Utilization and associated factors of modern contraceptives during postpartum period among women who gave birth in the last 12 months in injibara town Awi Zone, North-West Ethiopia 2019

Background: The postpartum period is an important entry point for family planning service providers to reduce unintended and too closely spaced pregnancy. A postpartum modern contraceptive service is one of the recommended public health interventions for reducing maternal and child morbidity and mortalities. However, In Ethiopia modern contraceptive use during the postpartum period is low; resulting in unintended pregnancies and unwanted childbearing . there for this study was done to assess utilization and associated factors of modern contraceptives during the postpartum period among women who gave birth in the last 12 months in Injibara Town Awi Zone, North-Western Ethiopia. Methods: A Community based cross-sectional study design was conducted from March 01 to 15/2019 on 400 women who gave birth in the last 12 months preceding the survey. A simple random sampling technique was used to recruit study subjects. Data was collected using interviewer-administered pretested and structured questionnaires. Data were entered using Epi data 3.5 and exported to SPSS version 23 for analysis. The association between variables was analyzed using Bivariate and multivariable logistic regression models and p-value < 0.05 at 95% Confidence interval was considered as statistically significant. The was

factors affecting contraceptive use in postpartum period.
Conclusion : The prevalence of modern contraceptive use among postpartum women was found to be high in Injibara town. Therefore, strengthen family planning counseling during antenatal care and postnatal care to reduce the missed opportunity of postpartum women to get family planning methods, especially long-acting reversible contraceptives.

Background
Family planning is defined as the ability for individuals and couples to attain their desired number of children in a family when to have children and an age interval between children through the use of contraceptive methods [1].
Worldwide, more than 90% of women during the postpartum period want to either delay or avoid future pregnancies. However, in most cases, sexual activity is resumed without using any contraceptive method [2].
The advantage of family planning has become increasingly recognized internationally to improve health and social outcomes of women and families, as well as public health, economic, and environmental benefits at a different level [3].
The postpartum period is the first 12 months following childbirth which is critical for addressing widespread unmet needs in family planning and for reducing the risks of closely spaced pregnancies [4].
The recommended time for the initiation of contraceptives in the postpartum period is 6 weeks after delivery but most women do not start taking contraceptives at the recommended time [2].
The first years after delivery is an important entry point for family planning service provision; however, women in Ethiopia are usually not the use of family planning methods during this period evidence has been shown that nearly half (47%) of pregnancies occur within a short birth interval of fewer than two years after the preceding birth [5].
When a mother becomes pregnant early after childbirth, she is more likely to develop complications including, spontaneous abortion, postpartum bleeding, and anemia, low birth weight newborn and/or preterm. The earlier delivered child may not receive adequate care and support which, thereafter, could lead to vulnerabilities to disease and malnutrition [3].
Women are more likely to engage with the healthcare system during antenatal care, delivery, postnatal care, and first-year infant immunizations. Each of these encounters is an opportunity for health care workers to integrate family planning into their existing counseling and services to better meet the needs of postpartum women [4].
Pregnancies that are either too early, too close, too many or too late, expose mothers to high morbidity and mortality during pregnancy and childbirth. Family planning can reduce maternal mortality by reducing the number of pregnancies, the number of abortions, and the proportion of births at high risk [6,7].
In Ethiopia, maternal mortality is an important public health issue; 412 per 100, 000 live births are dying as a result of complications related to pregnancy and childbirth, among the highest in the Sub-Saharan Africa countries [8].
Determining the level and associated factors of postpartum contraceptive utilization have the potential to contribute to achieving the Ethiopian Health Sector Transformation Plan (EHSTP) and to the Sustainable Development Goals (SDGs) [9].
Currently, in Ethiopia, family planning services are integrated into maternal and child health care services at all levels of the health care delivery system and the service has been provided to the rural communities at the health posts through health extension workers. Maximal efforts have been performed by the government, local and international partners on FP programs [10].
Despite all these efforts, the national modern contraceptive prevalence rate and unmet need for family planning were reported as 35% and 22% respectively in the Ethiopian demographic health survey report 2016, which was lower than the global family planning targets [8]

Study design
A Community based cross-sectional study was conducted in Injibara Town, Amhara Region, among women who gave birth in the last 12 months preceding the survey.

Study area and period
The study was conducted in Injibara Town, Awi Zone Amhara Regional State, Ethiopia from March 01 to 15/2019 among women who gave birth in the past 12 months.
Injibara Town is found in the southwestern part of the region and northwestern part of Ethiopia. It is located about 447 km away from Addis Ababa the capital city of Ethiopia and 118 km from Bahirdar city of Amhara National regional state. Agew Awi zone is one of the 13 zones in the Amhara region of Ethiopia. It is bordered on the West by Benishangul Gumuz Region, on the North by North Gondar zone, and on the East by West Gojjam. The administrative zone of Awi is Injibara; other towns include Chagni and Dangila.
According to the information obtained from the Injibara town health office, the town has five Kebeles and the current total population was 46,745 of whom, 23 Sampling procedure All fives Kebeles of the town were included in the study. The total sample size (n = 402) was allocated by using proportional allocation by size, as applied to the total number of postpartum women in the Kebeles. Before data collection, a census was conducted to identify postpartum women in each Kebele. The total number of postpar tum women in the last 12 months was 1,578. The study participants were selected by simple random sampling techniques. In case when the study participants are not able to interview for some reason, an attempt is made three times to interview the respondent and after all, they were considered non-respond. The lottery method was used if more than one mother who gave birth for the last 12 months found in the same house.

Inclusion and Exclusion criteria
Inclusion criteria

Operational definition
Postpartum period -the time from birth up to one year [2] Postpartum modern contraceptive utilization -a postpartum woman's current use of any modern contraception methods (pills, IUCD, injectable, condom (male or female), sterilization (male or female), implants) during the 12 months following her recent childbirth [14].
Good knowledge-is defined as a knowledge score of greater than or equal to the mean knowledge score [13,15] Poor knowledge-is defined as a knowledge score of less than the mean knowledge score [13,15] Favorable attitude -is defined as an attitude score of greater than or equal to the mean attitude score [13,15] Unfavorable attitude-is defined as an attitude score of less than the mean attitude score [13,15] Data collection instruments The data were collected from mothers who gave birth for the last 12 months by using a pre-tested and structured questionnaire adapted from different kinds of literature which are developed for similar purpose done by different authors. The data collection tool (questionnaire) was prepared first in English and then translated to a local language (Amharic and Awigni) and then re-translated back to the English language by a language expert. The questionnaire comprises socioeconomic and demographic characteristics, reproductive history and maternal health care, Knowledge and current practice of postpartum modern contraceptive use, the experience of contraception services and sexuality issue related variables.

Data collection procedure
Data were collected by 5 diploma midwives and Two BSc midwives for supervision.
Interviewer administers questionnaires via face to face interview was used to collect the data. A sampling frame was obtained from census and study subjects were selected by using simple random sampling techniques.

Data quality control
To assure the quality of the data, technical training for two days was given for data collectors and supervisors about the objective of the study, methods, and significance of the study. Before undertaking actual data collection, questionnaires were pre-tested in randomly selected 20 postpartum women (5 % of the sample) nearer to Injibara town at Addis Kidam that has similar characteristics with the study population to ensure the clarity of the questionnaire, to check the wording, and to confirm the logical sequence of the To assess the knowledge and attitude of participants towards postpartum family planning multiple questions were asked with 13 questions. Seven for assessing knowledge of contraceptive and six questions to assess the attitude of contraceptives. The mean score was calculated for knowledge and attitude variables separately. Any score greater or equal to the mean score was defined as a high score and hence labeled as "good knowledge" for knowledge variable while it was labeled as "favorable attitude" for attitude variable. Any score which is less than the mean score was defined as low score and hence labeled as "poor knowledge" and "unfavorable attitude" for knowledge and attitude variables respectively [13, 15]. Sixty-eight (17%) of the study participants had already started sexual intercourse after giving birth and more than half (54.8 %) of respondents resumed menses, and the rest were still amenorrheic. (Table 2) 3. Knowledge and attitude of Mothers towards modern contraceptive methods All study participants were heard about modern contraceptive methods and more than half (62%) of them were knowledgeable about postpartum modern contraceptive.

Socio-demographic characteristics of participants
Concerning the attitudes of the respondents towards postpartum contraceptive utilization more than half (53.5%) of them had unfavorable attitudes. (Table 3) 4. Utilization of modern contraceptive method during the postpartum period The prevalence of modern contraceptive use among women in the postpartum period was found to be 58.5% (95% CI: 53.5, 63). The most commonly used contraceptive method was injectables 91(39%) followed by implant 78(33%) and oral pills 43(19%) respectively. (figer1).
Among currently contraceptives users 103 (44%) of women start to use contraceptives methods from 6 weeks to 3 months. More than half (63.7%) of postpartum mothers start contraceptive used after menses resumes. (Table 4).

Reasons for not using contraceptive methods
Less than half, (41.5%) of the women in the postpartum period did not currently use any modern contraceptive at the time of the interview. The major reasons for not currently using contraceptives were feeling of not exposed to the risk of pregnancy due to amenorrhea after birth 48(29 %), followed by were feeling of not exposed to the risk of pregnancy due to breastfeeding 36(22%) and partner opposed to use family planning   [19] and EDHS 2016(23%) [20]. The difference could be due to the time gap of studies, study participant, socio-demographic and reproductive characteristics variation. The study conducted in Gondar, study participants were postpartum women in the extended postpartum period (6 weeks -12 months). But in this study, all postpartum (immediate postpartum up to 12 months) were included. The proportion of women who had higher education was lower (20.6%) than this study (36%). The study design was institutional-based but in this study community-based.
The study conducted in Debre Berhan study participants were in the extended postpartum period (6 week -12 months). But in this study all postpartum women who gave birth in the last 12 months The study conducted in Gida Ayana women who had 4 or more ANC visits were (28.5%) lower than this study (39.7%) and 50.2% women delivered at home which is high compared to this study only (1.3%) of women delivered at home. More than half (54.7%) of the respondents were not able to read and write but in this study low (5%). And also a difference in study setting since conducted in rural areas but this study conducted primarily in urban settings were access and service utilization would be high compared from rural.
The study conducted at Dabat district in which the proportion of women who could not read and write was (64.4%). it's higher than from this study (5.2%).
Another possible reason for the difference in PPFP use among postpartum women might be differences in prenatal service utilization. Mothers who had postnatal care visits were higher in this study (77.5%) than the study done in Aksum northern Ethiopia (43.7%).
It was also higher than studies conducted in Uganda (28%)[ [21]. The difference could be due to reproductive characteristics variation. The marital status of women may have contributions to the differences in the prevalence of postpartum family planning utilization. If a woman is married, she may have early postpartum sexual contact than those who are not married. The proportion of our participants who were married was higher (94%) than that of the study done in Uganda (83.6). However, this finding was found to be lower compared with the study done in Addis Ababa (80.3%) [22] and Ganta-Afeshum District Eastern Tigray (68.1%) [23]. The difference could be due to the presence of socio-economic and reproductive variation and service accessibility.
Study was done in Addis Ababa (89.5%) pregnancy was planned but this study (14.3%) recent pregnancy was unplanned, more than three fourths (78.3%) had histories of family planning use before their last pregnancies but in this study only (7.3%) participant had histories of family planning use and also living condition, access, and service utilization would be high compared from this study.
It was also lower than studies conducted in Rural Kenya (86.3%) [24] andNtchisi district hospital Malawi (75%) [25]. Study conducted in Malawi (90.2%) of the participants had resumed sexual activity which was higher than this study (17%). Over half of the respondents (58.5%) were used FP methods before pregnancy higher than from this study (7.3) and also both in Kenya and Malawi it might be due to policy; access and service utilization of postpartum family planning was high.
The odds of modern contraceptive utilization significantly increased as the educational level of women increases. Women who were at higher educational level 4.2 times increase the odds of using modern contraceptive methods than not educated and also women who were at secondary school 5 times increase the odds of using modern contraceptive methods than not educated. This might be due to that postnatal care visits give good opportunity counseling about the advantage and disadvantages of family planning use, birth space, and maternal and child health service. It leads to using of modern contraceptive methods in an effective and timely manner.
Women whose menses was returned after last delivery were 2.8 times more likely to use postpartum contraceptive than those who haven't seen menses. This finding is also supported by other studies done in Ethiopia Debre Birhan town, Gondar town, Aroressa District Southern Ethiopia [13, 18,26] and Malawi [25].
This finding could be justified by postpartum women whose menses are returned after delivery may assume that they are at risk of getting pregnant, so this can initiate them to start postpartum contraceptive utilization on time. But amenohorric women would perceive less vulnerable to get pregnancy by assuming that amenorrhea would protect against pregnancy irrespective of the postpartum duration. Most mothers dose not start using contraceptive until menses has returned regardless of the time of the postpartum period, which can be risky.
The odds of resuming sexual activities were 2.8 times higher to use postpartum modern contraceptive than the counterpart. A similar finding was seen in studies done in Debre Birhan [18], Northern Ethiopia[14], Gondar town[13]. This could be due to women resume sexual activities; they perceive exposed to the risk of unintended pregnancy then they motivate to use contraceptive methods. Therefore, resuming sexual activities is strongly linked to the initiation of modern contraceptives in the postpartum period. College of medicine and health sciences. The letter of permission was also obtained from the midwifery department and Injibara town health office administration for respective kebeles before the study has taken place both to ensure legitimacy and build trust with kebeles and study communities. After the purpose and objective of the study are informing, both verbal & written consent was obtained from each study participant.
All information gained during data collection kept confidential and any personal identification not recorded on the questionnaire. Participants were informed about they have the right to withdraw from the study at any time if they are not comfortable with the questionnaire.

Consent for publication
Not applicable

Availability of data and material
The data supporting this finding can be available at any time with request from the BMC pregnancy and child birth.
paper. GA, AA, and GB approved the proposal with some revisions, participated in data collection, analysis and manuscript writing. All authors read and approved the final manuscript.