It's about time: WHO and partners release programming strategies for postpartum family planning

Magnitude and associated factors of postpartum family planning uptake among postpartum women in Ethiopia: an umbrella review

Background

The World Health Organization indicates that despite advancements, the rates of maternal and neonatal mortality and morbidity during the postpartum period continue to be alarmingly high. Furthermore, untapped opportunities to enhance maternal health and promote effective newborn care, including family planning services, have not been fully leveraged. Earlier meta-analyses and systematic reviews have addressed this subject; however, a thorough evidence synthesis has not been provided. Therefore, the objective of this study was to compile the existing systematic reviews (SRs) concerning postpartum family planning uptake among postpartum women in Ethiopia.

Method

This review used an umbrella review method, incorporating numerous systematic reviews. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Meta-analysis of Observational Studies guideline (MOOSE). A comprehensive literature review was conducted across prominent four electronic databases (including MEDLINE/PubMed, Cochrane, Web of Science and Science Direct) from June 15, to July 15, 2024. This review encompassed investigations carried out within the uptake of family planning among post-partum women and its determinants in Ethiopia were the primary outcome. A set of inclusion criteria was established to identify all pertinent systematic reviews, including studies, with no restrictions on data collection and publication year. The quality of the methods was evaluated using the Assessment of Multiple Systematic Reviews tool, (AMSTAR) tool. Statistical analysis was conducted using STATA version 17 software, and the 95% confidence interval was utilized to establish statistical significance. I-squared statistics were employed to evaluate the heterogeneity of the studies by using a random-effects meta-analysis model.

Results

The umbrella review includes five studies with a total of 44,276 postpartum women. The pooled prevalence of postpartum family planning utilization was 36.41% (95% CI: 24.78, 48.03). Family planning counseling (AOR: 4.12, 95% CI: 2.89, 4.71), couple discussion (AOR: 3.06, 95% CI: 1.42, 5.60), and postnatal follow-up (AOR: 3.48, 95% CI: 2.60, 4.83) were significantly associated with postpartum family planning uptake.

Conclusion

The study results indicate that the adoption of postpartum family planning in Ethiopia requires focused intervention. This can be achieved by identifying and enhancing community frameworks to involve men in reproductive health initiatives and by providing comprehensive family planning information and services during postnatal care. Addressing the aforementioned factors is crucial to mitigate the risks associated with unintended pregnancies and to manage the swift increase in population.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024568435, PROSPERO (CRD42024568435).

Level of immediate postpartum family planning utilization and the associated factors among postpartum mothers, Bole Sub-city, Addis Ababa, Ethiopia: institution based cross-sectional study

BACKGROUND

The occurrence of pregnancy in the postpartum period poses a risk to women and their infants, and it also has increased risks of adverse health outcomes if a pregnancy happens less than two years after the preceding birth. Utilization of immediate postpartum family planning is a possible and simple way to reduce these unfavourable outcomes. However, only a small proportion of mothers use the service; but the reasons appear unclear. Thus, this study aimed to determine the level and factors associated with the utilization of immediate postpartum family planning in Bole sub-city, Addis Ababa, Ethiopia.

METHODS

A facility-based cross-sectional study was carried out from August 15 to September 15, 2022, among mothers who gave birth one year before the data collection period. A total of 425 mothers were selected with a systematic random sampling technique. A pretested and structured questionnaire was administered to collect data. Data entry and analysis were done by Statistical Package for Social Sciences 25. Chi-square, multicollinearity and Hosmer-Lemshaw model fitness tests were tested. The level of utilization was determined by descriptive statistics and the associated factors were determined by a binary logistic regression model, and presented with the adjusted odds ratios (AOR) with their respective 95% confidence intervals (95%CI). All statistical tests were conducted at a 5% level of significance.

RESULTS

Utilization of family planning method immediately after birth was 12.9% (95% CI = 11.3-14.5%), and it was statistically significantly associated with ages between 25 and 34 years (AOR = 5; 95% CI [1.38-18.41]) and 35 years and above (AOR = 6[1.47-25.70]), unfavourable attitude (AOR = 0.2[0.11-0.31]) and no counselling about immediate postpartum family planning during antenatal care visit (AOR = 0.43[0.20-0.89]).

CONCLUSION AND RECOMMENDATIONS

The level of utilization of immediate postpartum family planning is low in the study area. To improve it, dealing with younger women, working to achieve a positive attitude amongst women towards immediate postpartum family planning, and incorporating counselling about postpartum family planning methods during antenatal care visits are all recommended.

Immediate postpartum family planning utilization and its associated factors among postpartum women in Ethiopia: a systematic review and meta-analysis

Background

Family planning integration in areas where women contact the healthcare system routinely is essential for addressing the high unmet need for family planning among postpartum women and reducing the risk of short interpregnancies. Immediate postpartum family planning (IPPFP) is an integrated service, and opportunities exist for women by providing family planning (FP) counseling and contraceptives as part of care following childbirth within 48 h. Therefore, this review aimed to assess the pooled estimate of immediate postpartum family planning utilization and its associated factors in Ethiopia.

Method

Electronic databases were used to conduct an extensive search of all published studies, and the digital library was used to identify any unpublished studies. An observational study that reports the prevalence/magnitude and/or associated factors/predictors/determinants of IPPFP utilization in Ethiopia was included. Data were extracted on the Microsoft Excel spreadsheet and analyzed using STATA Version 11. A random-effects model was applied to determine the pooled prevalence of immediate postpartum family planning utilization with a 95% confidence interval (CI). Inverse variance (I2) was used to identify the presence of heterogeneity, and a funnel plot and Egger's test were used to check the presence of publication bias. Subgroup analysis was conducted based on the sample size, region, and year of study to identify the source of heterogeneity.

Result

Of 15 primary studies, the overall pooled prevalence of immediate postpartum family planning utilization among postpartum women in Ethiopia was 21.04% (95% CI: 13.08, 29.00). Received counseling on FP [OR: 3.59; 95% CI (1.84, 7.01; P < 0.001), having a positive attitude toward FP [OR: 3.2; 95% CI (1.23, 8.35); P = 0.017], and partner support to use FP [OR: 5.85; 95% CI (1.12, 30.54; P = 0.036) were significant predictors of immediate postpartum family planning utilization.

Conclusion

Generally, IPPFP utilization in Ethiopia was insufficient. Therefore, to enhance the utilization, integrating FP counseling at all maternal service care points, strengthening community awareness to develop a favorable attitude toward family planning, and promoting partner involvement in family planning counseling are essential.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=239053, identifier: CRD42021239053.

The effect of maternal educational status, antenatal care and resumption of menses on postpartum contraceptive use in Ethiopia: systematic review and meta-analysis

The postpartum period is a crucial starting point for the delivery of family planning services. To date, there are numerous primary studies in Ethiopia on postpartum contraceptive use and related factors. However, the results of key variables are inconsistent, making it difficult to use the results to advance the service dimensions of postpartum contraceptive use in the country. Therefore, this systematic review and meta-analysis was required to summarize this inconsistency and compile the best available evidence on the impact of maternal educational status, antenatal care and menstrual resumption on postpartum contraceptive use in Ethiopia. PubMed, Google Scholar, Scopus, Science Direct, and the repositories of online research institutes were searched. Data were extracted with Microsoft Excel and analyzed with the statistical software STATA (version 14). Data on the study area, design, population, sample size, and observed frequency were extracted using the Joanna Briggs Institute tool. To obtain the pooled effect size, a meta-analysis was performed using a weighted inverse variance random effects model. Cochran's Q X2 test, and I2 statistics were used to test for heterogeneity, estimate the total quantity, and measure the variability attributed to heterogeneity. A mixed-effects meta-regression analysis was performed to identify possible sources of heterogeneity. To examine publication bias, the Eggers regression test and the Beggs correlation test were used at a p-value threshold of 0.001. Of the 654 articles reviewed, 18 studies met the inclusion criteria and were included in this meta-analysis. Overall, the final analysis includes 11,263 study participants. In Ethiopia, postpartum contraceptive use correlated significantly with maternal educational status (OR = 3.121:95% CI 2.127-4.115), antenatal care follow-up (OR = 3.286; 95% CI 2.353-4.220), and return of the mother's menses (OR = 3.492; 95% CI 1.843-6.615). A uniform meta-regression was performed based on publication year (p = 0.821), sample size (p = 0.989), and city of residence (p = 0.104), which revealed that none of these factors are significant. The use of postpartum contraceptives was found to be better among mothers who are educated, attended antenatal appointments, and resumed their menstrual cycle. Based on our research, we strongly recommended that antenatal care use and maternal educational accessibility need to improve. For family planning professionals, removing barriers to menstruation resumption should be a key priority.

Process evaluation of postpartum contraceptive service delivery in Ayder Comprehensive Specialized Hospital Mekelle, Tigray, Ethiopia in 2020

BACKGROUND

Postpartum contraceptives during the first year after delivery is a key service for women to prevent unintended pregnancy and reduce the risk of maternal and child mortality by ensuring safe birth intervals. This process evaluation aimed to assess the availability, compliance, and accommodation of Post-Partum Contraceptives (PPC) and the experience of women's contraception in the first 12 months postpartum in Ayder Comprehensive Specialized Hospital (ACSH).

METHODS

A case study evaluation design with a mixed method was employed from February 16/2020 to Mar 30, 2020. Direct observations, 12-month document reviews, and key informant interviews were conducted. The quantitative data were entered into Epi-Data version 3.1 and exported to SPSS version 21 for analysis. In the multivariate logistic regression analysis, variables with < 0.05 p-values and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were used to declare the association. The qualitative data were transcribed, translated, coded, and analyzed using thematic analysis. The overall process of program implementation was measured based on pre-determined judgmental criteria.

RESULT

From the total of charts reviewed 302 only 188 (62.3%) postpartum mothers used any method within 12 months of the postpartum period out of which only 27.1% mothers used of long-acting reversible contraceptive (LARC). The overall evaluation of postpartum contraceptives was 84.1% (V/good). Notable gaps observed in this study were poor provision of information in relation to methods given, poor technical performance in following the aseptic procedure, poor utilization of postpartum family planning guidelines and clinical checklists for counseling, and poor use of information education materials compared to the national standards. Residence, number of stillbirths or neonatal loss, counseling status of family planning during ANC visits, and maternal counseling status of family planning during postnatal care visits were factors associated with PPC.

CONCLUSION

The overall postpartum contraceptive service delivery in ACSH was V/good compared to the national family planning guideline standards. With the notable gaps identified, specific recommendations were suggested to different responsible bodies.

The more, the better: influence of family planning discussions during the maternal, newborn and child health continuum of care on postpartum contraceptive uptake and method type among young women in Ethiopia

Background: This study examines the association between family planning (FP) discussions with health professionals during contact points on the maternal, newborn and child health continuum of care and timing of modern contraceptive uptake and method type in the one-year following childbirth in six regions of Ethiopia among adolescent girls and young women (AGYW). Methods: This paper uses panel data of women aged 15-24 who were interviewed during pregnancy and the postpartum period between 2019-2021 as part of the PMA Ethiopia survey (n=652).  Results: Despite the majority of pregnant and postpartum AGYW attending antenatal care (ANC), giving birth in a health facility, and attending vaccination visits, one-third or less of those who received the service reported discussion of FP at any of these visits. When considering the cumulative effect of discussions of FP at ANC, pre-discharge after childbirth, postnatal care and vaccination visits, we found that discussion of FP at a greater number of visits resulted in increased uptake of modern contraception by one-year postpartum. A greater number of FP discussions was associated with higher long-acting reversible contraceptive use relative to non-use and relative to short-acting method use. Conclusions: Despite high attendance, there are missed opportunities to discuss FP when AGYW access care.

Integrating contraceptive services into existing perinatal care: protocol for a community-based cluster randomised controlled trial in Shanghai, China

INTRODUCTION

Postpartum contraception is essential to preventing unintended pregnancies and short interpregnancy intervals. The first year after childbirth is a critical period with a high risk of unintended pregnancy and induced abortion. However, the postpartum contraceptive services are weak in China's existing maternal and child healthcare system. We propose to evaluate the effects of integrating postpartum contraceptive services into the existing perinatal care system via a cluster randomised controlled trial.

METHODS AND ANALYSIS

This cluster randomised controlled trial involves all 13 communities of Minhang District, Shanghai, China. Communities will be randomly allocated, seven in the intervention group and six in the control group. One thousand and three hundred women, 100 women in each community, will be recruited in the study. Women assigned to the intervention group will receive postpartum contraceptive education and counselling during pregnancy, childbirth hospitalisation, postpartum home visits and the 42-day postpartum clinic check-up. Women in the control group will receive routine antenatal and postpartum care. Participants will be recruited in the first trimester during pregnancy and followed up to 1 year postpartum. The primary outcome is the incidence of unintended pregnancy within 1 year after childbirth.

ETHICS AND DISSEMINATION

The trial received ethical approval from the Ethics Committee of Shanghai Minhang District Maternal and Child Health Care Hospital (#[2020]KS-02, #[2020]KS-05, #[2020]KS-05-EX). Results will be published in academic journals and disseminated in multiple formats for the health professionals and the public.

TRIAL REGISTRATION NUMBER

ChiCTR2000034603.

Immediate postpartum intrauterine contraceptive device utilization and associated factors among women who gave birth in public health facilities of Adama town, Ethiopia

Objectives

The evidence on utilization of immediate postpartum intrauterine contraceptive devices (IPPIUCDs) and its associated factors are limited in Ethiopia. Hence, this study intended to assess IPPIUCD utilization and related factors among women who gave birth in Adama town public hospitals, Ethiopia.

Method

A facility-based cross-sectional study was done among 493 postpartum mothers at selected government health facilities in Adama town from January 20 to February 20, 2021. All women who gave birth in selected government health facilities and within 48 h of postpartum were included in the study. Data were collected using an interviewer-administered questionnaire. Logistic regression models were used to identify the factors associated with IPPIUCD utilization. Adjusted odds ratios (AORs) with 95% confidence interval (CI) were calculated to measure the strength of association and statistical significance was declared at p < 0.05.

Result

In this study, 22.1% (95% CI: 17.3-25.2) of the mothers used IPPIUCDs within 48 h of giving birth. Having three or more children (AOR = 4.18, 95% CI: 1.79-9.79), having no desire to have another child (AOR = 3.9, 95% CI: 1.86-8.17), counseling after delivery (AOR = 3.1 95% CI: 1.52-6.34), and having good knowledge about PPIUCD (AOR = 3.82, 95% CI: 1.94-7.49) were significantly associated with IPPIUCD utilization.

Conclusion

The utilization of IPPIUCD in this study was low. Strategies to raise pregnant mothers' awareness of IPPIUCD through mass media, and integrating standard counseling on immediate postpartum intrauterine device (IPPIUD) during antenatal care, and the immediate postpartum period are required to improve IPPIUD utilization.

Time to initiate postpartum modern contraceptives among pregnant women in Ambo Town, Central Ethiopia; Cox-proportional hazard regression analysis

BACKGROUND

Timing of postpartum family planning is crucial for maternal and child wellbeing by preventing unintended and closely spaced pregnancies. However, studies are limited on the time to use modern contraceptives in Ethiopia. Therefore, this study aimed to fill these gaps by assessing the time to initiate postpartum modern contraceptive and identifying its predictors among pregnant women in Ambo town, central Ethiopia.

METHODS

An institution based cross-sectional study was conducted among 356 pregnant women in Ambo town, Central Ethiopia. The data were analysed using STATA-16 software. Kaplan-Meier estimates were performed to explain time-to- modern contraceptive use. A Cox-proportional hazard regression analysis was conducted to identify predictors. The adjusted hazard ratio (AHR) with a 95% confidence interval was considered to declare a statistically significant association.

RESULTS

This study showed that the median survival time to initiate postpartum modern contraceptives was 6 months. In this study, the risk of modern contraceptive use was 2.13 times higher (AHR = 2.13; 95% CI: 1.02-4.45) among younger women, 1.44 times higher (AHR = 1.44; 95% CI: 1.09-2.66) among women with no desire for more children, and 2.25 times higher (AHR = 2.25; 95% CI: 1.02-4.95) among nulliparous women. However, it is 57% times lower (AHR = 0.57; 95% CI: 0.32-0.94) among pregnant women with current unintended pregnancy.

CONCLUSION AND RECOMMENDATION

The median survival time to initiate postpartum modern contraceptive was 6 months. Age of the women, desire for more children, parity and pregnancy status were found to be the significant predictors of time to initiate postpartum modern contraceptive. Therefore health care providers and concerned stakeholders should consider these factors to increase the uptake of the postpartum contraceptive methods.

Factors associated with utilization of modern postpartum family planing methods during the extended postpartum period among mothers who gave birth in the last 12 months at Injibara town, Northwest, Ethiopia: a cross-sectional study

BACKGROUND

The extended postpartum period is the first twelve months following childbirth and is an important entry point for family planning service providers to reduce unintended and too closely spaced pregnancies. A modern postpartum family planning service is one of the recommended public health interventions for reducing maternal and child morbidity and mortalities in sitting where maternal mortality is high, like in Ethiopia.

OBJECTIVE

This study was aimed to assess factors associated with the utilization of modern family planning methods during the extended postpartum period among mothers who gave birth in the last 12 months at Injibara town, Northwest, Ethiopia.

METHODS

A community-based cross-sectional study design was employed from March 1-15/2019 at Injibara town among 402 mothers. The data was collected by a simple random sampling technique and analyzed using the SPSS 23.0 version. Logistic regression analyses were employed to estimate the crude and adjusted odds ratio with a confidence interval of 95% and a P-value of < 0.05 in multivariable analysis considered statistically significant. Frequency tables and descriptive summaries were used to describe the study variables.

RESULTS

The total sample size of this study was 402 and among them, 400 postpartum mothers participated in the study with a response rate of 99.5%. The utilization of modern family planning methods during the extended postpartum period among postpartum mothers was 58.5% [95% CI: 53.5- 63%]. Of these, 38.9% and 32.9% of the mothers were using injectables and implants respectively. Secondary and above educational level, having ≥ 3 antenatal care visits, resumption of menstruation, discussing with the partner on utilization of family planning method, being counseled on family planning method utilization during antenatal care visits and immediately after delivery, linkage of the mothers to a family planning unit during child immunization, and having good knowledge of family planning methods were associated with utilization of modern family planning methods during the extended postpartum period.

CONCLUSION

The utilization of modern family planning methods during the extended postpartum period among postpartum women was low compared to the world health organization recommendation. Socio-demographic, health care service uptakes, and reproductive characteristics were associated with the utilization of modern family planning methods during the extended postpartum period. We suggest emphasizing the education and counseling of women on the utilization of family planning during maternal and child health care service utilization. Mothers should be encouraged to start using modern family planning methods before the resumption of menses.

Perinatal intimate partner violence and postpartum contraception timing among currently married women in Southern Ethiopia: A multilevel Weibull regression modeling

Background

Adopting contraception on time is a critical intervention for postpartum women, but violence exposure around pregnancy may interfere with postpartum contraceptive use behaviors. Hence, this study aimed to investigate the time duration of the first modern contraceptive adoption and its individual-and community-level predictors among postpartum women in the Wolaita zone, South Ethiopia.

Methods

A community-based prospective follow-up study was conducted among 1,292 postpartum women nested in 38 "Kebles" (clusters) using multistage-clustered sampling techniques. A multilevel Weibull regression model was employed to investigate predictors of time-to-method initiation after childbirth using STATA Version 14. Kaplan-Meier curve and Wilcoxon log-rank test were used to estimate time-to-modern contraceptive use across different variables. All variables with p-values <0.05 were considered for multivariate analysis. Adjusted time ratios (ATR) with 95 % CI were computed using Weibull accelerated failure time models.

Results

Of the respondents, 62% (95% CI: 59.1-64.5) had started the first modern contraception within a year after childbirth. The restricted mean survival time-to-postpartum modern contraceptive use was 6.28 months. Being a rural dweller (aTR: 1.44; 95% CI: 1.06-1.99) and living in the middle household wealth quintiles (aTR: 1.10; 95% CI: 1.02-1.19) predicted longer time duration to adopt first modern contraception by 44 and 10%, respectively. The women from the community with a high early marriage (aTR: 1.14; 95% CI: 1.01-1.28) took longer time to initiate modern postpartum methods. Furthermore, women who had no history of perinatal abuse took less time than those who had a history of abuse to start postpartum contraception (aTR: 0.71; 95% CI: 0.66-0.78).

Conclusion

Rural residence, poor household wealth status, history of perinatal abuse, and a high rate of early marriage in the community are predicted to lengthen the time duration to start modern postpartum contraception. Thus, community-level women's empowerment, particularly among rural women and integration of intimate partner violence screening into family planning counseling throughout the continuum of care will likely to improve postpartum contraception timing.

The impact of having a dedicated obstetrics and gynecology resident to provide contraceptive counseling on immediate postpartum family planning uptake: a "pre-post" study

Background

Providing effective, high quality, antenatal and postpartum contraceptive counseling can reduce unintended pregnancies, decrease maternal and fetal morbidity and mortality, and prevent unsafe abortions. The postpartum period is a critical time to address unmet family planning need and to reduce the risks of short interpregnancy interval. This study aimed at determining the impact of assigning a dedicated obstetrics and gynecology resident for postpartum family planning counselling on the uptake of immediate postpartum family planning.

Methods

A “pre-post” observational study was conducted at Saint Paul’s Hospital Millennium Medical College (SPHMMC), in Addis Ababa-Ethiopia, from May 1, 2021 to June 30, 2021. Immediate postpartum family planning uptake between the months of June (when there was a dedicated resident assigned for postpartum family planning counselling and provison on weekdays) and May (when there was no such dedicated resident for similar purpose) were compared. Data was analyzed using SPSS version 20 software packages. Simple descriptive was used to describe baseline characteristics. Chi-square test of association was done to determine the correlation between dependent and independent variables. Multivariate regression analysis was applied to determine factors associated with uptake of family planning methods in the immediate postpartum period. Odds ratio, 95% CI, and p-value < 0.05 were used to describe results significance.

Results

Out of 776 mothers who delivered at SPHMMC in the month of June 2021, 158 (20.4%) of them used immediate postpartum family planning. This finding during the month of June is higher than a 15.4% immediate postpartum family planning uptake observed during the preceding month of May. Having a dedicated resident for postpartum family planning counselling was associated with an increase in immediate postpartum family planning use (AOR = 1.31, 95% CI [1.01, 1.69]).

Conclusion

In this study, presence of a dedicated obstetrics and gynecology resident for postpartum family planning counselling was associated with an increase in the uptake of immediate postpartum family planning. This implies the importance of assigning a dedicated care provider for the purpose of postpartum family planning counselling within the immediate postpartum, which gives postpartum women another opportunity of adequate counselling before they are discharge from Hospitals or obstetric service centers.

The postpartum period is a critical time to address unmet family planning need and to reduce the risks of short interpregnancy interval and unintended pregnancies, which translates in to a decrease in maternal and fetal morbidity and mortality. In this study, postpartum women who were counselled for family planning by dedicated obstetrics and gynecology resident were more likely to use immediate postpartum family planning (PPFP) compared to women who were not counselled by such care provider. This study aimed at determining the impact of assigning a dedicated obstetrics and gynecology resident for postpartum family planning counselling, by comparing immediate PPFP (family planning provided after delivery and before discharge of mothers from Hospital) uptake between the months of June (when there was a dedicated resident) and May (when there was no dedicated resident), in 2021. Out of 908 deliveries during the month of May, the uptake of immediate PPFP was 15.4%, which was significantly lower than an uptake of 20.4% in the following month of June. Mothers who delivered during the month of June were 1.3 times more likely to use immediate PPFP than mothers who delivered in the preceding month of May. In conclusion, presence of a dedicated obstetrics and gynecology resident for postpartum family planning counselling was associated with an increase in the uptake of immediate postpartum family planning.

Utilisation of immediate postpartum family planning among postpartum women at public hospitals of North Shoa Zone, Ethiopia: a cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence of immediate postpartum family planning utilisation and the associated factors among postpartum women at public hospitals of North Shoa Zone, Ethiopia.

DESIGN AND METHODS

A facility-based cross-sectional study was conducted in 1-30 May 2020. Systematic random sampling technique was used to select the participants. Data were collected through a face-to-face interview using a structured and pretested questionnaire. Univariate and multivariable logistic regression analyses were employed. In multivariable logistic regression analysis, p<0.05 and adjusted OR (AOR) with 95% CI were used to declare statistically significant factors.

SETTING AND PARTICIPANTS

The study was conducted at public hospitals of North Shoa Zone, Ethiopia. A total of 394 postpartum women within 48 hours after giving birth before discharge from the selected hospitals were enrolled in the study.

OUTCOME

Immediate postpartum family planning utilisation (used or not used).

RESULTS

Of the total 394 participants, 84 (21.3%) used immediate postpartum family planning. The factors associated with immediate postpartum family planning utilisation were women's age (30-34 years) (AOR: 0.118; 95% CI 0.023 to 0.616), planning status of pregnancy (AOR: 3.175; 95% CI 1.063 to 9.484), reproductive intention (AOR: 5.046; 95% CI 1.545 to 16.479), partner support (AOR: 4.293; 95% CI 1.181 to 15.61), attitude towards family planning (AOR: 2.908; 95% CI 1.081 to 7.824) and maternal satisfaction with intrapartum care (AOR: 6.243; 95% CI 2.166 to 17.994).

CONCLUSION

In the study area, only less than a quarter of postpartum women used immediate postpartum family planning. Therefore, enhancing immediate postpartum family planning utilisation, strengthening community awareness to develop a favourable attitude towards family planning, promoting partner involvement in family planning and ensuring maternal satisfaction during intrapartum care are essential.

Missed opportunities for family planning counselling among postpartum women in eleven counties in Kenya

BACKGROUND

Mothers may access medical facilities for their babies and miss opportunities to access family planning (FP) services. This study was undertaken to describe missed opportunities for FP among women within the extended (0-11 months) postpartum period from counties participating in Performance Monitoring and Accountability 2020 (PMA2020) surveys.

DESIGN AND SETTING

This study analysed cross-sectional household survey data from 11 counties in Kenya between 2014 and 2018. PMA2020 uses questions extracted from the Demographic and Health survey (DHS) and DHS definitions were used. Multivariable logistic regression was used for inferential statistics with p-value of < 0.05 considered to be significant.

PARTICIPANTS

Women aged 15-49 years from the households visited.

PRIMARY OUTCOME MEASURE

Missed opportunity for family planning/contraceptives (FP/C) counselling.

RESULTS

Of the 34,832 women aged 15-49 years interviewed, 10.9% (3803) and 10.8% (3746) were in the period 0-11 months and 12-23 months postpartum respectively, of whom, 38.8 and 39.6% respectively had their previous pregnancy unintended. Overall, 50.4% of women 0-23 months postpartum had missed opportunities for FP/C counselling. Among women who had contact with health care at the facility, 39.2% of women 0-11 months and 44.7% of women 12-23 months had missed opportunities for FP/C counselling. Less than half of the women 0-11 months postpartum (46.5%) and 64.5% of women 12 - 23 months postpartum were using highly efficacious methods. About 27 and 18% of the women 0-11 months and 12 - 23 months postpartum respectively had unmet need for FP/C. Multivariable analysis showed that being low parity and being from the low wealth quintile significantly increased the odds of missed opportunities for FP/C counselling among women in the extended postpartum period, p < 0.05.

CONCLUSIONS

A large proportion of women have missed opportunities for FP/C counselling within 2 years postpartum. Programs should address these missed opportunities.

Barriers and determinants of postpartum family planning uptake among postpartum women in Western Ethiopia: a facility-based cross-sectional study

Background

Despite Ethiopia’s efforts to avail postpartum family planning (PPFP) services, the unmet need for family planning among postpartum women remains high. Therefore, this study is aimed to assess barriers and determinants of postpartum family-planning uptake among women visiting Maternal, Neonatal, and Child Health (MNCH) services in public health facilities of western Ethiopia.

Methods

A facility-based cross-sectional study design with a quantitative method was conducted on 989 postpartum women in Western Ethiopia from September 1 to October 30, 2020. Data were collected through face-to-face interviews using pretested structured questionnaires, entered using EPI-INFO version 7.0, and analyzed by SPSS version 25. Descriptive analysis and logistic regressions were performed. The adjusted odds ratio with a 95% confidence interval was used and statistical significance was declared at P-value < 0.05.

Result

In this study, 56.1% of participants had used PPFP in the last year. The most commonly used method was injectable (51.7%). Family planning use before the index pregnancy (AOR = 2.09;95%CI:1.29,3,41),counselling on PPFP during antenatal care and delivery (AOR = 4.89;95%CI:2.31,10.37),health facility delivery (AOR = 7.61;95%CI:4.36,13.28), skilled birth attendance (AOR = 4.99;95%CI:2.88,8.64),COVID-19 restrictions (AOR = 0.59;95%CI:0.39,0.90) were factors associated with PPFP utilization. Being breastfeeding and amenorrhea were major reasons for not using postpartum family planning.

Conclusion

Post-partum family planning utilization among study participants was low. Given the associated factors, it is recommended that health facilities should make postpartum family planning one of their top priorities and focus on these factors to improve its utilization.

Uptake of postpartum modern family planning and its associated factors among postpartum women in Ethiopia: A systematic review and meta-analysis

OBJECTIVE

This study aimed to estimate the pooled prevalence and factors associated with postpartum modern contraceptive use in Ethiopia.

DESIGN

Systematic Reviews and Meta-Analysis.

METHOD

PubMed, MEDLINE, EMBASE, Hinari, Google Scholar, direct Google search, African Journal Online (AJOL), an online repository, and gray kinds of literature were used for searching. This meta-analysis included eighteen cross-sectional studies. The quality appraisal criterion of the Joanna Briggs Institute (JBI) was employed to critically appraise papers. The I2 statistics were used to test heterogeneity and subgroup analysis was computed with the evidence of heterogeneity. The Egger test with funnel plot was used to investigate publication bias. The "generate" command in STATA was used to calculate the logarithm and standard error of the odds ratio (OR) for each included study. Then odds ratio (OR) with a 95% confidence interval (CI) was presented.

RESULT

Eighteen studies were included in the systematic review and meta-analysis. The pooled prevalence of modern postpartum family planning utilization among postnatal women in Ethiopia was 45.44% (95%CI: 31.47, 59.42).Prenatal family planning counseling (AOR = 3.80; 95%CI: 2.70, 5.34), postnatal care utilization (AOR = 3.07; 95%CI: 1.39, 6.77), spouse communication on family planning (AOR = 1.86; 95%CI:1.36,2.54), resumption of menses (AOR = 4.20; 95%CI: 2.95, 5.99), and resumption of sexual activity (AOR = 3.98; 95%CI: 2.34, 6.79) were associated factors to uptake modern postpartum family planning among postnatal women.

CONCLUSION

The pooled prevalence of postpartum modern contraceptive use was low. The most common factors significantly associated with postpartum modern contraceptive use were prenatal family planning counseling, postnatal care utilization, spouse communication on family planning, resumption of menses, and resumption of sexual activity were the commonest factors significantly associated with postpartum modern contraceptive use.

Postpartum Family Planning Use and Its Determinants among Women of the Reproductive Age Group in Low-Income Countries of Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Background

Postpartum family planning is the initiation and use of family planning services within the first 12 months following childbirth. Postpartum contraceptives reduce maternal and infant mortality by preventing unplanned and unwanted pregnancies and by spacing pregnancies at least two years after the previous birth. Thus, it is usually designed as an integral part of reproductive and maternal and child health programs. Therefore, the aim of this systematic review and meta-analysis is to estimate the pooled prevalence of postpartum modern contraceptive use and identify its determinants in low-income countries of sub-Saharan Africa.

Methods

A systematic review and meta-analysis of published and unpublished studies were used. PubMed, HINARI, ScienceDirect, Cochrane Library, Wiley Library, ETH Library, and Google Scholar were used to search all articles. STATA 14 software was used for data analysis. Funnel plots and Egger's test were used to examine the risk of publication bias. Heterogeneity was checked by using Cochran's Q test and I² test. A random effect model was computed to estimate the pooled prevalence.

Results

A total of 33 articles were included. The pooled prevalence of postpartum contraceptive use in low-income countries of sub-Saharan Africa was 37.41%, 95% CI: (31.35, 43.48%). Secondary and above level of education (AOR 2.09, 95% CI: (1.52, 2.86)), discussion with husband (AOR 3.68, 95% CI: (1.96, 6.89)), resumption of menses (AOR: 3.98, 95% CI: (2.62, 6.03)), ANC follow-up (AOR; 5.10, 95% CI: (3.57, 7.29)), knowledge of modern family planning (AOR: 5.65, 95% CI: 3.58, 8.93)), and family planning counseling during ANC (AOR =5.92, 95% CI: (2.54, 13.79)) were found to be determinants of postpartum contraceptive utilization.

Conclusion

In this systematic review and meta-analysis, the prevalence of postpartum modern contraceptive use was found to be low compared to the existing global recommendations. Therefore, empowering maternal education, delivering adequate counseling, and strengthening existing integrated maternal and child health services are highly recommended to increase postpartum contraceptive use. This trial is registered with CRD42020160612.

Modern Contraceptive Use and Associated Factors During Extended Postpartum Period Among Women Who Gave Birth in the Last 12 Months at Northwest Ethiopia

BACKGROUND

The extended postpartum period is a one-year follow-up period after giving birth, and it is critical for women to prevent unintended pregnancy and reduce the risk of maternal and child mortality by ensuring safe birth intervals. Many women, however, are unaware that they are at risk for pregnancy throughout this period. Hence, the aim of this study was to assess the utilization and associated factors of modern contraceptives during extended postpartum family planning (EPPP) in northwest Ethiopia.

METHODS

A community-based cross-sectional study design was conducted using 630 samples from October 01 to October 30, 2020, in northwest Ethiopia. The study participants were drawn through a multistage sampling technique and data were collected using structured questionnaires via interview. The collected data were entered into EpiData version 4.2 and exported into SPSS version 25.0 for management and further analysis. A bivariable logistic regression model was used to identify variables having an association with the outcome variable. In bivariable analysis, variables having P ≤ 0.25 were selected and entered into multivariable logistic regression analysis. Finally, in multivariable analysis, variables having P ≤ 0.05 with a 95% CI were declared as significantly associated with the outcome variable.

RESULTS

About 60.6% of women were using modern contraceptive during extended postpartum period. Mothers to partner discussion (AOR= 7.6, 95% CI: 4.20-14.05), secondary educational status (AOR= 3.8, 95% CI: 1.36-10.93), college and above educational status (AOR= 7, 95% CI: 1.92-25.57), menstrual resumption (AOR= 9.2, 95% CI: 5.66-15.12), sex resumed (AOR=8.5, 95% CI: 2.19-33.58), fertility desire (AOR= 3.9, 95% CI: 1.99-6.15), linkage to FP during child immunization (AOR= 2.7, 95% CI: 1.67-4.50), and FP counseling during pregnancy (AOR=2, 95% CI: 1.25-3.34) were significantly associated with outcome variable.

CONCLUSION

Associating factors were identified as partner discussion, education, menstrual resumption, fertility desire, sexual resumption, FP counseling, and FP during child immunization. Improving mothers' education and informing couples about the dangers of becoming pregnant before menstruation are critical.

Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania

INTRODUCTION

Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors.

METHODS

A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted.

RESULTS

Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.

Initiation of postpartum modern contraceptive methods: Evidence from Tanzania demographic and health survey

Background

Postpartum contraceptive use is vital to improve maternal and child survival. It helps to have optimal child spacing, prevent unplanned pregnancies and associated adverse birth outcomes. However, postpartum contraceptive use in Tanzania remains low. Short median interval for resumption to sex after birth among African women has been associated with adverse maternal and child health wellbeing. This study aimed to assess optimal time to contraceptive use and predictors of time to contraceptive use after birth among women of reproductive age in Tanzania.

Methods

A cross section study using the TDHS 2015–16 data was used. A total of 3775 postpartum women were analyzed. Information on pregnancy, births and contraceptive use were recorded over the previous 5 years with the focus on most recent birth from the contraceptive calendar. Data analysis was performed using Stata 14.0. Analysis accounted for complex survey design. Time to modern contraceptive use after birth was computed using Kaplan Meier estimate. Adjusted time ratios with 95% CI were estimated using Weibull accelerated failure time models.

Results

A total weighted sample of 3775 women was analyzed. The median time to contraceptive use after birth was 7(IQR: 4–13) months, while for resumption to sex afterbirth was 2(IQR: 1–5) months. Factors such as never been married (TR: 1.63; 95%CI: 1.26–2.11) and breastfeeding (TR: 5.50; 95%CI: 4.12–7.35) were associated with longer time to postpartum contraceptive use. Belonging to richest wealth quintile (TR: 0.73; 95%CI: 0.54–0.99) and adopting long acting methods (TR: 0.70; 95%CI: 0.60–0.82) increased women’s likelihood of having shorter time to postpartum contraceptive use.

Conclusion

There was a time lag of five months from resumption of sex and initiation of postpartum contraception use. The interceptive measures to facilitate timely availing methods of women’s choice and promotion of utilization of maternal health care services may reduce delays in postpartum contraceptive use.

Determinants of Postpartum Intrauterine Contraceptive Device Uptake among Women Delivering in Public Hospitals of South Gondar Zone, Northwest Ethiopia, 2019: An Unmatched Case-Control Study

Introduction

Integrated use of postpartum intrauterine contraceptive devices with delivery service during the immediate postpartum period is ideal for both women and health-care providers. However, utilization of intrauterine contraceptive devices during the postpartum period was rare and in Ethiopia, with information regarding uptake of postpartum intrauterine contraceptive devices limited.

Objective

Identify determinants of postpartum intrauterine contraceptive devices uptake among women delivering in public hospitals of South Gondar zone, Northwest Ethiopia, 2019.

Methods

An unmatched case-control study was conducted in public hospitals of South Gondar, Ethiopia, from August 1, 2019, to November 10, 2019. A total of 140 cases and 280 controls have actively participated in the study. Five hospitals were selected by simple random sampling. Cases were selected consecutively, whereas two controls for each case were recruited by the lottery method. Pretested questionnaires were used to collect data and it was entered into Epidata version 4.4.2. Logistic regression analysis was used to identify variables associated with the use of outcome and adjusted odds ratio with a 95% confidence interval was used to determine the association between independent and outcome variables.

Results

Completing secondary education (AOR = 4.5, 95%CI 2.3-8.85), having a total number of children of 3-4 (AOR = 3.6, 95%CI 1.25-10.2), having  ≥ 5 (AOR = 4.7, 95%CI 1.5-15.3), attending 3 antenatal care (AOR = 2.8, 95%CI 1.44-5.6), ever hearing about postpartum IUCD (AOR = 6.6, 95%CI 2.7-16.1), and having counseling from health-care provider about a postpartum intrauterine contraceptive device (AOR = 6.2, 95%CI 2.99-12.8) were significantly associated with uptake of the postpartum intrauterine contraceptive. Conclusion and Recommendation. Completing secondary education, having 3-4 and ≥5 children, attending three antenatal care, ever hearing about postpartum IUCD, and having counseling from health-care providers about the postpartum intrauterine contraceptive device among women were significantly associated with uptake of an intrauterine contraceptive device after birth. Therefore, it is better to advise women to strictly follow their antenatal care, access to information, and provide counseling.

Prevalence of postpartum family planning utilization and associated factors among postpartum mothers in Arba Minch town, South Ethiopia

BACKGROUND

Contraception allows women to realize their human right to decide if and when to have children and helps people to attain their desired family size. Yet 214 million women of a reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method. Women who have recently given birth are among the group with the highest unmet need for contraception. Therefore, this study was aimed to assess the prevalence of postpartum family planning use and associated factors among postpartum women in Southern Ethiopia.

METHODS

Institution based cross-sectional study design was conducted. A structured and pretested interviewer-administered questionnaire was used to collect the data from study participants. Study participants were selected using a systematic random sampling technique by allocating proportionally to each health facility. The data was entered using EPI data version 3.1statistical software and exported to Statistical Package for Social Sciences version 22.0 for further analysis. Both bivariate and multivariate logistic regression analyses were performed to identify associated factors. P values < 0.05 with 95% confidence level was used to declare statistica significance.

RESULT

Overall, 44% of postpartum women utilize postpartum family planning. Having an antenatal care visit [adjusted odds ratio (AOR) =1.89(95%CI, 2.42-7.90), having planned pregnancy [adjusted odds ratio (AOR) = 1.17(95%CI, 1.60-2.28)], being married (adjusted odds ratio (AOR) =2.86(1.94-8.73), and having a college and above level educational status (AOR) =1.66(1.28-3.55) were significantly associated with utilization of postpartum family planning.

CONCLUSION

This study showed that the prevalence of postpartum family planning was 44%. Marital status, educational status of mothers, the status of pregnancy, and having an antenatal care follow-up during pregnancy were some factors associated with postpartum family planning utilization. Therefore, strengthening family planning counselling during antenatal and postnatal care visits, improving utilization of postnatal care services and improving women's educational status are crucial steps to enhance contraceptive use among postpartum women.

Family planning utilization and associated factors among postpartum women in Addis Ababa, Ethiopia, 2018

Background

Pregnancies that occur in the first year after birth can result in adverse outcomes for the mothers and their babies. Postpartum family planning (PPFP) can save lives of many mothers and children. Only few data are available about the magnitude of PPFP use and its determinants in Addis Ababa, Ethiopia.

Objective

To assess PPFP utilization and associated factors in Addis Ababa, Ethiopia.

Method

A facility-based cross-sectional study was conducted from April to June 2018. A total of 625 women were enrolled in the study. Statistical Package for the Social Sciences (SPSS) software was used to analyze the data. Binary logistic regression model with adjusted odd ratio (AOR) and 95% confidence interval (CI) was used to identify the factors associated with PPFP use. A p-value less than 0.05 was considered as significant.

Result

The magnitude of PPFP utilization in Addis Ababa was 71.8%. Previous family planning (FP) information (AOR = 13.2; 95% CI: (1.96, 88.07)), FP information from health facility visit (AOR = 2.23; 95% CI: (1.45, 3.43)), antenatal care (AOR = 4.96; 95% CI: (1.58, 15.64)), counseling on FP at postnatal care (AOR = 1.97; 95% CI: (1.27, 3.05)), menses resumption after birth (AOR = 1.75; 95% CI: (1.11, 2.76)), and commencing sexual activity after birth (AOR = 9.34; 95% CI: (5.39, 16.17)) were the factors associated with PPFP use.

Conclusion and recommendation

Though the magnitude of PPFP use is encouraging, still three out of the ten postpartum women did not use PPFP. The determinants of PPFP use were having FP information, having FP information from health facility visit, antenatal care, counseling about FP during postnatal care, menses resumption after birth, and commencing sexual activity after birth. The health system in the City and the healthcare providers should strive to reach every woman who is not accessing the PPFP services and antenatal care services, and improve counseling services on PPFP during delivery and postnatal care services.

Postpartum modern contraception utilization and its determinants in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Contraceptive use is the best and most cost-effective strategy to reduce feto-maternal adverse effects of short birth intervals. More than two-thirds of women in developing countries who do not want to conceive are not using contraception methods. Although there were various primary studies in different parts of the country, there is no nationally representative evidence on postpartum modern contraception utilization and its determinants in Ethiopia.

OBJECTIVE

This review was aimed to determine the best available pieces of evidence to pool the magnitude of postpartum modern contraception utilization and find out its determinants.

METHODS

Published studies were extensively searched by using electronic databases and unpublished studies were identified from the digital library. All observational studies conducted on the magnitude of postpartum modern contraception utilization and its determinants in Ethiopia were included. Data were extracted on the Microsoft Excel spreadsheet and analyzed using STATA 14.1 version. A random-effects model was used to estimate the pooled magnitude of postpartum modern contraception utilization with a 95% confidence interval (CI). Inverse variance (I2) was used to identify the presence of heterogeneity and forest plot was used to estimate the pooled magnitude of postpartum contraception utilization. The presence of publication bias was assessed by funnel plots and Egger's statistical tests. Sub-group analysis was computed to minimize underlying heterogeneity.

FINDINGS

In this review, 19 primary studies were included. The pooled magnitude of postpartum modern contraception utilization in Ethiopia was 45.79% (95%CI 36.45%, 55.13%). The review found that having more than four Antenatal care visits(ANC), having postnatal care visit (PNC), having a formal education, history of family planning use, history of counseling on family planning, and having greater than four alive children as significant determinants of postpartum modern contraception utilization.

CONCLUSION

The magnitude of postpartum modern contraception utilization in Ethiopia was low. ANC visit, PNC visit, maternal educational status, history of previous family planning use, counseling on family planning, and number of alive children were found to be significant determinants of postpartum modern contraception utilization. Therefore, strengthening focused ANC and PNC services to encourage women in utilizing modern contraception during the postnatal period is needed.

Factors associated with early resumption of sexual intercourse among women during extended postpartum period in Northwest Ethiopia: a cross sectional study

BACKGROUND

Postpartum sexual health and practice need to be integrated in the current maternal healthcare services to address sexual health problems. However, postpartum sexual practice has received little attention, and was not often discussed by healthcare providers during prenatal and postnatal care. Thus, this study was aimed to assess early resumption of sexual intercourse and associated factors among postpartum women in Gondar city, Northwest Ethiopia.

METHODS

A community based cross-sectional study was conducted from January 20 to February 20, 2020. A systematic random sampling technique was used to select 634 postpartum women. A pretested, structured and interviewer-administered questionnaire was used to collect data. Data were entered into Epi Info 7.2.2 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regressions analysis were done. Variables with p- value of < 0.05 were considered as statistically significant.

RESULTS

The magnitude of early resumption of sexual intercourse after childbirth was found to be 26.9% (95% CI: 23.2, 30.8). Urban resident (AOR = 6.12, 95% CI: 2.41, 15.66), parity of one (AOR = 2.26, 95% CI: 1.66, 7.78), husband demand (AOR = 2.66, 95% CI: 1.72, 4.11), postnatal care (AOR = 1.45, 95% CI: 1.06, 2.18) and use of family planning (AOR = 2.72, 95% CI: 1.51, 3.43) were factors significantly associated with early resumption of sexual intercourse.

CONCLUSION

The study found that more than one fourth of women had resumed sexual intercourse within six weeks of following childbirth. The finding of this study suggests the need of integrating discussions of postpartum sexual activity into routine prenatal, intrapartum and postnatal care with collaborative effort of policy makers, program planners, health care providers and other stakeholders. Moreover, spousal communication on postpartum sexual activity should be encouraged.

Survival Time to Modern Contraceptive Uses from the Resumption of Sexual Intercourse Among Postpartum Women in Ethiopia

Background

The timing of contraceptive use is important for a woman who intends to avoid pregnancy during the postpartum period and it has key implications for reproductive health outcomes. Therefore, this study aimed to determine the time it takes to start modern contraceptive uses from the resumption of sexual intercourse among postpartum women in Ethiopia and to identify its predictors.

Methods

A cross-sectional study using the 2016 Ethiopia Demographic and Health Survey (EDHS) was applied. The data were analyzed with SPSS version 20. Kaplan–Meier estimates were performed to explain time-to- modern contraceptive use. Cox-proportional hazard regression analysis was conducted to identify predictors. The adjusted hazard ratio (AHR) with a 95% confidence interval was considered to declare a statistically significant association.

Results

The total weighted sample comprised 1178 women. The median survival time to modern contraceptive use after birth was 4 months. In this study, the risk of modern contraceptive use was 1.29 times (AHR: 1.29; 95% CI: 1.04–1.61) higher among urban resident, 1.26 times (AHR: 1.26; 95% CI: 1.09–1.47) higher among women’s attended primary education and 1.19 times (AHR: 1.19; 95% CI: 1.02–1.38) higher among women’s accessed media. But, the risk of modern contraceptive use was lower among breastfeeding women by 17% (AHR: 0.83; 95% CI: 0.74–0.95).

Conclusion

The median survival timing of modern contraceptive use from the resumption of sexual intercourse was four months. Women residing in urban area, who attended primary education and accessed to media shorten the time to use contraceptives after birth, whereas women breastfed their infant lengthen the time to use a modern contraceptive. Therefore, the health-care provider should enhance modern contraceptive use through health education and promotion to curb down the four months lag period identified by considering the spotted factors.

Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives

Training and supervision to improve interpersonal aspects of care, including an emphasis on patient-centered counseling, informed choice, and respectful and nondiscriminatory service delivery, should be integrated into future postpartum family planning initiatives.

Background:

This qualitative study assessed implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Tanzania, a country with high rates of unintended pregnancy and low contraceptive prevalence. The PPIUD Initiative was implemented to reduce unmet need for contraception among new mothers through postpartum family planning counseling delivered during antenatal care and offering PPIUD insertion immediately following birth.

Methods:

We used the implementation outcomes framework and an ecological framework to analyze in-depth interviews with providers (N=15) and women (N=47) participating in the initiative. We applied a multistage coding protocol and used thematic content analysis to identify the factors influencing implementation.

Results:

Both women and providers were enthusiastic and receptive to the PPIUD Initiative. Health system and resource constraints made adoption and fidelity to the intended intervention challenging. Many providers questioned the sustainability of the initiative, and most agreed that changes to the initiative’s design (e.g., additional training opportunities, improved staffing, and availability of PPIUD supplies) would strengthen future iterations of the initiative. According to women, interpersonal aspects of care varied, with some women reporting rushed or incomplete counseling or an emphasis on the PPIUD over other methods. The perception that some providers treat older married women more favorably suggests that fidelity to the intended PPIUD Initiative was not uniformly achieved.

Conclusions:

Study findings inform initiatives seeking to develop and adopt postpartum family planning programs and enhance program implementation. A comprehensive needs assessment to evaluate feasibility and identify potential adaptations for the local context is recommended. Training and supervision to improve interpersonal aspects of care, including an emphasis on patient-centered counseling, informed choice, and respectful and nondiscriminatory service delivery should be integrated into future postpartum family planning initiatives.

Modern contraceptive use and factors associated with use among postpartum women in Ethiopia; further analysis of the 2016 Ethiopia demographic and health survey data

Background

The postpartum period is a critical time to improve maternal and child health. It is a time for accessing contraceptives to prevent short inter-pregnancy intervals. More than 95% of postpartum women do not want to get pregnant within 12 months. However, many women in Ethiopia experience an unintended pregnancy, and there is low information about postpartum contraceptive use among women who have family planning demand. Therefore, this study aimed to estimate the prevalence of postpartum contraceptive use and its predictors among women who give birth 12 months before the survey in Ethiopia.

Methods

We used the 2016 Ethiopia demographic health survey data for this analysis. The survey was a community-based cross-sectional study conducted from January 18 to June 27, 2016. The survey employed a two-stage stratified cluster sampling technique. A total of 2304 postpartum women were included. Bivariate and multivariable logistics regressions were done to identify factors associated with postpartum contraceptive use. A p-value < 0.05 was used to declare statistical significance.

Results

About 23.7% (23.7, 95% CI: 20.7–27.0%) of postpartum women were using modern contraceptives. Women who were urban residents (AOR = 2.18; 95%CI: 1.34–3.55), those who attended secondary or higher education (AOR = 1.79; 95%CI: 1.04–3.10), women who attended 1–3 (AOR = 2.33; 95%CI:1.27–4.25) or 4 or more ANC visits (AOR = 2.59; 95%CI:1.43–4.69) and women who delivered at a health facility (AOR = 1.86; 95%CI: 1.23–2.81) had higher odds of modern contraceptive use during the postpartum period. Similarly, women who reported the last child was no more wanted (AOR = 1.83; 95%CI: 1.01–3.31), women who decided for contraceptive use (AOR = 2.03; 95%CI: 1.13–3.65) and women whose recent child was male (AOR = 1.38; 95%CI: 1.01–1.88) had higher odds of modern contraceptive use.

Conclusion

Postpartum contraceptive use was low in Ethiopia. Strengthening health facility delivery, promoting girls’ education and encouraging women’s participation in deciding for contraceptive use would improve the uptake of modern contraceptives use during the postpartum period.

Associated Factors of Postpartum Modern Contraceptive Use in Burie District, Amhara Region, Ethiopia

METHODS

A community-based cross-sectional study was employed among 686 mothers in Burie District from March 16 to March 25, 2017. A multistage sampling technique was used to select the study participants. Data were collected using face to face interviewer administered structured questionnaires. Then, the collected data was entered, coded, and cleaned into EPI Data version 3.1 and exported to SPSS version 20.0 for data analysis. Bivariate and multivariate logistic regression was done to assess the association of factors with postpartum modern contraceptive use. Adjusted odds ratios with 95% confidence intervals were calculated, and p values <0.05 were considered to indicate statistical significance.

RESULT

This study revealed that postpartum modern contraceptive use was found to be 20.7%. Postpartum modern contraceptive use was significantly associated with women's level of education (AOR = 0.15, 95% CI (0.03-0.71)), discussing FP methods with partner (AOR = 0.60, 95% CI (0.40-0.90)), knowing menses return after birth (AOR = 0.39, 95% CI (0.25-0.59)), ever heard about modern FP methods (AOR = 0.06, 95% CI (0.01-0.43)), and contacting health professionals (AOR = 1.85, 95% CI (1.19-2.88)). Conclusion and Recommendations. Postpartum modern contraceptive use was found to be low. Therefore, health professionals should work on improvements in women's educational status, making awareness of the women and counseling of their husbands about the use of postpartum contraception, when fertility returned and risky timing for becoming pregnant.

Dynamic stagnation: reasons for contraceptive non-use in context of fertility stall

Background: While most countries have experienced reductions in the total fertility rate (TFR), there are countries where the fertility transition has not begun and others where the fertility transition has stalled with TFR still well above replacement level.  We use these contexts of "fertility stagnation" to explore reasons behind contraceptive non-use among women who desire to delay or avoid a future birth.  Specifically, we explore whether women's reasons for not using contraception are stagnant as the population-level indicator, TFR, suggests or are more dynamic. This nuanced understanding can inform programmatic direction for countries especially in need.  Methods: Using Demographic and Health Survey (DHS) data from the two most recent surveys of ten study countries-five countries that have not yet experienced a fertility transition ("pre-transitional") and five countries that began the fertility transition but stalled ("transitional")-we explore trends in reasons for non-use.  Results: We find that that reasons for non-use are changing. Specifically, in pre-transition study countries, women are increasingly citing attitudes opposing contraception as reasons for non-use.  In transition countries, women are increasingly citing reasons related to service quality and method side effects. Perceived low fecundability is increasingly cited among both pre-transition and transition study countries. Geographical access and cost are not prominent frequently cited at either time point.  Conclusions: These findings highlight the need for prioritized programmatic attention aimed at: reducing opposition to contraception in pre-transitional countries; improving service quality and addressing issues of side-effects, both experienced and perceived, in transitional countries; and addressing fecundability perceptions in both types of country contexts.  We remind policy makers that even in contexts of fertility stagnation, underlying attitudes, norms, and barriers to contraceptive uptake are shifting.  Lack of change at the population-level can mask important changes at the individual-level that must be accounted for in program development and implementation.

Characteristics of successful integrated family planning and maternal and child health services: Findings from a mixed-method, descriptive evaluation

Background: Most postpartum women in low- and middle-income countries want to delay or avoid future pregnancies but are not using modern contraception. One promising strategy for increasing the use of postpartum family planning (PPFP) is integration with maternal, newborn and child health (MNCH) services. However, there is limited evidence on effective service integration strategies. We examine facilitators of and barriers to effective PPFP integration in MNCH services in Kenya and India.  

Methods: We conducted a cross-sectional, mixed-method study in two counties in Kenya and two states in India. Data collection included surveying 215 MNCH clients and surveying or interviewing 82 health care providers and managers in 15 health facilities across the four sites. We analyzed data from each country separately. First, we analyzed quantitative data to assess the extent to which PPFP was integrated within MNCH services at each facility. Then we analyzed qualitative data and synthesized findings from both data sources to identify characteristics of well and poorly integrated facilities.

Results: PPFP integration success varied by service delivery area, health facility, and country. Issues influencing the extent of integration included availability of physical space for PPFP services, health workforce composition and capacity, family planning commodities availability, duration and nature of support provided.

Conclusions: Although integration level varied between health facilities, factors enabling and hindering PPFP integration were similar in India and Kenya. Better measures are needed to verify whether services are integrated as prescribed by national policies.

Engaging men in an mHealth approach to support postpartum family planning among couples in Kenya: a qualitative study

BACKGROUND

Involving male partners in family planning (FP) education and counseling may improve FP utilization and help meet couples' reproductive health needs in the postpartum period. We aimed to explore Kenyan men's and women's perspectives on an interactive short message service (SMS) approach to support postpartum FP decision-making, and inform intervention content for a randomized controlled trial (RCT).

METHODS

We conducted four focus group discussions (FGD) among men (n = 35) and two among pregnant/postpartum women (n = 15) in western Kenya. Female participants were recruited at antenatal clinics; male participants were referred by antenatal attendees. FGDs included participant critique of pilot theory-based SMS messages. FGD transcripts were coded by two investigators and analyzed using an iterative, modified grounded theory approach. These data informed the intervention and RCT design, in which women had the option to refer male partners for trial enrollment.

RESULTS

Men strongly desired inclusion in FP programs, and frequently discussed negative relationship consequences of women's covert contraceptive use. Female and male participants voiced a variety of concerns about contraceptive side effects and potential harms, which were central to narratives of community influence on personal contraceptive choices. Most participants felt that receiving FP-focused SMS and including men would be beneficial. They perceived that SMS dialogue with a nurse about FP could reduce misperceptions and may stimulate communication within couples, thereby improving contraceptive access and continuation. Shared decision-making around FP within couple relationships, in consultation with clinicians, was highly valued.

CONCLUSIONS

Health concerns about FP and limited couple communication are perceived contributors to postpartum unmet contraceptive need. With women's consent, the inclusion of male partners in FP services, and specifically in an mHealth SMS intervention, is acceptable and desired. Receiving SMS may trigger communication about postpartum FP within couples. SMS content should address contraceptive knowledge gaps, anticipated side effects and FP misperceptions, and allow for real-time method choice assistance.

Postpartum family planning utilization in Burundi and Rwanda: a comparative analysis of population based cross-sectional data

Introduction

Promotion of modern family planning is a major policy action for Africa to harness the demographic dividend. Family planning is an important public health intervention for maternal and child health.

Methods

Analysis was based on data from Demographic and Health Surveys conducted in 2010 on samples of women from Burundi (3396) and Rwanda (4670). Descriptive and multivariate logistic regression analyses to examine the contribution and comparison of the various predictors of uptake of modern contraceptives during the postpartum period (PPFP) in the two countries were carried out using STATA statistical software.

Results

Descriptive findings show only 20% of the samples of women in Burundi used while more than half of the women (51%) were using PPFP. Utilization of PPFP was significantly associated with primary (OR = 1.3, 95% CI = 1.1-1.6) and higher education (OR = 2.2, 95% CI = 1.6-3.1) in Burundi. Similarly in Rwanda increased use of PPFP in primary was (OR = 1.4, 95% CI = 1.2-1.6) while secondary education (OR = 1.6, 95% CI = 1.2-2.1). Protestant women were less likely to use PPFP in both Burundi (OR = 0.75, 95% CI = 0.6-0.9) and Rwanda (OR = 0.69, 95% CI = 0.6-0.8). Other significant variables in the regression models of both countries included wealth status, age of woman, number of living children and exposure to media. Professional birth delivery assistance was significant only in Rwanda.

Conclusion

Enhancing postpartum contraceptive use should target women with low education, low wealth status, and that the media has an important role to play in this transformation. Policies and programs must be put in place to ensure that the rural urban differences are eradicated.

Institutionalizing postpartum family planning and postpartum intrauterine device services in Nepal: Role of training and mentorship

OBJECTIVE

To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD).

METHODS

In this qualitative study, data were collected from 40 participants in December 2017 via focus group discussions (FGD) and in-depth interviews (IDI) in three hospitals implementing PPFP/PPIUD services and government line agencies in Nepal. Data were analyzed through content analysis and grouped into themes and categories.

RESULTS

The majority of participants reported that PPFP/PPIUD training and mentoring was useful and contributed to their professional development. Most found that on-the-job training (OJT) was more effective than group-based training (GBT).

CONCLUSION

Training and mentoring activities were perceived to be useful by health providers and OJT was the approach preferred by the majority. Further studies are necessary to explore the existing challenges and long-term effects of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers.

Integration of postpartum care into child health and immunization services in Burkina Faso: findings from a cross-sectional study

BACKGROUND

The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH).

METHODS

We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 (N = 757) and in 2014 (N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6-10 and during weeks 6-8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention.

RESULTS

The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6-10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration.

CONCLUSION

Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016

BACKGROUND

Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies.

METHODS

Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05).

RESULTS

Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts.

CONCLUSIONS

Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality.

Timely initiation of postpartum contraceptive utilization and associated factors among women of child bearing age in Aroressa District, Southern Ethiopia: a community based cross-sectional study

BACKGROUND

Globally, more than 90% of women during the first year of postpartum period want to either delay or avoid future pregnancies. The first year postpartum period is more crucial time to use modern contraceptives that enhance maternal and child health, so more attention should be given on time of initiating modern contraceptive utilization after delivery. Therefore, the aim of this study was to assess the magnitude and associated factors of timely initiation of postpartum contraceptive utilization among women of child bearing age in Aroressa district, Southern Ethiopia.

METHODS

The study was conducted in Aroressa district from March 15 to April 15, 2017. A community based cross-sectional study design with interviewer administered structured and pretested questionnaire was used. Multistage sampling technique was employed involving a total of 695 women of child bearing age who delivered a child in the past 12 months prior to the study period. Data were cleaned, coded and entered into Epi data version 3.1, then exported to statistical package for social science version 20 for analysis. Descriptive statistics, Bivariate and Multivariate logistic regression analysis were done. p-value < 0.05 was used to consider significant variables.

RESULTS

The magnitude of timely initiation of postpartum contraceptive utilization was found to be 31.7% [95% CI (28, 36)]. Antenatal care [AOR = 1.94, 95% CI (1.23, 3.01)], postnatal care [AOR = 1.90, 95%CI (1.23, 2.94)], spousal communication on contraceptive methods [AOR = 1.63, 95% CI (1.09, 2.41)] and resumption of menses after delivery [AOR = 2.6, 95% CI (1.47, 3.81)] were predictors positively associated with timely initiation of postpartum contraceptive utilization.

CONCLUSION

The magnitude of timely initiation of postpartum contraceptive utilization was low. Strengthening integration of family planning information with antenatal and postnatal care follow up and encouraging spousal communication by promoting information, education and communication activities is important to enhance contraceptive use on timely manner.

Predictors of postpartum contraceptive use in rural Tigray region, northern Ethiopia: a multilevel analysis

Background

Postpartum family planning services is one of the recommended public health intervention aimed at reducing maternal and child morbidity and mortalities. However, there is a paucity studies in rural Tigray region. Therefore, determining the level and associated factors of contraceptive use among postpartum women has the potential to contribute in achieving the Ethiopian Health Sector Transformation Plan and to the Sustainable Development Goals on maternal and infant survival.

Methods

A community-based cross-sectional study was done among 1109 postpartum women from March 29, 2017 to April 29, 2017. Face –to–face interview was used for data collection. The collected data were entered and cleaned using EPI - INFO version 7statistical software and later exported to and analyzed using STATA version 12. Mixed-effects multilevel logistic regression analysis was used to identify the individual and community-level factors associated with contraception adoption. A two side p-value< 0.05 was considered to be statistically significant.

Results

The level of contraceptive use was 38.3%. Individual-level variables such as women belong to fourth (AOR = 1.2; 95% CI: 1.1–3.2) and fifth (AOR = 1.5; 95% CI: 1.3–2.5) wealth quintiles were identified as key predictors of contraception use. In addition, partner secondary (AOR = 2.3; 95% CI: 1.8–3.5) and diploma (AOR = 1.2; 95% CI, 1.1–2.6) educational-level and postnatal care (AOR = 2.0; 95% CI: 1.9, 4.3) were also significantly affected contraception use. Community-level variables such as high community-level antenatal care services use (AOR = 2.1; 95% CI: 1.9–4.2) and proximity of women to health facility (AOR = 3.0; 95% CI: 2.7–4.6) were also determinants of contraception uptake.

Conclusions

The status of contraceptive use in rural Tigray region was found to be low. It was found that both individual and community-level variables showed a marked determinant on postpartum contraception use. This study suggested that in order to increase contraceptive use the government should focus on increasing postnatal care, antenatal care services use and reduction of poverty level are important avenues for intervention.

Role of antenatal and postnatal care in contraceptive use during postpartum period in western Ethiopia: a cross sectional study

OBJECTIVE

Little has been known about the magnitude and predictors of contraceptive use in extended postpartum period in Ethiopia. Thus, this study aims to assess the magnitude and determinants of contraception utilization in extended postpartum period. A community based cross-sectional survey was conducted in Gida Ayana district, Oromia regional state, Ethiopia in February 2015. Six hundred and three postpartum women were included using a multistage sampling technique. Descriptive statistics were used to summarize the data and logistic regressions were used to assess the predictors of modern family planning use at 95% confidence interval.

RESULTS

The proportion of women using any of the modern family planning in extended postpartum period was 45.4%. Women who had four and more antenatal care visits (AOR = 2.93; 95% CI 1.08-7.94), mothers who received post-natal care (AOR = 4.34; 95% CI 2.37-7.94), and those desiring less number of children (AOR = 5; 95% CI 2.19-11.41) were more likely to use modern family planning methods during the extended postpartum period. Therefore, health care providers should work to improve quality of health services provided during antenatal care and postnatal care to enhance family planning utilization among post-partum women.

Association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia

Background

The postpartum period provides an important opportunity to address unmet need for contraception and reduce short birth intervals. This study aims to assess the association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia.

Methods

Data for this analysis come from the 2011 to 2016 Ethiopian Demographic and Health Surveys (EDHS) and include nearly 5000 married women of reproductive age with a recent birth. Multivariate logistic regression was conducted to investigate the relationship between skilled maternal healthcare and postpartum contraceptive use.

Results

Between rounds of the 2011 and 2016 EDHS, the postpartum contraceptive prevalence increased from 15 to 23% and delivery in public facilities, use of skilled birth assistance, and skilled antenatal care also grew. In both survey rounds, educated women had approximately twice the odds of postpartum contraceptive use, compared with non-educated women, while an initially significant relationship between wealth and postpartum contraceptive use diminished in significance by 2016. Women with a desire to limit future pregnancy had five to six times the odds of postpartum contraceptive use in both survey rounds, and women in 2016 – unlike those in 2011 – with a desire to delay pregnancy were significantly more likely to use contraception (adjusted odds ratio (AOR) = 4.38, 95% CI: 1.46-13.18) compared to women who wanted another child soon. In 2011, no statistically significant associations were found between any maternal healthcare and postpartum contraceptive use. In contrast, in 2016, postpartum contraceptive use was significantly associated with an institutional delivery (AOR = 1.71, 95% confidence interval (CI): 1.12-2.62) and skilled antenatal care (AOR = 2.41, 95% CI: 1.41-4.10). No significant relationship was observed in either survey round between postpartum contraceptive use and skilled delivery or postnatal care.

Conclusions

A comparison of postpartum women in the 2011 and 2016 EDHS reveals increased use of both contraception and skilled maternal healthcare services and improved likelihood of contraceptive use among women with an institutional delivery or antenatal care, perhaps as a result of increased attention to postpartum family planning integration. Additionally, results suggest postpartum women are now using contraception to space future pregnancies, with the potential to help women achieve more optimal birth intervals.

Postpartum contraceptive choices among women attending a well-baby clinic in Ghana

OBJECTIVE

To assess postpartum contraceptive choices among women attending a well-baby clinic in Ghana.

METHODS

From April 1 to May 31, 2011, a descriptive cross-sectional survey was conducted among women who attended the well-baby clinic of Komfo Anokye Teaching Hospital, Kumasi, at 6-24 months after delivery. Participants were consecutively recruited and interviewed using semi-structured questionnaires. Data were collected on demographics, exposure to family planning counseling, message content, and postpartum contraceptive choices. Differences between the profiles of women who did or did not take up postpartum family planning were assessed.

RESULTS

Of the 200 women enrolled, 44 (22.0%) wanted no more children and the last pregnancy was unintended among 88 (44.0%). In all, 110 (55.0%) women took up postpartum contraception, with the calendar method (n=57; 51.8%) and injectable contraceptives (n=22; 20.0%) cited as popular choices. Family planning counseling was received at the prenatal clinic by 47 (23.5%) women, with 12 (6.0%) given written referrals on the postnatal ward. More previous contraceptive users than previous non-users chose long-acting or permanent postpartum methods (P<0.001).

CONCLUSION

Inadequate postpartum family planning counseling and referrals during maternity care were recorded, suggesting that a comprehensive educational intervention is required to improve uptake.

Postpartum modern contraceptive use in northern Ethiopia: prevalence and associated factors

OBJECTIVES

The postpartum period is a critical period for addressing widespread unmet needs in family planning and for reducing the risks of closely spaced pregnancies. However, contraception during the extended postpartum period has been underemphasized in Ethiopia. Therefore, this study aimed to assess postpartum modern contraceptive use among women in northern Ethiopia and to identify factors associated with modern contraceptive use in the postpartum period.

METHODS

A community based cross-sectional study was conducted from March to April, 2015. Data were entered using Epi Info version 7 and then exported into Stata version 12 for analysis. Bivariate and multivariate logistic regression models were fitted to identify the determinants of postpartum modern contraceptive use. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated, and p-values <0.05 were considered to indicate statistical significance.

RESULTS

Nearly half (48.0%) of women used modern contraceptives during the extended postpartum period. Postpartum modern contraceptive use was significantly associated with secondary and tertiary education levels (aOR, 4.25; 95% CI, 1.29 to 14.00; aOR, 5.36 ; 95% CI, 1.14 to 25.45, respectively), family planning counseling during prenatal and postnatal care (aOR, 5.72 ; 95% CI, 2.67, 12.28), having postnatal care (aOR, 2.36; 95% CI, 1.15 to 4.87), resuming sexual activity (aOR, 9.53; 95% CI, 3.74 to 24.27), and menses returning after birth (aOR, 6.35; 95% CI, 3.14 to 13.39). In addition, experiencing problems with previous contraceptive use was negatively associated with modern contraceptive use (aOR, 0.34; 95% CI, 0.16 to 0.72).

CONCLUSIONS

Low rate of postpartum modern contraceptive use were found in the study area. Therefore, strengthening family planning counseling during antenatal and postnatal care visits, improving utilization of postnatal care services and improving women’s educational status are crucial steps for to enhance modern contraceptive use among postpartum women.

Counseling during Maternal and Infant Health Visits and Postpartum Contraceptive use in Uttar Pradesh, India

CONTEXT

Postpartum family planning is a compelling concern of global significance due to its salience to unplanned pregnancies, and to maternal and infant health in developing countries. Yet, women face the highest level of unmet need for contraception in the year following a birth. A cost-effective way to inform women about their risk of becoming pregnant after the birth of a child is to integrate family planning counseling and services with maternal and infant health services.

METHODS

We use recently collected survey data from 2733 women from six cities in Uttar Pradesh, India who had a recent birth (since 2011) to examine the role of exposure to family planning information at maternal and infant health visits on (1) any contraceptive use in the postpartum period, and (2) choice of modern method in the postpartum period. We use discrete-time event history multinomial logit models to examine the duration to contraceptive use, and choice of modern method, in the 12 months following the last birth since 2011.

RESULTS

We find that receiving counseling in an institution at the time of delivery has the strongest influence on women's subsequent uptake of modern contraception (female sterilization and IUD). Being visited by a CHW in the extended postpartum period was also strongly associated with subsequent uptake of modern contraception (IUD, condom and hormonal contraception).

CONCLUSION

Providing postpartum family planning counseling at key junctures during maternal health visits has the potential to increase uptake of modern contraceptive method in urban Uttar Pradesh.

Postpartum uptake of contraception in rural northern Malawi: A prospective study

OBJECTIVES

Cross-sectional estimates of contraceptive use do not provide understanding of time to postpartum uptake. This paper uses a range of Malawian data sources: a prospective study to explore time to uptake of contraception and a cross-sectional survey to assess whether sexually active postpartum women whose fecundity has returned use contraception, and whether abstaining/amenorrheic women report using contraception.

STUDY DESIGN

A demographic surveillance site (DSS) in Malawi was used to identify 7393 women aged 15-49 years eligible for a 1-year prospective study of contraception using provider-recorded data on patient-held records (2012-2013). This provided a reliable record of time to uptake of postpartum contraception. The average timing of resumption of sexual activities after postpartum abstinence and return of menses was estimated from a population-based sexual behaviour survey in the DSS (2010-2011).

RESULTS

Of 4678 women recruited to the prospective contraception study, 442 delivered an infant during the observation period. Of these, 28.4% used modern contraception within 6 months of delivery. However, at 6-9 months after delivery, only 28.0% women had started menstruation and resumed sexual activities; of these, 77.6% used contraception. Amongst abstaining/amenorrheic women, a quarter reported contraceptive use.

CONCLUSIONS

The low uptake of postpartum contraception is likely due to many women abstaining and/or experiencing amenorrhea. Self-reports of contraceptive use amongst abstaining/amenorrheic women bring into question the quality of cross-sectional surveys and demonstrate that contraceptive use by women at low risk of pregnancy could contribute to the Malawi paradox of high contraceptive use and high fertility. Given relatively low risk of pregnancy in the postpartum period in this context, a focus on long-acting/permanent methods may be more effective to avert unintended pregnancies.

IMPLICATIONS

There has been increasing interest in the utility of postpartum contraceptive programmes to assist women to space births. Our findings suggest that, although uptake of contraception is low, this is partly due to postpartum abstinence and amenorrhea. Provision of long-acting/permanent methods will be more effective for women after delivery.

Safety and Acceptability of Community-Based Distribution of Injectable Contraceptives: A Pilot Project in Mozambique

Trained community health workers, including traditional birth attendants (TBAs), safely and effectively administered injectables in northern Mozambique; two-thirds of the women choosing injectables had never used contraception before. Including TBAs in the Ministry of Health’s recent task sharing strategy can improve rural women’s access to injectables and help meet women’s demand for contraception.

Mozambique has witnessed a climbing total fertility rate in the last 20 years. Nearly one-third of married women have an unmet need for family planning, but the supply of family planning services is not meeting the demand. This study aimed to explore the safety and effectiveness of training 2 cadres of community health workers—traditional birth attendants (TBAs) and agentes polivalentes elementares (APEs) (polyvalent elementary health workers)—to administer the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), and to provide evidence to policy makers on the feasibility of expanding community-based distribution of DMPA in areas where TBAs and APEs are present. A total of 1,432 women enrolled in the study between February 2014 and April 2015. The majority (63% to 66%) of women in the study started using contraception for the first time during the study period, and most women (over 66%) did not report side effects at the 3-month and 6-month follow-up visits. Very few (less than 0.5%) experienced morbidities at the injection site on the arm. Satisfaction with the performance of TBAs and APEs was high and improved over the study period. Overall, the project showed a high continuation rate (81.1%) after 3 injections, with TBA clients having significantly higher continuation rates than APE clients after 3 months and after 6 months. Clients’ reported willingness to pay for DMPA (64%) highlights the latent demand for modern contraceptives. Given Mozambique’s largely rural population and critical health care workforce shortage, community-based provision of family planning in general and of injectable contraceptives in particular, which has been shown to be safe, effective, and acceptable, is of crucial importance. This study demonstrates that community-based distribution of injectable contraceptives can provide access to family planning to a large group of women that previously had little or no access.

Leading With LARCs in Nigeria: The Stars Are Aligned to Expand Effective Family Planning Services Decisively

Despite years of family planning effort in Nigeria, the modern contraceptive prevalence (mCPR) has reached only 10%. Yet a few recent seminal, well-executed programs have been outstandingly successful providing long-acting reversible contraceptives (LARCs)—both in the public and private sector, and in the North and South. Remarkably, the LARCs they provided were equivalent to 2% mCPR in 2015 alone.

Accordingly, we advocate markedly increased support for: (1) private-sector approaches such as social franchising, particularly in the South, (2) mobile outreach, and (3) support to public clinical facilities, including expanding access through community health extension workers (CHEWs), particularly in the North. Success will require system support, quality, and concerted engagement from a variety of partners including the Government of Nigeria.

Without significant progress in Nigeria, the global FP2020 goal appears unattainable. Fortunately, leading with LARCs along with wide choice of other methods provides a clear avenue for success.

Assessing the Continuum of Care Pathway for Maternal Health in South Asia and Sub-Saharan Africa

OBJECTIVE

We assess how countries in regions of the world where maternal mortality is highest-South Asia and Sub-Saharan Africa-are performing with regards to providing women with vital elements of the continuum of care.

METHODS

Using recent Demographic and Health Survey data from nine countries including 18,036 women, descriptive and multilevel regression analyses were conducted on four key elements of the continuum of care-at least one antenatal care visit, four or more antenatal care visits, delivery with a skilled birth attendant and postnatal checks for the mother within the first 24 h since birth. Family planning counseling within a year of birth was also included in the descriptive analyses.

RESULTS

Results indicated that a major drop-out (>50 %) occurs early on in the continuum of care between the first antenatal care visit and four or more antenatal care visits. Few women (<5 %) who do not receive any antenatal care go on to have a skilled delivery or receive postnatal care. Women who receive some or all the elements of the continuum of care have greater autonomy and are richer and more educated than women who receive none of the elements.

CONCLUSION

Understanding where drop-out occurs and who drops out can enable countries to better target interventions. Four or more ANC visits plays a pivotal role within the continuum of care and warrants more programmatic attention. Strategies to ensure that vital services are available to all women are essential in efforts to improve maternal health.

"Every method seems to have its problems"- Perspectives on side effects of hormonal contraceptives in Morogoro Region, Tanzania

Background

Family planning has been shown to be an effective intervention for promoting maternal, newborn and child health. Despite family planning's multiple benefits, women's experiences of - or concerns related to - side effects present a formidable barrier to the sustained use of contraceptives, particularly in the postpartum period. This paper presents perspectives of postpartum, rural, Tanzanian women, their partners, public opinion leaders and community and health facility providers related to side effects associated with contraceptive use.

Methods

Qualitative interviews were conducted with postpartum women (n = 34), their partners (n = 23), community leaders (n = 12) and health providers based in both facilities (n = 12) and communities (n = 19) across Morogoro Region, Tanzania. Following data collection, digitally recorded data were transcribed, translated and coded using thematic analysis.

Results

Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births. However, side effects were consistently cited as a reason that women and their partners choose to forgo family planning altogether, discontinue methods, switch methods or use methods in an intermittent (and ineffective) manner. Respondents detailed side effects including excessive menstrual bleeding, missed menses, weight gain and fatigue. Women, their partners and community leaders also described concerns that contraceptives could induce sterility in women, or harm breastfeeding children via contamination of breast milk. Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn’s health in the first months of life.

Conclusions

To meet Tanzania’s national target of increasing contraceptive use from 34 to 60 % by 2015, appropriate counseling and dialogue on contraceptive side effects that speaks to pressing concerns outlined by women, their partners, communities and service providers are needed.

Enhancing contraceptive choice for postpartum women in sub-Saharan Africa with the progesterone vaginal ring: a review of the evidence

It is increasingly recognized that women who have just given birth have a high unmet need and require contraceptive protection in the first year postpartum. A majority of women in developing countries do breastfeed exclusively but for short durations, hence they may be sometimes unknowingly exposed to the risk of pregnancy if they are relying on nursing for contraceptive protection. The WHO’s Medical Eligibility Criteria for Contraceptive Use recommends the use of different contraceptives in the first year postpartum depending on whether the woman is nursing or not and the time since delivery. Some of the options available for breastfeeding women include implants, IUDs and injectables, which can be obtained only from a trained family planning provider. Since 2013, Population Council has been carrying out a study in Senegal, Nigeria, and Kenya to assess the acceptability of progesterone vaginal ring (PVR) as a new contraceptive option designed specifically for use by breastfeeding women to extend the period of lactational amenorrhea and promote birth spacing. Breastfeeding in sub-Saharan Africa is near universal with fairly long durations, a situation that increases the effectiveness of PVR. Each ring delivers a daily dose of 10 mg of progesterone and can be used continuously up to 3 months with a woman being able to continue with its use up to 1 year (four rings used consecutively). Preliminary results indicate that many women who had used the method found it acceptable and their partners supported its use. Activities aimed at having PVR registered and made available in focal countries are ongoing. Integration of family planning and immunization services for mothers and their newborns will be a key strategy in introducing PVR into targeted health care markets. Given that the use of PVR does not require extensive clinical training, it will be easier to integrate it at all levels of the health system from tertiary health facilities to community-based services. The PVR has been recently included in the WHO Model List of Essential Medicines and the WHO’s fifth edition of the Medical Eligibility Criteria for Contraceptive Use which should facilitate its introduction into the public and private sectors.

Postpartum contraceptive use and unmet need for family planning in five low-income countries

Background

During the post-partum period, most women wish to delay or prevent future pregnancies. Despite this, the unmet need for family planning up to a year after delivery is higher than at any other time. This study aims to assess fertility intention, contraceptive usage and unmet need for family planning amongst women who are six weeks postpartum, as well as to identify those at greatest risk of having an unmet need for family planning during this period.

Methods

Using the NICHD Global Network for Women’s and Children’s Health Research’s multi-site, prospective, ongoing, active surveillance system to track pregnancies and births in 100 rural geographic clusters in 5 countries (India, Pakistan, Zambia, Kenya and Guatemala), we assessed fertility intention and contraceptive usage at day 42 post-partum.

Results

We gathered data on 36,687 women in the post-partum period. Less than 5% of these women wished to have another pregnancy within the year. Despite this, rates of modern contraceptive usage varied widely and unmet need ranged from 25% to 96%. Even amongst users of modern contraceptives, the uptake of the most effective long-acting reversible contraceptives (intrauterine devices) was low. Women of age less than 20 years, parity of two or less, limited education and those who deliver at home were at highest risk for having unmet need.

Conclusions

Six weeks postpartum, almost all women wish to delay or prevent a future pregnancy. Even in sites where early contraceptive adoption is common, there is substantial unmet need for family planning. This is consistently highest amongst women below the age of 20 years. Interventions aimed at increasing the adoption of effective contraceptive methods are urgently needed in the majority of sites in order to reduce unmet need and to improve both maternal and infant outcomes, especially amongst young women.

Study registration

Clinicaltrials.gov (ID# NCT01073475)