We assessed the prevalence, pattern, reported reasons for refusal and associated factors for utilization of LARC methods among immediate postpartum mothers at JUMC, Southwest Ethiopia. The prevalence of current immediate postpartum LARC methods use was 53.2%. Over three-fourths (78%) used implanon followed by Jadelle/Sino Implant (11.5%) and IUD (10.5%). The commonest reported reason for not using LARC methods was preference of other methods. Being counseled at ANC, monthly income greater than 1000 ETB, family size more than four, completed family size, having plan to delay next pregnancy beyond two years and prior use of LARC methods have increased chance of current immediate postpartum use of LARC methods.
The prevalence estimated in our study was much higher than national estimates where only 10% of women used LARC methods as reported in EDHS 2016(12). This could be because of the fact that national estimate was for all reproductive age group women whether married or unmarried. But, our study was limited to specific group of women (immediate postpartum women) who are more likely to accept LARC methods. The proportion of women who used IUD in our study was much lower than 21.9% prevalence of immediate postpartum IUD use reported by facility based cross-sectional study conducted in Southern Ethiopia(28). Though there was similar proportion of ANC use (89.6% vs 84.2%), there was significantly lower proportion of counseling for LARC methods at ANC (27% vs 72.3%) and all were counseled at postpartum in our study. Hence, the lower percentage of IUD use could be because of the combination of lower proportion of counseling at ANC and availability of alternative LARC methods options in our study but, only IUD in the case of study conducted in Southern Ethiopia(28). However, it was similar to 12.4% prevalence of immediate IUD use reported by facility based cross-sectional study conducted in Bale zone, Southeast Ethiopia which reported similar proportion (87.6%) of ANC use(29).
Our finding was also higher than 36.7%(27) prevalence of LARC methods use in the extended postpartum period (42 days to 1 year) reported by community based cross-sectional study conducted in Southern Ethiopia. But the proportion of women counseled for LARC methods was significantly lower in our study (27% versus 51.5%). This indicates that LARC methods acceptance is better at immediate postpartum and mothers may change their mind and reject LARC methods offer at extended postpartum even if they were willing to use it at immediate postpartum.
Our finding was also higher than 22.9%(30) and 16%(31) prevalence of LARC methods use among family planning attendees of public health facilities in Jimma town, Southern Ethiopia. It was also higher than 38%(32), 29.1%(33), 37.7%(34), 25.2%(35), 28.3%(36), 30.3%(37) and 23.8%(38) prevalence of LARC methods use among family planning clients reported by community based studies conducted in different parts of Ethiopia. It was also higher than 33.7%(39), 16.4%(40), 33.7%(41), 16.3%(42), 28%(43), 17.6%(44) and 9.24%(45) prevalence of LARC methods use among family planning clients reported by facility based cross-sectional studies conducted in different parts of Ethiopia. The finding was also higher than 37.4%(46) prevalence of LARC methods use among HIV positive family planning attendees of public health facilities in Bahir Dar town, Northern Ethiopia. We also calculated 23.84% pooled prevalence from eighteen facility or community based cross-sectional studies conducted in different corners of Ethiopia(27,30–46) and found that our finding was higher than pooled prevalence.
Regarding pattern of LARC methods use, birth control Implant was the method used by almost 9 out of ten mothers. This finding was in line with findings of most previous studies conducted in different parts of Ethiopia where Implant was used by at least three-fourths of mothers(27,30–36,38,40,42,43,45–47) and higher than findings of some studies(37,39,41). This could be because of convenience and privacy as implants are inserted under the skin into the upper arm area whereas IUDs are inserted into the uterus. Thus, women may think that it’s painful while inserting IUDs into uterus especially during immediate postpartum and/or during sexual intercourse and/or while walking. They may also think that it can cause damage to the uterus. In facility based cross-sectional study conducted in Bale zone, Ethiopia, one-third of study participants agreed and only one-fifth disagreed that insertion and removal of IUD is highly painful. In the same study, more than one-third (37.6%) agreed that insertion of IUD causes loss of privacy and 41.6% agreed that IUDs may impair future fertility(29). In another community based study cross-sectional study, nearly one-third (31%) of study participants disagreed with the statement “insertion of intrauterine contraceptive devices does not lead to loss of privacy”. Similarly, nearly half (46%) disagreed with the statement “using intrauterine contraceptive devices does not restrict normal activities”(38).
In this study, counseling at ANC was significantly associated with immediate postpartum LARC methods utilization. Studies conducted in different corners of Ethiopia reported that women counseled at ANC and/or during delivery and/or postpartum and/or received postnatal care were more likely to use LARC methods(27,36,48). This could because women who received postnatal care were likely to be counseled for LARC methods and counseling increases women’s knowledge of LARC methods including its advantage and disadvantage and clears misconceptions increasing chance of LARC methods use. Previous studies have reported that women who heard(48), had awareness(42), had information(35) about LARC methods, had moderate or high knowledge of LARC methods(33,39,41,47) or previously used it(27,30,43) were more likely to utilize it now. Prior use of LARC methods was also positively associated with current use of LARC methods in our study which was in line with literature. Studies have also reported that women with misconception(33,38) and who heard myths(46) were less likely to use LARC methods. On the other hand, positive/supportive attitude towards LARC methods(33,40), not hearing myths(31), health professionals being source of information(47) and discussion of LARC methods with providers(31) were positively associated LARC methods use. Similarly, maternal literacy was also positively associated with LARC methods use(27,29,30,32–34,36,39,41,42,44) because education is likely to enhance women’s autonomy and confidence to make decision regarding their own health and demand higher quality of life. The association between prior use of LARC methods and current acceptance is an indication of knowledge influence.
In general, counseling builds knowledge of LARC methods, clears misconception and myths about LARC methods, develops positive/supportive attitude and finally leads to increased use of LARC methods. However, although counseling for postpartum family planning is also acceptable during early labor and immediately postpartum, it should optimally begin during ANC according to WHO recommendations(49) and it is the ideal time to counsel women. In this study, however, only 27% of participants were counseled at ANC follow up though all were counseled at immediate postpartum. This finding indicates the importance of integrating counseling for post-partum family planning into ANC and/or early labor and/or the immediate postpartum period to increase postpartum LARC methods utilization.
Limitations of study
This study was institution based and the respondents were immediate postpartum mothers (48 hours before hospital discharge) who were counseled for LARC methods. Therefore, the study findings may be not be generalized to all reproductive age women in the community. Counseling for contraception options was done after delivery but is better addressed before delivery especially for IUD to be inserted just post-placental delivery in either vaginal or cesarean delivery. Another limitation of this study was some mothers might have been discharged from the hospital before counseled and interviewed though we were actively looking for all postpartum mothers.