Long Acting Reversible Contraception use among postpartum women in Hossana Town, Southern Ethiopia: cross sectional study

doi:10.21203/rs.2.19848/v1

Download PDF

Research

Long Acting Reversible Contraception use among postpartum women in Hossana Town, Southern Ethiopia: cross sectional study

https://doi.org/10.21203/rs.2.19848/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 05 Aug, 2020

Read the published version in Contraception and Reproductive Medicine →

You are reading this older preprint version

Read the latest preprint version →

Background: In low and middle-income countries, 95% of postpartum women want to avoid a pregnancy for 2 years, but 70% are not using contraception. Delay in use of contraception by couples during postpartum period can result in many unwanted pregnancies. Long-acting reversible contraception (LARC) is ideal for postpartum women. Therefore this study aimed at assessing the prevalence and factors associated with LARC use among postpartum women.

Methods: Facility based cross sectional study was conducted among 381 women in extended postpartum period visiting Child Immunization service in hosanna health institutions. Pretested structured questionnaire was used for data collection. Data was analyzed by SPSS version 20. Binary and multivariate logistic regression analysis was done. The presence and strength of association was determined using AOR with its 95% CI. Variables with P value less than 0.05 were considered as statistical significant.

Results: Less than one fifth (18.1%) of participants intend to give birth within 2 years. The prevalence of LARC use was 36.5% (95%CI (33.05-39.95)). The main reason for not using was fear of side effect and false information. Previous use of LARC n (AOR=3.3, 95%CI (1.7-6.5)) and have ever discussed with health providers on LARC (AOR=2.5, 95%CI (1.1-5.74)) were found to be significantly associated with LARC use.

Conclusions: Despite their lesser intention to give birth within 2 years, the utilization of LARC among postpartum women was found to be low in this study. Provision of health education and expanding access should be emphasized to enhance its utilization.

Sexual & Reproductive Medicine

Long acting

contraception

Postpartum

Prevalence

Factors

Hossana

After one-time placement of a device, Long-acting reversible contraception (LARC) methods provide reliable long-term highly effective prevention of pregnancy. LARC methods include subdermal hormonal implant and Intra-Uterine Devices (hormonal IUDs and non-hormonal copper-containing IUDs) [1]. Regardless of considerable advances in contraceptive technologies, unintended pregnancies remain a significant global public health issue. In developing countries 214 million reproductive age women who desire to avoid pregnancy are not using a modern contraceptive method [2–3]. Modern contraceptive use has increased around the world. However, less than 15 percent of married women of reproductive age use a modern method in many of the poorest countries. The use of LARC among modern contraception users is still low [4]. In Ethiopia, among 35% of currently married women using a modern family planning only 10% use LARC (8%- Implants & 2%-IUD) [5]. Different studies conducted in Ethiopia also indicated lower prevalence of LARC use [6–13]. Utilization of LARC was found to have significant association with women's socio-demographic and reproductive characteristics. Knowledge, attitude and previous LARCs use was also found to have significant association with its use [13–18].

In the first year after childbirth, 95% of women in low and middle-income countries want to avoid pregnancy within the next 2 years; however 70% are not using contraception. Delay in practice of contraception by couples during postpartum period can result in many unwanted or mistimed pregnancies. A woman conceives within/less than 24 months of delivery has higher chances of complications like abortions, pre-term labor, low birth weight babies, postpartum hemorrhage, neonatal morbidity and mortality[19]. LARC methods are safe for almost all women, including those in a postpartum period. As they do not contain estrogen and have few contraindications, they are ideal for use in postpartum women [20]. Postpartum period is one of the important and crucial times when women and couples are highly motivated and receptive to family planning methods. The intention to use contraceptive during postpartum period is significantly higher especially after 45 days of delivery. However their intention towards LARC is very low. Study on LARC use among postnatal women is lacking in the study area. Therefore the aim of this study was to assess the prevalence and factors associated with LARC use among postpartum women which has paramount important to design and implement appropriate and feasible programs.

Study setting and population

Facility based cross sectional study was conducted from July 23-Aug 25, 2018 in hosanna health institutions, Hadiya zone Southern Ethiopia. Hossana town comprises of three KifleKetema and eight sub kebeles. According to CSA population count of May 2007, the total number of Hossana town population was 69,959 for the year 2007/8. Among these 34454 (49.25%) were females. There is 1 teaching referral hospital and 3 health centers in the town which provide family planning service including LARC. Women in extended postpartum period visiting child immunization service in the four health institutions during the study period were eligible for enrollment. Those women who are unable to speak or hear were excluded from the study. Sample size was calculated using single population proportion formula by taking account of Proportion of LARC use 36.7%[7], CI = 95% Margin of error = 5% and 10% non-response rate. A total of 392 postpartum women were invited to participate.

Sampling technique

Systematic random sampling technique was employed to select participants. The total number of women who visit child Immunization (N) was estimated by considering the immediate previous 1 month record of EPI chart. Then number of sampling intervals (k) was determined by dividing N by sample size (n = 392). Then lottery method was used to select the first participant. Then after every 3rd unit was included until the required sample reached. In case of refusal or not meeting inclusion criteria, the next person was selected. The sample size for each institution was distributed proportionally.

Data collection

Data were collected using pretested, interviewer administered structured questionnaire. The data collection tool prepared in English was translated in to Amharic and then returned back to English to ensure accuracy. Before the actual data collection, Pre-test was done on 5% women in a health center located outside the town and necessary corrections made accordingly. Four trained diploma midwives collected the data supervised by one BSc midwife. Completeness of the questionnaires was checked on the spot by supervisors.

Measurement

LARC use

was defined as utilization of any of LARCs (IUD or subdermal hormonal implant) at any times between delivery and data collection.

The mean score was used to categorize women’s knowledge towards LARC; women who scored above mean score were considered to have good knowledge and women who scored below the mean were considered to have poor knowledge. Women’s attitude towards LARC was categorized in the same approach. Those women who scored above the mean were considered to have positive attitude and scored below the mean considered to have negative attitude towards LARC.

Data analysis

Data was analyzed by using SPSS version 20. Descriptive statistics were computed. Binary logistic regression analysis was done and all explanatory variables with p value less than 0.2 were entered to Multivariate logistic regression model. The second analytical step used a stepwise backward model. Then association was assessed using AOR and its 95%CI. And p value of < 0.05 was considered as statistically significant. Goodness of model fitness was tested by using Hosmer and Lemeshow test.

Data were analyzed from 381 women, making response rate of 97.1%. Mean age of participants were 27(SD ± 4.6). Majority of participants were urban resident (89%). Less than one fifth of respondents attend diploma and above (17.1%). Half of the women were housewife (50.4%) (Table 1).

Table 1

Sociodemographic characteristics of postpartum women in Hossana health institutions, 2018(n = 381)
Variable		Frequency	Percentage
Age (years)	16–20	31	8.1
	21–25	124	32.5
	26–30	154	40.4
	31–35	50	13.1
	36–40	22	5.8
Residence	Urban	339	89.0
Residence	Rural	42	11.0
Marital status	Married	369	96.9
Marital status	Unmarried	12	3.1
Educational status	Can’t read and write	15	3.9
	Can Read & Write	19	5.0
	Primary	141	37.0
	Secondary	141	37.0
	Diploma & Above	65	17.1
Working status	Housewife	192	50.4
	Merchant	51	13.4
	Government Employee	67	17.6
	Private Employee	58	15.2
	Other	13	3.4
Reproductive characteristics of respondents
More than two-third (71%) of participants had two or more births. Median number of alive children per women and birth interval were 2 IQR[1, 4] and 36 months IQR [24, 48] respective.
ly. Around one-third (28.3%) participants do not want any more children for the future.
Less than one fifth (18.1%) intended to give birth within 2 years. More than one-forth (28.6%) had never discussed with health professionals and 52.4% were advised on LARC during the immediate postpartum period (Table 2).

Table 2

Reproductive characteristics of postpartum women in Hossana health institutions, 2018(n = 381)
Variable		LARC use
Variable		Yes n(%)	No n(%)
Parity	1	72(65.5)	38(34.5)
	2–4	137(61.7)	85(38.3)
	≥ 5	33(67.3)	16(32.7)
Number of alive children	1	75(65.8)	39(34.2)
	2–4	135(60.8)	87(39.2)
	≥ 5	32(71.1)	13(28.9)
Place of last birth	Home	15(71.4)	6(28.6)
Place of last birth	Health institution	227(63.1)	133(36.9)
Birth interval(in month) (n = 272)	0–23	28(73.7)	10(26.3)
	24–35	56(64.4)	31(35.6)
	36 & above	87(59.2)	60(40.8)
Number of children want for the future	0	74(68.5)	34(31.5)
	1–3	131(59.8)	88(40.2)
	4–6	37(68.5)	17(31.5)
Intended to give birth within 2 years (n = 273)	Yes	49(71.0)	20(29.0)
Intended to give birth within 2 years (n = 273)	No	119(58.3)	85(41.7)
Ever discussed with health professionals	Yes	123(45.2)	149(54.8)
Ever discussed with health professionals	No	16(14.7)	93(85.3)
Advised during immediate postpartum	Yes	95(47.5)	105(52.5)
Advised during immediate postpartum	No	44(24.3)	137(75.7)
Knowledge, Attitude and previous LARC use
More than two-third (71.4%) of the women had high level of knowledge towards LARC. Around half of them (53.2%) had positive attitude towards LARC. Two-third (68.5%) of participant’s partner had supportive attitude towards LARC. Two-third (66.4%) of the respondents had ever used at least one type of modern contraception and one-fourth (26%) had ever used LARC before delivery of last child (Table 3).

Table 3

Knowledge, attitude and previous LARC use among postpartum women in Hossana health institutions, 2018(n = 381)
Variable		LARC use
		Yes	No
Knowledge towards LARC	High level of knowledge	121(44.5%)		151(55.5%)
	Low level of Knowledge	18(16.5%)		91(83.5%)
Attitude towards LARC	Positve	77(41.8%)		107(58.2%)
	Negative	61(38.4%)		98(61.6%)
Previous LARC use	Used before	58(59.2%)		40(40.8%)
	Never used	81(28.6%)		202(71.4%)
Prevalence of postpartum LARC use
Two-third (66.6%) of postpartum women had started to use modern family planning method. LARC method use among participants was 36.5% (implant 32.1%, IUCD-2.4%). The main reason for not using LARC was fear of side effect (39.3%) followed by false information towards LARC (21.9%).
Factors associated with LARC use
Previous LARC use and ever discussed with Health Professionals on LARC were found to be significantly associated with LARC use. Those women who have ever used LARC before were 3.3 times more likely to use LARC on postpartum period (AOR = 3.3, 95%CI(1.7–6.5). Postpartum women who have ever discussed with health professionals on LARC were 2.5 times more likely to use LARC (AOR = 2.5, 95% CI (1.1–5.7)) (Table 4).

Table 4

Bivariate and Multivariate analysis of factors associated with LARC use among postpartum women in hossana health institutions, 2018 (n = 381)
Variable		LARC use		COR (95%CI)	AOR (95%CI)
Variable		Yes (n%)	No (n%)	COR (95%CI)	AOR (95%CI)
Residence	Urban	130(38.3)	209(61.7)	1
Residence	Rural	9(21.4)	33(78.6)	0.43 (.20-.94)	0.53 (0.19–1.42)
working status	Working	75(39.7)	114(60.3)	1.31 (.86-1.99)
working status	Not working	64(33.3)	128(66.7)	1
Intention to give birth within 2 years	Yes	20(29.0)	49(71.0)	1
Intention to give birth within 2 years	No	85(41.7)	119(58.3)	1.75(.97-3.15)	1.82 (0.94–3.54)
Knowledge towards LARC	Good	121(44.5)	151(55.5)	4.01(2.31–7.08)	0.95 (0.43–2.10)
Knowledge towards LARC	Poor	18(16.5)	91(83.5)	1
Partner attitude	Supportive	118(45.2)	143(54.8)	2.59 (1.48–4.54)	0.50 (0.24–1.03)
Partner attitude	Not supportive	20(24.1)	63(75.9)	1
Previous LARC use	Yes	58(59.2)	40(40.8)	3.61 (2.24–5.83)	3.34(1.70–6.55)*
Previous LARC use	No	81(28.6)	202(71.4)	1
Adviced during immediate postpartum	Yes	95(47.5)	105(52.5)	2.81 (1.81–4.36)	1.26 (0.66–2.42)
Adviced during immediate postpartum	No	44(24.3)	137(75.7)	1
Ever discussed on LARC with professionals	Yes	123(45.2)	149(54.8)	4.79 (2.68–8.58)	2.56 (1.14–5.74)**
Ever discussed on LARC with professionals	No	16(14.7)	93(85.3)	1
^{Significant at <0.05 * significant at <0.001}

In this study the prevalence of LARC use among postpartum women was found to be 36.5% (95%CI (33.05–39.95)), which is similar with a study done in Durame [13]. However it is higher than a study in Areka[9]. The difference can be due to variation in participants’ characteristics and future fertility intention which is higher in Areka[9] that might necessitate preference of short acting contraception. It is also higher than a study in Arba Minch. That might be due to difference on participants’ attitude towards LARC which can contribute to low utilization of LARC [7].

Majority of LARC users opted for Implant(93.5%) and very few used IUCD(6.5%). Which is consistent with different studies [6, 14] where strong preference for implants over IUD were observed. These can be due to prevailing misinformation towards IUCD.

The main reason for not using LARC was fear of side effect (39.3%) followed by false information towards LARC (it cause harm to uterus and infertility, interfere work, fly/lost in the body)(21.9%) which is consistent with other study[8]. This indicates the need of community health education and awareness creation programs.

In this study previous LARC use was found to be significantly associated with postpartum LARC use (AOR = 3.34 (1.70–6.55)). Similar finding were indicated by other studies [11, 13]. The possible explanation can be women possibly will have adequate information on the contraception method they used before, which can motivate them to use the same method repetitively.

Those women who ever discussed with health professionals on LARC were found to be more likely to use LARC (AOR = 2.569(1.148–5.7470)). It is in line with another study [6]. This can possibly explained by the fact that access to clear factual information on the benefits and limitations of contraceptive methods is imperative to promote informed choice and to overcome misperceptions and myths more broadly perpetuated in the community.

Limitation

Quantitative nature of the study hinders indepth exploration of women’s perception and barrieres for LARC use.

Despite their lesser intention to give birth within 2 years, the utilization of LARC among postpartum women was found to be low in this study. The main reason for not using LARC was fear of side effect and false information. Further qualitative studies need to be conducted to identify barrier for LARC use, mainly IUCD.

Ethics approval and consent to participate

Ethical approval was obtained from wachemo university ethical review committee. Cooperation letter submitted to health institutions. The objective, benefit and risks of the study were explained and informed written consent obtained from all respondents. The attainment of confidentiality was assured for participants.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors proclaim that they have no competing interests.

Funding

This study was conducted by the fund obtained from Wachemo University.

Authors' contributions

BFW, TLE, and LGL contributed to the initiation of the study, design, participating in organizing the data collection process and analysis of the result. BFW, TLE, LGL and NGG involved in writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We are indebted to data collectors and all women who agreed to participate in this study. We want to thank health institution administrators for their great collaboration.

Consent for publication

Not applicable

Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth J, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012 (366):1998–2007.

WHO. Family planning/Contraception Fact sheet. In: WHO, editor. 2017.

Curtis KM, Peipert JF. Long-Acting Reversible Contraception. N Engl J Med. 2017 (376):461–8. DOI:10.1056/NEJMcp1608736.

Family Planning Worldwide

2019

2019 Data Sheet www.prb.org/

Family Planning Worldwide 2019 Data Sheet www.prb.org/pdf19/familyplanning-2019-datasheet_eng.pdf Accessed December 11, 2019.

Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia Demographic and Health Survey 2016: Key Indicators Report. Maryland: Addis Ababa, Ethiopia, and Rockville; 2016.

Taye A, Woldie M, Sinaga M. Predictors of Long Acting Reversible Contraceptive use among Married Women Visiting Health Facilities in Jimma Town. J Women’s Health Care. 2014;4:217. doi:10.4172/2167-0420.1000217.

Shegaw G, Mohammed AA, Nadew K, Tamrat K, Zeru G, Desta H, Yinager W. Long Acting Contraceptive Method Utilization and Associated Factors among Reproductive Age Women in Arba Minch Town, Ethiopia. Greener Journal of Epidemiology Public Health. 2014;2(1):023–31.

Gebremichael H, Haile F, Dessie A, Birhane A, Alemayehu M, Yebyo H. Acceptance of Long ActingContraceptive Methods and Associated Factors among Women in Mekelle City, Northern Ethiopia. Science Journal of Public Health. 2014;2(4):239–45.

Kabalo MY. Utilization of reversible long acting family planning methods among married 15–49 years women in Areka town, Southern Ethiopia. International Journal of Scientific Reports. 2016;2(1):1–6. http://www.sci-rep.com.

10.

Fekadu H, Kumera A, Yesuf EA, Hussien G, Tafa M. Prevalence and Determinant Factors of Long Acting Contraceptive Utilization among Married Women of Reproductive Age in Adama Town, West Arsi Zone, Oromia, Ethiopia. J Women's Health Care. 2017;6(1):360. doi:10.4172/2167-0420.1000360.

11.

MelkaAS, Tekelab T, Wirtu D. Determinants of long acting and permanent contraceptive methods utilization among married women of reproductive age groups in western Ethiopia: a cross-sectional study. Pan African Medical. 2015;21 10.11604(246).

12.

Gebremariam A, Addissie A. Intention to use long acting and permanent contraceptive methods and factors affecting it among married women in Adigrat town, Tigray, Northern Ethiopia. Reproductive Health. 2014;11(24).

13.

Tamrie YE, Hanna EG, Argaw MD. Determinants of Long Acting Reversible Contraception Method Use among Mothers in Extended Postpartum Period, Durame Town, Southern Ethiopia: A Cross Sectional Community Based Survey. Health. 2015;7:1315–26. http://dx.doi.org/10.4236/health.2015.710146.

14.

Austad K, Shah P, Rohloff P. Correlates of long-acting reversible contraception uptake among rural women in Guatemala. PLoSONE. 2018;13(6):e0199536. https://doi.org/10.1371/journal.pone.0199536.

15.

Mekonnen G, Enquselassie F, Tesfaye G, Semahegn A. Prevalence and factors affecting use of long acting and permanent contraceptive methods in Jinka town, Southern Ethiopia: a cross sectional study. Pan African Medical Journal. 2014;18:98. doi:10.11604/pamj.2014.18.98.3421.

16.

Teferra AS, Wondifraw AA. Determinants of Long Acting Contraceptive Use among Reproductive Age Women in Ethiopia: Evidence from EDHS 2011. Science Journal of Public Health. 2014;3(1):143–9. doi:10.11648/j.sjph.20150301.33.

17.

Gudaynhe SW, Zegeye DT, Tarekegn A, Kibret GD. Factors Affecting the use of Long-Acting Reversible Contraceptive Methods among Married Women in DebreMarkos Town, Northwest Ethiopia. Global Journal of Medical Research. 2014;14(5):13–4.

18.

Gebre-Egziabher, et al. Prevalence and predictors of implanon utilization among women of reproductive age group in Tigray Region, Northern Ethiopia. Reproductive Health. 2017; 14(62). DOI 10.1186/s12978-017-0320-7.

19.

Shoupe D. LARC methods: entering a new age of contraception and reproductive health Contraception and Reproductive Medicine. 2016;1(4). DOI 10.1186/s40834-016-0011-8(http://creativecommons.org/publicdomain/zero/1.0/).

20.

Parks C, Peipert F. Eliminating Health Disparities in Unintended Pregnancy with Long-Acting Reversible Contraception (LARC). Am J Obstet Gynecol. 2016;214(6):681–8. doi:10.1016/j.ajog.2016.02.017.

Download PDF

Journal Publication

published 05 Aug, 2020

Read the published version in Contraception and Reproductive Medicine →

Review #2 received at journal
17 Jan, 2020
Editorial decision: Major Revision
17 Jan, 2020
Review #1 received at journal
15 Jan, 2020
Reviewer #2 agreed at journal
03 Jan, 2020
Reviewer #1 agreed at journal
01 Jan, 2020
Reviewers invited by journal
30 Dec, 2019
Editor assigned by journal
27 Dec, 2019
Submission checks completed at journal
26 Dec, 2019
Editor invited by journal
26 Dec, 2019
First submitted to journal
25 Dec, 2019

You are reading this older preprint version

Read the latest preprint version →

Long Acting Reversible Contraception use among postpartum women in Hossana Town, Southern Ethiopia: cross sectional study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Data analysis

Results

Discussion

Conclusion

Declarations

References

Status:

Journal Publication

Version 1