Quality improvement project to improve immediate postpartum family planning utilisation at Dilla University Teaching Hospital

Abstract

Background

Immediate postpartum family planning (IPPFP) is a proven intervention to reduce unintended and closely spaced pregnancies, yet its utilisation remains low in Ethiopia. At Dilla University Teaching Hospital (DUTH), only 10.2% of postpartum mothers received contraception before discharge. This quality improvement (QI) project was implemented to address gaps in counselling, provider readiness and interdepartmental linkages affecting IPPFP uptake.

Methods

A QI initiative guided by the Model for Improvement and Plan–Do–Study–Act (PDSA) cycles was conducted from 8 July 2025 G.C. to 1 October 2025 G.C. Five sequential PDSA cycles were implemented, including staff orientation, assignment of a focal person, integration of IPPFP indicators into the hospital’s daily system bottleneck focused reform (SBFR) monitoring dashboard, strengthening maternal, newborn and child health unit linkages and continuous monitoring with weekly feedback. Data were analysed using run charts and descriptive statistics following SQUIRE 2.0 guidelines.

Results

During the baseline period, 10.2% of eligible postpartum mothers received IPPFP. Major barriers included inadequate counselling, limited provider training and poor documentation systems. After implementing the QI interventions, IPPFP uptake increased to 45.8% among 786 postpartum mothers over 14 weeks. Implants were the most commonly chosen method (54.2%), followed by intrauterine devices (4.4%) and bilateral tubal ligation (1.1%). Although run charts demonstrated intermittent weekly improvements, the data did not meet criteria for a sustained performance shift, reflecting variable adherence to newly introduced processes.

Conclusion

Implementation of the QI intervention was associated with increased IPPFP uptake at DUTH and may have been supported by strengthened counselling, improved accountability, enhanced provider readiness and better data-driven decision making.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

WHAT THIS STUDY ADDS

• This quality improvement project demonstrated that a package of context-specific interventions, including provider orientation, strengthened counselling, improved documentation, enhanced accountability and regular performance monitoring, was associated with increased IPPFP uptake at a tertiary hospital in southern Ethiopia.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings suggest that low-cost quality improvement approaches can be integrated into routine maternity services to strengthen IPPFP delivery. Future work should assess the sustainability of these improvements and their applicability in other healthcare settings.

Background

Family planning (FP) is essential for reducing maternal and neonatal deaths by preventing unintended and closely spaced pregnancies.^{1 2} Women are more likely to accept FP during the immediate postpartum period, yet many leave health facilities without counselling or contraceptive options.^{1 3} The goal of immediate postpartum FP (IPPFP) is to prevent unintended and closely spaced pregnancies that pose health risks to mothers and breastfeeding infants.^{4 5} Pregnancies in the postpartum period are associated with increased health risks for both mother and infant.¹

Globally, about 214 million women have an unmet need for modern contraception, many of them in their first postpartum year.⁶ In Ethiopia, only about 22% of women use FP within 6 weeks after delivery.⁷ Another study found that although 95% of women within 12 months postpartum wished to avoid pregnancy for at least 2 years, about 70% were not using any contraception.⁸ Spacing pregnancies by at least 2 years could prevent up to 30% of maternal deaths and 10% of child deaths.⁹ Conversely, pregnancies in the first postpartum year increase the risk of preterm birth, low birth weight and small-for-gestational-age infants.¹⁰

The unintended pregnancy rate remains high in developing regions, ranging from 64 to 91 per 1000 women, compared with about 35 per 1000 in developed regions.¹¹ A minimum interval of 24 months between pregnancies is recommended to ensure better maternal, perinatal and infant outcomes.⁹ In Ethiopia, the 2019 Mini Demographic and Health Survey reports that 41% of married women use modern contraception and 1% use traditional methods.⁷ However, IPPFP performance is much lower: although about one-quarter of postpartum women receive counselling, only 13.6% obtain a method.⁸ In Sub-Saharan Africa, IPPFP use ranges from 2% to 14% and in Ethiopia from about 11% to 17%.^{4 12} More recent evidence shows IPPFP uptake in Ethiopia remains low, with a meta-analysis of 15 studies reporting a pooled prevalence of 21.04%.⁵ Factors associated with higher uptake include receiving FP counselling, having a positive attitude and partner support.^{3 4} Other large reviews estimate postpartum modern FP prevalence in Ethiopia at around 45.44%.^{5 6}

To address existing gaps, coordinated efforts have been implemented across the Ethiopian health system, including integrating FP into maternal and child health services, engaging government officials, strengthening provider capacity, improving contraceptive supplies availability and expanding contraceptive options.^{10 11} The Ethiopian National Health Care Quality Strategy promotes facility-based Quality Improvement Teams (QITs) to drive continuous improvement. Since 2017, the USAID Transform: Primary Health Care program implemented by several partners has supported maternal and child health interventions across more than 400 districts in six regions.²

Given the risks of closely spaced and unintended postpartum pregnancies, access to IPPFP is essential.¹² Long-acting reversible contraceptives are especially suitable postpartum because they are safe, effective, reversible and prevent the harms of unintended pregnancies. The WHO emphasises that integrating postpartum FP into routine maternity services, strengthening provider capacity and ensuring continuity of care are key strategies for increasing contraceptive uptake during the postpartum period.¹³ Similarly, the FP High Impact Practices initiative identifies IPPFP as an evidence-based intervention that can increase contraceptive uptake by integrating counselling and contraceptive services into routine maternity care.¹⁴

Globally, about 190 million women who want to avoid pregnancy are not using contraception,^{6 9} and in Sub-Saharan Africa, unmet need remains among the highest at 20%–26%. Nearly all postpartum women are medically eligible for postpartum FP.^{5 10} At Dilla University Teaching Hospital (DUTH), only 10.2% of postpartum women received FP before discharge, underscoring the need for a targeted QI initiative.

This QI project at DUTH aimed to increase IPPFP utilisation using the Model for Improvement and PDSA cycles. The goal was to raise uptake from a baseline of 10.2% to 25% between 8 July 2025 G.C. and 1 October 2025 G.C. through structured QI interventions addressing key barriers.

Methods

Study area

A QI project focusing on utilisation of IPPFP carried out in the Department of Obstetrics and Gynecology of DUTH. DUTH is a major teaching and referral hospital located in Dilla town, approximately 360 km south of Addis Ababa, serving a large catchment population from the Gedeo Zone and surrounding districts.

Study design

A QI approach using the Plan–Do–Study–Act (PDSA) cycle was applied to identify gaps and implement targeted interventions aimed at improving IPPFP counselling and uptake among postpartum mothers.

Baseline assessment

Baseline data were collected for a period of 6 months (9 January to 27 June 2025 G.C.) to determine the pre-intervention level of immediate postpartum FP uptake. During this period, exit interviews were conducted with postpartum mothers, and structured interviews were held with midwives and obstetrics and gynaecology general practitioners (GPs) to identify quality gaps related to counselling, awareness and service readiness. The baseline analysis showed an IPPFP utilisation rate of 10.2% among women who delivered at DUTH during the 6-month period before the intervention.

Intervention

Baseline findings showed that IPPFP services at DUTH were not consistently accessible during the immediate postpartum period. Counselling was weak, data collection and use for decision-making were poor, monitoring was inadequate, interdepartmental linkage was limited and overall postpartum FP uptake was low.

To address these gaps, the Department of Obstetrics and Gynecology established a dedicated QI team composed of the chief executive director (CED), chief clinical director (CCD), the obstetrics and gynaecology department head, a senior midwife and maternity service coordinators, working under the hospital’s QI Committee. The team designed targeted interventions to strengthen counselling, improve data collection and management, enhance monitoring, improve interdepartmental linkage and ensure all eligible postpartum mothers were offered IPPFP before discharge.

The QI team conducted a root cause analysis to identify and prioritise key problems identified during the baseline assessment. (Figure 1)

Figure 1. Root cause analysis (fishbone diagram) for low IPPFP service uptake in DUTH, Gedeo, Dilla, Ethiopia – November 2025.

Using drivers, the team generated appropriate change ideas and implemented them to track improvements. (Figure 2)

Figure 2. Driver Diagram on IPPFP Utilization in DUTH.

Progress was monitored through routine audits and feedback over a 14-week period. The team also provided orientation for midwives and GPs on quality of care and FP, with special attention to the needs of women in the postpartum period. New data collection tools were added to the maternal cards, and midwives and GPs were encouraged to record this information every day, so it could be used for weekly audits, feedback sessions and monthly reports.

Numerator

The total number of postpartum mothers who were provided with IPPFP within 48 hours.

Denominator

The total number of postpartum women admitted during the intervention period.

Intervention

We applied a QI approach using the PDSA model.

Strategy

To guide the improvement process, we carried out five PDSA cycles. Each cycle allowed us to test changes on a small scale, observe what worked, identify gaps and then refine the interventions accordingly. This step-by-step approach helped us continuously to adjust the implementation based on real-time feedback and lessons learnt throughout the project.

PDSA cycle 1: staff orientation

The first PDSA cycle focused on strengthening staff capacity to provide quality IPPFP services. Midwives and GPs were oriented on IPPFP counselling principles and informed consent. Service gaps were reviewed, roles clarified and updated job aids and counselling tools were provided. This cycle built a shared understanding among staff and prepared them for subsequent improvement activities. The orientation aimed to strengthen provider knowledge and readiness to deliver IPPFP services.

PDSA cycle 2: focal person assigned

In the second cycle, we introduced the assignment of a dedicated focal person responsible for coordinating IPPFP activities. This individual ensured that daily services were well organised, different types of contraceptives were consistently available and documentation was completed accurately. The focal person also served as the main contact for troubleshooting challenges, collecting feedback from providers and supporting on-the-spot mentorship. Assigning clear responsibility helped streamline communication, reduced missed opportunities for counselling and improved accountability across the team.

PDSA cycle 3: integration into SBFR dashboard

The third cycle aimed to strengthen data visibility and use. We incorporated key IPPFP indicators such as number of postpartum women counselled, method chosen and timing of IPPFP provided into the hospital’s SBFR dashboard.

This integration made the data accessible to unit heads and quality teams, enabling them to track progress in real time. Visualising the trends also helped identify high and low performing days or staff shifts, guiding targeted support. The dashboard became a useful tool for decision-making and motivating the team, as they could observe their improvements week by week.

PDSA cycle 4: linkage established within MCH units

The fourth cycle focused on strengthening linkages between different Maternal, Newborn and Child Health (MCH) units including ANC, the labour ward, GYN ward, NICU and FP clinic. The goal was to create a smooth referral and follow-up system so that women counselled during ANC, labour and immediate postpartum could receive the method they desired without unnecessary delay or missed opportunities.

Through improved communication and a structured referral pathway, postpartum mothers were guided to the appropriate service point, ensuring continuity of care. This linkage also allowed providers to track clients who deferred the method immediately but preferred to receive it later before discharge.

PDSA cycle 5: monitoring and continuous feedback

The final PDSA cycle emphasised routine monitoring, supportive supervision and ongoing feedback. Daily and weekly reviews were conducted using prepared checklists that assessed availability of different types of contraceptives, completeness of documentation and adherence to counselling standards.

Performance data were collected and analysed regularly and the results were discussed during team meetings. Any new challenges encountered during implementation such as stock outs, staff rotation or gaps in counselling were addressed promptly. This continuous monitoring helped sustain the gains, reinforced good practices and supported long-term improvement in IPPFP counselling and uptake.

Data processing and analysis

The principal investigator reviewed the data to ensure completeness and consistency and assigned codes where needed. After editing, the data were entered into EpiData v3.1 and then exported to SPSS v26 for cleaning and analysis. We used run charts and figures to present the findings. The manuscript was prepared following the SQUIRE 2.0 guidelines for QI reporting.

Patient and public involvement

Patients and members of the public were not involved in the design, conduct, reporting or dissemination of this study.

Result

Baseline findings

During the 6-month baseline period (9 January to 27 June 2025 G.C.), DUTH recorded 791 deliveries, with 786 mothers eligible for IPPFP after excluding hysterectomy cases. Prior to the intervention, IPPFP uptake was only 10.2%, showing a major gap in counselling and utilisation.

Exit interviews with 100 postpartum mothers revealed that 66.7% had unplanned pregnancies. Over half (58.7%) were para 2–4, and 72.1% had three or more living children. Most (93.8%) wished to delay their next pregnancy by at least 2 years. Although 85.6% had heard of postpartum FP, only 54.2% received FP counselling during ANC. Among those who obtained a method during the baseline, implants were the most preferred option, while intrauterine device (IUD) uptake was low.

Healthcare provider assessment

Structured interviews were conducted with midwives and obstetrics/gynaecology GPs working in maternity services. Findings revealed:

• Only 4 of 33 midwives and 2 of the 9 GPs had prior training on IPPFP.

• Among the 13 providers interviewed, 48% had no contraceptive training.

• 35% reported they were unable to provide methods due to contraceptive supplies stock-outs or absence of supplies at the point of care.

These gaps contributed to missed opportunities for counselling and provision of postpartum contraception.

Intervention outcomes

PDSA cycle 1: staff orientation

A total of 23 midwives and 5 GPs were oriented on IPPFP clinical standards, Rapport building, Exploring options, Decision making and implementing decision (REDI) counselling and quality of care practices. Training improved provider readiness and clarified roles in routine counselling, documentation, and service provision.

PDSA cycle 2: assigning a focal person

Assigning a dedicated focal person for IPPFP improved service coordination and consistency. Clear accountability organised daily activities, enhanced contraceptive supplies availability and ensured reliable documentation. Providers experienced fewer disruptions and better communication, with the focal person addressing challenges and providing on-the-spot mentorship. This intervention reduced missed counselling opportunities and strengthened IPPFP service continuity and quality.

PDSA cycle 3: integration into SBFR dashboard

Key IPPFP indicators (number counselled, number receiving a method, type of method) were integrated into the hospital’s SBFR dashboard. This improved real-time data visibility, allowed comparison across shifts and guided immediate decision-making.

PDSA cycle 4: strengthening MCH unit linkages

Referral and communication pathways were strengthened between Antenatal care (ANC), labour ward, Gynecology (GYN) ward, neonatal intensive care unit (NICU), and the FP clinic. This ensured that mothers who deferred immediate IPPFP utilisation could still receive a method before discharge.

PDSA cycle 5: continuous monitoring and feedback

Daily supervision and weekly performance reviews were implemented. Challenges such as staff rotation and documentation gaps were addressed through on-the-spot mentoring and routine feedback. This cycle contributed significantly to sustaining momentum.

IPPFP uptake during the intervention period

During the intervention period, a total of 786 mothers delivered at DUTH. Of these, 360 mothers (45.8%) received IPPFP services before discharge. This represents a significant improvement compared with baseline uptake. (Figure 3)

Figure 3. Run Chart for Improving Utilization of IPPFP at DUTH 2025.

Method distribution

Of the 360 mothers who received IPPFP services

• 195 mothers (54.2%) received implants.

• 25 mothers (6.9%) received an IUD.

• 10 mothers (2.8%) received a bilateral tubal ligation (BTL).

• 130 mothers (36.1%) received other methods (injectable and pills).

QI trend

Run chart analysis indicated intermittent improvements in IPPFP uptake; however, the data did not meet the statistical criteria for a performance shift. Although several weekly data points exceeded the baseline median of 42.8% most notably during Weeks 2 to 5 and Weeks 12 to 13 these increases. The observed fluctuations suggest that the implemented interventions had positive but variable effects, highlighting the need for continued reinforcement, process stability and sustained application of change ideas to achieve consistent improvement over time. [figure 3]

Discussion

This QI project significantly increased IPPFP uptake at DUTH from 10.2% to 45.8% over 14 weeks. The low baseline aligns with national estimates in Ethiopia, where postpartum FP utilisation ranges from 13% to 21%,^{4 5} reflecting barriers such as inadequate counselling, limited provider training and poor service readiness. Similar gaps have been reported in Western Ethiopia, including low partner involvement and contraceptive supplies shortages.¹

Counselling remains a key determinant of postpartum FP uptake. Compared with regional studies, our post-intervention uptake was higher; for instance, the Gurage Zone reported only 17%,³ and our post-intervention uptake was higher, which may be associated with the implementation of structured PDSA cycles targeting counselling, documentation and interunit linkages.

Implants were the most preferred method (54.2%), consistent with national trends due to availability, provider competence and perceived safety.¹⁰ IUD uptake was low (4.4%) and BTL minimal (1.1%), reflecting national patterns constrained by provider skills, misconceptions and limited routine counselling.^{6 11}

International comparisons show our improvement is encouraging: a Haitian QI project increased uptake from 5% to 32%,¹⁵ while a Kenyan project rose from 17% to 83% over 16 weeks due to intensive training and community engagement. Our relatively lower gains may reflect local challenges such as staff rotation and workflow variability. Run chart analysis showed intermittent weekly improvements without a full statistical shift, a pattern common in early QI implementation in resource-limited settings.

Overall, these findings suggest that strengthening counselling, ensuring method availability and increasing provider accountability may contribute to improved postpartum FP uptake. The project illustrates the feasibility of applying low-cost, context-appropriate QI methods to address service gaps in postpartum FP.

Sustainability and long-term monitoring

Although sustainability was not formally assessed during the project period, several interventions were designed to support continued improvement, including provider orientation, assignment of a dedicated focal person, integration of IPPFP indicators into the SBFR dashboard and routine performance review meetings. Long-term monitoring will use ongoing tracking of IPPFP indicators through the hospital’s routine QI system, regular supportive supervision and periodic review of performance data to assess whether improvements are maintained over time.

Strengths and limitations

Strengths

• IPPFP contraceptive supplies were consistently available at service delivery points throughout the intervention, reducing missed opportunities.

• Hospital leadership including the CED, QI committee and maternity unit coordinators actively participated, supporting ownership and sustainability.

• Integrating IPPFP indicators into the SBFR dashboard strengthened routine monitoring and supported timely decision-making.

Limitations

• Not all maternity care providers received orientation or refresher training, which may have caused variability in counselling and service provision.

• The intervention did not assess client satisfaction or follow postpartum mothers to evaluate method continuation or discontinuation.

• Weekly performance fluctuated, indicating that improvements were not yet stable and require continued QI efforts.

• Being a single facility experience, the findings may not be generalisable to other settings without further testing.

• This study did not directly measure provider learning outcomes such as knowledge and skills, limiting assessment of the educational impact of the intervention.

• Sustainability was not formally assessed because no post-intervention follow-up was conducted. In addition, limited stakeholder involvement may have constrained long-term ownership and sustainability of the intervention.

Conclusion

During the 14-week intervention period, IPPFP uptake at DUTH increased from 10.2% at baseline to 45.8%. The implementation of structured PDSA cycles focused on improving counselling, strengthening data systems, enhancing provider readiness and establishing.

Although performance fluctuated, the findings suggest that low-cost, context-appropriate QI interventions may help improve postpartum FP service delivery. Sustaining gains requires ongoing supervision, consistent data use and strong facility leadership support. Future studies should evaluate these strategies over longer periods and in additional facilities to support broader scale-up and enhance postpartum contraceptive uptake regionally and nationally.

Data availability statement

Data are available upon reasonable request.