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ELECTRONIC-BASED HEALTH PROMOTION MODELS ON THE USE OF POST

PLACENTAL IUD BIRTH CONTROL: A SYSTEMATIC REVIEW AND META-
ANALYSIS
Henri Sulistiyanto1*, Soetrisno2, A.A Subiyanto2, Retno Setyowati3
1
Doctoral Program in Development Counseling/Community Empowerment, Graduate School
of Universitas Sebelas Maret, Surakarta.
2
Faculty of Medicine, Universitas Sebelas Maret, Surakarta.
3
Faculty of Agriculture, Universitas Sebelas Maret, Surakarta.

*Corresponding author email: henrisulistiyanto3@gmail.com

Abstract
Low levels of IUD use, especially post-placental IUDs, are associated with bias and lack of
information because contraceptive counseling is limited, for example, through conversations
with doctors, written materials, or audiovisual techniques. This study aimed to identify
electronic (video) interventions using post-placental IUD contraception through systematic
review and meta-analysis. Based on those keywords, some results were obtained: 509 from
Google Scholar, 33 from PubMed, 14 from Science Direct, 88 from Sage Journal, 50 from
Springer Links, 20 from Scopus, and 178 from ProQuest. In addition, the recording was carried
out on the bibliography of review articles, 12 articles were obtained for systematic review, and
five meta-analyses were carried out. The heterogeneity test shows a value  greater than 0.05,
which is =0.88 with I2 = 0%, meaning that the variation between studies is homogeneous. The
Random Effects Model yielded a pooled odds ratio of 1.07 (95& CI 0.26-4.39). The value  =
0.93 so that there was no difference between the treatment and control groups, and the data
were homogeneous, an odd ratio of 1.07 was obtained, it was found that video use could
increase 1.07 times the knowledge, skills, and decision-making of using post placental IUD
compared to those who did not use video.
Keywords
Promkes model, video, placental post IUD

INTRODUCTION
Worldwide, nearly half of the pregnancies are unwanted, with estimates ranging from
13% to 82%. Socio-demographic factors related to unwanted pregnancy include age, parity,
education, and economic status. In addition to limited access to health services, barriers to
contraceptive use include concerns about the safety or effectiveness of various methods of
contraception and lack of knowledge or access to information about contraception (Dewart et
al., 2019). Many interventions designed to prevent unwanted pregnancies have focused on
patient education and contraceptive promotion to influence knowledge of contraception and
perceived barriers to contraceptive use (Oulman et al., 2015).
Preventing unwanted pregnancies through effective contraceptive use is critical to a
women's health, but choosing between different contraceptive methods can be challenging, and
opportunities for adequate discussion during regular consultations are often limited.
Controlling fertility and being satisfied with the method of contraception chosen is very
important for the
NOTE: This preprint health
reports and well-being
new research of women,
that has not been butreview
certified by peer unwanted pregnancies
and should remain
not be used to guide common
clinical practice.
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

and expensive for individuals and health services. About 40% of pregnancies globally are
estimated to be unplanned (Sedgh et al., 2014).
An RCT that integrates family planning into AIDS facilities shows a considerable effect
on contraceptive use but a negligible impact on IUD use compared to injectable or implant use
(Grossman et al., 2013). An RCT in Zambia directed at HIV couples found that video exposure
to long-term contraceptive use effectively increased long-term contraceptive use. Among
couples who did not use the method at first, 6% chose IUDs, 14% implants, 45% injections,
and 33% oral contraceptives. Among those who already used contraception, 29% switched,
mainly to long-term contraception (R. Stephenson et al., 2011).
Promotion concerning the use of IUDs is currently still low. Some respondents accept
that implants are more straightforward to promote than IUDs and are favored by some
institutions for various reasons so that the provider and client factors are involved in promoting
the use of IUDs. Providers tend to like implants because they are not as complex as IUDs. The
fact that implants are much more difficult to remove than IUDs is not explained to women. For
women, implants are less intrusive than IUDs and, as a relatively new method, less appealing
to misunderstandings and concerns (Cleland et al., 2017).
Research investigating contraceptive counseling is still limited, for example, through
conversations with doctors, written materials, or audiovisual techniques. Some studies have
assessed counseling for postpartum contraception but lost the opportunity for patients to initiate
long-term reversible contraceptive methods or permanent contraceptives because their
provision during labor periods is time-sensitive (Lopez et al., 2015). Previous research has
shown that video-based contraceptive education can result in increased absorption. Others
show increased knowledge and satisfaction, especially when paired with physician counseling
(Davidson et al., 2015).
Common modalities for providing contraceptive education include communication with
healthcare providers, written materials, audiovisual materials, and computer applications. With
the increasing availability of mobile technology, using electronic platforms to deliver health
education presents a unique opportunity for intervention. It can facilitate access to essential
health information, especially in resource-limited areas. The patient's report of eligibility and
willingness to use electronic modalities for contraceptive education is generally favorable
(McHenry et al., 2019).
Many interventions are designed to prevent unwanted pregnancies because they focus on
patient education and contraceptive promotion to influence knowledge of contraception and
perceived barriers to use (Xiong et al., 2021). Common modalities for providing contraceptive
education include conversations with healthcare providers, written materials, audiovisual
materials, and computer applications. With the increasing availability of mobile technology
capabilities, electronic platforms for delivering health education present a unique opportunity
for interventions to be disseminated in various settings (Prah, 2017). It can facilitate access to
essential health information, especially in resource-limited areas. The patient's report of
eligibility and willingness to use electronic modalities for contraceptive education is generally
favorable. However, a more formal evaluation of the effectiveness of the intervention delivered
via electronic format is required (Modugu et al., 2018).
The challenge of carrying out promotions on less familiar and well-known methods, such
as post-placental IUDs, is very severe. Providing comprehensive, well-balanced, and high-
quality advice, information, and education necessitates more targeted and well-designed
promotional approaches. Counseling of sufficient quality allows women to make the best
decisions. Post-placental IUD insertion can be increased if antenatal counseling about birth
control techniques is of higher quality. This systematic review and meta-analysis are intended
to assess the effectiveness of electronics (video) as a tool for providing post-placental IUD
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

contraceptive education. We searched for electronic interventions (videos) on post-placental

IUD contraception.

METHODS
In this study, data collection was conducted by systematically collecting articles in
English scientific articles through the database of PubMed, Science Direct, Sage Journal,
Springer Link, Scopus, ProQuest, and Google scholars using the keywords "video promotion
model" AND "postpartum IUD" "health promotion model" OR video AND "postpartum IUD,"
video OR m-health AND postpartum IUD. Three people conduct an abstract review to identify
articles matching the research criteria. The article to be analyzed is selected if at least two
reviewers agree with the case criteria.
Inclusion Criteria: (1) articles are limited to the last five years (2017-2022); (2) are
original research articles; and (3) scientific research articles with all research designs.
Exclusion Criteria: (1) the title is irrelevant; (2) no full text is available; (3) language other than
English; (4) the abstract is irrelevant; (5) the deletion of scientific articles.
Based on those keywords, some results were obtained: 509 from Google Scholar, 33 from
PubMed, 14 from Science Direct, 88 from Sage Journal, 50 from Springer Links, 20 from
Scopus, and 178 from ProQuest. In addition, the recording was carried out on the bibliography
of review articles, 12 articles were obtained for systematic review, and five meta-analyses were
carried out. Systematic review and meta-analysis adhered to the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analysis) protocol for selecting articles to be analyzed,
described in Figure 1.
Data analysis was conducted to obtain the pooled odds ratio, a combined odds ratio value
from research using a fixed effect model using Haenszel's Mantel method, and a random effect
model. Using software version 5.3 of Review Manager, data were evaluated. The heterogeneity
test is performed to establish the incorporation model for the meta-analysis. The statistical test
I2 was performed to measure heterogeneity among several percentage-based research impact
estimates. The Cochran Q test is also used to assess heterogeneity with a p-value. The final
result of the meta-analysis was a forest plot with a pooled odds ratio (OR) value and effect size
in each study. The results of the plot funnel were also analyzed for publication bias assessment
on the final results of the meta-analysis. The final value used to answer the research objective
is the pooled odds ratio value which indicates the combined OR value of several studies. It
shows how big the risk factors of each variable studied are. After obtaining the meta-analysis
results from the five articles obtained, the authors included the results with the best meta-
analysis compared to other variables based on the number of studies and the OR value of each
study combined with the appropriate confidence interval.
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Figure 1 Systematic review protocol flowchart based on PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analysis)

RESULT
- Combined Results
- Individual Study Results
The results of the article selection were obtained from 5 manuscripts that met the criteria. The
manuscript reviewer then extracted data on the author's name, year of publication, type of
design, number of samples and estimated sample age, type of hormonal contraceptive therapy
used, and statistical results of each study, then tabulated.
Table 1 Systematic Review of Electronic-Based Health Promotion Models on the Use of KB
IUD Post Placenta
Study Settings Objectives Study Sample Participant
Design Sizes Characteristic
Hersh, 2018 Colombia Assessing Multicenter 240 Structured
whether randomized, conversation
video-based controlled with a trained
contraceptive trial counselor or
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY-NC-ND 4.0 International license .

education can A 14-minute

be an efficient video
addition to provides the
contraceptive same
counseling information.
and achieve Both groups
the same received
contraceptive written
knowledge material and
acquisition as were invited
conversation- to ask
based questions.
counseling. Counselor's
questions.
McCarthy Palestine, Development Interventions 1310 Respondent
2019 Bolivia, and and are criteria: age,
Tajikistan evaluation of developed gender,
contraceptives using ethnicity,
behavioral behavioral occupation,
interventions science and level of
delivered by evaluated by education,
mobile phone randomized, intention at
to young controlled the
people in trials in each beginning,
Tajikistan, country the method at
Palestine, and baseline,
Bolivia. number of
children,
marital
status, and
results of
admissions at
follow-up
Tiwari 2019 India Data were A post- 831 Men and
collected intervention women from
from the quasi- the state of
mHealth experimental Bihar
intervention study with a
area in India 2x2 factorial
to test the design
association
between
exposure to
mHealth tools
for family
planning and
behavioral
predictors
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Stephenson London To evaluate parallel 927 Ladies

2020 interactive single-blind between 15
websites to experiment and 30 years
assist with of age with
informed present or
choices prospective
contraception contraceptive
needs, who
can read
English, have
an active
email
account and
an internet
connection,
and are
willing to be
tracked for
six months.
Burapasikarin Thailand To evaluate Randomized- 270 Postpartum
2020 whether controlled women who
postpartum trial are > 20
educational years old and
videos about willing to
MKJP can participate
increase are recruited
postpartum
MKJP use at
6-8 weeks
postpartum
and to assess
why
postpartum
women do not
receive
MKJP.

Data processing was conducted using Rev Man 5.3 comprehensive meta-analysis software by
calculating the effect size, weight, and heterogeneity of effect size to determine the model of
combining research and forming the final results of a meta-analysis in the form of forest plot
and funnel plot. The following are the results of the meta-analysis and forest plot diagrams, as
follows:
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY-NC-ND 4.0 International license .

Figure 2 Forest Plot Diagram

The heterogeneity test shows a value  greater than 0.05, which is =0.88 with I2 = 0%),
meaning that the variation between studies is homogeneous. The Random Effects Model
yielded a pooled odds ratio of 1.07 (95& CI 0.26-4.39). The value  = 0.93 so that there was
no difference between the treatment and control groups, and the data were homogeneous, an
odd ratio of 1.07 was obtained. It was found that video use could increase 1.07 times the
knowledge, skills, and decision-making of post-placental IUDs compared to those who did not
use video. The forest plot shows the information of each study studied and estimates the overall
results, visually indicating the magnitude of variation or heterogeneity. After determining the
model, the weight of each trial was calculated to obtain the meta-summary analysis's effect or
final results. Based on the forest plot above, there are no meaningful results because it intersects
the vertical line and the odds ratio of 1.07, so the data is homogeneous.
The funnel plot is a diagram that explains the possibility of publication bias, showing
the relationship between side effects and sample size or standard error of effect size from the
various studies studied. Figure 3 presents a funnel plot in this article's meta-analysis.

Figure 3 Funnel Plot Diagram

medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
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Based on the image indicates that there is a publication bias in the results of this meta-
analysis.
DISCUSSION
About 45% of pregnancies in the UK are unplanned despite the wide range of effective
contraceptive methods available for free, and abortion rates in England and Wales have not
changed much since 2011. Preventing unwanted pregnancy involves many steps, including
timely education, awareness, and socially influenced behaviors to strive for, choose and use
contraception consistently and correctly. Healthcare has a crucial role to play by supporting
people to choose and use the correct method that best suits their needs, but many people are
unaware of the various methods available to them. The contraceptive pill and condoms are
well-known and widely used, but they are not the most effective methods of contraception (J.
Stephenson, Bailey, Gubijev, D’Souza, Oliver, Blandford, Hunter, Shawe, Rait, Copas, et al.,
2020).
Husband/partner support for birth control can affect modern contraception. Socio-
demographic factors, couples' fertility choices, and communication about family planning are
known to affect contraceptive use. Perceived husband/partner consent was associated with a
threefold chance of using women's modern contraception and remained significantly
associated with a 1.6-fold chance after controlling for contraceptive accessibility and self-
efficacy. Husband/partner encouragement was initially significantly associated with
contraceptive use and became insignificant after adjusting for socio-demographic factors and
couple communication. Perceived husband/partner consent, apart from a woman's sense of
self-efficacy and perceptions of contraceptive accessibility, appears vital and positively
associated with the current use of modern contraception. Improved couple communication
can help women identify their husband/partner's approval. The difference between the
meaning of consent and encouragement must be explored. Interventions involving
information and communication campaigns aimed at men and encouraging their participation
in family planning may increase the prevalence of contraception (Prata N, Bell S, Fraser A,
Carvalho A, 2015).
Long-acting reversible contraception (LARC), which includes contraceptives,
intrauterine systems, implants, and injections, is at least 20 times more effective than oral
contraceptive pills and condoms, but these methods are less well known, and not all services
have the capacity to customize them. More and more women are turning to online sources of
information about sexual health, but information of varying quality and accuracy and
misconceptions about contraception are standard. Hormonal contraceptive methods have
many potential benefits besides fertility control, including acne treatment, reduced menstrual
pain, milder periods or no bleeding, and reduced premenstrual symptoms. However, women
may be more aware of contraception's risks and side effects than the benefits. Interactive
digital interventions increase knowledge of contraceptive uptake, more effective
contraceptive methods, and contraceptive compliance and reduce unplanned pregnancies.
Digital interventions offer the advantage of accuracy and fidelity of intervention content and
the potential to reach a broad audience at a relatively low dissemination cost. We, therefore,
developed an interactive website to help inform the choice of contraceptive methods and then
conducted randomized controlled trials to evaluate their impact on the clinic population (J.
Stephenson, Bailey, Gubijev, D’Souza, Oliver, Blandford, Hunter, Shawe, Rait, Brima, et al.,
2020).
The puerperium period is vital to promote family planning because puerperium mothers
are highly motivated to avoid rapid and recurrent pregnancies. This study shows that providing
knowledge about long-term contraceptive methods (MKJP) in postpartum wards using 7-
minute animated videos can increase postpartum MKJPC. Although the percentage is also
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

clearly increasing in the non-video group, it is much lower than in the video group
(Burapasikarin et al., 2020).
Among the six RCTs assessing contraceptive knowledge, two found evidence of
increased knowledge for those receiving electronic interventions (Dewart et al., 2019). A study
of women hospitalized for childbirth in Columbia evaluated video contraceptive counseling
compared to receiving the same information in a face-to-face conversation with a counselor.
The video featured a nurse who provided standard contraceptive information and was about 14
minutes long. The intervention group also had the opportunity to discuss contraceptive options
with a counselor, and both groups received written educational materials. No statistically
significant differences in knowledge (measured immediately after intervention) were found
between the two groups except for knowledge of the definition of family planning, where the
effect supported the receipt of information from a counselor (p=0.01 in post-intervention group
comparisons). Other measurable knowledge items focus on the efficacy of various methods of
contraception (Hersh et al., 2018a).
Electronic platforms provide diverse opportunities for disseminating contraceptive
education, although technology must be designed according to the evaluation of content based
on health education and behavioral theory. For example, in a study of three video interventions
(method-based, motivational, and combination-based), receiving content focused on methods
was associated with statistically significant effects related to method choice outcomes and
pregnancy incidence. In addition, given that some electronic interventions are conducted
similarly to direct counseling methods when followed by the opportunity to speak with a health
care provider, the use of electronic media to provide effective contraceptive education can have
significant implications related to reducing staff time load (Dewart et al., 2019).
Previous randomized and non-randomized studies assessed the impact of immediate
postpartum contraceptive education on postpartum contraceptive use, and the results were
inconclusive (Zerden et al., 2015). The 7-minute animated educational video has proven to be
a good tool in providing information for postpartum women during their hospital stay.
However, about a fraction of women who do not use MKJP admit that they do not know MKJP.
Additional qualitative exploration in this group of postpartum women should be helpful. As a
result, healthcare providers can implement different education delivery approaches to increase
knowledge about the MKJP (Burapasikarin et al., 2020).
In addition, the reasons for not using MKJP shown in this study inform strategies to
increase the use of MKJP in the postpartum period. They include MKJP education on prenatal
visits. Because many women do not receive prenatal care at the facility where they gave birth,
decisions about family planning before delivery are not easily communicated to hospital staff.
Given staff limitations, providing individualized contraceptive counseling is a challenge.
Furthermore, contraceptive counseling is not currently incorporated into routine prenatal care.
In this study, we sought to show that video-based contraceptive education can be an efficient
addition to counseling and achieve the same level of family planning knowledge as
conversation-based counseling (Hersh et al., 2018b).

Interactive digital interventions are effective at increasing the absorption of contraceptive

knowledge and helping to choose more effective methods of contraception and contraceptive
compliance, as well as reducing unplanned pregnancies. Digital interventions offer the
advantage of accuracy and fidelity of intervention content and the potential in order to reach a
broad audience at a minimal cost of deployment (McCarthy, 2019; J. Stephenson, Bailey,
Gubijev, D’Souza, Oliver, Blandford, Hunter, Shawe, Rait, Brima, et al., 2020). Mobile phones
serve as a tool that can improve women's participation in their health care and their families.
Mobile phone-based health tools that are easy to use have opened up new opportunities to
provide women with information that is important for their health and well-being, one of which
medRxiv preprint doi: https://doi.org/10.1101/2023.03.12.23286202; this version posted March 13, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

is information about birth control. Thus, technology-based communication tools can help
initiate dialogue at the community level that can lead to the dissemination of information, as
well as negotiation and mediation of the use of birth control (Tiwari, 2019). Videos about birth
control can be inserted into mobile phones to facilitate access to information for women,
couples, and families that impact the increased use of contraception, especially postpartum
IUDs.
CONCLUSION
Health promotion models that use electronic-based tools (video) 1.07 times can improve
knowledge, skills, and decision-making using long-term contraceptives, especially IUDs,
compared to those that do not use video

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