). Randomised controlled trials were not used to assess the effectiveness of the program. The provision of education on contraceptive use to postpartum mothers has come to be considered a standard component of postnatal care, with up to 84% of women noting that a discussion on contraception took place with a midwife on the postnatal floor (Glasier et al 1996). Although education frequently is provided as an integral component of discharge planning, many women experience this as a perfunctory discussion included as part of a checklist of topics (Glasier et al 1996). Midwifery and obstetric texts routinely refer to the provision of such education as a responsibility in the provision of postpartum care; however, the effectiveness of this intervention is seldom questioned (Keith et al 1980; Semeraro 1996). Questions have been raised about the assumptions that are the basis for such programs, e.g. that postpartum women are motivated to use contraception and that they will not return to a health centre for family planning advice (Winikoff et al 1991). In addition surveys conducted postpartum indicate that women may wish to discuss contraception antenatally and post hospital discharge, preferably in the context of general education about maternal and child health (Ozvaris 1997).
Postpartum education on contraceptive use is a routine component of discharge planning in many different countries with a wide variety of health care systems. This education is based on assumptions concerning women's receptivity to contraceptive education during the postpartum period and their presumed lack of access to such education after that time. The objective of this review is to assess the effects of education about contraceptive use to postpartum mothers.
We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, Psychlit, Popline, citations indexes and reference lists of relevant articles. We contacted subject experts to locate additional research, in addition to the Group's Specialised Register of Controlled Trials. Date of the most recent search: March 2001.
Trials using random or quasi-random methods of allocation which evaluated the effectiveness of postpartum education about contraceptive use.
Two independent reviewers abstracted data on trial characteristics and results.
No new trials were identified since this review was updated in 1999. Three trials were identified with 5438 women. These trials were conducted in Lebanon, Peru and Nepal. None of the trials examined all major prespecified endpoints. Postpartum education about contraceptive use influenced short-term use assessed between 40 days and three months post-partum. Women in the intervention groups were less likely to be non-users than women in the comparison groups (Odds Ratio (OR) = 0.47, 95% Confidence Interval (CI) 0.39 to 0.58). This benefit was not apparent following analysis of data from better quality studies (OR = 0.67, 95% CI 0.41 to 1.13). An apparent benefit on contraceptive use at six months post-partum (OR = 0.52, 95% CI 0.37 to 0.74) was not apparent following sensitivity analyses (OR = 0.59, 95% CI 0.33 to 1.06). Data are inadequate to assess the impact on cessation of breast feeding and non-attendance at family planning clinics. Unplanned pregnancies, knowledge about contraception and satisfaction with care were not assessed in any trial.
REVIEWER'S CONCLUSIONS: The effectiveness of postpartum education about contraceptive use has not yet been established in randomised controlled trials. Such education may be effective in increasing the short-term use of contraception. However, there are only limited data examining a more-important longer-term effect on the prevention of unplanned pregnancies. Research needs to be undertaken to assess the effectiveness of the minimalist education provided in more developed countries and the variety of programs provided in less developed regions. Such research should examine the content, timing, range and organisation of postpartum education on contraceptive use including lactational amenorrhea, as well as its impact on breast feeding rates.
1966年，人口理事会（一个致力于在全球促进生殖健康的非营利性非政府组织）发起了关于产后计划生育的示范项目（即“国际产后项目”），主要聚焦于发展中国家，涉及14个国家的25家医院（扎图奇尼，1970年）。这些项目基于以下假设：女性在产后阶段易于接受计划生育教育，并且出院后不会再返回健康中心获取避孕措施。鉴于这些示范项目能够覆盖大量女性，它们被宣布取得成功，并扩展至包括21个国家的医院（维尼康夫等人，1991年）。该项目的有效性并未通过随机对照试验进行评估。向产后母亲提供避孕使用教育已成为产后护理的标准组成部分，高达84%的女性表示在产后病房与助产士进行了关于避孕的讨论（格拉西尔等人，1996年）。尽管教育通常作为出院计划的一个组成部分提供，但许多女性认为这只是作为一系列主题清单的一部分进行的敷衍讨论（格拉西尔等人，1996年）。助产和产科教材通常将提供此类教育视为产后护理的一项职责；然而，这种干预措施的有效性很少受到质疑（基思等人，1980年；塞梅拉罗，1996年）。对于此类项目所基于的假设，例如产后女性有使用避孕措施的动机以及她们不会再返回健康中心获取计划生育建议，人们提出了质疑（维尼康夫等人，1991年）。此外，产后进行的调查表明，女性可能希望在产前和出院后讨论避孕问题，最好是在关于母婴健康的一般教育背景下进行（奥兹瓦里斯，1997年）。
在许多拥有不同医疗保健系统的国家，产后避孕使用教育是出院计划的常规组成部分。这种教育基于关于女性在产后阶段对避孕教育的接受程度以及她们在此之后可能无法获得此类教育的假设。本综述的目的是评估对产后母亲进行避孕使用教育的效果。
我们检索了考科蓝对照试验注册库、医学索引数据库、荷兰医学文摘数据库、护理学与健康领域数据库、心理学文摘数据库、人口数据库、相关文章的引用索引和参考文献列表。除了该小组的对照试验专门注册库外，我们还联系了主题专家以查找其他研究。最近一次检索日期：2001年3月。
采用随机或准随机分配方法评估产后避孕使用教育效果的试验。
两名独立的评审人员提取了关于试验特征和结果的数据。
自1999年本综述更新以来，未发现新的试验。共识别出三项试验，涉及5438名女性。这些试验分别在黎巴嫩、秘鲁和尼泊尔进行。没有一项试验考察了所有预先设定的主要终点。产后避孕使用教育对产后40天至三个月期间评估的短期使用有影响。干预组中的女性比对照组中的女性更不可能不使用避孕措施（优势比（OR）=0.47，95%置信区间（CI）0.39至0.58）。对质量更好的研究数据进行分析后，这种益处并不明显（OR = 0.67，95%CI 0.41至1.13）。产后六个月避孕使用方面的明显益处（OR = 0.52，95%CI 0.37至0.74）在敏感性分析后也不明显（OR = 0.59，95%CI 0.33至1.06）。数据不足以评估对停止母乳喂养和未前往计划生育诊所的影响。任何试验均未评估意外怀孕、避孕知识以及对护理的满意度。
在随机对照试验中，产后避孕使用教育的有效性尚未得到证实。此类教育可能在增加避孕措施的短期使用方面有效。然而，关于预防意外怀孕这一更重要的长期影响的数据有限。需要开展研究以评估在更发达国家提供的极简教育以及在欠发达地区提供的各种项目的有效性。此类研究应考察产后避孕使用教育（包括哺乳期闭经）的内容、时机、范围和组织方式，以及其对母乳喂养率的影响。
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