A hospital- based quasi- experimental study design with a comparison group was used for this study. The intervention group was exposed to the intervention plan while women in the comparison group were provided with the routine care at the postnatal ward, in addition to the placebo (health talk on umbilical care). Refer to Fig. 1.1 for further details.
Study Setting
The study was conducted in two health facilities. BGH as the intervention facility located in the Central River Region in rural Gambia, about 300 km from the capital city Banjul. Furthermore, in order to prevent contamination, the comparison group was observed at the 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.18 Using a prevalence of 57% and 49%, women that accepted contraceptives following PPFP counselling in Rwanda, 19 the sample size of this study was determined by the formula below:
Thus:
for α = 0.05; β = 0.20; p0 = 57% and p1 = 49%;
$$n=\frac{2\times {(1.96+0.84)}^{2}\times 0.53\times \left(0.47\right)}{{\left(0.08\right)}^{2}};where p=\frac{0.57+0.49}{2}$$
The calculated sample size (n) = 612; provision for 10% non-response rate was made and the final sample size was 674. Furthermore about 27 (8%) women were lost to follow-up in the intervention group.
The Intervention Group
The inclusion criteria for women in the intervention group was based on all those who gave birth at the BGH with a live baby on day 1, aged 13–49 years, and gave birth at the BGH during the months of November2017 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 the mother (mental, cardiac, cancer, liver, kidney), women with postpartum haemorrhage, infection and fever > 38ºc.
The Comparison Group
In order, to minimize contamination, the control group was at the SHC, which is about 120 kilometres from the intervention site. Furthermore, women in this group included those who gave birth at the health centre with a live baby, on Day 1, aged 13–49 years, and delivered at 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 the mother (mental, cardiac, cancer, liver, kidney); women with postpartum haemorrhage, infection and fever > 38ºc.
Study Tool
A questionnaire was developed by the Principal Investigator based on the literature review to assess women’s knowledge, attitude, and intention towards PPFP methods. The research objectives guided the development of the questionnaire, which consisted of 37 close- ended questions. It was divided into four sections as follows: Section A; This elicited the socio-demographic characteristics of the respondents. Section B obtained knowledge of family planning. Two points were given for any correct answer, and a zero point for any wrong or unknown answer. The total possible scores for this part of the questionnaire ranged from 0 to 54. Scores from 0–17 were considered poor knowledge, and 18–54 good knowledge. Section C addressed postpartum women’s contraceptive attitudes related factors were measured by nine items on a five- point Likert scale viz 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 were considered negative, 28–45 were positive. Finally, Section D which looked at intention to utilize contraceptives had eight items on a five- point Likert scale viz 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 contraceptives. The total possible score for this part of the questionnaire ranged from 8 to 40. Scores from 8–25 were considered low, and 26–40 were high. Each subscale was calculated separately, and therefore three different scores were obtained for each subject. The questionnaire developed for this study is provided as Additional File 1
Intervention Plan
The goal of the intervention was to increase contraceptive knowledge, attitude, and intention to use among the postpartum women, thus preventing unintended and closely spaced pregnancies. This was accomplished through contraceptive counselling designed to improve contraceptive knowledge, attitude, and intention.
Counselling was provided three times; day one before hospital discharge. This was conducted before or immediately after the medical ward rounds using the GATHER (Greet, Ask, Tell, Help, Explain and Return) approach.20 Sample contraceptive methods currently offered in The Gambia were used during councelling such as the male and female condoms, pills, emergency contraceptives, Depo Provera, Implants (Jadelle and Implanon), Intra-uterine Device, and Female Sterilization.
The second counselling was conducted on the 9th 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 8th day in The Gambia). It is a cultural practice that during the first week of postpartum women stay indoors and only go to the hospital if the child is ill. The second counselling session was conducted using the same GATHER approach - contraceptive poster and sample contraceptive methods as the first session.
The third counselling session was carried on the 40th 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 as the first and second counselling sessions. Refer to Fig. 1.2 for further details.
Post- Intervention
Regarding the post -intervention, the same questionnaire was administered to women in both groups in 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 eight already trained practising nurse-midwives and contraceptive counsellors. These practitioners were trained as research assistants and were fluent in at least two of the three languages; Mandinka Fula and Wolof ) spoken in the study sites. The baseline data was collected through face-to-face interviews and the questionnaire was retrieved immediately, thus a 100% return rate was obtained for both groups.
Data was collected from November 2017 to May 2018 in the following order: November –December 2017 was used to collect baseline data, and December 2017 - February2018 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, Difference -In- Difference analysis (DID, Single Difference (SD) and binary logistic regression. Statistical significance was set at p < 0.05.