Background
The use of modern contraceptives in general remains low in low- and middle-income countries (LMICs) as compared to the high-income countries [
1,
2]. Evidence suggests that myths and misconceptions regarding long acting modern contraceptives such as intrauterine contraceptive devices (IUDs) have attributed to the low usage of IUDs in LMICs [
1]. Studies from African countries such as Ghana and Burundi have identified lack of adequate knowledge among users, socio-cultural influences, health providers’ influences, and availability of the IUD as key barriers of uptake and continuation of IUD among users [
3,
4].
LMICs in South Asia such as Nepal are no exception to the challenge of low uptake and continuation of IUDs including the ones used in the immediate post-partum period [
5]. Post-partum intrauterine contraceptive device (PPIUD) is an effective and affordable long-acting post-partum family planning (PPFP) method which can be used immediately after childbirth within 48 h of post-partum period. It is known to be safe and has broad eligibility criteria for post-partum mothers [
6,
7]. PPFP such as PPIUD was first introduced in Nepal between 2008 and 2009 [
8]. Despite the decade-long effort, the country still lacks nationally representative data on the usage of PPIUD separately. Moreover, the overall usage of IUD remains as low as 1.4% in the country [
9].
Since 2015, the Nepal Society of Obstetricians and Gynaecologists (NESOG) carried out the initiative on institutionalizing PPFP services in 6 referral facilities through immediate long-acting method such as PPIUD in Nepal [
10,
11]. The initiative was supported by the International Federation of Gynaecology and Obstetrics (FIGO). The major interventions of the initiative includes training of the doctors and nurses working in the maternity units of the implementing facilities to provide timely and quality PPFP services to the women who give child birth in the facilities [
11]. The interventions also include advocacy with the key family planning stakeholders in Nepal, and implementation of behavior change communication (BCC) strategies through counselling of women on PPFP as part of antenatal care (ANC) and immediate post-partum care with the use of BCC materials such as leaflets, posters and videos on benefits of PPFP including PPIUD use.
NESOG has been working closely with the government line agencies with the aim to sustain the progress and scale up the program nationwide. The initiative has been able to improve the acceptance of PPIUD among post-partum mothers above the national average rate in the 6 facilities involved. However, the uptake still remains low and discontinuation rate among the users persists. Previous study from the same initiative suggested that the total uptake of PPIUD was around 3% of 70,098 total deliveries and 10% of the 20,679 women who had been counselled on PPIUD in the 6 implementing facilities in Nepal between 2016 and 2017 [
10].
Factors behind the behavioral outcomes related to uptake and continuation among the users for PPIUD are less understood. Understanding the underlying behavioral factors that has been directly or indirectly affecting the uptake and continuation could help improve the PPIUD program implementation strategies in Nepal and other LMICs with similar contexts. Therefore, this study intends to explore the factors affecting these behavioral outcomes using the theory of planned behavior (TPB) as a theoretical framework [
12].
Theory of planned behavior (TPB)
TPB has been widely used in health research to predict and explain a wide range of health behaviors including health services utilization, breastfeeding, substance use, condom use, and fertility intention [
13‐
17].
TPB states that behavioral outcomes depend on both intention and behavioral control. It distinguishes between the three types of beliefs - attitude, subjective norms, and behavioral control. Attitude is related to favorable or unfavorable perceptions towards behavior [
12]. The subjective norms deal with how the opinions of others shape an individual’s intention [
10]. Behavioral control results in the actual control of the behavior that could be internal or external control which brings out an individual’s ability to decide and take action [
12].
According to TPB, the combination of attitude, subjective norms and behavior control would lead to the intention which subsequently leads to a behavior outcome. TPB provides a more holistic perspective towards behavior change and suggests that improving knowledge alone or focussing on one dimension does not change a behavior [
12]. Application of TPB could provide an in-depth understanding to identify gaps and design more effective interventions to improve PPIUD uptake and continuation.
Discussion
As suggested in TPB [
12], this study shows that multiple factors influence the behavioral outcomes related to uptake and continuation of PPIUD among the women. The findings highlighted the need for a multidimensional approach to improve the attitude, subjective norms and behavioral control to improve PPIUD uptake and continuation.
In this study, attitude had an influence in shaping a woman’s intention in using PPIUD. However, it also highlighted that positive attitude alone was not enough to result in actual behavior outcome. Contrary to this, a negative attitude towards PPIUD was more likely to lead to women not choosing or discontinuing PPIUD. Though the beliefs about the effect of PPIUD played a crucial role in shaping either positive or negative attitudes, other factors such as intention to have a child immediately and family member’s influence also played important roles. A study by Ajzen, on fertility intention too suggested that the reasons behind positive and negative attitudes may not entirely be the same and attitude alone may not lead to behavior [
17].
As explained in TPB [
12], subjective norms also played an important role in shaping one’s intention and behavioral outcomes in this study. Influences from the family and society on women’s family planning behaviors have been discussed widely [
3,
4]. Similar to previous studies, myths over IUD were an important barrier that affected subjective norms [
3,
4]. In this study, peer influence too affected PPIUD uptake and continuation which was related to the fear of being left alone among the peers rather than the direct effect of PPIUD. A study on PPIUD uptake among African American adolescents has also shown the influence of peers on PPIUD behavior [
18].
Moreover, this study also showed that lack of timely counseling on PPFP in the peripheral facilities led to missed opportunities. Health providers play a key role to address PPFP needs in a timely fashion [
19,
20]. The previous quantitative study on PPIUD initiative indicated that multiple counseling by health providers had a significant influence on the uptake of PPIUD by women [
10]. Another qualitative study focussing on the training of health providers on PPFP counseling service and PPIUD insertion techniques had suggested that regular mentoring had helped in motivating the health providers on improving their services [
11]. Despite the efforts, the gap on counseling exists which is partly attributed to the low health providers to patients ratio in these busy hospitals [
10]. The task shifting of PPFP services such as counseling by establishing community linkages could help address the gap to some extent. The female community health volunteers (FCHV) and the peripheral health facilities are often the first points of contact for most women in Nepal [
21,
22]. Involvement of FCHVs by building their capacity has proven beneficial for many health interventions in Nepal [
23,
24]. The capacity building process by integrating the training packages on PPFP counseling for them into the national health system and by strengthening the local leadership to drive these training activities would be pertinent. Further, their inclusion in the BCC activities is crucial to gaining women’s trust in the family planning method.
In this study, both perceived internal and external control also played important roles in shaping the intention as well as the behavioral outcomes. Perceived behavior control is believed to have a direct influence over the behavioral outcomes irrespective of the attitude and subjective norms [
12]. Internal control in this study reflected the personality attributes such as the women’s self-confidence and her internal feelings. Whereas, external controls were related to subjective norms or health complications which had no influence on a woman’s attitude or intention. It is clear from the responses that in many instances the husband is in fact in control of the chosen method of contraception. Migrant husbands are not keen to leave their wives behind with a method of contraception in situ which they do not perceive as necessary given their absence. Perhaps inclusion of partners in counselling sessions would result in a better understanding of the advantages of a one stop approach and the efficacy of PPIUD in preventing pregnancies when comparing to other methods requiring user input.
This study has certain limitations. First, this study was conducted in a small population and therefore may not be generalised to a wider population. However, as a qualitative study, this study provides an in-depth perspective of women of different age groups, parities and PPFP related behavior. Second, this study was conducted at 6 week post-partum period and does not provide a longitudinal perspective on the contraceptive choices and behaviors of the women in the long run.
Despite the limitations, the findings of this study have important program implications for stakeholders related to PPFP. The findings highlight existing gaps and will aid in designing more effective interventions through evidence based practice. Community awareness through innovative approaches using mass media and community mobilization is an effective intervention [
25] which could help address attitude as well as subjective norms and behavior control. As with ANC group counselling [
26], more focused group counselling on PPFP during ANC could also help in shaping positive peer influence. Moreover, involving family members such as husband or mother-in-law in the PPFP counselling could also be effective to overcome barriers surrounding subjective norms and external control [
27]. Further, expansion of the institutionalization process to the peripheral facilities could help in capacity building of health providers and to reach out to more women in need of PPFP services. This would in turn widen the sphere of women using the method and hence make it more acceptable to the wider public [
25].
This study is one of the few studies that have explored the factors affecting the behavior outcomes in LMICs such as Nepal. This study indicates that a more layered, multidimensional and interlinked intervention is necessary to bring out the ultimate outcome of improving the uptake and continuation of PPIUD among women in LMICs.
Acknowledgements
The authors would like to thank Prof. Sir Sabaratnam Arulkumaran and the entire FIGO team for their valuable guidance and support. The authors will remain forever grateful to the NESOG executive team for all the hard work and dedication to make this initiative grow. The authors would also like to acknowledge Ms. Lata Bajracharya, former National Project Manager and Ms. Shikha Thapa, National Data Coordinator for coordinating data collection of this study. We are also thankful to the data collection officers for assisting in data collection. We are obliged to all the participants of this study for their valuable time.