Background
Initiating contraceptive use during the immediate postpartum period is cost-effective and efficient from the perspective of both the health system and women, particularly in developing countries like Nepal where access to healthcare services remains low. Most Nepali women interact with the health system only during pregnancy, for delivery, or for immunizing their children. Providing family planning (FP) services during immunization visits is often difficult since immunizations are primarily done by dedicated health workers who are not trained in FP service delivery. In contrast, antenatal checks and deliveries are largely conducted by obstetricians, nurses, or auxiliary nurse midwives (ANMs). Given their background and conditional on receiving FP-related training, these healthcare providers are better suited to deliver FP services to Nepali women without adding the burden of recruiting new staff on the Nepali health system [
1]. For Nepali women, provision of FP services in the immediate postpartum period allows them to conveniently meet their fertility goals as they do not have to make costly trips to health facilities at a later date for FP services.
Several studies across different settings have demonstrated the safety, effectiveness, and acceptability of immediate postpartum insertion of intrauterine devices (IUDs), especially when coupled with counseling on postpartum contraceptive methods [
2‐
12]. Recognizing its many advantages, the Nepali government has focused its efforts on increasing the availability of long-acting FP methods and FP counseling services. Despite this, IUD use in Nepal remains very low: only 1.4% of currently married women in Nepal were estimated to be using an IUD in 2016 [
13].
There are many reasons for the low uptake of IUDs in Nepal. First, unlike temporary FP methods which are available at most health posts, primary health care outreach clinics, or pharmacies, long acting reversible contraceptives (LARCs), such as IUDs, are only available at healthcare facilities that have obstetricians and gynecologists, or nurses, or ANMs who are trained in providing such FP services. In Nepal, both doctors and trained nurses are permitted to provide counseling and IUD insertion services. At the time of the launch of our study, a nurse or doctor attending a woman was expected to provide PPFP counseling or insertion services when requested to do so by the woman. However, there was no standardization in terms of the content and quality of the counseling provided to women and they largely depended on the workload faced by the service provider.
The effect of limited availability of LARCs on IUD uptake is compounded by the various geographical and financial barriers Nepali women face in accessing the health system. Additionally, medico-legal restrictions, fear of side-effects, poor perception of pregnancy risk, and socio-cultural factors such as lacking decision-making power due to lower status of women, pressure to give birth to at least one son, pressure to give birth soon after marriage, and stigma attached to pre-marital sex all affect the uptake of family planning in general and LARCs in particular [
14‐
16].
Lack of knowledge or pre-existing biases toward FP services in healthcare providers may also reduce the uptake of postpartum family planning (PPFP) methods. A recent systematic review of studies from countries across six different continents showed that many providers have low levels of knowledge regarding IUDs and limited training in their insertion or removal [
17]. Furthermore, many providers wrongly believe that IUD use results in serious side effects such as pelvic inflammatory disease and are thus reluctant to provide it to eligible women such as those who are HIV-positive [
17].
In Nepal, providers’ views on PPFP and immediate postpartum IUDs (PPIUDs) in particular are seldom documented because of which the role of providers in uptake of these contraceptive methods is unclear. We also do not know if providers value effectiveness of a PPFP method over convenience or consider women’s preferences for a method and if such views differ by type of providers – doctors compared to nurses or ANMs. The degree to which women are involved in choosing a particular method may differ by type of provider as well as by the nature of the provider-client interaction. We aim to fill these gaps in the literature by exploring the perceptions and experiences of service providers in Nepal with regard to PPIUDs. We also seek to understand trained providers’ attitudes in sharing and diffusing their knowledge and skills about PPIUDs to other service providers who have not received specific training on PPFP or PPIUD counseling and insertion.
Methods
Parent study details
This study is nested within a broader trial studying the impact of an International Federation of Gynecology and Obstetrics (FIGO) led intervention to institutionalize PPIUD training and provision as part of antenatal and delivery services in six public, tertiary hospitals in Nepal. Hospitals were selected based on geographical location and high volume of obstetric cases (between 6000 and 11,000 a year). They were pair-randomized into two groups of three based on geographical location and annual obstetric caseload. Group 1 hospitals implemented the intervention after three complete months of baseline data collection while Group 2 hospitals implemented it after nine complete months of baseline data collection. The intervention was implemented by the Nepal Society of Obstetricians and Gynecologists (NESOG).
The intervention has three main components: 1) training healthcare providers on PPFP counseling including PPIUD and its insertion; 2) providing information, education and counseling materials; and 3) providing insertion supplies to study hospitals. The Nepal Health Training Center (NHTC) of the Ministry of Health and Population (MOHP) conducted the training in all study hospitals using a national protocol. Training was done over a course of three days and included both theoretical and practical components. Content areas covered in the training included healthy timing and spacing of pregnancy; various PPFP methods; overview on PPIUDs; counseling for PPFPs and, in particular, PPIUDs; client assessment for PPIUD; insertion and removal of postplacental postpartum transcaesarean IUD; infection prevention, side effects and complication management for PPIUD services; and, recording, reporting and tracking of clients. Counseling materials were adopted from the Global Library of Women’s Medicines (GLOWM) and were approved by the NHTC and National Health Education Information and Communication Center of MOHP. From a total of 146 providers working in the obstetrics and gynecology departments of the six study hospitals, 78 were trained as part of the intervention (30 obstetricians and 48 nurses/ANMs).
In-depth interviews
We purposively selected 14 obstetricians/gynecologists and nurses from across the six hospitals and conducted in-depth interviews with them after they received training on PPFP and PPIUD as part of the intervention. We selected one physician and one nurse from five hospitals and two physicians and two nurses from the remaining hospital. Our decision to select 14 providers for in-depth interviews was informed by our past experience on the optimal number of respondents to capture the diversity of views and professional experiences. We conducted two more interviews in one hospital because we had insufficient information from the initial two interviews in this hospital. We conducted interviews with both physicians and nurses. None of the selected physicians and nurses were providing PPIUD services before the training. We conducted all interviews between December 2015 and October 2017, taking into account the stepped-wedge nature of the intervention roll-out. No provider approached for the interview refused.
We developed the in-depth interview guide in English (included as an Additional file
1) and translated it to Nepali. We did not back-translate the guide from Nepali to English; however, a third party not involved with the translation thoroughly checked the guide for accuracy. We covered a range of topics in the interviews including the background characteristics of respondents; knowledge, experiences, and preferences regarding contraceptive methods; experiences with PPIUD training and scale-up; and, their willingness to train others in their hospital and in other health facilities. We pre-tested the interview guide with four participants to assess question phrasing, question sequencing, and overall comprehension. Based on the results from the pre-test, we modified the interview guide.
Interview protocol
At the start of each interview, participants were asked to review and sign an informed consent form. They were given the opportunity to ask any questions they had regarding the overall study as well as the interview. After obtaining signed informed consent, a trained researcher conducted the interview in a private room in each facility and in the Nepali language. The interviews were audio-recorded with permission from participants. These recordings were then transcribed and translated into English.
Analytical strategy
We adopted a thematic approach to analyzing the data. First, we developed a codebook based on interview questions and an initial reading of interview transcripts. Two co-authors then independently read transcripts and developed the initial codes which were subsequently modified to develop a more refined codebook. The same co-authors coded all interviews using the codebook. Content codes were grouped into thematic categories. Key quotes that exemplified major themes and concepts are presented below.
ATLAS.ti (Version win 7.0, Scientific Software Development, GmbH, Berlin, Germany) was used for organizing the text, coding the data, grouping codes into relevant themes, and presenting the key themes.
Ethical approval
This study was approved by the Ethical Review Board of the Nepal Health Research Council (NHRC).
Discussion
The in-depth interviews with 14 providers reveal that they view PPFP positively, that the training they received as part of the intervention was useful in many ways, and that they are willing to transfer their skills and knowledge to colleagues across different types of facilities. However, participants also identified several factors which could improve the quality of PPFP training, PPFP service provision, and the process of transferring knowledge and skills.
Barriers to quality service provision and diffusion of knowledge and skills were largely related to failures in the health system and did not revolve around a provider’s personal beliefs toward FP methods. Doctors, nurses, and ANMs all agreed that the lack of a dedicated FP counselor and private counseling space in a facility, irregular and insufficient supply of IUDs and IEC materials, insufficient number of staff, high workload, and lack of support from hospital leadership were key barriers to the provision of high quality FP services and transfer of knowledge and skills.
These barriers are consistent with previous research from Iran and Uganda which show that facility logistics impact contraceptive counseling and provision [
18,
19]. Though postpartum contraceptive services, especially those that can be provided at the time of delivery like PPIUD, are generally thought to be easily integrated with maternity care [
1], our findings suggest that integrating such services into the Nepali health system may not be feasible without addressing several supply-side challenges identified by the participants of this study.
Providers saw postpartum contraceptive services as a worthwhile endeavor as we found no negative attitude toward provision of PPIUD services. However, the need for a dedicated counselor for postpartum contraception suggests that there is insufficient time during antenatal care (ANC) visits to cover these topics despite providers’ willingness to do so. A recent study showed that primary care providers in Nepal spend an average of two minutes with each patient [
20]. In one of our study hospitals, more than 200 women were served daily by only four providers for ANC check-ups. If service integration that complements the existing health structure is the goal, the Nepali health system should first focus on increasing existing human resources for health before scaling-up integrated postpartum contraceptive services.
Traditionally, the role of PPFP counseling has been largely assigned to nurses and ANMs while IUD insertions are done by doctors. In Nepal, however, doctors as well as trained nurses and ANMs are allowed to provide counseling and IUD insertion services. This practice of allowing different types of providers to deliver both counseling and insertion services is seen in neighboring India as well, is evidence-based [
21,
22], and is recommended by the World Health Organization [
23]. However, given their different training and roles within the healthcare system, it is natural to assume that nurses, ANMs, and doctors may have different notions about PPFP. We found that doctors, nurses, and ANMs agreed on a number of different issues surrounding PPFP, the training intervention, and in terms of disseminating knowledge and skills to colleagues. However, we also found that nurses and ANMS mentioned the need for additional refresher trainings and greater support from senior colleagues when handling PPIUD-related complications more often than doctors. Similarly, nurses and ANMs were also more likely to express concern about the short duration of the PPFP and PPIUD training relative to doctors. These results suggest that integrating PPFP training, counseling, and insertion services into the Nepali healthcare system will require not just addressing supply-side challenges but also ensuring buy-in from health facility management and potentially designing training sessions differently based on provider type.
Our results are subject to some limitations. First, given the qualitative nature of this study, we cannot generalize our results to all training participants. While broad themes may be applicable to other sites and providers, our results could also reflect issues and viewpoints specific to large public facilities in Nepal. Second, we interviewed providers immediately after they had received training on PPFP. This could have encouraged participants to talk more positively about the training they had received and the importance of immediate PPIUD services. Our study does not include information or perspectives of providers who were not trained by NESOG as part of the PPIUD intervention.
Conclusions
The in-depth interviews with providers from six study hospitals highlight strengths and shortcomings of improving postpartum contraceptive provision from the perspectives of service providers. Providers were highly motivated to provide quality family planning FP services and transfer their knowledge and skills; however, they also identified several facility and training related factors which could prevent them from doing so. Interventions aimed at addressing structural factors (such as increasing human resources for health and private space for counseling) and other supply-side factors (such as timely and regular supply of the required equipment, refresher training, and regular monitoring and support visits from concerned government departments) are needed to improve postpartum family planning services in Nepal. Integrating postpartum family planning services into the healthcare system will also require ensuring buy-in from facility management and potentially training doctors, nurses, and auxiliary nurse midwives differently.
Acknowledgments
We gratefully acknowledge the very valuable support provided by the PPIUD NESOG’s Nepal and FIGO team in London during the data collection of this study. We also thank the PPIUD Publication Committee for the helpful comments and suggestions on the abstract of this manuscript. Our thanks also go to the providers for sharing their perspectives and insights.