Women and Birth 27 (2014) 254–258

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Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Impact of having a high-risk pregnancy on future postpartum

contraceptive method choice
Sadiman Kiykac Altinbas a,*, Yesim Bayoglu Tekin b, Berna Dilbaz a, Selim Kilic c,
Susan S. Khalil d, Omer Kandemir a
a
Etlik Zubeyde Hanim Women’s Health Training and Research Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey
b
Recep Tayyip Erdogan University School of Medicine, Department of Obstetrics and Gynecology, Rize, Turkey
c
Gulhane Military Medical Academy, Department of Epidemiology, Ankara, Turkey
d
St. Luke’s Roosevelt Hospitals, Department of Obstetrics and Gynecology, New York, NY, United States

A R T I C L E I N F O A B S T R A C T

Article history: Background: To compare the knowledge and preference of preconceptional contraception to future
Received 26 August 2013 postpartum contraceptive method choice in high-risk pregnancies.
Received in revised form 19 June 2014 Research question: Does a high-risk pregnancy condition affect future postpartum contraceptive method
Accepted 20 June 2014
choice?
Method: Women hospitalised at the High Risk Pregnancy unit of a tertiary research and training hospital
Keywords: were asked to complete a self-reported questionnaire that included demographic characteristics,
High-risk
presence of unintended pregnancy, contraceptive method of choice before the current pregnancy, plans
Pregnancy
Family planning
for contraceptive use following delivery and requests for any contraceptive counselling in the
Preconceptional contraceptive methods postpartum period.
Postpartum contraceptive methods Findings: A total of 655 pregnant women were recruited. The mean age, gravidity and parity of the
women were 27.48  6.25 years, 2.81  2.15 and 1.40  1.77, respectively. High-risk pregnancy indications
included 207 (31.6%) maternal, 396 (60.5%) foetal and 52 (7.9%) uterine factors. All postpartum
contraceptive choices except for combined oral contraceptives (COCs) usage were significantly different from
preconceptional contraceptive preferences (p < 0.001). High-risk pregnancy indications, future child bearing,
ideal number of children, income and education levels were the most important factors influencing
postpartum contraceptive choices. While the leading contraceptive method in the postpartum period was
long-acting reversible contraceptive methods (non-hormonal copper intrauterine device Cu-IUD, the
levonorgestrel-releasing intrauterine system (LNG-IUS) (40%), the least preferred method was COCs use
(5.2%) and preference of COCs use showed no difference between the preconceptional and postpartum periods
(p = 0.202). Overall 73.7% of the women wanted to receive contraceptive counselling before their discharge.
Conclusion: A high-risk pregnancy condition may change the opinion and preference of contraceptive
use, and also seems to affect the awareness of family planning methods.
ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International
Books Australia Pty Ltd). All rights reserved.

1. Introduction High-risk pregnancies are associated with increased morbidity

The aim of preconception care for all pregnancies is to reduce
the risk of adverse health effects for the woman, foetus, or neonate
by optimising the woman’s health and knowledge before planning
and conceiving a pregnancy.1 Therefore, the timing of a pregnancy
is of great importance for improving pregnancy outcomes not only
for healthy couples, but also those with medical disorders.
* Corresponding author at: Akpınar Mah. 845. Cad, B7, Cankaya, Ankara 06450,
Turkey. Tel.: +90 5324200925; fax: +90 3123238191.
E-mail address: sadimanaltin@gmail.com (S. Kiykac Altinbas).
and mortality, either for the mother or the foetus, or both. Risk
assessment of a pregnant woman should be part of her routine
prenatal care. This risk assessment should be also noted soon after
her labour and at the postpartum period. Many risk factors,
including socioeconomic, medical and pregnancy related problems
– preexisting, antepartum, or intrapartum–, may cause deteriora-
tion of pregnancy outcome.2,3 Maternal or foetal health problems
that rise during pregnancy might alter patients’ view about future
pregnancies. Although these pregnant women, having a high-risk
condition in their pregnancies, are closely followed during the
antenatal period and have more antenatal visits than other

http://dx.doi.org/10.1016/j.wombi.2014.06.006
1871-5192/ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
 S. Kiykac Altinbas et al. / Women and Birth 27 (2014) 254–258
healthier counterparts and are even mostly hospitalised for long
periods; they do not have better counselling for future family
planning methods.4
When pregnancies are ‘‘too early, too late, too many, and too
close’’, maternal and neonatal outcomes are negatively affected.5
The risks of childbirth are known to vary with the mother’s age and
may also be linked to her parity and to the interval since the
previous birth.6 Despite the improvement in postpartum family
planning programmes and contraceptive technology, still unin-
tended and high-risk pregnancies occur frequently. The connec-
tions between contraceptive use, unintended pregnancies and
women with a recent preterm delivery have been reported.7–9
Women having unintended pregnancies unfortunately report not
using contraceptives, or inconsistent and ineffective method use.10
Though clinicians are assisted by the American College of
Obstetricians and Gynecologists (ACOG) and the US Centers for
Disease Control and Prevention (CDC) guidelines about contracep-
tive preferences for women with medical comorbidities, there is
still lack of knowledge and usage of contraceptive methods.4 It
should be kept in mind that family planning and consistent
contraceptive use is an important key to achieve maternal and
infant health.11
Our hypothesis in this study was that pregnant women
followed as having ‘‘high-risk pregnancy’’ would be more inclined
to use contraceptive methods after delivery and their current
situation may create awareness about planning the future
pregnancies. We evaluated and compared the knowledge and
preferences of preconceptional contraceptive methods and future
plans for postpartum contraceptive usage and analysed the
requests for any contraceptive counselling in the postpartum period.
2. Subjects and methods
The study was conducted at the High-Risk Pregnancy Clinic of a
tertiary research and training hospital. The Institutional Local
Ethics Committee and Institutional Education and Planning
Committee approvals were obtained and each patient gave a
signed informed consent for recruitment to the study. From
January 2009 to May 2011, face-to-face interviews were
carried out with 655 pregnant women with pregnancies greater
than 20 weeks of gestation who were admitted for at least one
high-risk obstetric indication and who were between the ages of 16
and 48. A high-risk pregnancy was defined as a pregnancy affected
by a pre-existing or a pregnancy-related condition that leads to
increased risk of morbidity or mortality before or after delivery for
the mother, foetus, or neonate. Patients who were not in a stable
medical condition and who could not fill in the questionnaire
without help were not included in the study.
Each patient was asked to complete a questionnaire that
included 25 questions related to demographic characteristics,
presence of unintended pregnancy, educational and economic
status, prior contraceptive use and postpartum plans for con-
traceptive use following delivery. Prior contraceptive use and
future plans for contraceptive use following delivery were
assessed with multiple-choice questions. The questionnaire also
contained questions about the source of contraceptive knowledge
and whether the individual wanted to get counselling on
contraception before discharge. All responses to the questions
are the basis for the findings.
2.1. Patient classification
High-risk conditions were classified as maternal, foetal
and uterine factors. Maternal factors included diabetes
mellitus (gestational or pregestational), hypertensive disorders
(preeclampsia, eclampsia, chronic hypertension and gestational
255
hypertension), obesity, grandmultiparity, pregnancy and other
factors (anaemia, infections, other systemic diseases). Foetal
factors consisted of foetal growth disorders, disorders of
amniotic fluid volume (AFV), postterm pregnancies, preterm
delivery, multifoetal gestation, foetal anomalies. Uterine factors
included previous uterine surgery (repeated caesarean section
or myomectomy), abnormalities of the placenta, umblical cord
and membranes (placenta previa, placenta accreata, – increata
or – percreata), and cervical incompetence.
2.2. Questionnaire variables
Sociodemographic characteristics. Age, gravidity, parity,
induced abortion, marital status, education levels, working status,
family income, and the presence of health insurance were noted.
Induced abortion was defined as surgically or medically terminat-
ed pregnancies by the request of parents without any medical
necessity. Education levels were considered as primary school for
5 years education, secondary school for 8 years education, high
school for 12 years education. Women who had never been to
school or had learned how to read and write but not able to finish
the school, were accepted as no education. Family income equal or
lower than minimum wage was considered as low, up to twice of
the minimum wage as moderate and higher than twice of the
minimum wage was evaluated as high-income level.
Pregnancy intention. Participants were asked if they had any
demand for another pregnancy and when they would prefer to
become pregnant again. They were also asked for the ideal
number of children.
Contraceptive use. Participants were asked ‘‘What kind of
birth control were you or your husband or partner using before
getting pregnant?’’ for their prior contraceptive use. To assess
future plans for contraceptive use following delivery, they were
asked ‘‘Are you or your husband or partner going to use a method
to prevent pregnancy?’’ The ones who responded ‘‘yes’’ to the
question were asked ‘‘What kind of birth control are you or your
husband or partner planning to use?’’ Participants were also
approached if they knew or had heard about all contraceptive
methods available in Turkey (barrier methods, copper intrauterine
device (Cu-IUD), the levonorgestrel-releasing intrauterine system
(LNG-IUS), combined oral contraceptives (COCs), combined
monthly injection, combined vaginal ring, depot-injection, mini-
pill, progesterone implant) by choosing ‘‘Yes, I have heard.’’, ‘‘No, I
have not heard before.’’. Traditional methods of contraception
included withdrawal (coitus interruptus) and periodic abstinence.
SPSS (Statistical Package for the Social Sciences) version 17.0
was used to record and statistically analyse the data. Normally
distributed data were expressed as means  standard deviation
and data that were non-normally distributed was expressed as the
median for descriptive statistics. Chi-square test was used and
statistical significance was defined as p < 0.05.
3. Results
3.1. Participants’ demographics
Of the 692 questionnaires distributed, 655 were returned. The
response rate was 94.6%. The mean age, gravidity and parity of the
patient group were 27.48  6.25 years (range 16–48 years),
2.81  2.15 (range 1–12) and 1.40  1.77 (range 0–11) respectively.
Of 655 pregnant women, 29.2% were nulliparous. Approximately two
thirds of the participants lived in Ankara, the capital city of Turkey,
and the vast majority of them (96.2%) had health insurance.
In the study population, while 80.2% of the women reported
that the current pregnancy was desired, one-fifth (19.8%) of them
reported the current pregnancy as unintended with a concomitant
256 S. Kiykac Altinbas et al. / Women and Birth 27 (2014) 254–258

Table 1 3.2. Effects of antenatal risk factors and future child bearing on
Characteristics of the patients.
contraceptive preferences
Age (year) 27.48  6.25, 26 (23–32)
Gravidity 2.81  2.15, 2 (1–4)
High-risk pregnancy indications were seen to influence the
Parity 1.40  1.77, 1 (0–2)
Induced abortion 0.14  0.47, 0 (0–0) preference of the postpartum contraceptive choices (p < 0.001).
Ideal number of children 2.69  1.42, 2 (2–3) Female sterilisation was the most preferred contraceptive
Values are reported as mean  standard deviation and median (IQR:
method in women with maternal factors (p < 0.001). Women
interquartile range 25–75). with a high-risk pregnancy condition related to foetal factors
had preferred reversible methods as IUD (39.2%), condom
(21.7%), traditional methods (19.4%) and COCs use (12.2%).
Table 2 The women who were considered as having high risk pregnancy
Demographic characteristics of the participants.
related to uterine factors mostly preferred IUD (44.2%), followed
No. (%) by COCs use and condom (21.2%).
Education Also the ideal number of children seemed to play an important
No education 141 (21.5%) role in the future contraceptive choice; while women who wanted
Primary school 231 (35.2%) only one or two children preferred IUD (35.7%) and condom
Secondary school 96 (14.6%) (28.6%), women who wanted three or more children preferred
High school 139 (21.2%)
long-acting contraceptive methods as IUD (41.1%) and sterilisation
University 48 (7.3%)
Total family income (23.4%) for postpartum contraceptive choices.
Low 296 (45.2%)
Moderate 304 (46.4%) 3.3. Contraceptive preferences before pregnancy and after delivery
High 55 (8.4%)
Desire for more children
Yes 283 (43.2%)
The evaluation of the preconceptional contraceptive
No 372 (56.8%) methods showed that 276 women were not using any contracep-
Ideal birth spacing (for future childbearing) 3.61  1.61 tive methods (42.1%) when they got pregnant, while 167
1 year 14 (4.9%) women (25.5%) were using traditional methods during concep-
1–2 years 62 (21.9%)
tion period. The percentage of women who had used traditional
2–3 years 79 (27.9%)
3–4 years 48 (16.9%) methods before pregnancy was 25.5% but this percentage
>4 years 80 (28.3%) decreased to 18.6% when women were asked the method that
Family planning discussed during current hospitalisation would be chosen after the delivery. There was an increase in the
Yes 229 (35%)
preference of all modern methods IUD (40% vs 10.9%), condom
No 426 (65%)
Interest in discussing family planning before discharge
(18.9% vs 12.4%) and depot medroxyprogesterone acetate (DMPA)
Yes 483 (73.7%) (5.8 vs 2.2%) except COCs (6.8% vs 5.2%) usage. A remarkable
No 172 (26.3%) number of women (n: 75, 11.5%) stated that they would like to
have female sterilisation during the postpartum period.
The leading contraceptive method before pregnancy had
been traditional methods, mainly coitus interruptus (%25.5), but
use of a contraceptive method. The highest rate of unplanned the number of women who would prefer to use this method
pregnancy was more likely to be in the traditional method use after the delivery dropped to 18.6% (p = 0.003) (Table 4).
(58.5%), followed by condom use (15.4%) and intrauterine devices More than half of women who were not using any
(12.3%). Demographic characteristics of the women included in the contraceptive method before pregnancy wanted to use long-
study are shown in Tables 1 and 2. acting reversible contraceptive (LARC) methods including Cu-
The participants were classified as high-risk pregnancy due to IUD, the LNG-IUS and also condom during the postpartum
maternal (n: 207, 31.6%), foetal (n: 396, 60.5%) and uterine (n: 52, period (40.6% and 22.5%, respectively). Women who preferred
7.9%) uterine factors. Risk factors were summarised in Table 3. traditional methods before pregnancy insisted on continuing
the same method, with a rate of 40.9%.
Another LARC method use regarding the injectable contracep-
tive method preference changed from 2.2% to 5.8% (p < 0.001) in
Table 3 the postpartum period. Half of these women (50%) were not using
Indications of high-risk pregnancy. any contraceptive method when they got pregnant and 21.1% used
Indications n % traditional methods before pregnancy.
Maternal factors 207 31.6
Overall preference for condom use changed from 12.4% to
Diabetes mellitus 83 12.6 18.9% (p = 0.001). Half of the women (50%) who had not used
Hypertensive disorders 65 9.9
Obesity–grandmultiparity 50 7.6
Systemic disorders 9 1.4 Table 4
Foetal factors 396 60.45 Contraceptive method choices before pregnancy and after delivery.
Postterm pregnancy 261 39.84
Preconceptional Contraceptive p
AFV disorders 58 8.85
method choice following
Foetal growth disorders 29 4.42
choice delivery
Preterm delivery 29 4.42
n (%) n (%)
Multifoetal gestation 12 1.83
Foetal anomalies 7 1.1 Traditional methods 167 (25.5%) 122 (18.6%) 0.003
Uterine factors 52 7.93 Condom 81 (12.4%) 124 (18.9%) 0.001
Previous surgery 27 4.12 IUD 72 (10.9%) 262 (40%) <0.001
Placental anomalies 19 2.9 COCs 45 (6.8%) 34 (5.2%) 0.202
Cervical incompetence 6 0.91 DMPA 14 (2.2%) 38 (5.8%) <0.001
655 100 Female sterilisation 0 (0%) 75 (11.5%) <0.001
 S. Kiykac Altinbas et al. / Women and Birth 27 (2014) 254–258
any method before pregnancy and 29% of the women who had
used condoms before pregnancy declared that they wanted to use
condoms for contraception after the delivery.
The choice for COCs use before pregnancy decreased from
6.8% to 5.2% after delivery (p = 0.202). The women who had been
using COCs when they became pregnant and planned to
continue using COCs after delivery consisted of 20.6% of the
population who chose COCs for the future contraceptive method,
while 52.9% of the future COCs users were not using any
contraceptive method previously.
Seventy-five women (11.5%) wanted to have female sterilisa-
tion in the postpartum period. Among these 75 women, 33.3% had
preferred traditional methods, 20% had not used any method and
18.7% had preferred IUD before pregnancy. Women who preferred
to have an IUD insertion after delivery were the women who had
either not used any contraceptive method before pregnancy
(42.7%) or IUD users before pregnancy (19.1%) and women using
traditional methods before pregnancy (17.6%).
3.4. Effects of education and total income in family planning
preferences
More than half of the participants had lower education levels;
21.5% had never been to school or had learned only how to read
and write without being a graduate of primary school, 35.2% were
graduated from primary school. The remaining participants’ level
of education was secondary school (14.6%), high school (21.2%) and
university (7.2%). The knowledge of contraceptive methods
seemed to differ with increasing educational level and total
income. When women were asked if they knew or had heard about
the contraceptive methods, 87.2% of them were aware of IUD, 77%
of COCs, 76.2% had knowledge about male condoms, 55.3% knew of
female sterilisation and 47% were aware of the injectable methods.
Calendar method, condom, IUD, COCs, DMPA and vasectomy were
commonly known by women with secondary school and higher
education levels (p < 0.001, <0.001, =0.002, <0.001, =0.001,
=0.005, respectively). The knowledge of withdrawal and female
sterilisation methods did not differ with the level of education
(p > 0.05). While calendar method, condoms, COCs, female
sterilisation and vasectomy were commonly known in the high-
income group (p < 0.001, <0.001, =0.007, =0.001, <0.001, respec-
tively), no difference was detected in method knowledge of
contraceptive methods for withdrawal, IUD and DMPA in relation
to the economic status of the women (p > 0.05).
Women with no education or primary education preferred
tubal ligation in the postpartum period, in comparison to the
women with a higher educational level (p < 0.001). Condom and
IUD usage were more common in the high-income group
(p < 0.001).
3.5. The other factors affecting postpartum contraceptive preferences
When women were asked the reason for their choice of
contraceptive method used before delivery; the availability
(44.6%), cost (26.3%), lack of potential systemic effects (20.8%)
and preferring a permanent contraceptive method (8.4%) were
noted. While IUD, COCs and female sterilisation were preferred
because of the reliability and availability of the methods;
traditional methods and condom were chosen, as they had no
systemic effects. The priority of making a decision about the
choice of contraceptive method varied due to educational level.
Although the potential systemic health effects related to the
contraceptive method were the most important factors in
decision-making for high school and university graduates,
permanency of the contraceptive method was the most important
factor for women with lower education levels.
257
3.6. Patient desire and source of information regarding family
planning
When the source of contraceptive knowledge was examined,
most of the women were informed by friends and family
members (45.6%), some by health care providers (39.7%) and
less by television, magazines or internet (media) (14.7%).
Overall 73.7% of the women stated that they wanted to receive
contraceptive counselling before they were discharged from
the hospital, since all the women were hospitalised. This rate
was found to be significantly higher for women with lower
education levels (p < 0.001).
4. Discussion
The aim of the presented study was to point-out the need for
contraceptive counselling for all pregnant women, especially for
the ones with high-risk pregnancy. The data were a situation
analysis study, as the actual contraceptive use after the delivery
was not presented. This study showed that preconceptional
contraceptive preferences were significantly different from the
postpartum choices in women hospitalised in the High-Risk
Pregnancy Clinic, except for COCs usage; since the leading
contraceptive method chosen for the postpartum period was
LARC methods including Cu-IUD, the LNG-IUS (40%); the least
preferred method was COCs use (5.2%). Preference of COCs use
showed no difference between the preconceptional and postpar-
tum periods. The reason for this might be the concerns about
potential effects of COCs use on breast-feeding in the postpartum
period; still these results show the lack of knowledge about the
eligibility criteria for contraceptive use at the postpartum period as
breast-feeding women should postpone COCs use until the 6th
month. No restrictions on the use of COCs based on postpartum
status apply after 42 days postpartum.12
Each pregnancy and childbirth may carry a health risk for the
mother related to the mother’s age, parity and birth interval. The
risk of having perinatal complications and poor maternal and foetal
outcome is even higher when the pregnancy is labelled as high-
risk, unwanted or mistimed.13,14 Unintended pregnancy is
estimated to account for 80 million of the 210 million pregnancies
that occur worldwide each year.15 Women continuing unintended
pregnancies are reported to be at a greater risk of pregnancy
complications and adverse behaviours.14,16,17 In the presented
study, one-fifth of the women reported that the current pregnancy
was unintended as it occurred during a contraceptive method use.
However, the method used was a traditional method in 25.5% of
the women and these methods have a high failure rate.18
In Turkey, fertility has decreased sharply over the past several
decades; a woman in Turkey is expected to have an average of 2.16
children by the end of her reproductive years.19 Almost all women
knew of at least one modern method, according to the most recent
Turkish Demographic Health Survey (TDHS-2008).19 The most
widely known modern methods were IUD, COCs, male condom,
female sterilisation and injectables, respectively.19
The most interesting point to be underlined in this study is that,
56.8% of the women declared that they did not want to have any
more children in the future. The reason for being reluctant to have
more children might be related to the high-risk condition they
experienced during their pregnancies. The women, who did not
want any more children, chose irreversible or LARC methods
(p < 0.001 and p = 0.001, respectively). The ones, who wanted
children in the future, noted that they would have preferred
traditional methods or COCs use after their current pregnancy
(p = 0.001 and p = 0.023, respectively). In the literature, it
was reported that women with medical comorbidities are at
higher risk for pregnancy-related maternal and neonatal
258 S. Kiykac Altinbas et al. / Women and Birth 27 (2014) 254–258
complications.1,13 Although these women are at higher risk than
their healthier counterparts, studies have shown that they receive
less or inappropriate contraceptive counselling.10,20 This implies
that contraceptive knowledge covering the failure rates of the
contraceptive methods is not given adequately to pregnant women
during their antenatal care even if they were diagnosed to have
high-risk pregnancies. A detailed analysis of the risks related to
their future pregnancies, birth spacing and modern contraceptive
methods should be discussed with the patients with care. The
methods not requiring daily or coital adherence such as LARCs
might be a good preference for these patients if no other
contraindications are noted. These methods are presented as
effective with typical use as they are with perfect use.21 They are
recommended for use of women including those with cardiovas-
cular risk factors (diabetes and obesity), epilepsy and physical or
intellectual disabilities.22
In our study group, the ideal number of children was
2.69  1.42. When the contraceptive method choice after delivery
was analysed according to the ideal number of children, the
leading method for all groups (for 1–4 or more children) was IUD
(35.7%, 45%, 30.1%, and 41.1%, respectively). Although the patients
stated that they had been aware of their high-risk conditions,
traditional methods were remarkably higher in all groups. We also
noted that with decreasing educational and economic status, the
ideal number of children increased (p < 0.001). This shows the effect
of education on the fertility goal and ideal number of children.
The majority of women (73.7%); especially those with low
educational levels wanted more information about effective
contraceptive methods that could allow them to space and/or to
limit their following pregnancies before discharge. This might be a
result of having high-risk conditions during pregnancy. A recent
study about postpartum contraception revealed that 97.9% of
women, including those with only one child, wanted to choose a
contraceptive method before discharge, but the authors reported
that only 6.0% of them received counselling.23 This ratio has been
reported as 41% in 48,775 women within 90 days after birth in a
recent study.24 Findings of the same study had shown that
provision of a contraceptive method within 90 days after birth was
associated with avoidance of short interpregnancy intervals.24
Thus, clinicians should be aware of the patients’ demands for
effective contraception and should provide a comprehensive
counselling about contraceptive methods so that the patients
could get the method of choice before discharge.
The strengths of the present study were its large sample size as
the hospital where the study conducted was a referral centre for
high-risk pregnancies, and its contribution to the small amount of
the published literature addressing the importance of postpartum
family planning in high-risk pregnancies. Several limitations to
this study also need to be acknowledged; the first limitation was its
design as the cases were only high-risk pregnant women. The
patients were evaluated only about their contraceptive choices
before and after pregnancy with no further follow-up that
showed the actual rate of postpartum contraceptive method
use. Further research regarding the role of high-risk pregnancy
condition with a control group of healthy pregnant women would
be of great help in the investigation of the effect of having such a
high-risk condition on contraceptive method choice. The third
limitation was the low educational level and low-income level of
the participants. These limitations may restrict the generalisation
of the findings of the presented study.
5. Conclusion
A high-risk pregnancy condition may change the opinion and
preferences of contraceptive use, and also seems to increase the
awareness on future fertility goals and family planning. Integration
of family planning counselling and service delivery into high-risk
pregnancy and postpartum care units is very important for
decreasing the unmet need for contraception and improving the
maternal and thus neonatal health.
Conflict of interest
The authors report no conflict of interest.
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