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Plain Language summary An inter-delivery interval (IDI) that is too short or too long increases the risk of adverse maternal and neonatal outcomes. However, the optimal IDI for trial of labor after cesarean delivery (TOLAC) remains unclear. We performed a multicenter, electronic medical record-based, retrospective cohort study that included 1080 pregnant women who had one or two cesarean deliveries and underwent TOLAC. Data on maternal and neonatal outcomes were collected from the electronic record system. In multivariable analysis, the incidences of postpartum hemorrhage, preterm birth, and low birth weight were significantly increased in women with an IDI of

Non-English language abstract (Spanish) Antecedentes Los intervalos intergenésicos cortos (menores de 33 meses, según la OMS) afectan la salud y el bienestar de la madre, el niño y la familia. Aunque los habitantes del norte de Nigeria reconocen muchos efectos adversos de un intervalo intergenésico corto (kunika en lengua hausa), éstos aún son frecuentes. Nosotros usamos cartografía cognitiva para sintetizar el conocimiento local sobre causas de kunika y guiar el codiseño de estrategias culturalmente seguras que permitan su disminución. Método Grupos de hombres y mujeres en doce comunidades hicieron 48 mapas, mientras funcionarios del Estado de Bauchi y del Área Local de Gobierno (LGA) hicieron otros cuatro. Cada mapa mostraba causas de kunika o de no-kunika con flechas indicando la influencia entre ellas. Los participantes ponderaron la influencia entre 1 (la más débil) y 5 (la más fuerte). Nosotros combinamos los mapas por grupos de mujeres, hombres y funcionarios. Con fuzzy transitive closure calculamos la máxima influencia entre factores cuando todas las relaciones en el mapa son consideraras. Condensamos los mapas agrupando factores individuales en categorías y calculamos la influencia neta acumulativa para cada una. Estos mapas los sintetizamos aún más para revisarlos con sus autores. Resultados Los mapas de los grupos comunitarios identificaron el sexo frecuente y factores relacionados, no usar anticonceptivos modernos o tradicionales y las dinámicas familiares (como el deseo de tener más hijos o la competencia entre esposas) como las causas más importantes de kunika. Los mapas de las mujeres identificaron el sexo forzado como causa importante y los mapas de los hombres destacaron la falta de conocimiento sobre anticoncepción y el temor a los efectos secundarios. La falta de participación masculina apareció en los mapas de las mujeres, del LGA y del Estado. Los mapas de los factores protectores reflejaron en gran medida los de las causas. Los grupos comunitarios aprobaron y apreciaron los mapas que sintetizaban el análisis. Conclusiones Los mapas comunitarios mostraron que kunika es el resultado de una compleja red de factores con dinámicas culturales específicas. Es poco probable que enfocarse solo en promover anticoncepción reduzca kunika. Los resultados del transitive closure pueden comunicarse al público en general para una mayor participación en la interpretación y uso de los resultados.

Background: Inter-delivery interval (IDI) has been proven to be a factor associated with adverse maternal and neonatal outcomes. However, the optimal IDI in trial of labor after cesarean delivery (TOLAC) remains unclear. We aimed to investigate the association between IDI and major maternal and neonatal outcomes in women who underwent TOLAC. Methods: A multicenter, retrospective cohort study including five hospitals was conducted between January 2018 and December 2019 in Foshan, China. This study included 1080 pregnant women with one or two cesarean deliveries who attempted a TOLAC. Data on maternal and neonatal outcomes were collected from the electronic record system. Maternal and neonatal outcomes in different groups of IDI were compared by univariate and multivariable analyses. Results: A short IDI of < 24 months did not show a statistically significant association with uterine rupture in the univariate analysis (P = 0.668). In multivariable analysis, the incidences of postpartum hemorrhage (OR 19.6, 95% CI:4.4–90.9, P < 0.05), preterm birth (OR 5.5, 95% CI:1.5–21.3, P < 0.05), and low birth weight (OR 3.5, 95% CI:1.2–10.3, P < 0.05) were significantly increased in women with an IDI of < 24 months than in those with a normal interval (24–59 months). Infection morbidity (OR 1.8, 95% CI:1.4–7.9, P < 0.05), transfusion (OR 7.4, 95% CI:1.4–40.0, P < 0.05), and neonatal unit admission (OR 2.6, 95% CI:1.4–5.0, P < 0.05) were significantly increased in women with an IDI of 120 months or more than in those with a normal interval. Postpartum hemorrhage (P = 0.062) had a trend similar to that of a significant IDI of 120 months or more. We found no statistically significant difference in maternal and neonatal outcomes between 24–59 months and 60–119 months. Conclusions: An IDI of less than 24 months or 120 months or more increased the risk of major maternal and neonatal outcomes. We recommend that the optimal interval for women who underwent TOLAC should be 24 to 119 months. Plain Language summary: An inter-delivery interval (IDI) that is too short or too long increases the risk of adverse maternal and neonatal outcomes. However, the optimal IDI for trial of labor after cesarean delivery (TOLAC) remains unclear. We performed a multicenter, electronic medical record-based, retrospective cohort study that included 1080 pregnant women who had one or two cesarean deliveries and underwent TOLAC. Data on maternal and neonatal outcomes were collected from the electronic record system. In multivariable analysis, the incidences of postpartum hemorrhage, preterm birth, and low birth weight were significantly increased in women with an IDI of < 24 months than in those with a normal interval (24–59 months). Infections, transfusion, and neonatal unit admission were significantly increased in women with an IDI of ≥ 120 months than in those with a normal interval. In conclusion, we found that an IDI < 24 months or ≥ 120 months increased the risk of major maternal and neonatal outcomes. We recommend that the optimal interval for women who underwent TOLAC should be 24 to 119 months. [ABSTRACT FROM AUTHOR]

Introduction: Despite evidence from recent Demographic Health Surveys that show 98% of the adult Pakistani population have an awareness of at least one modern contraceptive method, only 25% of married couples in Pakistan used a modern method of contraception. Of the modern contraceptive methods, LARC usage has increased only from 2.1 to 3%. This low uptake is puzzling in the context of high awareness of LARC methods and its availability through public sector facilities at subsidized costs. This study aimed to understand the social influences in initiating and continuing use of an LARC methods for contraception in a rural setting in Pakistan. Methods: In-depth interviews were conducted with 27 women who were using a LARC method for contraception. Data was managed using NVivo 12 and themes were identified using a content analysis approach to analyze the transcripts. Results: Four key themes, supported by sub-themes relating to a temporal model, were identified to explain women's experiences with initiating and continuing use of a LARC. The themes were (i) Use of trusted networks for information on LARCs; (ii) Personal motivation and family support in decision to use LARC; (iii) Choice of LARC methods and access to providers; and (iv) Social and professional support instrumental in long term use of LARC. Results highlight the significant role of immediate social network of female family members in supporting the women in initiating LARCs and maintaining the method's use. Conclusion: This study contributes to an in depth understanding of the decision-making process of women who adopted LARC and maintained its use. Women who proceeded to use an LARC and who persisted with its use despite the experience of side effects and social pressures, were able to do so with support from other female family members and spouse. Plain English summary: High proportion of married women do not use an effective contraceptive method and is a public health concern that is associated with unintended pregnancies, unwanted births, and unsafe abortions. This is also associated with increased risks of pregnancy and childbirth-related maternal morbidity. The decision to initiate use and continue the use of contraceptives is influenced by a number of factors. A greater understanding of these factors will inform policymakers, programmers, and other stakeholders to strengthen family planning and other health intervention programs to achieve the SDGs targeted maternal and under-5 child mortality reduction. Thus, the main objective of this study was to understand the social influences in initiating and continuing use of an LARC methods for contraception in a rural setting in Pakistan, using qualitative research. The analysis was done from a total of 27 women, aged 15–49 years, who started the use of long acting reversible contraceptive in the year preceding the study. The findings have an implication for policymakers, programmers, health care providers, and other stakeholders to evaluate and strengthen the provision of different contraceptive methods and improve support provided to women through the family planning programs. The findings of this study strongly recommended the provision of quality counseling on side effects and availability of contraceptive methods, peer support, and support for decision-making regarding long acting reversible contraceptive use. [ABSTRACT FROM AUTHOR]

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Background: Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear. Objective: To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia. Search strategy: MEDLINE, EMBASE and LILACS were searched (inception to July 2015). Selection criteria: Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals. Data collection and analysis: Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia. Main results: We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2-4 years, the aOR for recurrent pre-eclampsia was 1. 01 [95 % CI 0.95 to 1.07,I² 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19,I² 0 %] with intervals longer than 4 years. Conclusion: Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors. [ABSTRACT FROM AUTHOR]

Background: Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society - Pakistan implemented an operational research project - 'Evidence for Innovating to Save Lives', to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. Methods: We conducted a quasi-experimental (pre - and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, 1) Suraj model (meaning 'Sun' in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and 2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata® version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. Results: The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14 % percentage points, current contraceptive use by 5 % percentage points and long term modern method - intrauterine device (IUD) use by 6 % percentage points. The CMW model significantly increased contraceptive awareness by 28 % percentage points, ever use of contraceptives by 7 % percentage points and, IUD use by 3 % percentage points. Additionally the Suraj intervention led to a 35 % greater prevalence (prevalence ratio: 1.35, 95 % CI: 1.22-1.50) of contraceptive use among MWRA. Conclusion: Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas. [ABSTRACT FROM AUTHOR]

Background: High fertility rates, unwanted pregnancies, low modern contraceptive prevalence and a huge unmet need for contraception adversely affect women's health in Pakistan and this problem is compounded by limited access to reliable information and quality services regarding birth spacing especially in rural and underserved areas. This paper presents a study protocol that describes an evaluation of a demand-side financing (DSF) voucher approach which aims to increase the uptake of modern contraception among women of the lowest two wealth quintiles in Punjab Province, Pakistan. Methods/Design: This study will use quasi-experimental design with control arm and be implemented in: six government clinics from the Population Welfare Department; 24 social franchise facilities branded as 'Suraj' (Sun), led by Marie Stopes Society (a local non-governmental organization); and 12 private sector clinics in Chakwal, Mianwali and Bhakkar districts. The study respondents will be interviewed at baseline and endline subject to voluntary acceptance and medical eligibility. In addition, health service data will record each client visit during the study period. Discussion: The study will examine the impact of vouchers in terms of increasing the uptake of modern contraception by engaging private and public sector service providers (mid-level and medical doctors). If found effective, this approach can be a viable solution to satisfying the current demand and meeting the unmet need for contraception, particularly among the poorest socioeconomic group. [ABSTRACT FROM AUTHOR]