A mixed-methods exploratory study of factors that influence postpartum IUD uptake after family planning counseling among women in Kigali, Rwanda Open Access

Tounkara, Mariama (Spring 2019)

Permanent URL: https://etd.library.emory.edu/concern/etds/sb3979292?locale=en
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Abstract

Background:Rwanda has high unmet need for family planning (FP) methods, especially in postpartum periods during which women are advised to space pregnancies at least two years apart for improved maternal-child health. Despite increased interest in long-acting reversible contraceptive methods like the copper intrauterine device (IUD), a highly cost-effective method, access and uptake remain low among postpartum women. Research shows that low uptake of the postpartum IUD (PPIUD) may be due to poor knowledge, concerns about side-effects, and longstanding myths and misconceptions. This study aimed to determine factors associated with PPIUD uptake among postpartum women after receiving a PPIUD contraceptive counseling intervention (delivered along with discussion of the full range of contraceptive method options), as well as provider perceptions of facilitators and barriers to PPIUD uptake.

Methods:This mixed-methods study was conducted in Kigali, Rwanda in 2018. A case-control study was conducted with postpartum women who received PPIUD counseling (74 PPIUD users, 91 PPIUD nonusers) at three health facilities. Multivariate logistic regression analyses evaluated associations between women’s socio-demographics, FP knowledge, and FP decision-making factors and the outcome of PPIUD uptake. Additionally, six focus groups were conducted with providers (n=24) and community health workers (n=17) trained to deliver the PPIUD contraceptive counseling intervention to assess their perceptions of the intervention as well as client facilitators and barriers to PPIUD uptake. Focus group discussions were recorded, translated, and analyzed for emergent themes. 

Results: Factors associated (p<0.05) with copper PPIUD uptake included citing its non-hormonal nature, effectiveness, and duration of protection against pregnancy as advantages. Awareness of the 4-6 week postpartum insertion timing option, male partner control over FP decisions, and not considering fertility plans when making FP decisions were associated with non-use. Overall, low knowledge about the PPIUD persisted among clients even after counseling, indicating a need to further refine counseling messages. Provider focus groups highlighted client fears and concerns, inconsistent FP messaging, and male partner involvement as factors that influence non-use. 

Conclusion:Male partner education and involvement in reproductive and FP decisions with their partners is important for increasing PPIUD uptake. PPIUD counseling addressing women’s knowledge, fear, concerns, and misconceptions about the method as well as highlighting its advantages and insertion timing options delivered consistently by trained PPIUD providers and promoters is essential to increase PPIUD use in Rwanda.

Table of Contents

TABLE OF CONTENTS

CHAPTER I: INTRODUCTION 1

Problem Statement 4

Program Description 6

Theoretical Application 7

Purpose Statement 9

Significance of Statement 9

CHAPTER 2: LITERATURE REVIEW 11

2.1 – Commitments to Family Planning 11

2.2 – The Rwandan Context 12

2.3 – Postpartum Copper IUD and its Insertion 14

2.4 – Challenges and Contraindications of IUDs 14

2.5 – Factors Associated with Postpartum IUD Utilization 16

CHAPTER 3: STUDENT CONTRIBUTIONS 20

Data Collection Instruments 20

Ethical Considerations 21

Data Collection 21

Data Analyses 22

CHAPTER 4: JOURNAL ARTICLE 24

INTRODUCTION 25

METHODS 29

Study design 29

Setting and the postpartum counseling intervention 29

Recruitment and inclusion criteria: case-control study 30

Recruitment and inclusion criteria: provider focus groups 30

Data Collection: case-control study 31

Data collection: provider focus groups 32

Data analysis: case-control study 32

Data analysis: provider focus groups 34

Ethical Considerations 34

RESUTLS 34

Case-control study 34

Provider focus groups 39

DISCUSSION 43

Strengths and Limitations 47

Conclusion 47

CHAPTER 5: Public Health Implications 49

Theoretical Interpretations 52

Future Directions 53

REFERENCES 54

FIGURES 70

Figure 1: Flowchart for case-control study Participant Recruitment 70

Figure 2: Most recent (last) contraceptive method used by the women before their last pregnancy 70

TABLES 71

Table 1: Sociodemographic profile of respondents by PPIUD use 71

Table 2: Fertility and Reproductive Characteristics of respondents by PPIUD use 72

Table 3: Current and Future Contraceptive Methods for PPIUD Nonusers 73

Table 4: Knowledge about Family Planning and the PPIUD among respondents by PPIUD use 74

Table 5: Reasons for Acceptance of PPIUD among PPIUD users 75

Table 6: Reasons for Rejection of PPIUD among PPIUD nonusers 75

Table 7: Multivariate analysis of factors associated with PPIUD use 76

APPENDICES 77

Appendix A: PPIUD User Survey 77

Appendix B: PPIUD Nonusers Survey 85

Appendix C: Nurse Focus Group Guide 91

Appendix D: Community Health Workers Focus Group Guide 97

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