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

Obstetrics and Gynecology International, Volume 2021, Year 2021

Interpretation

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. An unmatched case-control study was conducted in South Gondar zones public hospitals such as Debretabor general hospital, Mekane-eyesuse primary hospital, Wogeda primary hospital, Addis Zemen primary hospital, and Nifas Mewucha primary hospital from August 1, 2019, to November 10, 2019. South Gondar is one of the zones found in Amhara region and its capital city is Debretabor, which is found 666 km far from Addis Ababa, capital city of Ethiopia. There are eight hospitals found in the zone, which serve 2,609,823 populations. Other maternal and family planning services were given without payment in all public hospitals. Currently, CUT 380 PPIUCD is available in all hospitals. A facility-based unmatched case-control study design was conducted. The source population is all postpartum women who gave birth in public hospitals of South Gondar zone, during the study period. All postpartum women delivering in selected public hospitals during the study period and using a postpartum intrauterine contraceptive device within the first 48 hours following vaginal delivery and intracaesarean after the expulsion of the placenta before uterine closure were considered as cases. However, all postpartum women who gave birth in the same hospitals but did not use postpartum intrauterine contraceptive devices were considered as controls. Postpartum women who gave birth by any mode of delivery in the selected public hospitals were included. Women who gave birth by any mode of delivery in selected public hospitals but did not fulfill WHO medical eligibility criteria for PPIUCD during the study period were excluded [9]. The sample size for the study was determined with double population proportion formula by using Epi info version 7 statistical software program for an unmatched case-control study. The calculation considered the following assumptions: 95% confidence interval, 80% power, 1 : 2 ratio of cases to controls, with a plan to have another child as the exposure variable, 47.7% of PPIUCD users and 32.8% of nonusers with exposure [7], and 10% nonresponse rate as compensation for both groups. Therefore, 450 postpartum women (150 cases and 300 controls) were included in the study. The sample size for each selected public hospital was proportionally allocated based on previous monthly average PPIUCD utilization. In south Gondar, there are eight hospitals, and about five (63%) of them were selected by simple random sampling methods. Then the number of PPIUCD utilizations per three months was obtained from each selected public hospital’s quarterly report to calculate average monthly cases flow. Cases were identified by asking them whether or not they use IUCD after delivery and by crosschecking their charts and they were selected consecutively, and as soon as cases were identified two controls were selected by simple random methods to increase the power of the study. Uptake of a postpartum intrauterine contraceptive device was a dependent variable. Data were collected using a pretested, semistructured, and interviewer-administered questionnaire. The questionnaire was adapted by reviewing similar researches conducted previously [5–7, 10–12]. The questionnaire involves sociodemographic, obstetric, reproductive, maternal health care, and family planning-related variables. Initially, the questionnaire was prepared in the English version then it was translated into the local language. Five trained BSc midwives and two BSc nurses have participated in data collection and supervisor, respectively. One data collector was assigned to each hospital. To assure the quality of data, the tool was tested by interviewing 5% of postpartum women who gave birth at Gina Mechawocha and Este health center two weeks before the actual data collection and a necessary correction was applied. Half-day training had been given for data collectors and supervisors about the purpose of the study, data collection procedures, and ways of communicating by the principal investigator. Continuous observation of the data collection process and its completeness was assessed every two weeks. At the end of data collection, completeness of data was checked; coding was implemented and entered into Epidata version 4.4.2.1. Statistical software and exported to SPSS version 23 software for further analysis. Descriptive variables were presented using tables and charts. Bivariate binary logistic regression was used to assess the association between PPIUCD uptake and each factor separately. All variables with p value less than or equal to 0.2 in the bivariate logistic regression were entered into the multivariable logistic regression model. Multivariable logistic regression was done by using a backward likelihood ratio method to control potential confounders. Correlation between independent variables was done to check multicollinearity. Finally, the adjusted odds ratio with 95% confidence interval was determined to measure the strength of association, and a p value less than 0.05 was used to determine the significant association between factors and outcome variables. The study obtained ethical clearance from the research review commute of the school of midwifery on behalf of the University of Gondar ethical review board. Written permission was obtained from the responsible body of the South Gondar zone health office and each selected hospital’s medical director after approval consent letter was submitted. Verbal informed consent was secured, after the purpose of the study was explained to each study participant.

AI Digest

Study Justification:

The study aimed to investigate the determinants of postpartum intrauterine contraceptive device (PPIUCD) uptake among women delivering in public hospitals of South Gondar Zone, Northwest Ethiopia in 2019. This research was conducted due to the rarity of PPIUCD utilization during the postpartum period and the limited information available on the uptake of PPIUCD in Ethiopia. The integrated use of PPIUCD with delivery services during the immediate postpartum period is beneficial for both women and healthcare providers. Understanding the factors influencing PPIUCD uptake is crucial for improving family planning services and promoting safe and effective contraception.

Highlights:

1. Completing secondary education, having 3-4 and ≥5 children, attending three antenatal care visits, ever hearing about postpartum IUCD, and receiving counseling from healthcare providers about the postpartum intrauterine contraceptive device were significantly associated with the uptake of PPIUCD.
2. The study was conducted in public hospitals of South Gondar Zone, Northwest Ethiopia, involving 140 cases and 280 controls.
3. Logistic regression analysis was used to identify variables associated with PPIUCD uptake, and adjusted odds ratios with a 95% confidence interval were calculated to determine the strength of the associations.
4. The findings highlight the importance of antenatal care, education, access to information, and counseling in promoting PPIUCD uptake among women after childbirth.

Recommendations:

Based on the study findings, the following recommendations are made:

1. Encourage women to complete secondary education, as it was significantly associated with PPIUCD uptake.
2. Promote antenatal care attendance, with a focus on ensuring women attend at least three visits.
3. Increase awareness about postpartum IUCD through health education campaigns and information dissemination.
4. Strengthen counseling services provided by healthcare providers, specifically regarding the postpartum intrauterine contraceptive device.
5. Emphasize the importance of family planning and contraception during antenatal care visits.

Key Role Players:

1. Ministry of Health: Responsible for policy development, coordination, and implementation of family planning programs.
2. Regional Health Bureau: Oversees the implementation of healthcare services, including family planning, at the regional level.
3. Health Facilities: Public hospitals and health centers play a crucial role in providing counseling, education, and access to PPIUCD services.
4. Healthcare Providers: Midwives, nurses, and other healthcare professionals involved in antenatal care and postpartum services.
5. Community Health Workers: Engage in community outreach and education to increase awareness and promote PPIUCD uptake.

Cost Items for Planning Recommendations:

1. Training and Capacity Building: Budget for training healthcare providers on PPIUCD counseling and insertion techniques.
2. Information, Education, and Communication (IEC) Materials: Allocate funds for the development and distribution of educational materials on PPIUCD.
3. Health Education Campaigns: Plan and budget for community-based campaigns to raise awareness about PPIUCD and its benefits.
4. Service Delivery: Ensure availability of PPIUCD devices and necessary supplies in healthcare facilities.
5. Monitoring and Evaluation: Allocate resources for monitoring and evaluating the implementation and impact of PPIUCD interventions.
Please note that the provided cost items are general suggestions and may vary based on the specific context and requirements of the implementation.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a detailed description of the study design, sample size calculation, data collection methods, and statistical analysis. However, it lacks information on the representativeness of the sample and potential limitations of the study. To improve the evidence, the authors could include information on the generalizability of the findings and any potential biases in the study design or data collection process.

Abstract

An unmatched case-control study was conducted in South Gondar zones public hospitals such as Debretabor general hospital, Mekane-eyesuse primary hospital, Wogeda primary hospital, Addis Zemen primary hospital, and Nifas Mewucha primary hospital from August 1, 2019, to November 10, 2019. South Gondar is one of the zones found in Amhara region and its capital city is Debretabor, which is found 666 km far from Addis Ababa, capital city of Ethiopia. There are eight hospitals found in the zone, which serve 2,609,823 populations. Other maternal and family planning services were given without payment in all public hospitals. Currently, CUT 380 PPIUCD is available in all hospitals. A facility-based unmatched case-control study design was conducted. The source population is all postpartum women who gave birth in public hospitals of South Gondar zone, during the study period. All postpartum women delivering in selected public hospitals during the study period and using a postpartum intrauterine contraceptive device within the first 48 hours following vaginal delivery and intracaesarean after the expulsion of the placenta before uterine closure were considered as cases. However, all postpartum women who gave birth in the same hospitals but did not use postpartum intrauterine contraceptive devices were considered as controls. Postpartum women who gave birth by any mode of delivery in the selected public hospitals were included. Women who gave birth by any mode of delivery in selected public hospitals but did not fulfill WHO medical eligibility criteria for PPIUCD during the study period were excluded [9]. The sample size for the study was determined with double population proportion formula by using Epi info version 7 statistical software program for an unmatched case-control study. The calculation considered the following assumptions: 95% confidence interval, 80% power, 1 : 2 ratio of cases to controls, with a plan to have another child as the exposure variable, 47.7% of PPIUCD users and 32.8% of nonusers with exposure [7], and 10% nonresponse rate as compensation for both groups. Therefore, 450 postpartum women (150 cases and 300 controls) were included in the study. The sample size for each selected public hospital was proportionally allocated based on previous monthly average PPIUCD utilization. In south Gondar, there are eight hospitals, and about five (63%) of them were selected by simple random sampling methods. Then the number of PPIUCD utilizations per three months was obtained from each selected public hospital’s quarterly report to calculate average monthly cases flow. Cases were identified by asking them whether or not they use IUCD after delivery and by crosschecking their charts and they were selected consecutively, and as soon as cases were identified two controls were selected by simple random methods to increase the power of the study. Uptake of a postpartum intrauterine contraceptive device was a dependent variable. Data were collected using a pretested, semistructured, and interviewer-administered questionnaire. The questionnaire was adapted by reviewing similar researches conducted previously [5–7, 10–12]. The questionnaire involves sociodemographic, obstetric, reproductive, maternal health care, and family planning-related variables. Initially, the questionnaire was prepared in the English version then it was translated into the local language. Five trained BSc midwives and two BSc nurses have participated in data collection and supervisor, respectively. One data collector was assigned to each hospital. To assure the quality of data, the tool was tested by interviewing 5% of postpartum women who gave birth at Gina Mechawocha and Este health center two weeks before the actual data collection and a necessary correction was applied. Half-day training had been given for data collectors and supervisors about the purpose of the study, data collection procedures, and ways of communicating by the principal investigator. Continuous observation of the data collection process and its completeness was assessed every two weeks. At the end of data collection, completeness of data was checked; coding was implemented and entered into Epidata version 4.4.2.1. Statistical software and exported to SPSS version 23 software for further analysis. Descriptive variables were presented using tables and charts. Bivariate binary logistic regression was used to assess the association between PPIUCD uptake and each factor separately. All variables with p value less than or equal to 0.2 in the bivariate logistic regression were entered into the multivariable logistic regression model. Multivariable logistic regression was done by using a backward likelihood ratio method to control potential confounders. Correlation between independent variables was done to check multicollinearity. Finally, the adjusted odds ratio with 95% confidence interval was determined to measure the strength of association, and a p value less than 0.05 was used to determine the significant association between factors and outcome variables. The study obtained ethical clearance from the research review commute of the school of midwifery on behalf of the University of Gondar ethical review board. Written permission was obtained from the responsible body of the South Gondar zone health office and each selected hospital’s medical director after approval consent letter was submitted. Verbal informed consent was secured, after the purpose of the study was explained to each study participant.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide information and resources related to postpartum intrauterine contraceptive devices (PPIUCD), including educational materials, appointment reminders, and access to counseling services.

2. Telemedicine Services: Establish telemedicine services that allow women in remote areas to consult with healthcare providers regarding postpartum intrauterine contraceptive devices. This can help overcome geographical barriers and increase access to information and counseling.

3. Community Health Workers: Train and deploy community health workers to educate women about the benefits and availability of postpartum intrauterine contraceptive devices. These workers can provide counseling, distribute informational materials, and facilitate access to healthcare services.

4. Integration of Services: Integrate postpartum intrauterine contraceptive device services with existing maternal health programs, such as antenatal care and postnatal care. This can ensure that women receive comprehensive care and information about contraceptive options during their pregnancy and after delivery.

5. Public Awareness Campaigns: Launch public awareness campaigns to promote the importance of postpartum intrauterine contraceptive devices and address misconceptions or cultural barriers. These campaigns can use various media channels, including radio, television, and social media, to reach a wide audience.

6. Training and Capacity Building: Provide training and capacity building programs for healthcare providers on the insertion and removal of postpartum intrauterine contraceptive devices. This can increase the number of skilled providers and improve the availability of these services in healthcare facilities.

7. Financial Support: Explore options for financial support, such as subsidies or insurance coverage, to make postpartum intrauterine contraceptive devices more affordable and accessible to women. This can help overcome financial barriers that may prevent women from accessing these services.

It is important to note that these recommendations are general and may need to be tailored to the specific context and needs of the South Gondar zone in Northwest Ethiopia.

AI Innovations Description

Based on the study conducted in public hospitals of South Gondar zone, Northwest Ethiopia, the following recommendations can be made to improve access to maternal health:

1. Increase awareness and education: It is important to provide comprehensive information about postpartum intrauterine contraceptive devices (PPIUCD) to women during antenatal care visits. This includes educating women about the benefits, safety, and availability of PPIUCD as a contraceptive option after childbirth.

2. Strengthen antenatal care services: Encouraging women to attend at least three antenatal care visits can help increase their knowledge and understanding of PPIUCD. Antenatal care visits provide an opportunity for healthcare providers to discuss family planning options and address any concerns or misconceptions.

3. Improve counseling services: Healthcare providers should be trained to provide accurate and non-judgmental counseling on PPIUCD. This includes discussing the benefits, potential side effects, and addressing any concerns or misconceptions that women may have. Counseling should be offered both during antenatal care visits and immediately after childbirth.

4. Enhance access to information: Efforts should be made to ensure that women have access to accurate and reliable information about PPIUCD. This can be done through the distribution of educational materials, community outreach programs, and the use of mass media campaigns.

5. Address barriers to access: Identify and address any barriers that may prevent women from accessing PPIUCD, such as cost, availability, and cultural or religious beliefs. This may involve providing subsidies or financial assistance for PPIUCD, ensuring a consistent supply of devices in healthcare facilities, and engaging with community leaders to address cultural or religious concerns.

6. Strengthen healthcare provider training: Healthcare providers should receive regular training on PPIUCD insertion and removal techniques, as well as counseling skills. This will ensure that they are equipped to provide high-quality care and support to women who choose PPIUCD as a contraceptive option.

By implementing these recommendations, it is hoped that access to maternal health, specifically the uptake of postpartum intrauterine contraceptive devices, can be improved in the South Gondar zone and other similar settings.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Develop and implement comprehensive educational programs to increase awareness among women about the importance of maternal health and the availability of postpartum intrauterine contraceptive devices (PPIUCD). This can include community outreach programs, workshops, and informational campaigns.

2. Strengthen antenatal care services: Enhance antenatal care services by ensuring that all pregnant women have access to regular check-ups and counseling sessions. This can help in providing information about PPIUCD and addressing any concerns or misconceptions.

3. Improve counseling services: Train healthcare providers to provide accurate and comprehensive counseling on PPIUCD during antenatal care visits and postpartum periods. This can help women make informed decisions about their contraceptive options and increase the uptake of PPIUCD.

4. Enhance availability and accessibility: Ensure that PPIUCD is readily available in all public hospitals and health centers. This includes training healthcare providers on proper insertion techniques and ensuring a sufficient supply of PPIUCD devices.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of women who are aware of PPIUCD, the percentage of women who receive counseling on PPIUCD, and the percentage of women who choose PPIUCD as a contraceptive method.

2. Collect baseline data: Conduct a survey or review existing data to establish the current status of these indicators before implementing the recommendations. This will serve as a baseline for comparison.

3. Implement the recommendations: Roll out the recommended interventions, including awareness campaigns, training programs, and improvements in healthcare services.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the identified indicators. This can be done through surveys, interviews, or data collection from healthcare facilities.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on the identified indicators. This can be done using statistical methods such as logistic regression analysis to determine the association between the recommendations and the outcomes.

6. Interpret the results: Interpret the findings to understand the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas for further improvement.

7. Adjust and refine: Based on the results and findings, make any necessary adjustments or refinements to the recommendations and interventions to optimize their impact.

8. Repeat the process: Continuously repeat the monitoring and evaluation process to track progress over time and make further improvements as needed.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for future interventions.

Authors & Co-Authors

Statistics:

Citations: 4

Authors: 5

Identifiers:

DOI: 10.1155/2021/1757401

ISSN: 16879589

Research Areas:

Genetics and Genomics, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female