Background: Stillbirth and neonatal mortality are very high in many low-income countries, including Malawi. Use of family planning to encourage birth spacing may optimize outcomes for subsequent pregnancies. However, reproductive desires and influences on birth spacing preferences of women who have experienced a stillbirth or neonatal death in low-resource settings are not well understood. Methods: We conducted a qualitative study using 20 in-depth interviews and four focus group discussions with women who had experienced a stillborn baby or early neonatal death to explore attitudes surrounding birth spacing and potential interventions to promote family planning in this population. Qualitative data were analyzed for recurrent patterns and themes and central ideas were extracted to identify their core meanings. Results: Forty-six women participated in the study. After experiencing a stillbirth or neonatal death, most women wanted to wait to become pregnant again but women with living children wished to wait for longer periods of time than those with no living children. Most women preferred birth spacing interventions led by clinical providers and inclusion of their spouses. Conclusions: Many influences on family size and birth spacing were noted in this population, with the most significant influencing factor being the spouse. Interventions to promote birth spacing and improve maternal and neonatal health in this population need to involve male partners and knowledgeable health care providers to be effective. Trial registration: Clinicaltrials.gov NCT02674542 Registered February 1, 2016 (retrospectively registered). Keywords: Birth spacing, Stillbirth, Neonatal death, Malawi, Africa Background neonatal death in Malawi is preterm birth . Several Stillbirths and neonatal deaths remain high in many retrospective studies have shown an association between a low-income countries. Worldwide, there are an estimated short interpregnancy interval (IPI) and adverse maternal 2.64 million stillbirths and 2.0 million early neonatal and newborn outcomes: low birth weight (LBW), small deaths yearly . The perinatal death rate in Malawi is 35 for gestational age (SGA), preterm birth, premature pre- per 1000 pregnancies of 7 or more months gestation , term rupture of membranes (PPROM), and maternal much higher than a rate of 6.51 in high income countries death . Adverse perinatal outcomes are seen with IPI such as the United States. . The leading cause of less than 18 months [6–8]. In Malawi, pregnancies that occurred fewer than 15 months after the previous preg- * Correspondence: email@example.com nancy have the highest perinatal mortality rate (55 deaths UNC Project-Malawi, Private Bag, A-104 Lilongwe, Malawi per 1000 pregnancies) when compared to other birth spa- UNC Department of Obstetrics & Gynecology, Chapel Hill, NC, USA cing intervals . The World Health Organization Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 2 of 12 (WHO) currently recommends an IPI of at least of life; 3) ability to speak Chichewa (the local language) or 24 months to reduce infant and child mortality as well as English fluently; and 4) age 18–45 years old. to benefit maternal health . We recruited 60 women with and without living chil- Few Malawian women have a birth interval less dren from prior pregnancies at a 1:1 ratio from the post- than 18 months (2.9%) if the preceding child is living natal wards. A demographic form was completed for at the time of the next birth. However, this propor- women who consented to be part of the study. This tion increases to 22.8% if the preceding birth’sstatus form collected information about age, number of other is deceased at the time of the next birth . It is un- living children, HIV status, marital status, completed clear if women in this situation desire short IPIs, are education, and occupation. Data on access to a working influenced to do so by people or situations, or are phone and roof type were collected to assess socioeco- aware of the risks associated with short IPI. nomic status. HIV testing is performed on all Malawian There may be a role for postpartum birth spacing educa- women during antenatal care unless they opt out. HIV tion and provision of family planning to increase IPIs in this status was determined by verifying the participant’s population. Postpartum contraception has been shown to be health passport (a government-issued personal medical protective against preterm birth . Though lactational record booklet kept by the patient) with the participant’s amenorrhea is a very effective method of contraception in permission at time of enrollment. the first 6 months postpartum  and breastfeeding rates Enrolled women were then contacted and traced 4– in this time period are very high in Malawian and other 8 weeks later to either participate in an in-depth inter- sub-Saharan African populations [12, 13], women with a view or a focus group discussion. All in-depth interviews stillbirth or neonatal death are unable to use lactational and focus group discussions were conducted by the amenorrhea as a family planning method as they have no same experienced bilingual researcher (M.T.). Twenty living child to breastfeed. In low-resource settings, the rates in-depth interviews took place in participants’ homes or and reasons for postpartum contraceptive use for birth spa- another private setting and four focus group discussions cing after a neonatal death or stillbirth are largely unknown. (of 6–8 participants each) took place in a private confer- Understanding the attitudes surrounding future fertil- ence room on the campus of Kamuzu Central Hospital ity and birth spacing in this population is critical to in Lilongwe, Malawi. Interviews and focus group discus- propose socially and culturally acceptable interventions sions were audiotaped, transcribed and translated into to address their potential unmet need for family plan- English. All transcriptions and translations were com- ning. Therefore, we conducted a qualitative study to ob- pleted by the same researcher (M.T.). Accuracy of the tain data exploring birth spacing intentions, influences translations was verified by two other bilingual members on these intentions, and preferred modes of birth spa- of the research team (A.B. and G.H.). cing interventions among Malawian women who had ex- Our analysis approach was to use content analysis to perienced poor obstetric outcomes. compare the birth spacing intentions of women who did and did not have living children. The interview and focus Methods group discussion guide (Additional files 1 and 2) focused This was a qualitative study using in-depth, on several domains, two of which are relevant to this ana- semi-structured interviews and focus group discussions. lysis: 1) birth spacing plans and influences, and 2) accept- Approval was obtained from the National Health Sci- able educational interventions to promote birth spacing ences Research Committee of Malawi (Protocol #1354) and family planning among women with poor obstetric and the University of North Carolina School of Medicine outcome. Focus group and in-depth interview guides were Institutional Review Board (#14–2677). Women gave used to ensure that all critical topics were discussed, but written informed consent at the time of enrollment in the interviewer was given license to cover topics in a man- the language of their choice (Chichewa or English). ner that facilitated flow and rapport. A specific aim of the The study population was recruited from Bwaila Hos- focus group discussions was to facilitate brainstorming pital, a district government hospital in Lilongwe, the cap- about potential birth spacing interventions, whereas the ital city of Malawi. Bwaila has approximately 15,000 in-depth interviews focused more on individual and social deliveries annually, of which 2900 are preterm. Between influences on birth spacing that may be too personal to 80 and 110 cases of birth asphyxia (a portion of which re- share in a group setting. For each domain, results were an- sults in stillbirth or neonatal death) occur each month on alyzed separately for women with and without living chil- the labor ward. Inclusion criteria for the study were: 1) dren prior to the stillbirth or neonatal death to examine current admission to the postpartum ward at Bwaila Hos- the role this plays on reproductive desires. pital; 2) delivery of a stillborn over 28 weeks gestation or Previous qualitative exploration in this field has dem- with a birthweight ≥1000 g, or delivery of a liveborn infant onstrated that the minimum threshold for data satur- weighing ≥1000 g with a neonatal demise in the first 7 days ation can be reached within 20 in-depth interviews and Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 3 of 12 four focus group discussions [14–16]. Transcripts of Although 30 women with living children and 30 women completed interviews were independently analyzed by without living children were recruited, slightly more two of the investigators (A.B. and D.K.). A code diction- women who participated in the study (n = 28, 61%) had liv- ary was developed in an iterative process based on iden- ing children (Table 1). Most women were between the ages tified domains, and this dictionary was assigned to of 18–34 years, and women without living children were sections of the text using qualitative software NVivo® 10. younger than those with living children. Seven women Recurrent themes and sub-themes were identified based (15%) were HIV-infected. Those with living children had a on these initial codes, and any discrepancies were re- median of 2children(range1–8). More women with living solved through discussion. Matrices and tables were children were married, HIV-infected, had no education, used to organize the data and display these to facilitate and had a metal, wood, or cement roof. During the inter- analysis that integrated both in-depth interviews and views and focus groups, many sub-themes emerged under focus group discussions based on the conceptual do- content analysis (Table 2), which revealed the dynamics be- mains determined a priori. hind reproductive decision-making in this group of women. Results Birth spacing plans and influences Participant characteristics We identified two themes of influence on birth spacing Of the 60 women enrolled in the study, 46 women partici- plans among women who had experienced poor obstetric pated in focus group discussions or in-depth interviews 4– outcome: biological and social. These two themes were 8 weeks after delivery. Twenty in-depth interviews and four then broken down into relevant sub-themes. focus groups with 6–7 women per group were conducted. Table 1 Participant Characteristics n = 46 (20 in-depth interview participants and 26 focus group discussion participants) Characteristic All participants (n = 46) n (%) Women with living children (n = 28) n (%) Women without living children (n = 18) n (%) Age 18–24 years 24 (52) 8 (29) 16 (89) 25–34 years 16 (35) 14 (50) 2 (11) ≥35 years 6 (13) 6 (21) 0 (0) Pregnancy Outcome Stillbirth 23 (50) 14 (50) 9 (50) Neonatal death 23 (50) 14 (50) 9 (50) Marital Status Married 39 (85) 28 (100) 11 (61) Not married 7 (15) 0 (0) 7 (39) HIV status HIV-uninfected 39 (85) 22 (79) 17 (94) HIV-infected 7 (15) 6 (21) 1 (6) Religion Christian 37 (80) 22 (79) 15 (83) Muslim 9 (20) 6 (21) 3 (17) Education None 12 (26) 9 (32) 3 (17) Some primary 21 (46) 13 (46) 8 (44) Secondary or more 13 (28) 6 (21) 7 (39) Phone Has working phone 17 (37) 12 (43) 5 (28) No working phone 29 (63) 16 (57) 13 (72) Roof type None/Grass 16 (35) 8 (29) 8 (44) Metal/wood/cement 29 (63) 20 (71) 9 (50) Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 4 of 12 Table 2 Domains, categories, themes, and sub-themes from interviews and focus groups with Malawian women after a poor obstetric outcome Domain Theme Sub-theme Birth spacing plans and influences a. Biological 1) Role of the incident pregnancy and number of living children 2) Return to fertility: correct and incorrect knowledge 3) Gaining strength after birth 4) Influence of delivery experience/maternal health 5) Replacing the deceased child b. Social 1) Care for existing children/preparing for next child 2) Husband’s desires/Concerns about marital conflict 3) Influence of family/friends Acceptable educational interventions to promote a. Personal experience with birth spacing birth spacing education b. Recommendations for birth spacing 1) Timing of birth spacing intervention interventions 2) Location of birth spacing intervention 3) Providers of birth spacing intervention 4) Group or individual sessions 5) Involving men in birth spacing intervention Biological the 28 women with living children, four did not want Role of the incident pregnancy and number of living any additional children and were planning to obtain children sterilization. None of the women without living children All but one woman agreed that the birth spacing interval expressed a plan for sterilization. should be shorter for women who had experienced a Of those who desired more children, most women stillbirth or neonatal death than those who had experi- wanted to wait to become pregnant again. The amount enced a live birth of a healthy newborn, though they did of time women wished to wait until their next pregnancy not agree on exactly how long this waiting time should varied by whether or not they had living children. Most be. The one woman who felt birth spacing intervals women with living children wished to wait at least would be the same had no living children and was not 2 years, whereas most of those without living children married. wished to wait 1–12 months before attempting pregnancy. “Because if the child is alive, it is understood and even the husband can agree that you should use child Return to fertility: Correct and incorrect knowledge spacing methods, but if the child is not alive, there is Most women correctly named having sexual inter- no way you can wait for a longer time…But not that course before initiating family planning methods as the child spacing period between the child that is dead being a main influence on birth spacing. Several can be the same as that of the child that is alive women recognized that they and other women who because you can have a spacing of three or four years just had a stillbirth or early neonatal death might for a child that is alive and this cannot apply to the have a higher fertility after delivery than those who child that is dead. The woman with a child that is recently gave birth to a living child. dead can only wait for some months or one year.” (Focus group 1, participant no. 4, age 18–24 years, no “There is a difference between a woman who has a live living children). child and the one who has a child that did not live. The one with a live child can stay for one year without All women were also asked about their personal plans pregnancy because she is breastfeeding but for someone for birth spacing. There were differences between those who has a child that did not live she can become who had living children and those who did not. Among pregnant soon [after] she resumes sex.” (In-depth Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 5 of 12 interview participant no. 13, age 25–34 years, 6 living Interviewer: “What factors would encourage women to children). use family planning after having babies that are living?” However, not all women understood the signs and symp- Focus group 1 participant no. 4: “The problems that toms of a return to fertility postpartum. Specifically, some the women went through during labor and delivery.” thoughtthat women could not getpregnantiftheystill had some bleeding after childbirth (lochia). Other women incor- Interviewer: “Like what problems?” rectly noted that before normal menstrual cycles resume again, women are unable to become pregnant. Focus group 1 participant no. 4: “Say during pregnancy the woman was experiencing high blood Gaining strength after birth pressure, anemia, she can be afraid to become Nearly all women cited the need to gain strength and/or pregnant soon. She can decide to wait…so while energy after birth as an influencing factor on birth spa- waiting for the time to become pregnant again the cing. Most women also closely associated gaining of women will need to use reliable family planning strength with the replacement of blood lost during methods.” (age 18–24 years, no living children). delivery. A few women specifically felt that their health condi- Interviewer: “Why do you want to become pregnant tion made any future pregnancies risky and influenced again after two years?”Participant: “My body should their decision to seek permanent sterilization to have no regain its strength and it should be strong enough to more future pregnancies. accommodate another pregnancy. Because it happens that during labor and delivery, a woman may lose a Interviewer: “Why do you want to go for permanent lot of blood. So the blood which was lost during contraception?” delivery has to be replaced before she gives birth to another child. By the end of two years going upwards, Participant: “I am HIV positive, and it just happened the woman has regained her energy and the blood that that I became pregnant because my new husband she lost has been replaced.” (In-depth interview wanted a child, but I had many complications during participant no. 7, age 25–34 years, 1 living child). pregnancy, labor and delivery, and had it been that I was not rushed to Bwaila [Hospital] I would have lost my life. So I don’t want to become pregnant again.” Influence of delivery experience/maternal health (In-depth interview participant no. 17, age ≥35 years, Women also cited their prior delivery experience as 4 living children). a factor influencing them to wait before getting pregnant again. However, the way this experience in- Though 15% of participants were HIV-infected, this fluenced them differed. Some women said that mode was the only mention of HIV status as an influence on of delivery influenced birth spacing. birth spacing. No differences in frequency or type of re- sponses were seen on the influences of birth spacing be- Interviewer: “Why after two years?” tween HIV-infected and HIV-uninfected women. More than half of the women seemed to have almost no Participant: “Because of the problem of cesarean… understanding about associated conditions or complica- because the wound by then is not yet healed.” tions that led to their child’s stillbirth or neonatal death. For these women unanswered questions about how they could Interviewer: “What if she had normal prevent this in future pregnancies influenced them to wait delivery?”Participant: “She can wait for one year.” (In- before attempting another pregnancy. Another way delivery depth interview participant no. 3, age 18–24 years, 1 experience influenced women was through psychological living child). trauma. Some women noted that dealing with loss of a child they had been anticipating for months would be alive Other women pointed out that they had experi- was difficult, and they would need time to emotionally re- enced medical complications that caused them to de- cover from this. sire longer waiting periods before achieving another pregnancy. These women pointed out that perhaps by “Sometimes you are afraid after experiencing a waiting longer, they might be able to avoid these stillbirth because you never know what went wrong in complications or more severe exacerbations of these your womb and this can encourage you to be on family conditions in future pregnancies. planning method before becoming pregnant again. Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 6 of 12 Also fear. Like myself, I am always afraid of to be able to care for their existing children or prepare experiencing the same problem. So I feel like it is for their next child. They did not make a distinction be- better to take family planning methods so that may be tween their experience of having had stillbirth or neo- time can help me to recover from the trauma that I natal death and other women whose pregnancy resulted went through.” (Focus group 1, participant no. 7, age in a live child. Other women noted that birth spacing 18–24 years, no living children). was important for financial reasons, such as being able to spend more time farming or growing their business to have the resources to buy and provide the necessities for Replacing the deceased child raising future children. Nearly all women cited an impulse to replace the child that was recently lost with another pregnancy as a strong “…we want to work in our farm and see how best we influencer on birth spacing after poor obstetric outcome. can take care of the children that we already have. So Few women expressed that this was an internal motivating even we already had plans of waiting to take care of factor, but many more expressed that the husband was our children before I become pregnant again.” (In- pushing this perspective within the family. depth interview participant no. 9, age 18–24 years, 3 living children).2 Interviewer: “Why do you think the woman should wait for one year if she gave birth to a child that did not live”? Husband’s desires/concerns about marital conflict Although several women stated that their husband Participant: “Because the husband may say that he agreed with their plans for birth spacing, many dis- wants a child in the house. So the family has to forge cussed a conflict or a potential conflict between their ahead and not just to be disappointed because they views and the views of their spouses. In all cases, the con- had a child that did not live”. (Focus group 3, flict arose because women wanted to wait longer to be- participant no.2, age 18–24 years, 1 living child). come pregnant than the husband wanted to wait. A related concept to the need to replace the child that Interviewer: “How about your husband, when would had passed was termed by several women both in in-depth he want you to be pregnant again?” interviews and in focus groups as “spacing the grave”. Participant: “He may want me to be pregnant very Participant: “Because here in the village, people talk a lot. soon but that may not be a good idea.” ‘You are using injection to space the grave?’”Interviewer: “What does ‘spacing the grave mean?”Participant: Interviewer: “What reason may your husband have for “Meaning that you are using child spacing methods for wanting you to be pregnant very soon?” thechild whodied.” (In-depth interview participant no. 3, age 18–24 years, 1 living child). Participant: “It’s because you know most men do not understand the suffering that a woman goes through “But if the child did not live the time will be short: during pregnancy and childbirth.” maybe six months later the woman should become pregnant again because it is said that you cannot Interviewer: “Now according to what happened to you space a child that you don’t see.” (In-depth interview during your last child’s birth, what reason might your participant no. 8, age ≥35 years, 8 living children). husband have for wanting you to be pregnant soon?” It seems that these women had interpreted or had Participant: “According to what happened, he might others around them interpret the concept of birth spa- think that the solution is getting another child soon.” cing as delaying the interval between one live birth and (In-depth interview participant no. 19, age 18– the next pregnancy. To women using this definition, 24 years, 3 living children). birth spacing cannot and does not apply to women who don’t have a living child. Women also noted that it would be a disadvantage to women to wait 18 months or more after stillbirth or Social neonatal death to become pregnant again because it will Caring for existing children/preparing for the next child cause marital conflict. Many women discussed that hus- When discussing a need to space their pregnancies, bands routinely make decisions regarding family plan- some women felt birth spacing time should allow them ning use and timing of pregnancy. Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 7 of 12 “…normally men are the ones who facilitate Influence of family/friends decisions of not using family planning methods. Unlike the influence of husbands, women reported Sometimes a woman may think of taking family that their family and friends were more divided: ei- planning methods, but if the husband says ‘no’,the ther agreeing with their preferred birth spacing or ad- woman has no say and to avoid quarrels in the vising either more or less time before becoming house that woman will just follow what the pregnant again. Family and friends seemed to often husband has said.” (Focus group 1, participant no. 4, express concern over the woman’s health and remind age 18–24 years, no living children). women of the difficult and stressful delivery they had just experienced. One woman stated that a conflict over pregnancy tim- ing might lead to dissolution of marriage: “I can also add that it can take the challenges that the woman went through during labor and delivery Interviewer: “What may bring the because most of the times they are the friends and misunderstandings?” relatives who know the problems that the woman went through during labor and delivery. This is when the Participant: “It may be that she may want to use friends and relatives can have a say as when can be [a] family planning method while her husband the best time for the woman to become pregnant wants another child; so it may bring chaos in the again.” (Focus group 1, participant no. 5, age 18– family with the man telling the woman that if she 24 years, no living children). goes for contraceptives her marriage will be over. The woman may choose not to go for the methods.” Stillother womenfeltthatitis not theroleof (In-depth interview participant no. 10, age 18– anyone outsidemarriagetogiveadviceorhavea say 24 years, 2 living children). in the timing of a couples’ pregnancy. Four women noted that this marital conflict could lead “They cannot tell me when I should become pregnant to the husband to have affairs to have children with again. It is a family and confidential decision.” (Focus other women. group 4, participant no. 3, age 25–34 years, 2 living children). Interviewer: “What problems could happen to the mother for getting pregnant more than 18 months after Other women said that they experienced or feared giving birth to a baby that did not live?” social stigma after undergoing stillbirth or neonatal death from friends and community members. Participant: “Theproblem could bethereif theman wanted to have a baby before the waiting period of “Some people may be talking a lot when they see that hiswife[is completed],hecan go outsidetohave you have had a stillbirth. Like other women may say other women. In so doing he can be infected and ‘We were all pregnant but look at that one she doesn’t later infect the mother and that can have an have a baby.’ So due to fear of being insulted, the impact if the mother was to have a child after the woman may tell her husband that it is better for them waiting period.” (Focus group 1, participant no. 4, to have a replacement of the child that died.” (Focus age 18–24 years, no living children). group 3, participant no.6, age 25–34 years, 2 living children). Another woman felt that this marital conflict might be dangerous for the woman because if a wife does not want to have a child soon after one that died, it “…some people may laugh at her because she doesn’t could implicate her for playing a role in the child’s have a child and she may want to have another death. child.” (In-depth interview participant no. 20, age 25– 34 years, 3 living children). “The problem that can be there is conflict in the family. The husband may think that the woman is deliberately not becoming pregnant because she doesn’t Acceptable educational interventions to promote want to have a child, and he may also think that the birth spacing wife killed the child deliberately so that she should not Personal experience with birth spacing education have a child.” (Focus group 3, participant no. 6, age When asked about family planning or birth spacing advice 30 years, 2 living children). women had received after their stillbirth or neonatal death, Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 8 of 12 only one woman could recall any health provider discussing Focus group 1 participant no. 4: “Soon after this either prior to discharge from hospital or at any experiencing the stillbirth the woman should start follow-up visits they had attended since delivery. Perhaps as discussing about family planning so that when the a result, some women expressed confusion about starting family will decide to start having sex, the woman family planning after delivery. should implement her decision by going for family planning before they start having sex. It is unlike when Interviewer: “For those of you who are not using any the issue is discussed the time the family wants to have family planning method, why are you not using any sex, the woman will be taken for surprise. But if this family planning method?” was done prior, the woman will have a say to the husband that before they start having sex [and] she Focus group 2 participant no. 1: “Like myself, I should go for family planning.” (age 18–24 years, no planned to go to the hospital but I was not told when I living children). can start using a family planning method.” (age 25– 34 years, 3 living children). Location of birth spacing intervention For other women, this lack of information exacerbated Nearly all women agreed that a family planning discus- conflicts between them and their spouses when they were sion either in a clinical setting (hospital ward or out- not in agreement about birth spacing plans. One woman patient clinic) would be acceptable to them. However, describes deliberately misrepresenting the advice given one woman mentioned that it would be preferable if the about birth spacing during a discussion with her husband. discussion happened at home between the husband and wife prior to a woman going to a clinic and receiving a Participant: “I told him that I was told at the hospital family planning method. to wait for one year so he just agreed.” Few women did not think that they would be able to have an informed discussion about family planning at Interviewer: “Were you told by anybody at the home because they would not have access to hospital that you should wait for one year?” knowledgeable health providers. Though most women felt that health surveillance assistants (local community Participant: “No, but my mother told me that I should health workers) would be able to provide adequate not rush to become pregnant again because I need to contraceptive information to women and couples, others regain my strength, so one year would be ideal time. I did not feel these providers were appropriately informed mentioned the doctors because I knew that if I could or trained. say it was my mother he would have not accepted it.” Women were divided about the necessity of returning to (In-depth interview participant no. 14, age 18– the place of delivery to receive family planning education 24 years, no living children). and contraceptives. Most women felt it was important to go back to the same place because the health providers may remember her delivery complications and be able to Recommendations for birth spacing interventions ensure she was healthy and to assist her if she was still hav- Next, we asked women about their thoughts about rec- ing issues. However, few women felt that the nearest health ommendations for birth spacing interventions. facility may be able to provide the same care and counsel- ing. One woman was concerned that returning to the same Timing of birth spacing intervention location may be emotionally painful: When women were asked when counseling about birth spacing and family planning should be given after ex- “Sometimes the care that you received during labor periencing stillbirth or neonatal death, they were divided. and delivery matters most. Sometimes if the reception Just over half suggested that it should be between 4 and at the hospital was poor, you cannot have the desire to 8 weeks after delivery, before couples resume sexual go back to that clinic. You would opt to go to a intercourse. The other women suggested it should take different clinic where you would see different faces.” place soon after delivery or at the time the child has (Focus group 1, participant no. 7, age 18–24 years, no died. Some also mentioned that this should take place in living children). the presence of the husband if possible. Most women did not feel it was helpful to have a spe- Interviewer: “When would be the best time for women cial postnatal clinic for evaluation and counseling of to discuss family planning after having a baby that women who had experienced stillbirth or neonatal death. isn’t living?” These women feared possible discrimination and stigma. Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 9 of 12 However, other women felt this may be useful for those recommendations, they could agree on an appropriate with chronic conditions that may have led to the poor birth spacing interval and family planning method to- obstetric outcome. Some thought evaluation and treat- gether, which could be beneficial for marriage as well as ment of underlying medical conditions and specialized health of the woman. counseling in such a setting could lead to improved fu- ture pregnancy outcomes. Interviewer: “Do you think it is important to involve men so that they can be providing support to their Providers of birth spacing intervention spouses on issues of family planning?” Most women thought that health care providers (health surveillance assistants, nurses, and physicians) would be Focus group 4, participant no 3: “It is important the most appropriate people to provide birth spacing in- because you can have the same information and there terventions. Few women felt that fellow women (friends, can be trust on each other if each one of you is sisters, mothers, and elderly women in the community) involved.” (age 25–34 years, 2 living children). could also lead discussions on family planning. Focus group 4, participant no 2: “It can be good if the Group or individual sessions for birth spacing men can be asked to accompany their spouses to the intervention clinic so that they can be educated as a couple on Most women felt that group sessions with groups of different family planning methods and the couple women who had all experienced poor obstetric outcome should be able to choose the method.” (age 25– would be beneficial. 34 years, 3 living children). Interviewer: “Do you think it would be useful for Some women advocated standing up for their own women who had children that did not live could be health and reproductive desires in their marriage. meeting in groups as we have done here at the clinic?” “I just want to add that we as women we don’t need to Focus group 3 participant no. 3: “It is useful.” (age 18– keep quiet when it comes to childbearing issues. We 24 years, 2 living children). don’t need to just listen and implement what men tell us. We need to rise and tell the men the truth about Interviewer: “How?” our experiences, feelings and opinions regarding childbirth. He should understand that we are the ones Focus group 3 participant no. 6: “Because when we who suffer childbirth and we have the right to tell him experience stillbirths or neonatal deaths, we have how long we want to wait before having the next worries but when we meet in a group like this one, we child.” (Focus group 1, participant no. 5, age 18– feel encouraged that ‘I am not the only person, other 24 years, no living children). women had the similar experience.’ So we share ideas and encourage each other but when you are alone you are stressed up with a lot of worries.” (age 25– Discussion 34 years, 2 living children). These qualitative interviews and focus group discussions revealed the reproductive desires and challenges women However, those women who participated in in-depth face in birth spacing after experiencing poor obstetric interviews expressed concern that this could lead to dis- outcome. This study shows that the concept of birth crimination and stigma. Some women felt individual ses- spacing is not always thought to apply to those who have sions to discuss their situation with a health care worker experienced a stillbirth or neonatal death. Many women would provide more confidentiality. expressed a plan to wait to become pregnant again, with women with no living children wanting to wait less time Involving men in birth spacing interventions than those with living children. Husbands were named Though many women expressed fear of conflict and feel- as strong influencers of family size, family planning use, ings of powerlessness in disagreements with their hus- and birth spacing plans in families. Many women feared bands over birth spacing, others thought they could be marital conflict if they disagreed with their husband’s de- influenced with education or through being assertive in sire to try again for another pregnancy sooner than they reproductive conversations. They proposed inviting themselves desired, illustrating gender imbalance in re- them to attend and participate in individual or group productive decision-making among couples. Most sessions either in clinical or home-based settings. women felt that involving their husband in birth spacing Women felt that if a couple heard the same health educational interventions would be beneficial and would Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 10 of 12 help them to understand the need to wait for longer pe- nurse and physician within the first 6 months after pre- riods between pregnancies, even with poor obstetric term delivery and focuses on preterm prevention points, outcomes. such as smoking cessation, stress reduction, folate sup- Few studies have examined the relationship between plementation, and dental hygiene, with an emphasis on poor obstetric outcomes and future pregnancy inten- delaying conception through the use of family planning tions. A study of HIV-infected adolescents in Kenya did by at least 12 months after delivery. Similar programs not find an association between poor birth outcomes may be effective in a low-income setting where preterm and postpartum contraceptive use . In a study of birth, stillbirth, and neonatal death occur at higher rates. postpartum women with a living child in central Malawi, Because of gender inequities and imbalanced power 90% of the women in the study used contraception by 3 dynamics with reproductive decision-making in marital months after delivery , and in another study of relationships that was expressed by many participants, women in northern Malawi 28% used a modern form of we suggest that involvement of men is critical to any contraception by 6 months after delivery . However, intervention to promote healthy birth spacing in this neither of these studies examined women whose prior population. Qualitative studies examining couples after delivery was a stillbirth or neonatal death. Uptake of stillbirth have found this experience is deeply shared be- family planning is affected by attitudes regarding contra- tween a woman and her partner, sometimes in a way ceptive methods, which have been shown to be influ- that isolates them from the community . This ex- enced by the perceived and actual adverse effects among perience has also been shown to either have a positive Malawians . Qualitative studies involving women or negative impact on the couples’ relationship . Un- who have experienced stillbirth or neonatal death have derstanding the complex nature of relationships between not previously focused on future pregnancy intentions. men and women who have experienced perinatal loss in Instead, prior studies discuss the invisibility of perinatal an African setting is imperative to effectively encour- loss , ways to improve mental health of women , aging birth spacing in this population. or perceptions of care at the time of delivery . The discrepant finding between husbands encouraging In this study, we were able to identify different birth women to get pregnant soon and family and friends en- spacing intentions between women with and without liv- couraging women to wait may be due to differential in- ing children. Though women were enrolled at a 1:1 ratio volvement in pregnancy and delivery. In Malawi, it is for this characteristic, more women with living children common to have a female guardian, usually a relative or could be traced and agreed to participate 4–8 weeks close friend, present with the woman during labor, who after delivery. However, data from women without living is responsible for knowing the health status of the children reached saturation more quickly than from mother and for providing support . Since guardians women with living children as the group with living chil- witness first-hand the pain and complications women dren had a greater variety of perspectives. have gone through, they are more likely to remind The proportion of participants who are HIV-infected women of this than their husbands, who are not usually was 15%, very similar to the proportion of women who allowed in the labor rooms for privacy reasons since the receive antenatal care at Bwaila Hospital (14.7%) . rooms often house more than one laboring woman. Though this study was conducted in an area with a high Though not all women agreed on the exact way a birth background of HIV infection, HIV status was only men- spacing intervention could be effective for women with tioned once as an influence on birth spacing and no perinatal loss, many felt that counseling given by health meaningful differences in responses were seen when an- providers was important. However, only one woman in alyzed by HIV status. Further studies are needed to this study recalled receiving any information on birth understand if having a stillbirth or neonatal death im- spacing after a loss. This may be secondary to avoidance pacts postpartum contraceptive use, continuation of or minimal interaction with these women by health care antiretroviral therapy, and integration into the health providers since they do not have living children or system for HIV-infected women. low levels of knowledge among providers regarding rec- There are currently no targeted interventions in ommendations for birth spacing after poor obstetric out- Malawi encouraging appropriate birth spacing among come. A survey of American obstetricians found that women who have experienced poor obstetric outcome. two-thirds recommended attempting pregnancy less The March of Dimes has instituted a “Wait One Year” than 6 months after perinatal loss despite literature on program in parts of the United States to encourage the risks of short IPIs to future pregnancies . Asses- women who have experienced preterm birth to use ef- sing knowledge and attitudes of Malawian clinical pro- fective contraception to space their pregnancies and de- viders on birth spacing after perinatal loss is important crease the risk of recurrent preterm birth . This prior to undertaking an intervention that involves their program utilizes an educational intervention with a counseling to women and their partners. Kopp et al. BMC Pregnancy and Childbirth (2018) 18:197 Page 11 of 12 Conclusions Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in Most women wanted to wait before becoming pregnant published maps and institutional affiliations. again after experiencing stillbirth or neonatal death, but some women felt that birth spacing was not an applic- Author details 1 2 UNC Project-Malawi, Private Bag, A-104 Lilongwe, Malawi. UNC Department able concept after this outcome. Few women who of Obstetrics & Gynecology, Chapel Hill, NC, USA. Kamuzu Central Hospital, already had living children wanted no further pregnan- 4 Lilongwe, Malawi. UNC Department of Health Behavior, Chapel Hill, NC, cies and even desired permanent sterilization, whereas USA. Malawi College of Medicine Department of Obstetrics & Gynaecology, Blantyre, Malawi. Bwaila Hospital, Lilongwe District Health Office, Lilongwe, women with no living children were more likely to de- Malawi. sire another pregnancy within 1 year. Many influences on family size and birth spacing were noted in this Received: 4 June 2016 Accepted: 20 May 2018 population, with the most significant influencing factor being the spouse and fear of marital conflict. Interven- References tions to promote birth spacing and improve maternal 1. Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, Creanga and neonatal health in this population need to involve AA, Tuncalp O, Balsara ZP, Gupta S, et al. National, regional, and worldwide male partners and knowledgeable health care providers estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011;377:1319–30. to be effective. 2. ICF NSONMa. Malawi Demographic and Health Survey 2015–6. Zomba, Malawai and Rockville, Maryland, USA: National Statistical Office and ICF; 2017. 3. 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Published: May 31, 2018
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