Background
Postpartum women are at a high risk of unplanned pregnancies, especially in the first year after delivery [
1]. Adoption of postpartum contraceptives leads to not only a reduction in unplanned pregnancies, but also improves maternal and child well-being [
2], since short birth intervals of less than 15 months are associated with adverse pregnancy outcomes: induced abortions, miscarriage, preterm births, neonatal and child mortalities, still births and maternal depletion syndrome [
3‐
5].
During the postpartum period, there are multiple contacts between women and healthcare providers when women are seeking child immunization services, yet the unmet need for contraception is still high [
6,
7]. A demographic health survey of four countries (2001) found that only 25% of women in Kenya had adopted postpartum family planning (PPFP) by six months, and 35% at one year [
8]. Studies have shown that the need for contraceptives varies during a woman’s reproductive years, but demand is highest during the postpartum period [
9,
10].
We do not know why there is a low uptake of family planning amongst postpartum women despite their multiple contacts with healthcare providers in health facilities.
Despite these interventions, unmet need for family planning among postpartum women remains high [
11,
12]. Amixed methods study was designed to understand characteristics of postpartum women, correlates of family planning use, and the role of health providers in contributing to uptake of postpartum family planning. Our goals were to estimate the prevalence of postpartum family planning use in a rural hospital in Kenya (Kisii Level 5 Hospital) and to examine the factors that influence adoption of contraceptives among postpartum women.
Discussion
In this study, more than three quarter (86.3%) of the respondents were found to have adopted postpartum contraception. This finding contrasts with some recent studies in Kenya. For instance, the Nairobi Urban Health and Demographic Surveillance System (NUHDSS, 2011) indicated that while resumption of sex occurs quite early (50%) by the third month, relatively few women initiate contraceptive use during the first six postpartum months [
13]. This variation between the present study and other studies in sub Saharan Africa [
14], can be explained by the difference in methodologies adopted in the highlighted studies. Whereas, this was a cross sectional study of postpartum women attending a health facility in a quasi-rural setting the NUHDSS was a longitudinal study which recruited participants at the household level in a primarily urban setting. As such, women who are not regular attendees of postpartum clinics participated.
In this study, use of COCs, DMPA injections and condoms was relatively high. This finding reflects national trends that show that women prefer modern contraceptives (53%) to the traditional methods (5%) [
15]. This finding is also consistent with a recent Demographic Health Survey (DHS) analysis of 21 low and middle income countries, which showed that women who adopt modern contraceptive methods postpartum are likely to opt for short term hormonal methods [
1]. In our study, as in prior studies, married women were more likely to adopt family planning compared to their unmarried counterparts [
16,
17]. This could be because married women are exposed to frequent sexual activities [
18].
Adoption of PPFP was high among women with high post primary education, this is in keeping with other studies [
16,
17,
19], and there was a significant association between higher education level and contraceptive awareness. This finding is consistent with a study done in Ethiopia, where it was observed that women with higher education level were more likely to adopt a family planning method [
20].
Our findings showed that condoms were most popular among women with primary level of education and below, whereas highly effective long-acting methods such as contraceptive implants and IUCDs were more common among women with secondary education and above. See Table
3. Women’s employment status is positively associated with PPFP in our study. Studies done elsewhere have revealed a similar relationship between employment and contraceptive use [
18,
21,
22]. This may be explained by the fact that economically empowered women can access facilities and can afford the cost of contraceptives more easily than women who do not have a source of income.
Table 3
Relationship between level of education and family planning methods
Male condoms | Count | 6 | 11 | 4 |
% FP Method | 28.6% | 52.4% | 19.1% |
IUCD | Count | 9 | 34 | 45 |
% FP Method | 10.2% | 38.6% | 41.2% |
Implant | Count | 4 | 23 | 24 |
% FP Method | 7.9% | 45.1% | 47% |
Injection | Count | 6 | 57 | 39 |
% FP Method | 5.9% | 55.9% | 38.2% |
Female Sterilization | Count | 0 | 4 | 1 |
% FP Method | 0.0% | 80% | 20% |
Oral pills | Count | 7 | 27 | 21 |
% FP Method | 12.7% | 49.1% | 38.2% |
None | Count | 3 | 22 | 16 |
% FP Method | 7.5% | 52.50% | 40% |
This study established that younger women were the most avid users of postpartum contraception especially between age 19–24 years. Previous studies have demonstrated a significant relationship between age and contraceptive use [
17,
23]. A DHS analysis of 21 countries showed that a majority of women who use contraceptives are aged between 20 and 34 years [
21]. This may be because women in the higher age groups may assume that they are not fecund and therefore, have no need for contraception, or they are not accessing the facility so we did not capture them in this study. It may also be because the women in higher age groups are more socially conservative and declined to participate in the interviews.
A majority of women at the clinic obtained contraceptives from government hospitals. In this facility, we established that the quality of care is relatively good because the participants felt they got adequate counseling on family planning. However, the impact of these excellent services was diminished due to frequent stock outs at the public facilities, long waiting queues and staff shortage appeared to be pushing women to use private pharmacy services, where women felt that they were not adequately counseled. The demand for contraception among the respondents driven by information disseminated by healthcare workers was not matched by efficient supply which resulted in frequent stock outs.
In addition, some of the respondents had their contraceptive implants and DMPA injections administered by chemists contrary to the National Family Planning Guidelines for Service Providers, 2010 [
24]. Previous studies have demonstrated that a woman’s decision to adopt a family planning method is strongly influenced by how she perceives the quality of health care service provided [
17,
25]. This conclusion has been corroborated by a qualitative study done in the informal settlements of Mathare, Kenya. The women were more confident of the family planning services offered at public facilities than in private institutions, perceiving the latter to have prioritized profits over safe medical practice [
12].
Unlike a population based study in Uganda which demonstrated a positive association between a woman’s number of living children and her likelihood of using PPFP, parity was not a predictor of PPFP uptake in this study [
19]. Some women expressing no intention to have more children or those with spacing plans of more than two years were either not on any contraceptives, or opted for short term hormonal methods. This finding is consistent with a study conducted in five low income countries by Pasha et al., which showed that the uptake of long acting reversible contraceptives among postpartum women is low [
14]. Some women expressing no desire to have more children in the future were on short term methods of contraceptives. This suggests that there is room for improvement for counseling services even in government facilities, to promote long acting methods. Further research should investigate reasons why uptake of long term contraceptive methods is low among postpartum women.
Our study had some limitations. Our results may not be generalisable as we conducted the study among women attending maternal and child health clinics in a rural area. Our study also used a non random selection of participants. We may have missed some women who did not come to the clinic for immunizations, or who received their health care in other settings. Our FDGs took place in the hospital and as such the women may have viewed the principal investigator as part of the healthcare providers, which may have prevented them from answering questions as freely as if they were offsite.
Conclusions
Among postpartum women attending a government health clinic, we found that uptake of FP at one year postpartum was high and was strongly associated with marital status, higher education level, younger age, being employed and getting contraceptives at the clinic. Public health campaigns targeting women with low levels of education should be the focus of future efforts to improve uptake of PPFP. Policy makers should work with various family planning stakeholders to make sure that postpartum women who do not want additional children are counseled to use long acting contraceptives. The study also reveals a gap in the skills and knowledge of family health care workers especially those in private facilities and presents an opportunity for training them in family planning methods. Finally, we identified that stock outs at the facility were consistently hindering motivated women from getting the method that they wanted, and were increasing risk of unplanned pregnancies in the postpartum period. In our sample, government family planning clinics are trusted and attended by women in the community; therefore the simplest way to increase uptake of PPFP is to ensure that they are always stocked with the desired contraceptives.
Acknowledgements
We express our sincere gratitude to all participants, research assistants and others involved in the logistics of this study. We convey our special thanks to Dr. Alison Roxby, University of Washington for her advice and constructive comments in drafting this paper.