Our systematic review showed that a combination of community-based interventions targeting young married couples, influential family members, community members and health systems were effective in delaying pregnancy, increasing contraceptive use and pregnancy care (Fig. 2). The interventions, which were shown to be effective in reaching young married couples to educate and motivate them for positive healthcare seeking behaviors include formation of women groups, involving them in group-counseling sessions, home visits by frontline functionaries/outreach workers [23, 24, 26, 27, 30] and support them with the establishment of a small fund (village health fund) for use in emergencies [24]. Interventions, shown to be effective in addressing family and community members included group counseling [23–27] and opportunistic interactions [24] with them. The latter included street plays [26, 27], wall paintings [23], involving community groups and local media [27] to spread the message. Further, the strategy of stratifying young women in line with specific needs of women in different reproductive life stages (newly married, nulliparous pregnant women, couples with one child and pregnant women with one/more children) was found to be effective in reaching them with the required package of interventions [24, 25]. Interventions to make health workers and health facilities or systems more responsive included sensitizing managers and training different cadres of health workers active in the community, in providing education, counseling and health services [25, 30]. Training of health service providers, paramedics and community workers on the health-service needs of young married women/couples improved the knowledge of the target group on reproductive health as well as service utilization for contraception and pregnancy care [23, 26, 27].
There is substantial evidence that community based interventions have the potential to improve maternal and newborn health outcomes. A recent review of literature on community level interventions to improve quality of care for maternal health indicated that home visits, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve reproductive health outcomes [31]. The determinants of reproductive health behaviors including health care comprehensive package of intervention is expected to improve reproductive health access of young married women.
Although there is very little evidence on the role of community based interventions in improving the reproductive health of young married couples [15–24 years], two reviews on young women’s contraception use highlight the importance of community-based multifaceted interventions [32, 33]. Consistent to our findings, a recent literature review on reaching first time parents for healthy spacing of second and subsequent pregnancies found that programs that successfully combine a number of approaches to offer an integrated package of information and appropriate services for a woman, her partner, her support network and her access to health services will likely to be most effective in increasing reproductive decision making, use of contraceptives and better spacing of additional pregnancies [32]. Further, another systematic review on contraceptive use among young women (married and unmarried girls in the age group of 11–24 years) indicated that community wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth friendly health services are necessary to reduce the barriers that restrict young women’s contraceptive choices across developing countries [33].
The review highlighted the importance of addressing influential family members as well as young people that was reiterated by the findings of FTP [24]. It showed significant change in indicators such as use of contraception to delay the first birth, uptake of comprehensive antenatal care; delivery preparation, routine postpartum check-ups and breastfeeding practices, but it excluded institutional delivery at first birth. The reason being many young women had gone to their natal homes for first delivery; and the interventions they were exposed to, were not being able to influence family or health service environments outside the project sites. Our review showed that the key determinants of health and healthcare seeking behavior need to be understood and then can be addressed using a combination of tailor-made approaches. This was entirely in line with the recommendations of two documents–one published by WHO [2] and the other by UNFPA [34]; although the focus of both documents was beyond healthcare seeking for contraception, abortion and maternal health.
However, the findings of our review need to be interpreted in terms of paucity of data on community based interventions on young married couples, as only eight studies/project reports met our inclusion criteria. Most of the programs tend to focus on young/adolescent (i.e. youth friendly health services especially for unmarried youth), married women or mothers in general. There are a couple of interventions that focus on the specific information and service delivery needs of young married women with a child. There are far less interventions on delaying first pregnancy than on spacing or delaying second and subsequent births among young married women.
Our search was only limited to English language publications. Another important limitation was that all projects included in this review were from South Asia except one. Further, the studies/project reports had some methodological problems including inadequate information about fidelity of implementation [25, 29], sample selection [24, 25, 29, 30], and methods to control confounding and/or contamination [24, 26, 27]. In addition, there were disparities between the proposed objectives of some studies/project reports and the outcomes assessed after intervention, thus making it impossible to know, if they have really achieved their objectives. For example, two of them [24, 26] set out to increase the knowledge and capacity of healthcare providers to meet the needs of married young women/adolescents; however, at the end line neither of these studies provided any data on these objectives. One of the projects [27] aimed to increase contraceptive negotiation skills of young married women, but it did not provide any evidence about the outcome of this objective at the end line.
Most of the projects had reported loss to follow up of the target women/couples in the study, which might have led to participation bias. One project reported contamination of intervention effects in the control arm [23], leading to difficulty in identifying changes attributable to the intervention. High baseline values and proximity to the control area were a potential source of bias in one project [24]. Both the projects from Nepal were interrupted by political conflicts, unrest and closure of health facilities for long durations, and so the effectiveness had to be interpreted cautiously. Finally, none of the studies/project reports have evaluated changes in health outcomes (maternal and neonatal morbidity/mortality) and none of them addressed abortion care explicitly.