The findings of the study showed that the uptake of PPIUCD was associated with normal birth, PPIUCD counselling, spousal approval, parity, birth interval, level of education. Health education of mothers and partners on PPIUCD, training of health care providers and availability of supplies to provide PPIUCD influenced use PPIUCD.
Overall the prevalence rate of 28.1% for the use PPIUCD in this study was generally higher than other study done in Ethiopia 12.4%, in India 12.6%, Texas in 13.5% Brunson et al., ;Gonie et al.,; Rajasthan et al.,(18)(12)(14) and this prevalence was in line with with findings from Tanzania which found 27% (19) and was attributed on the fact that the health care providers from Tanzania setting were trained to provide PPIUCD and enhance women knowledge during ANC. The high prevalence rate in Rwanda could be attributed to the fact that Muhima Hospital is one of the piloting health facility for PPIUCD implementation in Rwanda and Ministry of health has put many resources such training of health care providers, supplying the methods in the facility which might have increased the use of the PPIUCD in the facility. This shows that if there is commitment from government, there is a sustainability of any outcome.
The level of education influences health behavioral, in this study, it was observed that the use of immediate PPIUCD increased with the level of education. Women who are educated are empowered to decide fertility control and can better understand the health information offered to them regarding the use of PPIUCD, Additional women who are educated were more likely to visit a health facility and receive counselling for different methods available in the health facility. This is in line also with a study done in Ethiopia where women with formal education were more likely to use PPIUCD compared with counterparts (12) .
Counselling for mothers during prenatal visits increase the awareness for mothers regarding the PPIUCD. In this study, counselling the couple during antenatal was significantly associated with the use of PPIUCD, which was consistent with the various studies done in West central Africa and Ethiopia (20)(21). The role of counselling was also confirmed in the in-depth interviews, where midwives noted that counselling during antenatal care increased the demand and utilization of PPIUCD as is the convenience and suitable time for counselling. The antenatal counselling also allows the client to have enough time to discuss with the family methods and also to have access information from health care providers which enables them to make an informed decision before the time of delivery as women may have more information on benefits of initiating postpartum contraceptives utilizations on timely manner and this can increase their intention to use immediately after delivery.
Male involvement in reproductive health is an essential component in promoting maternal and family health. In this study, women who received approval to use the method from their partners were more likely to use the method than their counterparts. This were similar with the study done in Ethiopia which showed that the higher odds of women who accept the PPIUCD were women who have had discussion with their partners(24) and study in India (22) reported that 42.96% of women declined to use PPIUCD due to partners' non-involvement in decision making. This indicates that the male's involvement in the decisions making process is necessary to increase the use of PPIUCD and prolong the continuation of the method and also it should be explained the importance of male involvement during counselling and decisions making in regard to fertility and reproductive health decisions and the need for involving partners in issues related to health and specifically reproductive health.
To achieve optimal birth spacing and ultimately to improve birth outcomes, there is need to have access to postpartum family planning service after birth. The short birth to pregnancy interval less than two years was significantly associated with use of PPIUCD. These findings were in line with study done in India(26) who got the same findings such as among women with short birth interval were more likely to use PPIUCD, this was also supported by WHO guidelines released that healthy timing and spacing of pregnancies has a positive effect on maternal health and newborn outcomes, when promoted in countries with high birth rates, 32% of all maternal deaths and over 1 million deaths of children under five could be prevented (27).
The number of children have been identified as an important individual characteristics influencing women’s reproductive health behaviors including uptake for postpartum family planning. The Parity was associated with use PPIUCD, women with a higher parity were more likely to use PPIUCD, this simply reflects that women with high parity required long term contraceptives for spacing secondly women who are multipara were more likely to meet the health service provider and obtained suitable information regarding mode of family planning. The findings were consistent with study done in Ghana which reported high acceptance rate to use PPIUCD among multipara women(28).
The mode of delivery either spontaneous vaginal delivery or cesarean section contribute to PPIUCD insertion, in this study women who delivered normally were more likely to use PPIUCD compared to women who had a caesarian section. The higher utilization of PPIUCD among women with normal delivery could partly be attributed to the fact that during the training sessions a lot of emphasis was put on the midwives and the obstetricians were not trained so they lacked the knowledge and information. There is need to train both Midwives and obstetricians so that the service could be provided by both. In India both midwives and obstetricians were trained and the findings from the study done in India reported that 83% of PPIUD were inserted during normal delivery(29).
The findings from health care providers interview show that various measures need to be considered for effective PPIUCD delivery to the mothers who are in need including ; the training of health services, the availability of the method in facility, providers respects to women, privacy, waiting and counseling time were predictors for PPIUCD use, this shows that the facility need to make regular training and supply of the method at facility level, these predict the use of the PPUCD and increases the provider confidence to counsel and to provide the method and hence it impact the client satisfaction. Similar findings were reported by Melissa et al., shows that the competence of health service provider is linked to client’s satisfaction(30).