The past decade has seen a resurgence of interest in postpartum family planning, partly in response to recommendations for programming strategies published by the World Health Organization (WHO) [1]. The rationale for this focus is threefold. First, the risk to the health and survival of closely spaced children is well established. A recent analysis, based on 4.5 million births from 77 countries, controlling for unobserved heterogeneity by using within-family models, supported the WHO recommendation that births should be spaced almost 3 years apart. Moreover, adverse effects of short inter-birth intervals were found to be most severe in high fertility counties at low levels of development [2]. Short intervals also pose risks for the mother including obstructed labor, hemorrhage, and hypertensive disorders, though no clear association with maternal death has been established [3]. Second, the subjective desire for pregnancy prevention is high following a birth, as a large majority of couples wish to delay the next pregnancy for 2 years or more [4]. Third, contact between women and health services is most intense during pregnancy, delivery, and in the 12 months following birth. Antenatal, delivery, and infant care services all offer opportunities for family planning counselling and contraceptive methods can be provided immediately after delivery or later during the postpartum period, for instance when mothers bring infants for immunization. All contraceptive methods can be initiated immediately following birth or after a delay of 6 weeks, with the exception of combined oral contraceptives for breast feeding women.
Postpartum contraceptive services need to consider the fact that lactational amenorrhea also offers protection against pregnancy. This protection was recognised by WHO and other family planning agencies in 1998 in the form of the Lactational Amenorrhea Method (LAM). LAM is acknowledged as an effective method under the following conditions: the mother is fully breastfeeding with little or no supplementary feeding, is amenorrheic, and her infant is less than 6 months old [1]. It can be argued that these conditions are too restrictive. A review of nine studies concluded that the risk of pregnancy in the 12 months after birth is, on average, 6% for sexually active, breastfeeding, amenorrheic women [5]. This risk is about the same as the failure rate for oral contraception and lower than the rate for condoms. There is, however, an important distinction. Pregnancy while using oral contraceptives or condoms is largely attributable to incorrect or inconsistent use, while pregnancy during lactational amenorrhea reflects the fact that first ovulation typically precedes resumption of menses, and thus cannot be anticipated or the risk of conception reduced by behavioural precautions. Though one study found that socio-economic development weakens the contraceptive effect of breastfeeding, presumably through the pathway of improved maternal nutrition, the risks of pregnancy during lactational amenorrhea in the first six postpartum months were found to be less than 2% in a study of well-nourished women despite supplementation [6, 7].
While it is uncertain whether women are aware of the risks of relying on lactational amenorrhea, it is firmly established that many in low- and middle-income countries delay contraceptive uptake until the return of menses. An analysis of survey data from 17 countries, mostly in sub-Saharan Africa, found that contraceptive use was typically two to three times more prevalent at six to nine months after birth among women whose menses had returned than among those still amenorrheic [8].
Though the standard Demographic and Health Survey (DHS) measure of unmet need considers delayed resumption of menses, most analyses of postpartum contraception follow the restrictive WHO approach which advocates contraceptive adoption except for those observing LAM, and derive high estimates of unmet need in the 12 months following birth [4, 9]. A systematic review and meta-analysis of postpartum contraception found that use of a modern contraceptive method was lowest in West Africa, at 36%, and unmet need highest at 59% [10]. Another systematic review investigating factors that influence postpartum contraceptive use and unmet need in sub-Saharan Africa reported that use of maternity services and receipt of family planning counselling were associated with reduced unmet need. Major reasons for non-use of contraception included fear of side effects, husband’s disapproval, absence of menses, delayed resumption of sex, and low perceived risk of pregnancy [11].
None of the papers cited in the previous paragraph included Cameroon. Indeed, little is known about postpartum contraception in this country. We located only one relevant study, which examined knowledge and attitudes based on a small sample of 300 respondents in one district [12]. Accordingly, the broad aim of this paper is to remedy this lack of evidence and provide guidance on ways in which postpartum family planning services can be improved. The specific objectives are to: (1) establish the level of exposure to the risk of an unintended pregnancy in the 18 months following childbirth, taking into account the protective contribution of sexual abstinence and amenorrhea as well as use of contraception; (2) identify population groups most at risk; (3) investigate the factors associated with use of a modern method of contraception in the extended postpartum period; and finally (4) explore opportunities for increasing postpartum contraceptive use by documenting the extent to which mothers have received recent counselling on family planning and whether receipt is associated with contraceptive use.
Context
Cameroon has an ethnically diverse population of about 26 million. Between 1990 and 2019 life expectancy rose from 53 to 59 years, mean years of schooling from 3.5 to 6.3, gross national income per head (at 2017 PPP$) from 3,100 to 3580, and the human development index from 0.448 to 0.563 [13]. According to the Cameroon Demographic and Health Surveys (CDHSs), the maternal mortality ratio dropped by 40% between 2011 and 2018, from 782 to 406 deaths per 100,000 livebirths. The 2018 CDHS found that 67% of recent births took place in a health facility; infant mortality fell from 70 deaths per thousand births in the 1990s to 48 in the recent past. The percent of children receiving the full schedule of vaccinations rose from 40 to 52% over the same period. CDHSs also document a fall in HIV prevalence from 6.6% in 2004 to 3.4% in 2018 among in women aged 15 to 49, and from 4.1% to 1.9% among men in the same age bracket. Likewise, a more recent study revealed that HIV incidence has fallen dramatically since its peak of 500 cases per 100,000 population in the late 1990s [14].
CDHS reports show that despite these positive trends, the total fertility rate (TFR) has declined at a slow pace from slightly over six births per woman in the mid-1980s to just below five births per woman in 2015–18, with a large rural–urban contrast of about 6.0 in rural areas compared with 3.8 in urban localities. The level of modern contraceptive use in married women remains low at 15% in 2018, with little change since 2004. Total demand for family planning in married women actually fell from 46 to 42% between 2012 and 2018. However, modern method use is much higher, at 43% in 2018, among sexually active unmarried women. The main driver of fertility decline has probably been delayed marriage and first birth, together with increased uptake of contraception before marriage, rather than falls in marital fertility.
Birth intervals and postpartum behaviour are of particular relevance to the purposes of this paper. Unlike many other African countries, the length of birth intervals in Cameroon has remained unchanged since 1991, the date of the first CDHS, with a median length of about 30 months. Similarly, the percentage of inter-birth intervals that are less than 24 months has fluctuated over time between 21 and 25%. The combination of high fertility and short birth intervals underscores the important potential contribution of postpartum contraception to further improvement in child health and survival. In a country with a TFR of two births, only half of children are exposed to the risk of a short preceding birth interval, whereas in Cameroon, with a TFR of close to 5, four-fifths (i.e., 80%) of children have an elder sibling and are thus potentially exposed.
The risk to child survival of short intervals is severe in Cameroon. The 2018 CDHS reveals a sharp gradient in under-five mortality. For children born within 24 months of an elder sibling, 135 per thousand died before their fifth birthday. This figure falls to 92, 67 and 47 for children born after intervals of two, three and four or more years, respectively.
While births reported by mothers in Cameroon as unwanted are rare, at 4% in the 2018 CDHS, 19% were reported as mistimed and this proportion has changed only minimally since 1991. This estimate constitutes strong evidence of a demand for improved birth spacing and thus a need for improved postpartum contraception.
Postpartum behaviours—breastfeeding and delayed resumption of sex—are major determinants of birth interval length. In Cameroon, prolonged breastfeeding remains the norm; the median length of lactation declined only slightly between 1991 and 2018, from 17 to 15 months. The relative decline in postpartum amenorrhea was more pronounced, from 10.5 to 8.3 months. The most emphatic change concerns postnatal sexual abstinence, which fell from 13 months in 1991 to 4.2 months in 2018. This trend is likely to be associated with the decline in polygyny, with the proportion of married women with co-wives falling from 39 to 25% over the same period.
Family planning services
Over the past 40 years, Cameroon government policy on population has shifted gradually from a pronatalist to a cautious anti-natalist stance. Population policies, initially adopted in 1993 and revised in 2002, were characterised by broad-based goals with little reference to demographic topics and no quantifiable targets [15].
Policies on family planning have strengthened in the past decade. In 2012, as part of the fulfilment of its FP2020 commitments, Cameroon adopted a budget line for the purchase of contraceptives in order to improve the availability of contraceptives, but these funds could not be mobilized, due to competing priorities for government funding [16]. The country developed its 2015–2020 operational plan which describes high-impact interventions to increase contraceptive prevalence from 16.1% to 30%. The Plan targeted about 1.8 million new users at the national level [17]. No doubt in response to these developments, Cameroon’s National Composite Index for Family Planning, which measures the strength of family planning policy and implementation, rose from a score of 51 in 2014 to 67 in 2018 [18]. However, there is little sign, so far, that contraceptive use has increased. According to CDHSs, the prevalence of use of a modern method by married women remained unchanged at 15–16% between 2011 and 2018 and reported use among sexually active unmarried women actually fell. Though use of injectables and implants has gradually increased, condoms, typically obtained from commercial sources, remain the most commonly used modern method, even among married women.
In Cameroon, the Family Health Department within the Ministry of Health is responsible for family planning. Services are offered by health personnel trained in contraceptive technology, either by pre-service or continuous training. According to the level of the health facility, family planning is offered either by a dedicated unit or within the framework of integrated services. In general, staff who offer family planning in health facilities are insufficient in number. Though accurate data are not available on the number of personnel trained in intrauterine device (IUD) and Implant insertions, a severe shortage of such staff has been acknowledged by the government and its partners as a major barrier to family planning service delivery in the country.
Limited information on postpartum family planning comes from a project and quasi-experiment, implemented by Evidence to Action (E2A), led by Management Sciences for Health (MSH) with funding from the United States Agency for International Development (USAID). The quasi-experiment involved six hospitals in Yaoundé and the effect on contraceptive uptake was measured in terms of couple-years of protection (CYPs) over a three-month period prior to, and following, the intervention. The effect was positive but very modest. In hospitals receiving management and clinical training, CYPs rose from 23.8 to 33.1 and from 20.8 to 35.0 in hospitals receiving clinical training only [19]. Perhaps for this reason, the project failed in its intention to become a basis for widespread scale-up. Many barriers to postpartum family planning were identified, including lack of demand, supply-chain defects, weak staff motivation, heavy obstetric work load, and inability of some patients to pay fees. More recent experimental evidence indicates that offering discounts on the full fee for IUDs and implants (CFA 4000 = US$ 7.25) can increase uptake, including among postpartum women [20].
Both long-acting reversible contraceptives (LARCs) and short-acting methods are part of essential drugs and their availability is the responsibility of the national centre for supply of essential drugs and medical consumables. Moreover, the procurement of contraceptives is done at the global level with the support of the United Nations Population Fund (UNFPA) and other partners, on the basis of national quantification. At the level of health facility, despite the subsidization of cost in order to improve financial access to long-acting methods, their availability remains low due to a poorly functional logistics chain and insufficient demand creation. Accessibility to family planning services, particularly injectables and including Sayana Press (DMPA-SC), has been improved by community-based distribution through trained community health workers.
In a bid to expand services, social franchising and social marketing strategies are also implemented in Cameroon. Population Services International (PSI)’s Cameroon affiliate, Association Camerounaise pour le Marketing Social (ACMS) has been implementing social franchising, especially for long-term methods. Social marketing activities have also been carried out since the early 1990s, with focus on HIV/STD prevention, family planning, and improved awareness and preventive behaviour.
Data from the 2018 CDHS suggest that mass media promotion of family planning is limited. Almost seven in ten women (69%) and nearly six in ten men (58%) were not exposed in the last 12 months before the survey to messages about family planning. Indeed, they neither saw nor heard messages about family planning through media such as radio, television, newspapers/magazines, cell phone. The percentages of women and men who listened to family planning messages on radio and television are 14% and 21%, respectively, for radio and 18% and 22% for television. Newspapers/magazines and cell phones are uncommon information channels for conveying family planning messages, to both women and men. Overall, then, the population in Cameroon, and postpartum women in particular, have limited access to family planning messaging. It should be noted that an effort is being made through community radio stations to raise awareness of RH/FP, particularly in the most affected regions.