Post-Partum Family Planning Integration With Maternal Health Services & Its Associated Factors: an Opportunity to Increase Postpartum Modern Contraceptive Use in Eastern Amhara Region, Ethiopia, 2020

Background: Postpartum family planning (PPFP) is the prevention of unintended and closely spaced pregnancies through the rst 12 months following childbirth. Despite evidence of increased FP uptake when FP is integrated with maternal health, newborn health, childhood immunization, and prevention of mother-to-child transmission of HIV services; opportunities for integrated service delivery are often missed. Methods & materials: The study was conducted in four selected hospitals of Amhara region, Ethiopia. Institution based interventional pre/posttest study design was used. A total of 607 study participants (400 from the intervention facilities and 207 of them from the non-intervention facilities) were involved. This study have done in 3 phases. Baseline assessment data was collected from January 15 to February 15/2020. Intervention was done from April to June, 2020 and data collection for post intervention assessment was done from July 1-15, 2020. Data was collected through interviewer administered standardized and pretested questionnaires. The collected data were presented in tables, graph & chart. Association between dependent and independent variables were tested using logistic regression model of SPSS version 20. Variables that had P-value less than 0.25 at bivariate analysis were entered to multivariate analysis model. Finally, those variables which had P-value of less than 0.05 were considered as having statistically signicant association with the dependent variable. The intervention packages were refreshment training for health care provider, discussion with involvement of hospital administrators and coordinators to identify the gap & act accordingly, coaching, mentoring, incorporating post-partum family planning activity in annual health care provider evaluation criteria as well as fullling stock out family planning methods. Result: About 92(23%) of participants got integrated postpartum family planning service among the intervention hospitals during the assessment but after providing intervention the level of postpartum family planning service integration was 116(29%) which is increased by 6%.This increment was signicant with in short period of time and the COVID 19 pandemic situation such change acceptable. The level of post-partum family planning service integration with maternal health services among the non-intervention hospitals similar in both pre & post intervention phases.


Introduction
Postpartum family planning (PPFP) is the provision of family planning for the prevention of unintended and closey spaced pregnancies through the rst 12 months following childbirth (1). Thus, before and after delivery mothers should be counseled and encouraged to decide and initiate modern contraceptive method within the speci ed period.
If a woman had only the number of pregnancies they wanted, at the intervals they wanted, maternal mortality can drop by 30% (2). Family planning (FP) can avert 3.2 million out of 5.6 million under ve deaths and 109,000 out of 155,000 (70%) of maternal deaths. However, a demographic health survey data from 57 different countries showed that, right after delivery (62%), after 6 months of amenorrhea (43%) and at the end of amenorrhea (32%) of women in the rst year after birth have an unmet need for contraception (3).
If a woman is amenorrhic, fully or nearly fully breast feeding and in the rst 6 months of delivery, the risks of getting pregnancy will be reduced by 98%. Therefore, post-partum mothers have a special privilege of using lactational amenorrhea (LAM) as one of the alternatives of family planning methods (1)(2)(3). The six month period however, is a hallmark of shifting from exclusive breastfeeding to complementary feeding (1).
LAM users should shift to other modern contraceptives methods. Pregnancies that occur in the rst year of the delivery are mostly unplanned and risky for the mothers. It can results in adverse birth outcomes for the babies such us, preterm, low birth weight and small for gestational age (2,4). If couples spaced their pregnancies at least 2 years apart from the previous birth, the morbidity and mortality risk both for the mothers and their babies can be reduced. In addition, spacing births allows parents to devote more time to each child in the early years (1) The postpartum period provides a crucial window of opportunity in which to address unmet need for contraceptives for several reasons including the health bene ts of an increased inter-pregnancy interval for mother and child, a high desire to delay or avoid subsequent births, and opportunities for interactions between women and health care provider. Contraceptive use during the postpartum period have many health bene ts. For example, a data showed from 52 countries demonstrated a positive association between increased birth interval, child survival and reduced risk of under nutrition. Another study showed infants conceived 18-23 months after a live birth have a reduced risk of low birth weight and preterm birth as compared with others. Further, postpartum contraceptive use decreases the risk of subsequent maternal morbidity and mortality (5).

Implications of this study
As this study is an original research it have the following implication for different scienti c communities and population at large. Post-partum family planning service integration is poor in Ethiopia and other developing countries. This implies that the post-partum family planning service coverage is low and have high unmet need. This study have also assessed the factors associated with low PPFP integration. One of the factors is being referral hospital. No study showed this associated factors. This nding show that there is low attention of this service in the referral Hospitals as compared with District Hospitals. The other implication of this research is that client centered counseling is vital for the service integration. The other implication of this study is if the post-partum family planning service is integrated with other maternal health services, unwanted pregnancy, closely spaced pregnancy, unsafe abortion and other maternal morbidity will reduced which are the major causes of maternal mortality.

Methods And Material
Study area and period The study was conducted at selected health facilities of east Amhara region. These hospitals were Dessie referral hospital, Debre brehan referral hospital, Woldia General Hospital and Kemissie general hospital.
The rst two hospitals were used as intervention facilty and the other two categorized for nonintervention facility respectively. Dessie referral hospital is one of referral hospital who serves for more than 8 million population of south wollo zone, north wollo zone, some part of north shoa, afar region and Oromia special zone. This hospital give an average of 60 delivery per day. This hospital name changed Dessie comprehensive specialized hospital starting from September, 2020. It provide holistic specialized service. Debrebrehan referral hospital also called Debreberhan comprehensive specialized hospital started from September, 2020. It serves for more than 2 million population. All facilities serve maternal, neonatal and child health service. Kemissie general hospital is found in Amhara region, Oromia special zone. It serves for more than 250,000 population. Family planning service is provided in this hospital. Woldia general hospital is found in north wollo zone, Amhara region. The two General hospitals grow to a rank of referral hospital in September, 2020.
The baseline assessment was conducted from January 15 to Feb. 15/2020, Intervention was done from April to May, 2020 while data collection for post intervention assessment was done from July 1-17, 2020 Study design: An institution based pre-posttest intervention was employed Sample size determination CI-95%, Power 80%, ratio of control to case=2, % control exposed=6%, % case exposed=13%, OR=2.4 taken from study done in Somali region (26) The total sample size=607(400 in intervention hospitals and 207 in non-intervention hospitals) Population Source population All post-partum mothers who were found in east Amhara region Study population Selected postnatal mothers who come for post-partum care services Inclusion and Exclusion criteria Inclusion criteria Clients seeking services at targeted MNCH service like delivery areas (ANC, PMTCT, PNC and immunization) in selected health facilities and women aged 18-49 years who were pregnant or had a child under 1 year of age Exclusion criteria: Those participants who was seriously ill during the interview Sampling procedures A total of 4(four) Hospitals were selected which are found in east Amhara region. The hospitals were selected randomly. It is expected that all hospitals need to provide similar service regarding post-partum family planning service. The sample was taken by proportional allocation to size for each hospital. The study had 3 phases. The rst phase was baseline assessment from all Hospitals. The 2 nd phase would be providing intervention for interventional facilities and the last phase would be assessing the change (follow up) after 3 month of intervention. Modern contraceptive methods were female and male sterilization, IUDs, oral pills, emergency contraceptive pills, injectables, male condom, female condom and spermicide.

Variables
Postpartum contraceptive use will be coded '1' for women who reported using any of the above mentioned methods during the postpartum period; those who reported using a traditional method or who did not use any method will be coded '0'.
Post-partum family planning service integration: those mothers who come for either of the following services like labor/delivery, PNC, EPI, under 5 children examination, PMTCT, ANC and got postpartum family planning.
Counseling on PPFP: 'received information on FP from any health provider during ANC in the third trimester', 'received information on FP from any health provider after reaching the facility or before leaving the facility after delivery' and 'received information on FP from a health provider during the postpartum period'.

Data collection procedures
The research was conducted in selected hospital from January 15 to February 15, 2020 while the post intervention data collection period was from July 1-17, 2020. Structured pre-tested interviewer administered questionnaire were prepared by adapting from different studies considering the local situation of the study area and purpose of the study was employed (8). It was developed in English language to be understood by data collectors. Four (4) supervisors and 16 Bachelor of Science midwives were employed as data collectors and trained for ve days regarding data collection, timely collection and Checking of the collected data from the respondents. These all procedures were done for both baseline and post intervention phase of the study.

Data quality management
To make the data valid and reliable; the structured questionnaire were pre-tested in Borumeda hospital (5% of total sample) which was not involved in this study. In addition ve days training were provided for data collectors. To get informed consent and reliable data clear explanation of the purpose and procedure of the study were given to the study participants. Finally the lled questionnaire were checked to ensure that all the information were properly collected and recorded.
Data processing, analysis and interpretation Data clean up and cross-checking were done before analysis. Data were checked, coded and entered to EPI Info version 3.5.3 then it was exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Both descriptive and analytical statistical procedures were utilized. Descriptive statistics like percentage mean and standard deviation used for the presentation of demographic data and PPFP service integration. Tables and gures were also be used for data presentation.
Multivariate logistic regression models were tted to control the possible effect of confounders and nally the variables which have independent association with PPFP service integration were identi ed on the basis of AOR, with 95%CI and p-value less than 0.05.

Ethical considerations
The data collection were carried out after getting permission from Wollo University. O cial letter of cooperation was submitted to each hospital.
Informed verbal consent were obtained from each participant prior to starting the data collection process. Each participant were informed about the aim of the study and its contribution for further advancement of health services. Participants who were not willing to participate in the study were not forced to be involved in the project and have full right to refuse or withdraw from participation. They were also informed that all data obtained from them would be kept con dential. Recommendation was given for both intervention and non-intervention hospitals to know the gap and act accordingly. Counseling and intervention were given for participants who did not have FP service in both interventional and noninterventional hospital during data collection period. For non-interventional study hospitals based on the recommendation intervention have done accordingly.

Results
Results on the baseline assessment Part I: sociodemographic & reproductive health characteristics of respondents This study was done to assess post-partum family planning integration with maternal health services in eastern Amhara region. In this study a total of 607 post-partum women were involved. From those respondents the intervention group were Dessie referral hospital and Debrebrehan referral hospital with a sample size of 201 and 199 post-partum women were involved respectively while Woldia General Hospital and kemissie General hospital were non interventional hospitals with study participants of 100 and 107 respectively were participated.
In the intervention facilities out of 400 participants; the majority of them were in the age group between 15-30 years old which were 285(71.2%) while the rest were above 31 years old 115(28.8%).
In non-interventional facilities a total of 207 study participants were involved. Most of them 149(72%) were in the age group between 15-30 years old.
Post-partum family planning service utilization with maternal health service About 279(70%) of participant in the intervention hospitals did not used any family planning methods ( g 1) Most of the respondents in the intervention hospitals used injectable 39(9.7%) next to this lactational amenorrhea method accounts the 2 nd most used family planning method as a method of choice ( Table  2).
Out of 242 post-partum family planning (PPFP) users in both intervention and control health facilities; most of the respondents 153(63.2%) used short term family planning methods. From those short term methods; injectable constitute the highest ( g 2). Only 92(23%) of mothers in the intervention area got FP whereas 169(42.3%) of mothers did not have any additional service (table 3).
Over all in the intervention hospitals; only 92(23%) of mothers got PPFP service while the majority of them did not get the service ( g 4) But 152(25%) respondents got PPFP service who comes for different maternal health service in both intervention and control hospital ( g 5).
Regarding discussion with Family planning methods 241(60.3%) mothers did not discuss on PPFP in the intervention health facilities.
The majority of mothers decided to start the family planning methods in the intervention health facilities were implant and injectable (table 4) Factors associated with PPFP integration with maternal health services in the baseline study To identify the factors associated with post-partum family planning service integration different variables were entered and their p-value less than 0.25 at the bivariate analysis were entered to multivariate level analysis (table 6). The following variable were not associated in our baseline study like reason for visit, age, distance, and number of children but the other ve variables were statistically signi cant with the outcome variable. These factors were intervention hospitals(referral hospitals) were less likely to provide integrated PPFP as compared to control arm(general hospitals) with AOR(95% CI) of 0.42(0.2-0.8).
Those participants who were not pregnant get integrated PPFP service as compared to those mothers who were currently pregnant with AOR (95% CI) of 6.8(1.5-29.5).
Those mothers who do not currently use family planning method were less likely to get integrated PPFP service as compared to mothers who currently use PPFP with AOR(95% CI) of 0.4(0.2-0.8) Those Post-partum mothers who decided to seek service with provider suggestion were more likely to get integrated PPFP service as compared to those clients who decide by their own AOR(95% CI) of 3.6(1.8-7).
Those mothers who did not discuss on FP with health care provider were less likely to get integrated PPFP service as compared with mothers who discuss on FP with health care provider AOR(95% CI) of 0.17(0.1-0.3).
Counseled mothers but did not decided to use PPFP were less likely to get integrated maternal health service as compared with those mothers who decided to use PPFP in current counseling AOR(95% CI) of 0.26(0.1-0.5) (table 5).
Even if religion, educational status, distance to reach to health facility were signi cantly associated with PPFP service integration in other studies but it is not signi cantly associated in this study.

Result during the intervention phase
The intervention were given for three months and the outcome was measured after three month of intervention. The follow up have been done regularly by the research team, Hospital administrators and health care providers.
The intervention package were the following. One of the main intervention package were equip health care provider and mother with knowledge and skills regarding PPFP service integration bene ts. For those health care providers who did not get updated training; refreshment training was given, coaching health care provider while they counsel and providing FP procedure were undertaken, baseline research nding dissemination was done during the training and discussion with the top managers and health care providers, ful lling stock out FP supply were done during the intervention phase, discussion were undertaken on their major bottleneck regarding PPFP service integration and mutual understanding were got, and onsite monitoring by the principal investigators were done during the intervention phase. These intervention were done with collaboration of midwife, medical director, hospital CEO, gynecologist/obstetrics and nurses who were working in MNCH ward.
During data collection period therapeutic counseling were given for all study participant and their partner on the bene t of utilizing PPFP. This intervention were different from other routine activities due to frequent monitoring with the service provider, gave opportunity to identify their challenge, participating their manager in follow up and incorporate it in their annual performance and evaluation criteria.
Discussion were undertaken to counsel those ANC mothers to utilize PPFP after birth. So intervention were given during ANC visit.

Results during the Post intervention
Post-partum family planning service integration during post intervention A total of 607 study participant were involved in the post intervention study. About 400 participant were taken from intervention facility and 207 participants were taken from non-intervention facility which was similar with the baseline study. Post intervention were done after 3 month of intervention period.

Sociodemographic data during the post intervention
Out of 607 study participants 431(71.5%) of them were in the age group between 15-30 years old which was similar from the baseline nding. About 51.1% of them were Christian while the rest were Muslim and most of them living with their sexual partner(married) accounts 554(91.3%) while the rest did not living with their sexual partner. Regarding their level of education 251(41.1%) of them attended grade 1 to 8 while few of them attended college and above which was 93(15.3%).
Out of 400 participant from intervention facility; 116(29%) of mothers got integrated post-partum family planning service whereas during the baseline assessment only 92(23%). It was increased by 6% from the baseline result. While in the non-intervention facility the post-partum family planning service integration was 48(23.2%) which was similar with the baseline ndings ( g 6).
Factors associated with PPFP service integration during post intervention period Ten variables were entered to multivariate logistic regression analysis. These were educational status of the mother, marital status, distance to hospital, age, currently using a family planning, type of health facility, discussion with health care provider on post-partum family planning, decision to seek PPFP service, current pregnant, and currently using FP by todays counseling. From those variable only 4 of them were statistically signi cantly associated. These were type of health facility, decision making of the mother to seek PPFP service, counseling on post-partum family planning and currently using post-partum family planning.
The primary reason for their visit to the hospital in the intervention hospitals were most of them 358(89.5%) come for utilizing other post-partum maternal health service and the rest come for taking PPFP. In the non-intervention hospitals 136(65.7%) of them come for taking other maternal health service other than PPFP and 71(34.3%) of them come for the purpose of PPFP service.
Most of the nding regarding to factors associated with post-partum family planning service integration with maternal health services were similar with the baseline study nding except some difference. These are the following Mothers who previously used postpartum family planning service got integrated maternal newborn and child health service as compared with mothers who were not currently using postpartum family planning service.
Those mothers who did not get counseling on PPFP service were less likely to get integrated PPFP service as compared with their counterpart.
Mothers who did not decided to use PPFP service during counseling were less likely to get integrated PPFP service than those who decided by themselves (table 6).

Discussion
In this study the level of post-partum family planning service integration with maternal health service like EPI, PNC, PMTCT, ANC, labor and delivery was 23% during the baseline assessment while 29 % after providing intervention(post intervention phase).
This level of PPFP service integration was very low as compared with study done in Addis Ababa, Ethiopia 80.3% (18), at Debre Tabor town which was 63% (1) and a study conducted at Malawi which was 74.6 % (15). In Jharkhand, 71.1%-73.2% of clients accessing ANC also receiving FP, but PNC-FP integration was also high at 60% (10).
This discrepancy might be due to the difference in the socio-demographic characteristics of the respondents, the time gap of the studies. It could also be due to the difference in study design as well as our study is on PPFP service integration but others study were on utilization of PPFP.
Our nding is similar with study done in Bihar 28.1% -35.2% of clients receiving ANC services also received FP services. By contrast, only 0 -10.9% of clients receiving PNC and 2.2%-4.1% of clients receiving child health services also received FP services (5).
In our study the level of post-partum family planning integration with maternal health service was higher than studies that were done in Burundi 20% (16) ,kenya(5.5%) (10), India (16.3%) (11) and at Kebridehar Town, somali region, Ethiopia 12.3% (17).This may be due to study design.
A study done at Bondo Hospital only 1.8% of clients accessing ANC, about one-third (34.5%) of clients accessing PNC and one-fth (20.2%) of clients accessing child health also received FP services. Embu sites showed FP integration with ANC was 14.3%-28.6% (19). This nding is similar with our nding low PPFP service integration with ANC, PNC, labor and delivery, under 5 years child clinic, EPI and PMTCT (18)(19)(20)(21) This differences might be due to health care provider negligence, high case load, poor monitoring and evaluation by their respective manager, poor internal facility communication. On the other hand the sociodemographic characteristics of respondents, study design and types of data used (used secondary data in other study) can be the possible reasons.
A study done on integration of family planning with maternal health services in urban Uttar Pradesh, India found that FP information provision as part of antenatal care in the third trimester, delivery and the postpartum period have a positive association with postpartum modern contraceptive use in urban Uttar Pradesh. However, health providers often miss these opportunities. Even if a high proportion of women coming into contact with health providers when up taking maternal health services, only a small proportion of them received FP information during these visit (5). This nding is in line with our study in which many mother come for delivery, PNC, EPI, Under 5 children OPD, PMTCT, ANC services but majority of them did not got PPFP service. So we have great chance to provide counseling on PPFP service in order to prevent unwanted pregnancy and to reduce unmet need in PPFP in Ethiopia which constitute 78%.
Regarding factors associated with post-partum family planning service integration. In our study the following factors are associated with PPFP service integration with maternal health service. These are being referral hospitals, currently using FP, got counseling on PPFP, decision of mother to use FP by the same day of facility visit. Being referral hospital is one of the factors which is associated with postpartum family planning integration. This result is new and not in line with other study as well as it is acceptable nding in our setup because most referral hospitals have high case load, most of them have not adequate space for providing counseling, and most referral hospitals provide service for referral complicated cases. Due to these reason referral hospital provide PPFP service less than expected as compared to other district hospitals. The other possible reasons may be lack of staff commitment, more complicated cases in the referral hospitals may make less attention for routine FP service, poor monitoring and supervision can constitute in our study The other associated factors are decisions making of the mother to seek the PPFP service and client centered PPFP counseling ndings were in line with study done in Tanzania (11).
Clients had greater odds of receiving a modern method when they received information on two or more versus fewer methods, had a FP discussion with their partner versus no discussion, made their own FP decisions versus not made own FP decisions, received FP information from two or more versus fewer sources (11) In other studies the following factors were associated with postpartum family planning service integration like Age, income, number of live birth, marital status but in our study these factors are not signi cantly associated with the dependent variable. T reason may be study design, socioeconomic difference, sample size and time of the study done before 5 years ago.
This study have the following implications for health care provider, administrator and NGOs.
Firstly the result showed that post-partum family planning service was not adequately integrated with other maternal newborn and child health services. Even if short term interventions were given, the service integration was not satisfactory. This nding may show everyone who directly or indirectly involved in the maternal, newborn and child health service should be committed to save the life of mother, newborn and children by avoiding unwanted pregnancy during the postnatal period. The post-partum family planning service is not only the responsibility of health care worker who is assigned in family planning clinic. Every service delivery units like ANC, EPI, under ve children clinic, PMTCT, ART should collaborate to reduce the unmet need for PPFP service.
Regarding the factors associated with post-partum family planning service integration. Most of the factors are avoidable. It can be managed with less intensive resource. Comprehensive specialized/referral hospitals should give emphasis for family planning service especially in post-partum family planning because in our country Ethiopia the highest unmet need for family planning service was during the postpartum period according to EDHS 2016 and mini DHS 2019 data.
The other implication of this study was client centered counseling should be given for all mothers who want to take family planning service. This counseling should be given during ANC, labor and delivery, EPI and under 5 children clinic, ART and so on. So every health care provider should not forget to provide information and counseling about the importance of family planning.
On the other hand internal and external mentoring and supportive supervision should be done in all health institution hierarchal from referral hospitals up to health center in order to assess the gap and intervene accordingly. So every health facility managers should provide special attention on this service area.
Strength & limitation of the study Strength of the study Using large sample size. The study design (interventional) make the study to identify the gap and provided intervention accordingly. Ongoing monitoring during and after the intervention as well as involvement of senior hospital manager made to get great emphasis on the issue.

Limitation of the study
Time shortage for intervention phase. COVID 19 affect our study during intervention and post intervention period including monitoring the progress of their intervention.

Conclusion
In this study the level of post-partum family planning service integration was 23% during baseline assessment but after providing intervention the level of post-partum family planning service integration was 29% which was 6% higher than the baseline result. This nding was very low as compared with other studies.
The factors associated with PPFP service integration with maternal health service were Referral hospitals, current using FP, counseling on FP, decision making ability of mother to use FP. These factors are similar in both the baseline and post intervention assessment result except some difference. The authors have no con icts of interest to declare for this study.

Recommendation
Funding: This study was nancially sponsored by UKAID, Engender health and Mariestopes Ethiopia.
Technically Addis Ababa University assisted this study by assigning advisor Ethics approval & consent to participate: Ethical approval were gained from Wollo University College of medicine & health science. And also verbal consent were taken from all study participant before gathering the data. The reason for taking verbal consent was it is not experimental study as well as it does not harm any study participants.

Authors' Contribution
DT, MT, SY & AB Participated in all phase of the study process including developing & editing the manuscript. All authors approve the nal manuscript for publication.

Consent for publication: not applicable
Availability of data and material: All data is available for anyone who needs it and want to utilize at any time.