A mixed-methods exploratory study of factors that influence postpartum IUD uptake after family planning counseling among women in Kigali, Rwanda 公开
Tounkara, Mariama (Spring 2019)
Published
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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