An Exploratory Analysis of Factors Associated With Interest in Postpartum Intrauterine Device Uptake Among Pregnant Women and Couples in Kigali, Rwanda

Rwanda has high unmet need for family planning (FP), especially in the postpartum period when women are advised to space pregnancies at least two years for improved maternal-child health. Despite interest in the copper intrauterine device (IUD), a highly cost-effective method, access and uptake remain low. This study aimed to determine factors associated with postpartum IUD (PPIUD) uptake after postpartum family planning (PPFP) counseling as well as provider perceptions of facilitators and barriers to clients' PPIUD uptake. Postpartum women who received PPFP counseling and were less than 6 weeks postpartum were recruited for a case-control study in Kigali, Rwanda in 2018. We recruited n = 74 women who had accepted and n = 91 women who had declined the PPIUD. Multivariate logistic regression analyses evaluated associations between women's socio-demographics, FP knowledge and decision-making, and the outcome of PPIUD uptake. Six focus groups (FGs) were conducted with FP providers (n = 24) and community health workers (n = 17) trained to deliver PPFP counseling to assess perceptions of PPFP counseling and facilitators and barriers to PPIUD uptake. FG discussions were recorded, translated, and analyzed for themes. Factors associated (P<0.1) with PPIUD uptake included citing its non-hormonal nature, effectiveness, and duration of protection against pregnancy as advantages. Exclusive male partner control over FP decisions (relative to women's control or joint decision-making) was associated with non-use. Overall, limited knowledge about some aspects of the PPIUD persisted among clients even after counseling. Provider FGs highlighted client concerns, inconsistent FP messaging, and lack of male partner involvement as factors influencing non-use. Knowledge of the IUD and its benefits was associated with PPIUD uptake. There is need to refine PPFP counseling messages to address remaining knowledge gaps and concerns. Additionally, male partner involvement in FP counseling and decisions with their partners could be a key strategy to increase both PPIUD and FP uptake in Rwanda.

IntroductionRwanda has high unmet need for family planning (FP), especially in the postpartum period when women are advised to space pregnancies at least two years for improved maternal-child health. Despite interest in the copper intrauterine device (IUD), a highly cost-effective method, access and uptake remain low. This study aimed to determine factors associated with postpartum IUD (PPIUD) uptake after postpartum family planning (PPFP) counseling as well as provider perceptions of facilitators and barriers to clients’ PPIUD uptake.MethodsPostpartum women who received PPFP counseling and were less than 6 weeks postpartum were recruited for a case-control study in Kigali, Rwanda in 2018. We recruited n = 74 women who had accepted and n = 91 women who had declined the PPIUD. Multivariate logistic regression analyses evaluated associations between women’s socio-demographics, FP knowledge and decision-making, and the outcome of PPIUD uptake. Six focus groups (FGs) were conducted with FP providers (n = 24) and community health workers (n = 17) trained to deliver PPFP counseling to assess perceptions of PPFP counseling and facilitators and barriers to PPIUD uptake. FG discussions were recorded, translated, and analyzed for themes.ResultsFactors associated (P<0.1) with PPIUD uptake included citing its non-hormonal nature, effectiveness, and duration of protection against pregnancy as advantages. Exclusive male partner control over FP decisions (relative to women’s control or joint decision-making) was associated with non-use. Overall, limited knowledge about some aspects of the PPIUD persisted among clients even after counseling. Provider FGs highlighted client concerns, inconsistent FP messaging, and lack of male partner involvement as factors influencing non-use.ConclusionsKnowledge of the IUD and its benefits was associated with PPIUD uptake. There is need to refine PPFP counseling messages to address remaining knowledge gaps and concerns. Additionally, male partner involvement in FP counseling and decisions with their partners could be a key strategy to increase both PPIUD and FP uptake in Rwanda.

BackgroundThe use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal.MethodsThis qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework.ResultsThe themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women’s intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband’s preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions.ConclusionAs suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

BackgroundThe use of immediate postpartum intrauterine contraceptive devices during the postpartum period supports women’s need for spacing births and prevents them from unplanned pregnancies. However, in developing countries, utilization of immediate postpartum contraceptives is low. This increases the risk of maternal morbidity, maternal mortality, preterm birth, child mortality, low birth weight, and small gestational age in subsequent pregnancy with interpregnancy interval.ObjectiveTo assess immediate postpartum intrauterine contraceptive device utilization and the associated factors among women who gave birth in Hospitals in West Wolegga Zone in 2020.Methods and materialsAn institutional-based cross-sectional study was conducted in public hospitals in the West Wolegga Zone from 1 April 2020 to 30 April 2020 among 290 postpartum women. The sample size was proportionally allocated to six hospitals by considering their monthly delivery. Study subjects were taken by systematic sampling technique (Kth=N/n =1025/290=3.53), thus every 4th woman who gave birth in the hospital was recruited in each hospital until the total sample size for this study was obtained.Bivariable and multivariable logistic regression was used to assess the association of independent variables with immediate postpartum intrauterine device utilization. A significance level of 0.05 was used to assess the statistical significance of the study’s associations.ResultsIn this study, the magnitude of the Immediate postpartum intrauterine contraceptive device utilization was 19.3%.factors like Early initiation of antenatal care [AOR=4.46 95% CI:1.84-10.78], Planning of future pregnancy [AOR=3.7(95% CI: 1.43-9.54)], Ever heard of the immediate postpartum intrauterine contraceptive device [AOR=2.67(95% CI: 1.08-6.58)] and Counseling about postpartum intrauterine contraceptive device [AOR=5.15(95% interval: 2.00-13.28] were associated with immediate postpartum intrauterine device utilizations.ConclusionThe use of immediate postpartum intrauterine contraceptive devices is low compared to other studies conducted in Ethiopia. Age, early antenatal care initiation, pregnancy planning, hearing of the immediate postpartum intrauterine device immediately inserted after delivery, and counselling on the immediate postpartum intrauterine device were significantly associated with mothers’ use of immediate postpartum intrauterine devices. Health Program directors should develop strategies to increase the use of immediate postpartum intrauterine contraceptive devices.

Background: Most women do not desire pregnancy immediately after delivery and are highly motivated to accept family planning methods. The post partum intrauterine device is one of the family planning methods that can address this need. According to prior reports intrauterine device use has been very low from the contraceptive method mix. Objective: To assess barriers to postpartum intra uterine device uptake among mothers who delivered at two public hospitals in Addis Ababa, Ethiopia. Method: It is an institution based cross-sectional study. Simple random sampling method was used to select study participants. Descriptive statistics and regression analysis were used to determine the presence and strength of association between uptake of post partum intrauterine device and independent variables. Result: In this study the uptake of postpartum intrauterine contraceptive device was 11% (95%CI=8.0, 14). The stated barriers for the none uptake of post partum intrauterine device were fear and concern (61.6%), religions value for family planning (16.9%), husband and relative opinion (7%), culture norm (5%) and health provider related factor (5% (17/367)). Parity and mode of delivery were significantly associated post partum intrauterine device uptake. The odds of intrauterine contraceptive device utilization for mothers with previous number of deliveries of ?3 and 1-2 were 35 (AOR=34.8, 95%CI=7.33, 165.4) and 4 (AOR=4.2, 95%CI=1.47, 12.07) times higher than those with no previous delivery. In addition, assisted vaginal delivery had 11 (AOR=11.06, 95%CI=3.26, 37.5) times increased odds of intrauterine contraceptive device uptake than SVD. Conclusion and recommendations: The uptake of post partum intrauterine device was low (11%). The main barriers identified for the low uptake were fear and concern to myth and misconceptions, religions value for family planning, husband and relative opinion, culture norm and health provider related factors. To identify and address reasons for gaps in knowledge and to clear public misconceptions and fears further large scale studies are recommended. Key-words: PPIUD, Contraception, post partum, Ethiopia.

BackgroundUganda has one of the highest total fertility rates globally and in Sub-Saharan Africa. Her high fertility is mainly attributed to the high unmet need for family planning. Use of Long-acting reversible contraceptives (LARC) is low (13%) in Uganda yet they are the most cost-effective contraceptives. This study aimed to assess the reproductive aged women’s knowledge, attitudes, and factors associated with use of LARC.MethodsA cross-sectional study was conducted involving 565 women (15–49 years) attending private and public health facilities in Lubaga division, Kampala district. Semi-structured questionnaires were used to measure knowledge, attitudes and factors associated with use of LARC; Intra-Uterine Devices, Implants and Injectables. The outcome variable was current use of LARC. A generalized linear regression model was run in STATA version12.0. Prevalence Risk Ratios for associations between current LARC use and independent factors were obtained and regarded significant at 95% CI with p < 0.05.ResultsMean age (SD) and current use of LARC was 26.34 (5.35) and 31.7% respectively. Factors associated with current use of LARC were; previous use adj.PRR 2.89; (95% CI 2.29, 3.81), knowledge of implant administration site adj.PRR 1.83; (95% CI 1.17, 2.87), and perception that; male partner decisions positively influence their contraceptive choices adj.PRR 1.49; (95% CI 1.18, 1.88). Contrary, perception that LARC should be used by married women was negatively associated with use of LARC adj.PRR 0.63; (95% CI 0.44, 0.90).ConclusionKnowledge about site of administration, previous use of LARC and women’s attitude that male partners’ choice influence their contraceptive decisions were positively associated with current use of LARC. Contrary, the attitude that LARC was for married women was negatively associated with its use. This study suggests a need to strengthen client education about LARC to dispel possible myths and to consider integrating male partner’s decision making in contraceptive choices for women.

BackgroundGlobally, approximately half of all pregnancies occur before 24 months after child birth. In Sub Saharan Africa the unmet need for family planning is highest among postpartum women. There is a dearth of information regarding factors associated with postpartum use of long acting reversible contraception (LARC) in Tanzania particularly in the Lake zone. This study aimed to determine the prevalence and factors associated with postpartum use of LARC (< 24 months) in Bukombe District, Geita Region in the Lake zone, in 2018.MethodologyCommunity based analytical cross-sectional study was conducted between May and June 2018 among women with less than 24 months since delivery. Multistage sampling technique was used to recruit participants. Face to face interviews with 768 postpartum women was conducted using standardized questionnaire. Data were analyzed using Stata Version 13.0. Multivariable logistic regression model was used to determine factors associated with postpartum use of LARC.ResultsPrevalence of postpartum use of LARC was 10.4%. Urban residence (AOR = 2.94, 95% CI: 1.07–8.06), having formal employment (AOR = 4.81, 95% CI: 1.85–12.57) and receiving family planning counseling (AOR = 4.39, 95% CI: 1.89–10.20) were significantly associated with postpartum LARC use.ConclusionThe postpartum use of LARC was low in the studied population with implants being the most commonly used method. Urban residency, formal employment and receiving family planning counseling were associated with postpartum LARC use. Improving prenatal and quality of family planning counseling is warranted to increase postpartum LARC utilization in Bukombe.

Factors associated with postpartum use of long-acting reversible contraception

Predictors of long-acting reversible contraception use among unmarried young adults

Immediate postpartum long-acting, reversible contraception (LARC)-providing intrauterine devices (IUDs) and contraceptive implants immediately following birth-is an effective strategy to prevent unintended pregnancies and improve birth spacing. We measured US certified nurse-midwives' (CNMs') and certified midwives' (CMs') knowledge, training needs, current practice, and perceived barriers to providing immediate postpartum LARC. We invited currently practicing CNM and CM members of the American College of Nurse-Midwives to complete an online survey about their knowledge and experience with the use of LARC and analyzed eligible questionnaires using descriptive statistics. Of 4609 eligible midwives, 794 responded (17% response rate). Most were female (99.5%) and non-Hispanic white (92.1%), with 45.0% attending births in urban settings. Responses revealed multiple knowledge gaps related to IUD expulsion rates and appropriateness of immediate postpartum LARC in certain clinical scenarios. Only 10.1% of respondents reported feeling confident to insert an immediate postpartum IUD and 43.3% an implant. Many reported desiring additional training in immediate postpartum IUD (63.5%) and implant (22.8%) insertion; few reported access to such training (IUD, 19.9%; implant, 15.2%). Most respondents had never inserted an immediate postpartum IUD (90.7%) or implant (86.8%). The most commonly cited barriers to immediate postpartum LARC provision were that it is not standard practice (IUD, 40.9%; implant, 39.0%) or is not available (IUD, 27.8%; implant, 34.8%) at one's institution and feeling inadequately trained (IUD, 26.5%; implant, 10.7%). Nine in 10 midwife respondents have never inserted an IUD or implant immediately postpartum, but more than half indicated they would like the opportunity to provide these services. Our findings highlight opportunities to enhance the immediate postpartum LARC-related knowledge and skills of the midwife workforce. They also suggest that logistic and institutional barriers to immediate postpartum LARC access must be removed in order to make this evidence-based reproductive health service available to all women who desire it.

Mali has one of the highest maternal mortality ratios in the world coupled with one of the lowest modern contraceptive use rates. Nearly a quarter of the country's 750,000 annual births occur within 24 months of a previous birth, increasing the risks for mothers and babies. Nearly 70% of postpartum women have an unmet need for family planning. In 2016, Population Services International Mali (PSI-Mali) introduced a dedicated postpartum intrauterine device (PPIUD) inserter to replace the technique of using forceps for PPIUD insertion, with the aim of helping to address this substantial family planning gap. A mixed-methods approach was used to assess program results and the experiences of PSI-trained providers using the dedicated PPIUD inserter in 5 health facilities in Bamako. We conducted 10 key informant interviews with providers and 4 key informant interviews with operational and clinical staff involved in training and supporting providers. Further data were collected from district health surveys and facility registers. Secondary data encompassed documentation from 2011 through 2017, with the service delivery figures of PPIUD using the dedicated inserter focused on the pilot period of March 2016 through December 2017. Primary data were collected in Mali in July 2017. Between March 2016 and December 2017, PSI-Mali trained 134 providers on the dedicated PPIUD inserter and provided more than 3,500 voluntary PPIUDs. Of the 1,840 voluntary PPIUDs provided in 2017 alone, 67% were provided by facilities trained to use the dedicated PPIUD inserter. Providers stated a preference for the inserter (compared with the use of forceps) due to its ease, speed, and perceived lower associated risks of infection. Service data from the 5 facilities visited showed an overall average PPIUD uptake of 7.3% of deliveries in 2017. Although private facilities had considerably fewer deliveries than public facilities (600-900 compared with 20-30, respectively), a much higher proportion of women delivering in the private facilities chose a PPIUD. The acceptance of the dedicated PPIUD inserter by providers may help reduce some of the supply-side barriers that inhibit women's access to postpartum family planning methods. With continued support to providers, coupled with ongoing efforts to address differences in service trends between sectors and demand-side barriers to the PPIUD and family planning more broadly, the dedicated PPIUD inserter could play an important role in responding to the high unmet need among postpartum women in Mali.

To examine characteristics of U.S. women that are associated with use of long-acting reversible contraception and changes in these characteristics between 2002 and 2006-2008. We analyzed data from two nationally representative samples of women aged 15-44 in the National Survey of Family Growth, including 7,643 women in 2002 and 7,356 women in 2006-2008. We conducted simple and multinomial logistic regression analyses to identify demographic and reproductive health characteristics associated with use of long-acting reversible contraception. Long-acting reversible contraception (intrauterine devices and subdermal implants) use among U.S. women using contraception increased from 2.4% in 2002 to 5.6% in 2006-2008. The largest increases in long-acting reversible contraception use during this time occurred among the youngest and oldest age groups, non-Hispanic white and non-Hispanic African American women, foreign-born women, and those in the highest income group. High prevalence of long-acting reversible contraception use in 2006-2008 was seen among women who had given birth once or twice (10%), foreign-born women (8.8%), and Hispanic women (8.4%). After adjusting for key demographic and reproductive health characteristics, in comparison with users of other contraceptive methods and with those not using contraception who were at risk for unintended pregnancy, foreign-born women and women who experienced coitarche before age 18 were approximately twice as likely to be using long-acting reversible contraception as women without those characteristics. A more diverse population of women used long-acting reversible contraception in 2006-2008 compared with 2002. However, there is likely more potential for increased uptake, especially among populations historically not considered to be candidates for these methods.

Use of modern contraceptive methods in Nigeria remained at 10% between 2008 and 2013 despite substantive investments in family planning services. Many women in their first postpartum year, in particular, have an unmet need for family planning. We evaluated use of postpartum intrauterine device (IUD) insertion and determined factors associated with its uptake in Nigeria. Data were collected between May 2014 and February 2015 from 11 private health care facilities in 6 southern Nigerian states. Women attending antenatal care in participating facilities were counseled on all available contraceptive methods including the postpartum IUD. Data were abstracted from participating facility records and evaluated using a cross-sectional analysis. Categorical variables were calculated as proportions while continuous variables were calculated as medians with the associated interquartile range (IQR). Multivariate logistic regression analysis was used to identify factors associated with uptake of the postpartum IUD while controlling for potential confounding factors, including age, educational attainment, marital status, parity, number of living children, and previous use of contraception. During the study period, 728 women delivered in the 11 facilities. The median age was 28 years, and most women were educated (73% had completed at least the secondary level). The majority (96%) of the women reported they were married, and the median number of living children was 3 (IQR, 2-4). Uptake of the postpartum IUD was 41% (n = 300), with 8% (n = 25) of the acceptors experiencing expulsion of the IUD within 6 weeks post-insertion. After controlling for potential confounding factors, several characteristics were associated with greater likelihood of choosing the postpartum IUD, including lower education, having a higher number of living children, and being single. Women who had used contraceptives previously were less likely to choose the postpartum IUD than women who had not previously used contraception (adjusted odds ratio, 0.68; 95% confidence interval, 0.55 to 0.84). A high percentage (41%) of women delivering in private health care facilities in southern Nigeria accepted immediate postpartum IUD insertion. Scale-up of postpartum IUD services is a promising approach to increasing uptake of long-acting reversible contraceptives among women in Nigeria.

Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis

Background and Aim: Postpartum intrauterine device (PPIUD) is a reversible, long-term and effective technique of contraception. The intrauterine device (IUD) is inserted within 48 hours of delivery. The immediate insertion of an intrauterine device causes certain complications. The present study aimed to assess the prevalence of complications after Interval Postpartum Intrauterine Device Insertion. Materials and Methods: This cross-sectional study was carried out on 147 women who underwent postpartum IUD (PPIUD) insertions during from January 2021 to June 2021 at Gynecology department, Mufti Mehmood Memorial Teaching Hospital (MMMTH), Dera Ismail Khan and Muhammad Teaching Hospital Peshawar. All the women who delivered and showed willingness for PPIUCD insertion were enrolled and continuously follow-up for 4 to 6 weeks after delivery. Demographic, obstetric, and clinical parameters were recorded on pre-designed medical proforma. PPIUCD insertion after 6 weeks of delivery were followed-up for the evaluation of complications. Uterine infection, medical removal of IUD, IUD expulsion, perforation, and method discontinuation were the outcome variables. SPSS version 20 was used for data analysis. Results: Of the total deliveries, 147 women inserted the postpartum intrauterine contraceptive device (PPIUCD). Of the total, about 122 (83%) women returned for follow-up after 6 weeks. All the women underwent transvaginal insertion of intrauterine contraceptive devices. The PPIUCD insertion related complications with prevalence were uterine infection 26 (21.3%), overall method suspension 17 (13.9%), perforation 20 (16.4%), interceptive uterine device expulsions 25 (20.5%), and intrauterine device removal 32 (26.2%). The severe uterine infection was in 2 (1.7%) cases who were hospitalized. Conclusion: The postpartum intrauterine device cumulative expulsion rate was higher among women compared to the expulsion rate of insertions. The longer duration of bloody lochia flow and delivery intrauterine device insertions were the key risk factors for expulsion of PPIUCD. Women can safely utilize intrauterine contraceptive devices with low complications beyond four week. Keywords: Postpartum intrauterine device; Complications; Intrauterine device expulsion