Abstract
Background:
Postpartum Family Planning (PPFP), which aims to prevent high risk unintended and closely spaced pregnancies during the first year following childbirth, is one of the highest impact interventions to avoid increased risk of premature birth, low birth weight, fetal and neonatal death, and adverse maternal health outcomes. This study aimed to assess the combined effect of a package of interventions on the use and quality of PPFP services at Y12HMC, Addis Ababa Ethiopia.
Method:
Cross-sectional study design was conducted to evaluate the effect of the package of chosen interventions: creating a private counseling space near the postpartum ward and providing training for health care providers on the WHO decision tool kit and Long Acting Contraceptive Methods (LACM). Interviews were conducted with 470 women (235 before and 235 after the intervention). Frequency tables and graphs were used to describe the study variables and statistical significance between pre and post intervention indicators was declared at P value <.05
Results:
From 470 participants, 421 respondents participated which makes response rate of 90%. The majority of the participants were in the age category 20 to 29 years, married/lived together, completed at least primary education and had more than one child both at baseline and post intervention. The proportion of women who chose PPFP increased from 55.8% at baseline to 69% after the intervention. The most preferred contraceptive method was implant. The overall service satisfaction level of the study participants was 95.4% post intervention, significantly higher than at baseline (78%, P < .05). Providers indicated that clients are satisfied with the service and that the institutional structure is appropriate for delivering integrated services following the intervention.
Conclusion:
This study demonstrated that quality improvement interventions like creating a private counseling space and providing training using WHO decision tool kit can achieve significant improvement on satisfaction of clients and PPFP uptake
Background
It is widely recognized that family planning (FP) has played a substantial role in decreasing maternal and neonatal mortality through the use of contraceptives by reducing unwanted births and by reducing the burden of high-risk births. 1 It is an essential component of antenatal and postpartum care. 2
Closely spaced births within the first year of postpartum is significantly associated with a higher risk of preterm birth and low birth weight.3,4 Decreasing the interval between pregnancies to 24 months would significantly increase maternal and under 5 mortality 5
Postpartum family planning (PPFP) can help to reduce unintended and closely spaced pregnancies during the first year following childbirth.6,7 It is one of the highest impact interventions in low-resource countries to prevent maternal and child morbidity and mortality. 8
The International Conference on Population and Development stressed the importance of FP and timely birth spacing, stating that “all couples and individuals have the basic right to determine freely and responsibly the number and spacing of their children and to have the information, education, and means to do so.” Nevertheless, the postpartum period still has an unacceptably high unmet need for FP, which is significantly higher than the FP unmet need of other women. 9
In low- and middle-income nations, birth-to-pregnancy intervals are unacceptably short, at less than 23 months, for 50% or more of pregnancies. 9 Ethiopia is characterized by a context of high fertility rates, low contraceptive prevalence and high unmet need for family planning (FP) services. Among postpartum women who did not intend to have children soon, only 23.7% use modern FP. 10 As shown in EDHS 2019, only 41% of currently married women use modern FP methods. Furthermore, and only 9% of postpartum women use PPFP. The national total fertility rate is 4.2 children per woman. 11
In less developed countries, there is a large knowledge gap regarding the full range of PPFP services and limited competence in providing PPFP services.12-14
In addition to insufficient numbers of skilled care providers, poor organization of care processes, fragmented delivery of FP, routine maternal care, and a lack of a private counseling space for PPFP counseling are often barriers for postpartum women.15-17
The aim of this study was to assess the combined effect of a package of interventions (creating a private counseling space near the postpartum ward and providing training for health care providers on the WHO decision tool kit and LACM) on the uptake and quality of PPFP services at Y12HMC, Addis Ababa, Ethiopia. the study used WHO decision tool kit for counseling clients. It is a decision-making aid for clients, a job-aid, and reference manual for providers. With one page for the client and a corresponding page for providers, it has helpful pictures, key points and detailed reference information covering 14 family planning methods. It includes medical eligibility criteria, side-effects, when to start and how to use each method. 18
Methods
Study setting and period: Yekatit 12 Hospital Medical College (Y12HMC) is the second oldest hospital in Ethiopia, established in 1931 to serve the people at large and gets its current name in the memory of Ethiopian martyrs massacred by Italian aggression. The hospital provides services in more than 13 specialty areas. In 2020 it served 184 815 patients in the regular outpatient department (OPD) and 21 896 emergency patients as outpatients, 14 856 patients as inpatients and conducted 5218 surgeries. In the same year the gynecology and obstetrics department provided emergency service to 7877 patients, conducted delivery for 5662 mothers, performed 2432 CS deliveries, performed ANC for 3040 mother, and performed 131 elective gynecologic surgeries. Additionally, it provided FP service to 574 clients. The actual data collection period was June 5 to 28, 2020 for the baseline and January 3 to 29, 2021 for the post intervention
Study Design: cross-sectional study design using mixed methods, including qualitative and quantitative methods, was used to evaluate the effect of the package of chosen interventions: Establishing private room (FP corner) for the woman and her husband to receive PPFP counseling, providing training for health care providers on the WHO decision tool kit and long acting contraceptive method (LACM) and providing counseling using the WHO decision tool kit soon after delivery.
Study population and inclusion Criteria: During the study period, all women who visited the Y12HMC labor and delivery unit, postnatal clinic, and were willing to participate in the study were included.
Sample size: The sample size for this study was calculated using Epi-Info 7.2 statistical software package by assuming a PPFP method acceptance rate of 50%, with the study designed to detect a 20% difference between the groups before and after the intervention, with 80% power at 95% confidence level (α = .05), and using a 10% non-response rate. A total of 470 women (235 pre and 235 post intervention) were included in the final sample. In-depth interviews were conducted with a selection of 10 health workers to assess the overall standard of care, quality of counseling and client satisfaction feedback on PPFP service provision. The total number of participants was determined by the level of data saturation.
Sampling technique: The study participants were selected via systematic sampling based on available data on the number of births during the study period; a total of 900 women delivered at Y12HMC. A sampling interval (K) of 2 was calculated by dividing the total population by the total sample size. The study subjects for in-depth interviews were selected through purposeful sampling.
Dependent variable
PPFP uptake
Quality of PPFP service
Independent variables
Sociodemographic characteristics: age, residence, marital status, women’s educational status, women’s occupational status and family monthly income, number of children.
FP-related characteristics: ever heard about PPFP, ever counseled on PPFP, method of choice availability, information provision, and client-provider interaction, uptake of PPFP
Client satisfaction on PPFP service related characteristics: Privacy of the counseling room, waiting time, friendly providers, receiving information
The quality of PPFP services was assessed through client satisfaction, 3 satisfaction levels were used: completely satisfied, roughly satisfied & not satisfied
Data collection and analysis: Data were collected via client exit interview, chart audit, and postnatal FP register log book. The quality score of all indicators of interest was measured using a standardized, interviewer-administered, closed-ended questionnaire. The data were checked, cleaned and entered using Epi Info Version 3.5.1 and exported to SPSS version 20 for analysis. The study variables were described using descriptive statistics such as frequency tables and graphs. Pearson chi-square tests were used to detect differences before and after the intervention, with significance declared at P value <.05. For the qualitative study, experienced interviewers (both male and female) having in-depth knowledge of the target communities and able to communicate in the spoken language was recruited. One to one in-depth interviews were conducted by data collectors using structured in-depth interview guide which was prepared in English and translated to Amharic. The interview was recorded by a tape recorder. It was transcribed by 2 investigators and cross checked. Translated data were exported to open code software for coding, categorization in thematic areas followed by content analysis. Reanalysis was done until no new topics are emerging and data saturation is reached
Data quality control: To achieve good data quality: Training was provided to data collectors for 3 days about the objective and process of data collection; close supervision was undertaken during data collection; The supervisors and the primary investigator double-checked each questionnaire on a daily basis; before the actual data collection, the questionnaire was pre-tested on 10% of the total sample size in a separate sample of participants that were not enrolled in the study.
Ethical consideration: The Y12HMC Institutional Review Board (IRB) provided approval and ethical clearance with reference number Y12HMC/271/20. The study’s objective and purpose were explicitly explained to the participants and prior to data collection, each participant signed a written informed consent form. Participants were also informed that they could leave the study at any moment if they didn’t want to. Throughout the study, the confidentiality of the information was preserved, and the data was recorded anonymously. All in-depth interviews were audio recorded with the consent of participants.
Results
Socio-demographic characteristics of the participants
A total of 226 participants at baseline and 195 after intervention were included in this study among 470 participants, yielding a response rate of 90%. Two hundred twenty-six (96.6%) of clients approached for participation at baseline and 195 (83.3%) at post intervention was participated in the study. One hundred sixty-seven (73.9%) and 132 (67.7%) clients were 20 to 29 years of age at baseline and after the intervention, respectively (Table 1). In both the baseline and post intervention groups, more than 85.0% lived in urban areas, were married and lived together, and had children. In both groups more than half had high school education and would like to have more children in the future.
Socio-demographic characteristics of participants attending the labor and delivery unit of Y12HMC, Addis Ababa, 2020.
Statistically significant difference between baseline and after intervention groups (P < .001).
A significant difference was noticed between clients in the 2 groups with regard to discussion about FP with their husbands: 131 (64.5%) of clients at baseline and 135 (73.8%) of clients at post intervention (P < .001).
Information provision and client-provider interaction
Compared with baseline, post intervention clients participated more actively in consultations with providers. One hundred eighty-four (81.4%) and 177 (90.0%) of the study participants reported that the health professional provided adequate information and services regarding PPFP before and after intervention, respectively (Table 2).
Method of choice availability, information provision, and client-provider interaction at Y12HMC, Addis Ababa, January to March 2020.
Statistically significant difference between baseline and after intervention groups (P < .001).
The proportion of the respondents that testified that the provider was approachable and easily understood by them during consultation periods remained about the same at baseline (94.2%) and after the intervention (91.4%) (Table 2).
There was a significant difference between baseline and after intervention in the proportion of respondents who believed that the health professional explained how the method works (baseline n = 106, 84.1%, post intervention n = 128, 94.1%), demonstrated how to use it (baseline n = 98, 77.8%, post intervention n = 127, 93.4%) and discussed possible side effects (baseline n = 75, 59.5%, after intervention n = 124, 91.2%) (Table 2).
The major outcome that we found from this study regarding privacy during consultation was that 161 (71.2%) and 173 (87.8%) of the respondents reported that their privacy was kept secret during counseling and consultation at baseline and after intervention, respectively.
Uptake of PPFP
Uptake of PPFP by the clients was low at baseline, as just about half (55.8%) of the study participants chose to use a method but after the intervention the proportion reached 69% (Figure 1). The most preferred method at baseline and post intervention was implants and the proportion of women preferring IUCDs increased after the intervention (32.1%) compared with baseline (21.1%) (Figure 2).
Uptake of PPFP, Y12HMC, 2020.
PPFP methods chosen, Y12HMC, 2020.
Client satisfaction on PPFP service
To assess client satisfaction on quality of PPFP services, 3 satisfaction levels were used: completely satisfied, roughly satisfied, & not satisfied. There was a significant increase in client satisfaction across several domains before and after intervention (Table 3). The proportion of respondents who reported to be completely satisfied with provider’s behavior of demonstrating friendship, satisfaction with the chosen method and waiting times remained consistent from baseline to post intervention. Satisfaction with privacy, information provision and opportunities to ask questions increased significantly from baseline to post intervention (P < .001). There was a significant change from baseline to post intervention on overall satisfaction levels, from 77.9% at baseline to 94.9% post intervention (P < .05).
Clients’ post partum family planning service satisfaction at Y12HMC, Addis Ababa, 2020.
Statistically significant difference between baseline and after intervention groups (P < .05).
Statistically significant difference between baseline and after intervention groups (P < .001).
In-depth interview results
Ten health workers were interviewed to assess the overall standard of care, quality of counseling and client satisfaction feedback on PPFP service provision. Emerging themes from the interviews were identified based on the goals of this study. The themes that emerged were organizational structure, supportive supervision & training, quality of counseling, client satisfaction, and PPFP availability & accessibility. Most of the interviewees agreed that the institutional structure is suitable for providing integrated services. Participant 1 in depth interview stated “Our institution structure for PPFP is relatively Good. The units including ANC, PNC, EPI, and FP clinics are on the same Building which makes easy access for every service though there is over congestion on waiting areas.” Seven out of 10 interviewees reported that supportive supervision and training is not adequate. Regarding client satisfaction “most of the clients are grateful for the information provided and service as a whole. For example, there are times that women come for depot medroxyprogesterone acetate (DMPA) but with proper counseling they understand and opt for implants or IUD as LARC method.” Regards the quality of counseling all of them agree that counseling has to be initiated at ANC in order to increase acceptance rate. Participant 2 stated that “In my opinion counseling has to be initiated at ANC. Most patients don’t have that counseling. When you counsel them in the ward for the first time they won’t accept.”
Discussion
This study identified that the majority of the participants are in the age category 20 to 29 years, married/live together, completed at least primary education and have more than one child both at baseline and post intervention.
Uptake of PPFP by the clients was low at baseline, as just about half of the study participants chose a method but after intervention the proportion increased to 69%. A study in Kenya found a substantial increase in client receipt of their selected contraceptive method from baseline 35% to 63% after intervention (P < .01). 19
A Study in Swaziland also showed there was a significant increase in women choosing a PPFP method from 28% at 6 weeks before intervention to 70% after intervention. 20 Study in Tanzania on effect of PPFP intervention on IUD counseling and choice the intervention increased the choice by 6.3%. 21 This indicates that a package of interventions (provider training, establishing a private room and counseling using WHO tool kit) improved women’s willingness to utilize PPFP
In this study the most preferred method was implants and the proportion of women preferring IUCD increased after the intervention (32.1%) compared with baseline (22.1%). Integrating PP counseling and IUD insertion in Nepal increased the preference of IUD by 4%. 22 Additional postpartum home visits focusing on FP resulted to greater uptake, according to a research done in Bangladesh. At 3 months, 22.8% of women in the intervention regions and 0% of women in the control areas had chosen IUCDs. 23 This difference is attributed to the intervention of making available IUCDs in the facility. A WHO toolkit dedicated to PPFP counseling, emphasizing the advantages and methods of birth spacing, and addressing myths about contemporary contraception, will aid both providers and their clients in making informed and choice-based PPFP decisions. 24 Effectiveness of FP counseling and information provision are key points in this study and Frontline health professionals’ capacity to deliver excellent PPFP services is hindered by their lack of knowledge and limited competence in providing PPFP services.12,13 In this study there was a significant change in the proportion of respondents reporting that the health professionals explain properly how the method works, demonstrated how to use it and discussed possible side effects after intervention. These findings are aligned with studies done in northwest Ethiopia, Zambia and Afghanistan: that training and use of the WHO decision tool kit can help health-care practitioners perform better on counseling clients to provide effective PPFP service.25,26 This shows that in most cases when service providers approach clients in a friendly and clear manner it has positive impact on postpartum contraceptive acceptance.
Clinic readiness and establishing a women friendly environment is one of the criteria to measure the quality of PPFP services. In this study there was significant improvement from baseline in that the majority of women reported in post intervention that their privacy was kept during counseling and consultation. Similar finding in Afghanistan also show that establishing a private corner can improve the satisfaction level of clients. 25
Levels of satisfaction were assessed in this study before and after intervention and the majority of the study participants were completely satisfied on receiving necessary information, duration of wait for the service, privacy of the counseling room, and the selected contraceptive. The study participants overall satisfaction with the service was 95.4% at post intervention. The finding is line with study done in Jordan, which found that following the use of consult and chose tools by trained providers, clients expressed 83% satisfaction with the recommended FP technique. 27 and similar finding also reported in Tanzania that 91% of clients are satisfied with FP service. 28 This shows that the intervention done in the facility improved the service quality in most of quality measurement domains.
Strength of the study
We used reasonable sample size and the mixed methods: provider view is important as well as client’s perspective. The study assessed maternal satisfaction and service provider-related factors.
Limitations of the study
Lack of control data to compare the true effect of the intervention.
Conclusions
Competency-based training for counseling and technical skills, followed by mentorship and quality improvement activities done in the intervention facility, led to significant improvements being noted in counseling for FP. In turn, there has been rise in rates of PPFP counseling and immediate PPFP uptake and a transition to more reliable FP methods (LACM including IUCD) immediately post-delivery. WHO tool kit-guided counseling soon after delivery improved client participation in the decision-making process and increased satisfaction levels of client in terms of quality of the service. The establishment of private space (FP corner) for PPFP counseling for both woman and her spouse also improved the satisfaction level of the clients.
Footnotes
Acknowledgements
The authors would like to express their gratitude to the study participants who volunteered to take part in this research, the full research consortium and our funders Marie Stopes International.
Funding:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was conducted with the financial support of Marie Stopes International but has no other role in the manuscript.
Declaration Of Conflicting Interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions
EM, TK, AT, AS, TA and BK were responsible for the conceptualisation of the study. EM and TK performed the data analysis and drafted the manuscript. TK, AS, SS, TA and EM provided training and supervision. All authors read and approved the final manuscript.
