Abstract
Introduction:
Approximately one-third of maternal deaths worldwide are attributed to unsafe contraceptive practices, a major contributor to maternal mortality. In Ethiopia, immediate postpartum family planning services are not yet widely used. Only 9% of postpartum women use immediate postpartum family planning. Additionally, there was insufficient information regarding the utilization of immediate postpartum family planning in the study area.
Objective:
The objective was to assess immediate postpartum family planning utilization and associated factors among mothers attending childbirth at a tertiary hospital in Ethiopia.
Methods:
A facility-based cross-sectional study was employed among 402 postpartum women from 1 June to 30 July 2023, using a systematic random sampling technique. Training was provided to data collectors, and data were collected using a structured questionnaire that had been pretested and revised as necessary. The collected data were entered into EpiData 4.6. The data were exported into the software SPSS Version 26 for data cleaning and further analysis. Factors associated with the utilization of immediate postpartum family planning were declared by odds by 95% CI and P < 0.05.
Result:
This study involved 393 postpartum mothers, yielding a response rate of 97.76%. As identified from this study, utilization of immediate postpartum family planning was 24.9% (95% CI: 20.6, 29.2) in the study area. Planned pregnancy [adjusted odds ratio (AOR) = 1.84, 95% CI: 1.10–3.13], Postpartum mothers who had five and above children (AOR = 4.68, 95% CI: 1.70–12.88), counseled about family planning before delivery (AOR = 1.78, 95% CI: 1.03–3.10), and intention of postpartum mothers to space their pregnancy (AOR = 3.77, 95% CI: 1.50–9.52) identified associated factors.
Conclusion and recommendation:
The utilization of immediate post-partum family planning is low in the study area. Planned pregnancy, the greater number of children, prior information about family planning, and intention to space births during reproductive age were factors significantly associated with the utilization of family planning. Health workers should provide strengthening advice and counseling about family planning, from antenatal care follow-up to the postpartum period. Furthermore, the collaboration of health extension workers provides awareness for the community.
Keywords: associated factors, Ethiopia, immediate post-partum family planning
Introduction
Immediate postpartum family planning (IPPFP) refers to the provision of family planning (FP) counseling and services as part of care to postpartum women within 48 hours of childbirth and before discharge from the health facility[1]. In the world, nowadays, around 80 million unplanned pregnancies are due to low FP use during the postpartum period[2]. A study in low- and middle-income countries revealed that only 31% of all postpartum women used FP[3]. Postpartum FP utilization is inconsistent in Sub-Saharan countries, for example, 15% in Nigeria, 20% in Tanzania, and 25% in Kenya[4]. Unsafe contraceptive use in the developing world is a significant factor in maternal deaths; according to the WHO 2023 Report, unsafe FP services account for an estimated one-third of maternal deaths globally[5].
HIGHLIGHTS.
Identified from this study were only 24.9% of postpartum women utilized of immediate postpartum family planning (IPPFP) at Dilla University Referral Hospital.
Planned pregnancy, having five or more children, counseled about family planning before delivery, and intention to space their pregnancy identified associated factors.
Facility-based cross-sectional study design involving 393 postpartum women with 97.76% response rate.
Public health implication is strengthening antenatal care, and counseling on family planning is crucial to improving IPPFP uptake.
In Ethiopia, IPPFP services are not yet widely used. Only 9% of postpartum women use IPPFP[6]. In the same country, another study revealed that <1% of modern FP users use an immediate postpartum intrauterine contraceptive device as one optional method of IPPFP[7]. Research conducted in Jimma, west Ethiopia, showed that only 53.3% of women used the IPPFP method before discharge from the facilities[8].
As a result, studies in three regions, namely South Central Asia, Southeast Asia, and sub-Saharan Africa, indicated that annually 49 million women have unintended pregnancies, leading to 21 million unplanned births, and 21 million induced abortions (15 million of which are unsafe), 116 000 maternal deaths, and the loss of 15 million healthy years of women’s lives[9]. On top of that, one-third of maternal deaths can occur due to the misuse of contraception in women who are seeking to postpone or delay their postpartum period. The study done in Southeast Ethiopia among postpartum women showed that the practice of immediate was 12.4%. Another study conducted in Southern Ethiopia among postpartum women revealed that the postpartum intra-uterine contraceptive device (one of IPPFP’s optional methods) used within 48 hours of delivery was 21.6%[10].
Varieties of the literature showed that factors like marital status, length of time after delivery, fear of side effects, antenatal care (ANC) follow-up, death of infant, religion, and lack of awareness were among the factors affecting postpartum FP use among women in the immediate postpartum period[8].
Another study identified FP counseling during ANC, the immediate postpartum period, level of education, partner support, and prior knowledge of IPPFP as factors that increase the rate of utilization. On the other hand, the desire to have more children and opposition from a partner are some of the reasons mentioned for declining the use of IPPFP in the immediate postpartum period[11].
Many postpartum women do not know their risk of a subsequent pregnancy and often fail to start contraceptive use immediately after childbirth. In Ethiopia, the rate of contraceptive usage during the first year of the postpartum period indicates that immediate postpartum contraceptive provision remains a challenge due to low acceptance by women[12]. However, the prevalence of immediate postpartum contraceptive use varies across different regions of the country[6,13,14]. Most women do not initiate contraceptives at the recommended time. Specifically, in the Gedeo Zone, the utilization of FP among postpartum women is not well documented. Therefore, this study aims to assess the factors associated with the utilization of IPPFP at the study hospital.
Methods and materials
Study area and period
This study was conducted at Dilla University Referral Hospital from 1 June to 30 July 2023. The study Hospital is found in Dilla City, South Ethiopia, and 365 km away from Addis Ababa, the capital city of Ethiopia. The study hospital provides services for a population of 2 million in the Gedeo Zone and neighboring regional states. Besides the other medical services, maternal-child health services are one of the main services that are provided in the hospital. According to the 2023 hospital maternity unit report, annually, more than 3426 postpartum women were served in the hospital.
Study design
A facility-based cross-sectional study was employed. This work has been reported in line with the STROCSS criteria[15].
Population
Source population
All post-partum women attending the study hospital within 48 hours of the post-partum period
Study population
Selected postpartum women attending the study hospital during data collection within 48 hours of the postpartum period
Inclusion criteria
All postpartum women within 48 hours of delivery, before discharge from the study hospital, were included and were eligible for at least one IPPFP method.
Exclusion criteria
Postpartum women who were critically ill, developed emergency cases, and were subjected to hysterectomy or tubal ligation.
Sample size and sampling technique
Sample size
Sample size calculation for the objective is Summarized in Table 1. The sample size was determined using a single population proportion formula, considering the following assumptions: the proportion of women who used IPPFP among postpartum women in Gonder was 45.8% (P = 0.458) and a 95% confidence interval with 5% margin of error[13].
Table 1.
Sample size calculation for the second objective, 2023
| SI. NO. | Factors | AOR | 95% CI | Power | Two-sided significance level | % of Exposed with outcome | Total sample size |
| 1 | Support from husband to use IPPFP | 4 | (1.181–15.61) | 80 | 95 | 63 | 114 |
| 2 | Educational status (nonformal education)[8] | 0.016 | (0.001–0.223) | 80 | 95 | 40 | 42 |
n = (Zα/2)2 × p × (1 − P)/d2
= (1.96)2 × 0.458 × (1 − 0.458)/(0.05)2
= 382
Adding 5% to the calculated sample size gives 402.
The sample size for the second objective was determined as follows.
From objective 1, the largest one is 114, by adding 5% non-response rate (114 + (114 × 5/100)) = 114 + 6 = 120 = n = 120. This is less than 402. Therefore, the final sample size is objective 2 (402), as it is greater than the second objective.
Sampling technique
Initially, the number of postpartum women was obtained from the study's Hospital Maternity unit, which was 1,800 per 3 months. Then, by adjusting these numbers to the data collection period, which was 2 Months ago, the expected number of post-partum women attending the hospital was 1200. Then, by using these numbers and the sample size, the K-value was obtained, which was 3. Finally, the mothers were selected for every K by using systematic random sampling techniques.
Study variables
Dependent variables
IPPFP utilization.
Independent variables
Socio-demographic factors: Age, religion, ethnicity, marital status, educational status, occupation of women, household income, and residence.
Reproductive factors: Number of pregnancies, number of children, status of current pregnancy, place of birth, mode of birth, ANC follow-up status, birth interval, postnatal care (PNC) visit, future reproductive intention, and informed about early PPFP.
Data collection procedure
A structured questionnaire was prepared, and a pretest was done among 10% of postpartum women in Yigachafe Prime Hospital, and was corrected according to. Four data collectors and one supervisor were used for data collection. During data collection, the principal investigator was supervised daily and provided corrective feedback every morning. Data clearance on the hard copy was checked and entered into the computer. Data clearance on soft copy was also run to ensure data quality.
Operational definitions
Utilization of IPPFP is defined as a postpartum woman using any one of modern postpartum FP methods [progesterone-only pills, intrauterine contraceptive device, injectable, dual method, sterilization (permanent FP method), or implants] immediately within 48 hours of delivery before being discharged from the health facility
The postpartum period is a time during which pregnant mothers take rest time and prepare for the next pregnancy if contraception intervention is not given[2].
Data analysis procedure and presentation
Data was entered using Epi Data V.4.6 and then exported to SPSS V.25 for further analysis. Descriptive analysis is summarized using proportion, mean, and SD. Bivariate and multivariable logistic regression analysis methods were employed. In the bivariate analysis, variables with P < 0.25 are candidates for multivariable logistic regression analysis. Multicollinearity among variables was then checked using the variance inflation factor. The goodness of fit of the model is also checked using the Hosmer-Lemeshow goodness of fit test. Measures of association were done using statistical significance at P < 0.05, along with adjusted odds ratios and 95% CI.
Data quality management
The questionnaire was developed from related previous studies, and pretesting was done in adjoining hospitals to finally include the comments given. Data collectors were health professionals and had experience selected from the hospital or from other similar facilities. The selected data collectors were oriented on how to collect the data, and supervisors will correct them daily. The collected data were again cleared on the hard copy before starting to enter it into the computer.
Ethical clearance
Ethical approval was obtained from the Institutional Review Board (Ref: IRB/48/23). Written and verbal informed consent was secured from all participants. Data confidentiality was maintained by omitting personal identifiers.
Dissemination plan
Initially, the findings of this study will be presented as a master’s thesis in an open defense. Second, the findings of the study will be disseminated to the study Hospital and other concerned bodies. Finally, an attempt will be made for publication in different journals.
Result
Socio-demographic characteristics
In this study, 393 postpartum mothers participated, making the response rate 97.76%. The age of participants ranges from 18 to 39 years, with a mean age of 25.64 (±4.68 SD), and 364 (92.6%) were in a marital status. Concerning the educational status of study participants, nearly half of postpartum mothers (46.8%) had no formal education. Regarding the occupation of the mothers, 254 (62.3%) of them were housewives. About 288 (73.3%) of study participants earned less than 3000 birr per month, and 209 (53.2%) of mothers live in urban areas (Table 2).
Table 2.
Socio-demographic characteristics of participants on utilization of immediate postpartum family planning among mothers, Ethiopia 2023 (n = 393)
| Characteristics | Category | Frequency | Percent |
| Age (years) | 18–25 | 55 | 14.0 |
| 25–34 | 223 | 56.7 | |
| ≥35 | 115 | 29.3 | |
| Marital status | In union | 364 | 92.6 |
| Not in union | 29 | 7.4 | |
| Religion | Orthodox | 151 | 38.4 |
| Muslim | 25 | 6.4 | |
| Protestant | 191 | 48.6 | |
| Others | 26 | 6.6 | |
| Ethnicity | Sidama | 288 | 73.3 |
| Oromo | 58 | 14.6 | |
| Gurage | 13 | 3.4 | |
| Amhara | 34 | 8.7 | |
| The education status of women | No formal education | 184 | 46.8 |
| Primary school | 83 | 21.1 | |
| Secondary school | 62 | 15.8 | |
| College and above | 64 | 16.3 | |
| Occupation status of women | Housewife | 254 | 62.3 |
| Government employee | 67 | 17.1 | |
| Private employee | 81 | 20.6 | |
| Income (ETB) | <3000 | 288 | 73.3 |
| ≥3000 | 105 | 26.7 | |
| Residence | Urban | 209 | 53.2 |
| Rural | 184 | 46.8 |
Reproductive characteristics of participants
This study identified that three-fourths of 295 (75.1%) of participants had had pregnancies 3–4 times, and 369 (93.9%) of respondents had less than five children. Regarding pregnancy status, 201 (51.1%) of their current pregnancy was planned, 176 (44.8%) had ANC follow-up in their current pregnancy, and 239 (60.8%) of participants had the intention to limit their child. In addition, 230 (58.5%) of the participants had been informed about early PPFP before delivery (Table 3).
Table 3.
Reproductive characteristics of participants on utilization of immediate postpartum family planning among mothers, Ethiopia 2023 (n = 393)
| Characteristics | Category | Frequency | Percent |
| Number of pregnancies | 1–2 | 86 | 21.9 |
| 3–4 | 295 | 75.1 | |
| ≥5 | 12 | 3.0 | |
| Number of children | <5 | 369 | 93.9 |
| ≥5 | 24 | 6.1 | |
| Current pregnancy planned | Planned | 201 | 51.1 |
| Unplanned | 191 | 48.9 | |
| Birth interval | 1–2 years | 361 | 91.6 |
| 3–4 years | 32 | 8.1 | |
| Reproductive intention | Unintended | 61 | 15.5 |
| Went to the limit | 239 | 60.8 | |
| Went to space | 93 | 23.7 | |
| ANC visit for the last pregnancy | Yes | 176 | 44.8 |
| No | 217 | 55.2 | |
| Place of delivery | Institution | 375 | 95.4 |
| Home | 18 | 4.6 | |
| Mode of delivery | Vaginal delivery | 230 | 89.1 |
| Cesarean section | 43 | 10.9 | |
| PNC visit for the last child | Yes | 101 | 25.7 |
| No | 292 | 74.3 | |
| Informed about early PPFP before delivery | Yes | 230 | 58.5 |
| No | 163 | 41.5% |
Utilization of IPPFP
As identified from this study, utilization of immediate FP among post-partum mothers was revealed to be 24.9% (95% CI: 20.6, 29.2, Fig. 1).
Figure 1.
Utilization of immediate postpartum family planning among postpartum women, Ethiopia, 2023.
Factors associated with the utilization of IPPFP utilization
In this study, seven variables: marital status, current pregnancy status, ANC follow-up, number of children, mode of delivery, information about FP, and reproductive intention were candidates for binary logistic regression. After controlling for potential confounders, four variables: status of current pregnancy, number of children, information about FP before pregnancy, and reproductive intention were significantly associated with utilization of immediate FP in multivariable logistic regression at 95% CI with a P-value < 0.05.
The odds of utilizing IPPFP among postpartum mothers whose pregnancy was planned were 1.84 times higher (95% CI 1.10–3.13) compared to those whose current pregnancy was unplanned. Postpartum mothers who had five or more children were 4.68 times greater (95% CI 1.70–12.88) than their counterparts. In addition, postpartum mothers informed about early PPFP before delivery were 1.78 times more likely (95% CI 1.03–3.10) to utilize FP than those who had not been notified. Last, postpartum mothers who went to space their pregnancy were 3.77 times higher (95% CI 1.50–9.52) and utilized IPPFP compared to those who did not decide about reproductive intention. The results of the bivariable and multivariable regression analysis are presented in Table 4.
Table 4.
Bivariable and multivariable logistic regression analysis of the utilization of immediate postpartum family planning among mothers, Ethiopia 2023 (n = 393)
| Variables | Categories | Utilization of IPPFP | OR (95%) | P-value | ||
|---|---|---|---|---|---|---|
| Yes (98) | No (295) | COR (95% CI) | AOR (95% CI) | |||
| Marital status | In union | 81 (22.3%) | 283 (77.7%) | 1 | 1 | 1 |
| Not in union | 17 (38.6%) | 12 (41.4%) | 4.95 (2.27–10.79) | 2.31 (0.93–5.75) | 0.071 | |
| Status of current pregnancy | Planned | 61 (30.3%) | 140 (69.7%) | 1.83 (1.14–2.92) | 1.84 (1.10–3.13)* | 0.023 |
| Unplanned | 37 (19.3%) | 155 (80.7%) | 1 | 1 | 1 | |
| ANC follow-up | Yes | 55 (31.3%) | 121 (68.8%) | 1.84 (1.56–2.92) | 1.58 (0.93–2.67) | 0.090 |
| No | 43 (19.8%) | 174 (80.2%) | 1 | 1 | 1 | |
| Number of children | <5 | 81 (22%) | 288 (78%) | 1 | 1 | 1 |
| ≥5 | 17 (70.8%) | 7 (29.2%) | 8.64 (3.46–21.54) | 4.68 (1.70–12.88)* | 0.003 | |
| Mode of delivery | CS | 17 (39.5%) | 26 (60.5%) | 2.17 (1.12–4.20) | 2.06 (0.90–4.69) | 0.087 |
| Vaginally | 81 (23.1%) | 296 (76.9%) | 1 | 1 | ||
| Informed about early PPFP before delivery | No | 30 (18.4%) | 133 (81.6%) | 1 | 1 | |
| Yes | 68 (29.6%) | 162 (70.4%) | 1.86 (1.14–3.03) | 1.78 (1.03–3.10)* | 0.037 | |
| Reproductive intention | Undecided | 9 (14.8%) | 52 (85.2%) | 1 | 1 | 1 |
| Went to the limit | 44 (18.4%) | 195 (81.6%) | 1.30 (0.30–2.84) | 1.23 (0.52–2.88) | 0.651 | |
| Want to space | 45 (48.4%) | 48 (55.6%) | 5.42 (2.40–12.25) | 3.77 (1.50–9.52)* | 0.005 | |
AOR = adjusted odds ratio; CI = confidence interval; COR = crude odds ratio.
Discussion
This study assessed the magnitude of IPPFP utilization and associated factors in the study hospital. In this study, the prevalence of postpartum modern use is 24.9% (95% CI: 20.6, 29.2). This is in line with the study conducted in North Shoa Zone, Ethiopia, which was 21.3%[6], and Addis Ababa public hospitals, which was 26.6%[16]. Utilization of immediate post-partum FP was higher than the studies conducted in Public Health Facilities in Eastern Ethiopia, which was 18.5%[14]. The discrepancy is due to differences in the study area. On the other hand, the findings of this study are lower than the studies conducted in Injibara Town, Amhara Regional State, Ethiopia, which was 58.5%, and Mekelle Public Hospitals, which was 52.8%[17]. This might be due to differences in sample size, and this discrepancy may be due to socio-economic variations and different awareness-creating techniques between communities and health extension workers in different towns. Furthermore, the discrepancy might be due to variations in socio-cultural characteristics and differences in sample size.
Planned pregnancy was a factor that identified the utilization of IPPFP. This is supported by the public hospitals of North Shoa Zone, Ethiopia[18]. This might be because women who had unplanned pregnancies were found to be less likely to initiate and seek ANC early than women with planned pregnancies, and as a result, these women are less likely to be exposed to and receive postpartum FP-related information.
The number of children is one of the factors identified in this study. Those mothers who had ≥5 children were more likely to utilize IPPFP. This is supported by the studies conducted in different parts of Ethiopia and the Tigray Region, Ethiopia[19]. This might be because, as the number of children increases, the need for children decreases, and they decide to use FP more than others.
Counseling about immediate FP is a factor for utilizing IPPFP. This is supported by the study conducted in a longitudinal study conducted in Ethiopia[20]. This might be due to FP counseling before discharge from the facility and during child immunization, which improved the postpartum modern contraceptive uptake. Last, this study identifies mothers who went to space and is utilized in IPPFP. Last, intention to reproductive status is also identified as a factor in this study. Postpartum mothers who have the intention to space were more likely to utilize immediate FP. This is supported by the study conducted in the western part of Ethiopia[20]. This might be due to a family that decided on a birth space; they need FP.
Strengths and limitations of the study
The strength of this study was that well-trained data collectors were used, and the data were also collected from referred women who gave birth at home and sought health care.
The limitation of this study is that the data were collected in the hospital; thus, the study might be prone to social desirability bias as well, and the study did not cover postpartum women in the community.
Conclusion and recommendation
Conclusion
Utilization of immediate post-partum FP is low in the study area, which was 24.9%. Planned pregnancy, the greater number of children, prior information about FP, and intention to space births during reproductive age were factors significantly associated with the utilization of FP.
Recommendation
For health workers
The health workers should be strengthening advice and counsel about FP, starting from ANC follow-up to the post-partum period. Furthermore, collaboration with health extension workers provides awareness of immediate post-partum FP through mass media, health education at ANC, early labor, PNC visits, as well as community outreaches.
For zonal stakeholders
Stakeholders should work to create awareness of the importance and benefits of the use of IPPFP. This could be achieved through the development and implementation of strategies that specifically target the use of the IPPFP scale-up program in the town.
For further research
To find other factors linked to IPPFP that were not covered in this study, more research should be done with larger populations and a variety of research techniques.
Acknowledgements
We are deeply grateful to the postpartum mothers who participated in this study. Our thanks also go to the data collection team, hospital administrators, and the ethics review committee for their invaluable assistance.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Contributor Information
Mulugeta E. Shate, Email: muleredao@gmail.com.
Robel Mesfin, Email: robyrobin171@gmail.com.
Ethical approval
Ethical approval was obtained from the Institutional Review Board (Ref: IRB/48/23). Written and verbal informed consent was secured from all participants.
Consent
Not applicable.
Sources of funding
There was no funding obtained from any organization for this study.
Author contributions
M.E.S.: Conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing – original manuscript draft, writing – review and editing, visualization, supervision, and project administration. R.M.: Took part in methodology, software, formal analysis, investigation, writing – review and editing, and visualization. All authors reviewed and approved the final manuscript before submission.
Conflicts of interest disclosure
All authors declared that no conflicts of interest exist.
Research registration unique identifying number (UIN)
Not applicable.
Guarantor
Mulugeta Edao Shate.
Provenance and peer review
This article was not commissioned and was externally peer reviewed.
Data availability statement
We described all the relevant information in the manuscript, but the refined dataset can be obtained from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
We described all the relevant information in the manuscript, but the refined dataset can be obtained from the corresponding author upon reasonable request.