Effects of Postpartum Family Planning Counseling on Contraceptives Among Women Attending a General Hospital in the Gambia: A Randomized Trial


 Background Postpartum Family Planning (PPFP) counselling is a critical component of maternal health care that has the potential of meeting women’s desire for contraception. The study aimed to evaluate the effectiveness of postpartum family planning counselling among women attending a general hospital in Gambia.Methods The study used a quasi-experimental design with two groups; the intervention and the comparison group. A sample size of 674 participants was determined by a formula for comparison between two groups. The questionnaire was developed base on a literature review and was pre-tested on 10% of the total study participants (68). A reliability of 0.731 was obtained. Systematic random sampling method was employed to select those who met the inclusion criteria. Data were collected on face-to-face interviews in the Wollof, Mandinka and Fulla local languages with a 100% response rate at baseline and 96% at posttest. The intervention strategy was family planning counselling using the GATHER approach. Data were analyzed using SPSS version 21.00 and statistical analysis included both descriptive and inferential methods. Ethical approval was obtained from the Research and Ethic Committee, School of Basic Medical Sciences, College of Medicine, University of Benin (CMS/REC/2017/017); The Gambia Government/Medical Research Council Laboratories Joint Ethics Committee (R017016Av1.1). Results Baseline respondents' socio-demographic characteristics revealed that the two groups had similar characteristics and were therefore comparable (P>0.05). A statistically significant difference existed on knowledge, attitude, and intention between the intervention and comparison groups at post intervention (p<0.05) while no significant difference was observed at baseline. Significant gains were achieved in the intervention group in terms of knowledge, attitude, and intention post intervention. Conclusion The present study therefore highlights the need to conduct family planning counselling during the immediate postpartum period, particularly before discharge of women from the hospital so as to ensure improve contraceptive uptake, prevent unwanted pregnancy and closely spaced pregnancy and thus improve maternal health outcomes. Keywords: Postpartum Family Planning, Counseling, Contraceptives, Women, The Gambia

intervention, a statistically significant difference was noticed on knowledge, attitude, and intention between the intervention and comparison groups (p<0.05).
In conclusion, the study has highlighted the need to conduct a structured and regular family planning counseling in order to increase women's knowledge, attitude, and intention and subsequently contraceptive uptake. This will help to address the already low contraceptive uptake and thus reduce maternal mortality and morbidity in the country.

Abstract Background
Postpartum Family Planning (PPFP) counseling is a critical component of maternal health care that has the potential of meeting women's desire for contraception. The study aimed to evaluate the effectiveness of postpartum family planning counseling among women attending a general hospital in the Gambia.

Methods
The study used a quasi-experimental design with two groups; the intervention and the comparison group. A sample size of 674 participants was determined by a formula for comparison between two groups. The questionnaire was developed based on a literature review and was pre-tested on 10% of the total study sample size (68). A reliability of 0.731 was obtained. Systematic random sampling method was employed to select those who met the inclusion criteria. Data were collected on face-to-face interviews in the Wollof, Mandinka and Fulla local languages with a 100% response rate at baseline and 96% at posttest. The intervention strategy was family planning counseling using the GATHER approach. Data were analyzed using SPSS version 21.00 and statistical analysis included both descriptive and inferential

Introduction
Postpartum Family Planning (PPFP) counseling is a critical component of maternal health care that has the potential to meet women's desire for contraception, and hence improve contraceptive uptake. PPFP is defined as the prevention of unintended pregnancy and closely spaced pregnancies through the first 12 months following childbirth 1  15 % in Nigeria and less than 10 % in Ethiopia 5 . In The Gambia, the unmet needs stand at 25.8% 6 , and prevalence of contraceptives use among women is 9%. However, PPFP usage is unknown and is believed to be low as well.
The goals of contraceptive counseling are to educate women about contraception, discuss current and future contraceptive needs, and select a contraceptive modality, if needed, thereby avoiding the risks of unintended pregnancy 7 . Evidence indicates that structured counseling both protects women's rights to an informed and voluntary decision regarding their reproductive choices and improves the use of modern contraception methods 8 9 ). The largest population of women with an unmet need for contraception is found among those in their first year after childbirth 10 .
Studies reported that the rate of pregnancy within the postpartum period is 6-40% 11 .
The level of women's knowledge has a significant effect on future use and non-use of postpartum contraception. Researchers found that 12 , knowledge, and awareness on contraceptive is high among the Nigerian population. However, this awareness has not been translated into increased contraceptive use, and so contraceptive prevalence has remained low. Furthermore, a cross-sectional observational study conducted among postpartum women attending Kathmandu Medical College Teaching Hospital, revealed that contraceptive awareness and knowledge among the postpartum women was high but their usage was low 13 .
Attitude is the most difficult part to measure as it is characterized in a very abstract way. In Ebonyi State, Nigeria, researchers found postpartum women to have favorable attitude towards contraception 14 . A study in Iran revealed that among postpartum women the intervention group had higher positive attitude towards contraceptives than their counter parts in the control group (p<0.05) 15 .
A study conducted in Uganda revealed that 71.4% of women in the control and 87% in the intervention had intention to use a modern contraceptive method following counseling on Postpartum Family Planning 16 . Similarly studies from Nigeria showed that most women intended to use a method of postpartum contraception 17 while in Ohio, most post-partum women (91%) intended to use contraception before their discharge following delivery at a large University hospital 18 .
In The Gambia, family planning services have been free of charge and available in all public health facilities since 1975, yet, the contraceptive prevalence rate (CPR) is showing a downward trend in married women aged 15-49 years for various reasons such as low educational level and religious barrier 6 . Hence, contraceptive counseling during the postpartum period is of paramount importance to improve knowledge, attitude and intention and the use of modern contraception methods which help to prevent or delay a subsequent pregnancy after a live birth. A literature search revealed that no published study on PPFP counselling on the topic was found credited to the country. Therefore, the aim of this study was to evaluate the effects of postpartum family planning counseling on contraceptive knowledge, attitude and intention to use among women attending health facilities in The Gambia.

Methodology
A hospital based quasi experimental study design with a control group was used for this study.

Study Setting
The study was conducted in two health facilities; Bansang General Hospital (BGH) was the intervention facility located in Central River Region, rural Gambia, about 300 km from the capital city Banjul. Furthermore, in order to prevent contamination, the control group was observed at Soma Health Center (SHC) located in the Lower River Region, about 180km from the capital.

Sample Size and Sampling Technique
The sample size estimation of this study was determined by using a formula for sample size calculation for comparison between two groups when endpoint is quantitative data 19 . Using a prevalence of 57% and 49%, women that accepted contraceptives following postpartum family planning counselling in Rwanda 20 , the sample size of this study was determined by the formula below: for α = 0.05;  = 0.20; p 0 = 57% and p 1 = 49%; The calculated sample size (n) = 612; provision for 10% non response rate was made and the final sample size was 674.

The Intervention Group
Inclusion criteria for women in the intervention group was based on all those who delivered at Bansang General Hospital (BGH) with a live baby on day 1, aged between 13-49 years, and delivered in BGH during/between the months of November, 2017 and May, 2018 and were receiving postnatal care and attending infant welfare clinic at the BGH or within its catchment area. Exclusion was based on severe chronic illness of mother (mental, cardiac, cancer, liver, kidney), women with postpartum hemorrhage, infection and fever > 38ºc.

The Control Group
In order, to minimize contamination, the control group was at Soma Health Center (SHC) located in the Lower River Region, which is about 180 kilometers from the intervention site.
Furthermore, women in this group included those who delivered at the health center with a live baby, on day 1, aged between 13-49 years, and delivered in SHC during/between the months of November, 2017 and May, 2018 and were receiving postnatal care and attending infant welfare clinic at the SHC or within its catchment area. Exclusion was based on severe chronic illness of mother (mental, cardiac, cancer, liver, kidney); women with postpartum hemorrhage, infection and fever > 38ºc. planning. Two points were given to any correct answer, and zero point to any wrong or unknown answer. The total possible scores for this part of the questionnaire ranged from 0 to 54. Scores from 0-17 was considered poor knowledge, and 18-54 good knowledge. Section C addressed postpartum women's contraceptive attitudes related factors were measured by 9 items on a five point Likert scale ranging from strongly agree=5, agree=4, don't know=3, disagree=2, strongly disagree=1. The total possible score for this part of the questionnaire ranged from 9 to 45. Scores from 9-27 was considered negative, 28-45 was positive. Finally Section D looked at intention to utilize contraceptives has 8 items on a five point Likert scale ranging from agree strongly =5, agree somewhat=4, don't know=3, disagree somewhat=2, and disagree strongly=1. This section determined if the woman intended to use modern contraceptive. The total possible score for this part of the questionnaire ranged from 8 to 40. Scores from 8-25 was considered low, and 26-40 was high. Each subscale was calculated separately, and therefore four different scores were obtained for each subject.

Intervention Plan
The primary goal of the intervention was to increase contraceptive use (this will be discussed in the follow up paper) among postpartum women, thus preventing unintended and closely spaced pregnancy. This goal was accomplished through contraceptive counseling designed to improve knowledge, attitude, and intention Counseling was provided three times; day one before hospital discharge. This was conducted before or immediately after the medical wards rounds using the GATHER (Greet, Ask, Tell, Help, Explain and Return) approach 21 .
The second counseling was conducted on the 9 th day at the post-natal clinic, before or after the change of card (women came for a change of card, from antenatal to infant welfare card. This is because the child is given a name on the 8 th day in The Gambia). It is a cultural practice during the first week of postpartum for women stay indoors and only goes to the hospital if the child is sick. The second counseling session was conducted using the same GATHER approach, contraceptive poster and sample contraceptive methods as the first session.
The third counseling session was carried on the 40 th day at the Infant Welfare Clinic (e.g. while the woman was waiting for, or immediately after the baby received immunization). This session was conducted in the same way and manner as the first and second counseling sessions.

Post Intervention
Regarding the post intervention, the same questionnaire was administered to women in both groups at the sixth week to assess knowledge, attitude, and intention to utilize modern contraception. Similarly, at the end of the first six weeks both groups were assessed to determine the level of knowledge, attitude, and intention to utilize modern contraception

Reliability
The study interview schedule was pre-tested tested using 10% of the total study participants (68), from two different health Facilities (34 for each Facility), on participants that had similar inclusion criteria as those that participated in the study. In this study, the reliability was 0.731.
The questionnaire was modified based on the pre-test results.

Data Collection
Data was collected using interviewer administered questionnaires by trained 8 practicing nursemidwives who were trained as research assistants, they were fluent in at least two of the three languages (Wolof, Mandinka and Fula) spoken in the study sites. The baseline data were collected through face-to-face interviews and the questionnaire was retrieved immediately, thus a 100% return rate was obtained for both groups.
Data were collected from November, 2017 to May, 2018 in the following order: November -December 2017 was used to collect baseline data, and December 2017-February-2018 post -test data. Analysis of data included both descriptive and inferential statistics. Data was presented using frequency tables, and summary statistics. Statistical tests were done using Chi-squared tests, t-tests and binary logistic regression. Statistical significance was set at p < 0.05.
Results: Table 1 shows the socio-demographic characteristics of the study participants. There was no statistically significant difference between the intervention and control groups in terms of their socio-demographic characteristics except for ethnicity, marital status and employment. More than a third of participants in both intervention and control groups had no formal education.
It was observed that at baseline there was no statistically significant difference between the two groups except for knowledge on types of contraceptives. Similarly, there was no significant difference in mean knowledge score between the intervention and the comparison group.
(p=0.860). However, at post intervention there was a statistically significant difference in terms of knowledge on the entire domain measured and the mean knowledge score (p=0.000) as shown in Table 2. Table 3 shows that the intervention group, a lesser proportion of respondents (18.4%) had good knowledge at baseline and a higher proportion (61.3%) had good knowledge post intervention, thus a difference of 42.9% was gained. Regarding the comparison group, a lesser proportion of respondents (14.8%) had good knowledge at baseline and a greater proportion (25.2%) had good knowledge post intervention, thus a difference of 10.4% was achieved. Therefore, the difference between the two study groups was 32.5%. Table 4 revealed that the respondents from the intervention group were 4.694 (95% CI: 3.356-6.566) times more likely to have good knowledge of contraceptives than their counterparts in the comparison group. This was statistically significant (p= 0.000). Table 5 shows that at baseline there was no statistically significant difference between the two groups for attitudes towards contraceptives and the mean attitude score (p>0.05).. However, at post intervention there was a statistically significant difference in terms of attitude on the entire domain measured and the mean attitude score (p=0.000). Table 6 shows that in the intervention group, a lesser proportion of respondents (57. Therefore, the difference between the two study groups was 17.4%. Table 7 revealed that the respondents from the intervention group were 2.712 times (95% CI: 1.913-3.843) more likely to have positive attitude to contraceptive use than their counterpart in the comparison group. This was statistically significant (p=0.000).
According to Table 8, there was no statistically significant difference between the two groups in terms of intention to utilize contraceptives between the two groups and the mean intention score at baseline (p>0.05). However, at post intervention there was a statistically significant difference on intention on the entire domain measured and the mean intention score (p=0.000). Table 9 revealed that in the intervention group, a lesser proportion of respondents (29.0%) had low intention at baseline and a higher proportion (98.4%) had high intention post intervention, thus a difference of 69.4% was gained. Regarding the comparison group, a higher proportion of respondents (28.8%) had low intention at baseline and a lesser proportion (20.5%) had low intention post intervention, thus a difference of -8.3% was registered. Therefore, the difference between the two study groups was 77.7%.

DISCUSSION
In this study, the mean ages of participants were 25.4 and 25.8 years in the intervention and comparison groups respectively. These were not statistically significant (p>0.05). This shows that participants had a similar characteristic in terms of age, were young and within their reproductive ages. This age group was a very good target for postpartum contraceptive uptake for the increase of contraceptive prevalence rate and reduction of unwanted and of closely space pregnancy. This age characteristic is consistent with a study conducted in Kenya which revealed that the mean age of post-partum women was 26 years 22 . Similarly, an Indian study found that the mean age of its participants was 25.6 years 23 . A greater proportion of women were multiparous in both groups. A possible explanation for the multiparity among women could be the desire for a male child and large family size for economic and security reasons. This means that the study participants may want to use contraceptives for spacing but not to limit family size.
The health implication of high parity could be associated with increased adverse obstetric outcomes and socio-economic implications for the family. This is congruent with a study which reported similar findings in The Gambia 24 . In this study, a higher proportion of participants had elementary education in the intervention group while most had no formal education in the comparison group. The difference in educational levels was not statistically significant(p>0.05) and could be attributed to the fact that most rural Gambian families prefer to send the male child to formal school as opposed to the girl child and secondly, it could be due to early marriage of the girl child. This implies that respondents might be unable to make an informed decision with regards to their reproductive health matters such as marriages, family size and contraceptive use.
To avert this state of affairs improving girls' education and empowering them to make informed decisions in this part of the country should be a government priority. In a similar study found that about 41.7% of postpartum women were uneducated in rural Tigray region, northern Ethiopia 25 .

Participants' Knowledge on Contraceptives
At baseline, majority of respondents had poor contraceptive knowledge level in both the intervention and comparison groups. There was no significant difference in knowledge between the two study groups. This is in line with a Zimbabwean study on contraceptive counselling among HIV positive mothers, which showed that there was no significant difference in knowledge between the intervention and comparison groups at baseline (P>0.05) 26 .
At six weeks post intervention, contraceptive knowledge was statistically significant between the two groups. The intervention group had higher contraceptive knowledge scores than the comparison group in all the 6 domains of the knowledge domain. Respondents in the intervention group were five times more knowledgeable than those in the comparison group (p<0.05). This is because the intervention group was exposed to postpartum family planning counselling and showed that as contraceptive counselling increases, so does contraceptive knowledge and the likelihood that respondents would scale up contraceptive uptake better. This further indicates that the intervention offered to women in the intervention group was effective in improving post-partum women's contraceptive knowledge. This supports the need to provide and sustain this counseling offered to women post partum The above, findings are consistent with a Zimbabwean study on contraceptive counselling among HIV positive mothers, which showed that a significant difference in knowledge existed between the intervention and comparison groups at 3 months with 85.5% of the intervention, and 56.3% (P<0.002) in the comparison group 26 .

Attitude towards Contraceptives Usage
In this study, at baseline, contraceptive attitude was not statistically significant between the two groups. This showed that the two groups had similar contraceptive attitudes at baseline. This is in line with a study among postpartum women which revealed that at baseline there was no significant difference between the intervention and comparison group in terms of contraceptives attitude in Iran (p>0.05) 15 . Interestingly, at posttest, contraceptive attitude was statistically significant between the two groups. The intervention group had more positive contraceptive attitude scores than the comparison group in all the 9 domains of the attitude subscales.
Respondents in the intervention group had about three times more positive attitude towards contraceptives than those in the comparison group. This is because the intervention group was

Intention towards Contraceptives Usage
At baseline, intention towards contraceptives did not differ significantly between the two groups.
Both groups had the same low intention towards contraceptives. In Uganda researchers found that there was no significant difference in women's intention to use contraceptive at baseline 16 .
At six weeks posttest, a statistically significant difference existed in women's intention between the intervention and comparison groups (p<0.05). The intervention group had higher intention contraceptive scores than the comparison group in all the 9 domains of the intention subscales.
Similarly, the mean contraceptive intention score was higher in the intervention group than the comparison group. Furthermore, respondents in the intervention group had about 36 times higher intention to contraceptives than those in the comparison group. There was statistically significant between the two groups. This difference can be accounted for because the intervention group was exposed to postpartum family planning counselling and it shows that the post-partum contraceptive counselling offered to women in the intervention group was able to improve women's intention towards contraceptive.
A study conducted in Uganda revealed that 71.4% of women in the comparison and 87% in the intervention had intention to use a modern contraceptive method following counselling on postpartum family planning and the difference was statistically significant 16 . One study from Pakistan, found that at 8-12 weeks postpartum all women in the counselling group planned to use a modern contraceptive method compared with only a third in the comparison group 27 .
Within the intervention study group, all the 8 items of the intention subscale were found to be statistically significant (p<0.05). This shows that significant gain in intention was registered from pretest to posttest.

Conclusion
Effective family planning counseling is one of the cornerstones for increasing contraceptive acceptance and use, during the postpartum period. Findings of this study indicated that at post intervention participants had better knowledge, more positive attitudes, and higher intentions towards contraceptive uptake. These were found to be statistically significant. The present study therefore highlights the need to conduct family planning counseling during the immediate postpartum period, particularly before discharge of women from the hospital so as to ensure improve contraceptive uptake. This would curb unwanted pregnancies, unsafe abortions, improve birth spacing and reduce the high fertility rate and maternal mortality in the country. All these would improve maternal health outcomes and help to achieve the sustainable development goals 3 and 5.