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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.
The study design was informed by rapid ethnographic approaches developed as part of applied qualitative research for health [18–20]. Rapid ethnographic approaches, or “quick ethnography,” represents an adaptation of traditional (long term) anthropological inquiry with an aim to reduce the duration of time for fieldwork in order to provide timely insights to program planners, evaluators and stakeholders [21]. Similar to traditional ethnography, rapid ethnography subscribes to the constructivist worldview, which posits that knowledge is socially constructed [22, 23]. Because the goal of this research was to inform a program that promotes community-facility linkages, and aims to understand access to and opinions of facility-based maternal health services, the research team conducted in-depth interviews (IDIs) across a variety of respondents: postpartum women, their partners, community leaders (including religious and opinion leaders), community health workers (CHWs) and facility-based providers. These interviews explored several aspects of reproductive health including knowledge and use of FP, barriers to accessing and consistently using FP, and sources of influence that shape women’s perceptions and decisions related to FP. Sampling among the community-based respondent groups was stratified by communities living near (<3 km) and far (3–10 km) from health facilities. This was done across 16 villages in the catchment areas of 8 government health centers (8 villages near, and 8 villages far from a health center) in four districts of the region (Morogoro, Mvomero, Kilosa1 and Ulanga District Council). Stratification was done with an intention of exploring nuances in utilization of maternal, neonatal and child health services across districts and by distance to facilities. Facility-based providers helped the research team identify distant villages by discussing with the research team communities that were situated within their catchment area but were known to seldom interact with the formal health system. Once in communities, the data collection team presented themselves to village leaders (this sometimes included CHWs) and asked to be introduced to any woman known to have delivered in the preceding 14 months who may be available for an interview in the coming days. The 14-month time period was chosen as it reduced recall bias, but allowed enough time for women to reinitiate FP. Although couples were prioritized for IDIs, roughly two-thirds of all male partners were not available to participate. Prior FP use was not a criterion for participation, although nearly all postpartum women had prior experience using FP. Interviewed leaders included religious leaders, as well as members of an elected village board and/or village health committee. These individuals also assisted the research team in identifying CHWs. Leaders and CHWs were interviewed irrespective of gender, age, education level or length of service. Leaders and CHWs helped data collectors identify women and their partners. In addition, data collectors canvassed the village and invited eligible mothers and fathers to participate. A second phase of data collection included IDIs with facility-based providers. In total, 100 IDIs were conducted (88 community-based interviews and 12 facility-based provider interviews) (See Table 1). Demographic characteristics of postpartum women, their partners, community leaders and health providers aWomen who have delivered a child within the preceding 14 months bPartners of postpartum women interviewed cIncludes politicians, Muslim clerics and Christian ministers dIncludes Clinical Officers, Assistant Clinical Officers and Assistant Medical Officers with the ability to prescribe drugs eIncludes Enrolled Nurses, Registered Nurses, Nurse Midwives and Nursing Officers who do not prescribe drugs Interviews were carried out by six Tanzanian data collectors (three male, three female) with masters-level training in social sciences or public health and with previous experience in qualitative data collection. All data collectors were native Kiswahili speakers and they conducted all interviews in Kiswahili. The team was accompanied by a researcher from Johns Hopkins University (SAM) who conducted training and supervised field work with the team. The study team received one week of training, which included pilot testing. Data collection took place between July and September 2011. Upon entering a community, researchers sought guidance from members of village health committees to identify participants fulfilling the study criteria: women who gave birth in the 14 months preceding the study, their partners, public opinion leaders (including religious leaders), and community health workers (CHWs). Consenting participants were interviewed in a setting of their choosing—often their homes or surrounding environs—and IDIs typically lasted 60–90 minutes. In the event that an interview was compromised by the presence of a curious onlooker, the interviewer politely explained the purpose of the interview (“to learn about maternal health”) and requested that the onlooker leave. In two cases, a research manager (SAM) approached especially curious onlookers and engaged them in a separate, informal conversation that was not within the vicinity of the IDI. This approach was effective in maintaining privacy during IDIs. IDIs focused on knowledge, attitudes and experiences related to careseeking and counseling during the most-recent pregnancy and birth. At the outset of data collection, the research team did not intend to explicitly investigate opinions of and experiences with family planning. However the theme of contraception (coupled with concerns about side effects) emerged in the earliest interviews, and was probed more explicitly as data collection progressed. Following each day’s interviews, the field supervisor led debriefing sessions to triangulate findings, strengthen probing among data collectors, identify a need for follow-up interviews and develop themes for a codebook. All interviews were digitally recorded and transcribed by the same data collectors who carried out the interviews. Each transcript was quality controlled by bilingual researchers (JJC and IHM) and coded. Codes were first developed during data collection and later refined via open coding of a representative sample of transcripts. A codebook was developed collaboratively by the data collection team with lead researchers, and codes were applied to all transcripts using ATLAS.ti, a data management tool [24]. Coded texts were then translated into English, coded by the lead author with validation checks by SAM and PJW. In-country debriefings with regional and national stakeholders who included representatives from spheres of academia (Muhimbili University), policy (the MOHSW) and maternal health programming (Jhpiego) further informed the co-authors’ understanding of contextual realities related to contraception, which informed the presentation of this data. Ethical clearances were obtained from the Institutional Research Boards of Johns Hopkins Bloomberg School of Public Health in Baltimore, USA and Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania and informed consent was provided by all research participants.
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