Study area and period
The study was conducted at Muhima hospital, Department of Obstetrics and gynecology which is located in Nyarugenge District sector, Kigali city. Muhima is a 128-bed hospital specializing in gynecology and neonatology. This hospital oversees eight functional health centers. Muhima is the training site for all medical schools and schools of nursing and midwifery in Rwanda.
Muhima District Hospital was chosen because it has a high number of deliveries and it is also one of the hospitals where the implementation of PPIUD was initiated. It has an average of more than 500 deliveries monthly.
The Study design
Mixed-method concurrent design was employed to determine the use of PPIUCD and its associated factors. The cross-sectional design involved the use of an interviewer-administered questionnaire which was conducted among women who were in the immediate postpartum period. Immediate postpartum was defined as women who have given have given birth10 minutes after birth up to 48 hours of delivery(8) Also, in depth-interviews was conducted among health care providers at Muhima hospital to share their experiences about PPIUD service delivery.
Study participants and sampling procedures
The study population consisted of women who were in the immediate postpartum care within 48 hours after delivery before discharge at Muhima district hospital and Midwives who were working in the labor suite, immediate postpartum ward, and family planning department who were actively involved in the provision of PPIUCD.
The study used a consecutive sampling method to select the eligible participants who were within 48 hours after delivery. The participants were approached in the labor ward or postpartum ward where they were invited to take part in the study. The files of women who had delivered were checked to ensure that they had fulfilled the inclusion criteria of the study. The inclusion criteria for PPIUCD were Women aged 15-49 years, delivering either vaginally or by cesarean section, at Muhima hospital from January – February 2019 had received counselling for postpartum contraception and consented for postpartum use who were in the immediate postpartum period after delivery within 48 hours of birth and midwives who were working in FP services, labor suite, immediate postpartum ward who were providing FP services and other maternal health services on the days of the study were included in the study.
The exclusion criteria include: The study excluded women who were within10 minutes after childbirth to 48 hours after delivery but clinically unstable such as the women who had PPH, Women who have been diagnosed with chorioamnionitis, Women who have a fever ³37.5 degree Celsius during labor, and delivery, Women who had active genital tract infections or were are at high risk for STD, Women are known to have ruptured membranes for greater than 24 hours before delivery. Women who have had 3rd and 4th-degree tears, Women who had been diagnosed to have uterine abnormalities, Health care workers who were not providing the methods.
The participants were informed about the study including providing adequate information regarding the purpose, procedure, benefits, and risks of the study. The potential participants consented before they were interviewed for the study. Women who accepted to be inserted an IUD were considered to have used PPIUCD, while women who declined to use IUD were considered to have not used the PPIUCD.
Sample size determination
The sample size was powered to determine the prevalence of PPIUD. The sample size was calculated using a prevalence of 48 % for contraceptive prevalence, 95 % confidence interval, and an error margin of 5 %. A total of 383 mothers were recruited for this study(20).
The sample size for factors associated was calculated using α = Type 1 error 5%., Z = the standard normal statistic corresponding to 1.96; β = Type II error as 20%; Odds= 3.1. The odds were derived from literature; Percent of exposed with outcome=14; Risk/Prevalence ratio=2.8; Risk/Prevalence difference =9; Assuming a power of 80%, type 1 error of 5%, type II error of 20%, and odds of 3.10, the sample size of the study was estimated at 374 women. The study adopted a sample size of 383 to increase the statistical power of the study. Therefore, a sample size of 383 women was used in this study. The Fleiss formula in OpenEpi was used for determining the factors associated with the use of PPIUCD. (Ref: Fleiss, Statistical Methods for Rates and Proportions, formulas pages 3.18 & 3.19). The OpenEpi Calculator was used to calculate the sample size and it was accessed from https://www.openepi.com/SampleSize/SSCohort.htm
Data were collected through face-to-face interviewer-administered questionnaires; mixed-method were applied to collect data. The data collected include Social demographic factors;(age, level of education, marital status religious beliefs) knowledge about PPIUCD; Social-cultural factors:, (myths cultural norms, partner, support, peer influence) social-economic factors; (poverty, source of income, occupation), Reproductive factors: (parity, number of living children desired, mode of delivery, fertility desire, side effects of methods), Service delivery related factors; (availability for suppliers and IUCD, health care worker knowledge and skills, access to the health facility, knowledge for health care providers, quality of care delivered to the women, Family planning information and counselling during antenatal care ). The prevalence of participants who used PPIUCD was measured. The tools were piloted and pretested before starting data collection to assess appropriateness, content clarity, and comprehensiveness of the questions and time taken to fill the questionnaires.
Quantitative data collection
The interviewer-administered structured questionnaires were used to collect quantitative data. The questionnaires included questions regarding the social demographics, knowledge about PPIUD use, social-cultural, social-economic, and reproductive factors.
The study used a consecutive sampling method to select the eligible participants who were within 10 minutes to 48 hours after childbirth. The participants were approached in the labor ward or postpartum ward where they were invited to take part in the study at Muhima hospital. The files of women who had delivered were checked to ensure that they had fulfilled the inclusion criteria of the study. The participants were informed about the study including providing adequate information regarding the purpose, procedure, benefits, and risks of the study. The potential participants consented before they were interviewed for the study. Women who accepted to use an IUD were considered to have used PPIUCD, while women who declined to use IUD were considered to have not used the PPIUCD.
Qualitative data collection
In-depth interviews (IDI) were used on one to one to explore the health care provider's experience regarding PIUCD service provision. An IDI was used because it was able to capture detailed information and offers participants opportunities to share their personal experiences regarding provision for PPIUCD including the mode of supply, the training opportunity, and the institution support through PPIUCD provision. The approach has helped to distinguish an individual's opinions about provision for PPIUD.
Participants were purposively selected among the team of midwives working in antepartum, labor suite, postpartum, and family planning for the time of data collection. The study purposively selected midwives for an interview until saturation was met, which was reached after interviewing 10 midwives. The IDI was conducted at the workplace in the Muhima hospital.
The IDI was conducted among selected health care providers in a convenient place where she or he was working at the time for data collection. An interview guide containing questions related to experience and practice and their perception regarding provision for PPIUCD was used in this facility-based. The interview was audiotaped and notes were taken by the research assistant.
Quantitative Data analysis
The outcome variables in this analysis are a binary variable for postpartum intrauterine contraceptive use and proportions were used to summarize participants who used PPIUCD. PPIUCD use is defined as any participant who chose IUD as postpartum family planning. Those women who did not choose to use IUD as postpartum contraceptive were classified as non-user. The prevalence of PPIUCD use was determined by dividing the number of women who had accepted to use PPIUCD by the total number of all postpartum women who participated in the study.
To determine the factors associated with the use of PPIUCD, chi-square tests, and binary logistics regression were used. The bivariate analyses were conducted to determine the independent variables that were significantly associated with PPIUCD use. The significant variables were of value less than p<.05 at the 95% confidence interval. The variables that were p<0.2 were subjected to multivariate analyses in the binary logistic model to obtain the adjusted odds ratios of the statistically significant variables.
Qualitative Data analysis
The interviews were recorded and transcribed verbatim in Kinyarwanda, after validating the transcription, the typed narratives were then translated into English and verified the accuracy. Analysis of the data was conducted by the primary author and included several iterative steps. Using thematic analysis, the transcripts were reviewed several times, and a set of codes were developed to describe groups of words or categories with similar meanings. The transcripts were then coded and managed using Atlas’s version 7. The grouped categories were refined and used to generate themes emerging from the data. Direct quotations from midwives are presented in italics to highlight key findings.
Ethical review and approval
Ethical review and approval were obtained from the Higher Degrees and Research Ethics Committee of the College of Health Sciences at Makerere University #SHSREC REF NO: 2018-045 and Research Ethics Committee of the College of Medicine and Health Sciences University of Rwanda No 404/CMHS IRB/2018. The administrative clearance and permissions were obtained from Muhima hospital ethical committee. Written informed consent was obtained from the mothers and the midwives. Participation was voluntary and all the interviews were conducted in private settings to ensure participant’s confidentiality.