Drivers of Uptake of Immediate Postpartum Modern Contraceptives by Postpartum Women in Lira City, Northern Uganda: A Qualitative Inquiry

Background

Globally, among the 1.9 billion women of reproductive age who have a need for contraception, only 1.1 billion are planning to use or are currently using a contraceptive method.¹ The use of contraceptives of any method was estimated at 65% as of 2021 during the 2022 world family planning.^1,2 The use of modern contraceptives among women of reproductive age in low-income countries of Sub-Saharan Africa still stands low at 37.4%.³ The use of modern contraceptives among married women in East Africa is 45.7%.⁴ In Uganda, 43% of sexually active unmarried women and 38% of currently married women utilize modern contraceptive methods.⁵ The global prevalence of postpartum modern contraceptive use in low- and middle-income countries is 41.2% with a high unmet need at 48.5%.⁶ The contraceptive uptake among immediate postpartum women in Uganda is low, only at 15.4%.⁷

The Immediate Postpartum Modern Contraceptives helps women in prevention of unintended and inter-pregnancy intervals.⁸ It is provided immediately after birth, that is within the first 48 hours of childbirth.⁹ This is vital in reducing the number of short-interval pregnancies, thus improving maternal and new-born health outcomes.⁸ Failure to address the low uptake of immediate postpartum contraception is most likely to result in an increased rate of unintended pregnancies, which could lead to unsafe abortions and pregnancies in this high-risk groups.¹⁰

A study conducted in Addis Ababa, Ethiopia, revealed that knowledge, attitude, and counselling at delivery are some of the factors influencing uptake of immediate postpartum modern contraceptives.¹¹ Similarly, a study conducted on contraceptive use and its associated factors among women in the immediate postpartum period in Kawempe Hospital cited factors such as grand parity, caesarean delivery, and prior contraceptive counselling during antenatal visits.⁷ However, a gap remains in understanding the drivers to the uptake of the immediate postpartum modern contraceptives among women in Lira City.

The World Health Organisation (WHO) recommends immediate postpartum contraception as the safest and secure means of contraception before a woman leaves the health facility.¹² In Uganda, especially in rural areas, the uptake of these services still remains very low despite the efforts such as improving education, partner notification and perceived need for family planning as part of antenatal and postnatal counselling.¹³ Other initiative like the Ministry of Health implementation of Family Planning Costed Implementation Plan II, by integrating FP counselling into antenatal care (ANC), childbirth, postnatal care, health workforce capacity building and improving supply chain.^3,4 Despite these initiatives, the uptake of IPPMC remains sub-optimal due to barriers such as social, cultural, religious and health system-related barriers like stockouts and staffing challenges.^5–9

In Uganda, the majority of the research has focused on the use of modern contraceptives among women without a clear focus on the contraceptive use in the immediate postpartum period. Therefore, the study explored the drivers of uptake of immediate postpartum modern contraceptive by women in Lira City, Northern Uganda.

Methods

Study Design

The study used a descriptive qualitative study design using key informants interview guide to collect data. This research approach was used to gain an in-depth understanding of a phenomenon by describing its characteristics and the context in which it occurred.¹⁴

Study Site and Setting

The study was conducted at Lira regional referral hospital, Lira city, northern Uganda at Obstetrics and Gynecology department. It is located 340 kilometers north of Kampala in Lango sub-region of northern Uganda. The hospital is one of the 13 public regional referral Hospitals in the country serving more than 500 out patients per day. The Hospital sits in a 16.34 hectares piece of land along Kitgum Road in Lira city, neighboring Lira School of Comprehensive Nursing from the North, Lira Central Police Station from the South and Lira Central Prison from the west. It is located at a Latitude: 2°15’1.53” Longitude: 32°54’8.77”. The Hospital has a 400-bed capacity serving a population of about 2.5 million people with the catchment area in all the districts in Lango sub-region which includes; Amolatar, Apac, Dokolo, Lira, Lira City, Oyam, Otuke, Alebtong Kole and Kwania.¹⁵

Participants

The study target population included all healthcare workers involved in Obstetrics and Gynecology care provision at Lira regional referral hospital, Lira city, northern Uganda. Healthcare workers involved in day-to-day running of maternity, postnatal unit at Lira regional referral hospital.

We included healthcare providers giving maternity and postpartum care at Lira Regional Referral Hospital.

We excluded all healthcare workers in maternity and postpartum care who declined to consent to participate in the study and healthcare workers in maternity and postpartum care who were on leave or absent during data collection period.

Sample Size Estimation

Based on the principal of data saturation, a purposive sample of 15 healthcare workers were recruited as key informants in the study. The principal of data saturation, a point at which no more new themes are being generated from the sampled population, it was assumed that given that no new similarities or differences could be identified during the process, data collection is stopped.¹⁶

Sampling Technique and Procedure

Purposive sampling technique was used to identify the study participants, the healthcare workers.¹⁷ A non-probability sampling in which decisions to include participants in the sample are taken by the researcher, based on the criteria or attribute of a participant to give meaningful information.¹⁸ This was based on the experience, discipline, years of work and level of education of the participants. Participants were identified based on the above characteristics they possessed.

Recruitment of Study Participants

After ethical and administrative clearance were obtained from Lira University Research Ethics Committee (LUREC), and administrative clearance from management of Lira Regional referral Hospital (LRRH), the researcher sought permission from the department of Obstetrics and Gynecology about the study and permission was granted to start data collection. Written informed consent was obtained from the eligible study participants who were then recruited in the study. Purposively fifteen participants working in the department of obstetrics and gynaecology were selected to obtain the population for qualitative data based on their experience, qualification and discipline. This was done only on those involved in handling mothers during and immediately after delivery as they are the primary caregivers in provision of immediate postpartum modern contraceptives (IPPMC).

Data Collection Instruments

A Key Informant interview (KII) guide was used for data collection. The interview guide had four main sections comprising sociodemographic characteristics, recipients of care, providers of care, and health system constraints to explore the drivers of uptake of immediate postpartum modern contraceptives. An audio-recorder was also used to record the voices during the data collection.

Data Collection Procedure and Methods

The researcher and trained research assistant identified eligible study participants, a suitable place for conducting the interview within the facility was identified. All participants signed a written informed consent before starting the interview. Audio recordings were done for all interviews conducted with participants. The interviews took on average 15 to 45 minutes for each participant.

Data was collected using a Key Informants Interview (KII) conducted by the researcher and a trained research assistant. Open-ended questions from the question guide were asked to participants, and they narrated their answers as appropriate. Voice recordings were obtained during the interview process.

Data Management and Analysis

A transcriber who had signed confidentiality agreement recorded and transcribed verbatim every interview. Data were assessed for themes on the drivers of immediate postpartum contraceptive uptake inductively. Data were transcribed verbatim, and the transcripts were verified against the audio recordings to clarify any unclear information before conducting the next sets of interviews. Follow-up interviews were organized with respondents and semantic data coding was independently done following the guidelines for the inductive thematic analysis.¹⁹ Themes were generated based on the frequency of codes and sufficiency of data extracts to back up the codes. Discrepancies in codes and themes were resolved through group discussions involving the researcher, co-authors and supervisors. Data were presented as direct quotes while providing a contextual understanding of the drivers of uptake of immediate postpartum modern contraceptives among the study participants (healthcare workers).

Trustworthiness

Trustworthiness was ensured through various strategies aimed at enhancing credibility, transferability, dependability, dependability and confirmability and researcher reflexivity. Rigorous data analysis was done through close collaboration with the authors. Recruitment of experienced research assistants ensured unbiased data collection. There was careful selection of participant by researcher based on their experience, age, level of education as well as cadre of practitioner. The first set of data collected was first cross-checked together by authors before proceeding to complete the data collection process. Also, track of data collected was kept by documenting concerns found in data collection process. Transferability was ensured through application of resonance by ensuring rigorous literature review and proper sampling of study participants and presentation of result as participants verbatim.²⁰ Careful screening the parameters used in the data collection tool by using the SURE framework domains. The choice of key informants across all cadres with different characteristics and experience was also key in ensuring the degree of consistency, reliability, and stability of findings and interpretations throughout the research process.²¹ Audio recordings of all interviews conducted and continuous documentation of data collection as timely audits. Re-checking the transcribed data with the audio recorded was also done throughout the analysis to ensure the results could be confirmed or verified by others.²²

Ethical Consideration

Ethical approval was sought from Lira University Research Ethics committee (LUREC-2023-70). Administrative clearances were obtained from the management of Lira Regional Referral Hospital. We also sought permission from the unit in-charge of postnatal.

All eligible participants consented with a written informed consent form upon being given an explanation of the purpose, benefits, and risks of participating in the study. Participation in the study was entirely voluntary and no form of coercion was used. All participants informed consent included publication of anonymized responses.

Results

Participant’s Demographic Characteristics

A total of 15 healthcare workers attached to the department of Obstetrics and Gynecology attached to maternity and postnatal unit participated in the study.

The mean average age of participants was 37.933 with a standard deviation of 10.138. Of the participants; 93% female, more than a third attained certificate, 86.7% midwives, 46.7% were enrolled midwives (Table 1).

Table 1 Participants’ Socio-Demographic Characteristics

Presentation of Themes and Codes Generated in the Analysis

Thematic analysis was done and 199 codes were generated during the process, the main themes that were based on were deduced from the conceptual framework. It based on the drivers related to providers of care, health system-related factors as well as recipients of care-related factors. Twenty-five sub-themes were generated in the process and were categorized as positive drivers (facilitators) or negative drivers (barriers) of uptake of immediate postpartum modern contraceptives (Table 2).

Table 2 Themes and Codes Generated in Qualitative Data Analysis

Positive Drivers (Facilitators) to Uptake of Immediate Postpartum Modern Contraceptives by Study Participants (N=15) March, 2024

Drivers Related to Providers of Care

Participants identified providers’ knowledge and skills, training, ability to counsel the women, positive attitude of providers to facilitate its uptake among women. They believed that having well-trained providers with skills to provide counselling and administer the IPPMC would facilitate its uptake.

They need to train us we need to be trained by the responsible persons on what to do, because every time we are calling them from Family planning unit to do everything. (Participant 15, NO, 47, Female)

You know … when you talk to them well or counsel them, they get interested and some even take a method just because of how you treat them at delivery …” (Participant 7, Registered Midwife, 32, Female)

…me as a person I am so much interested in providing family planning and for providing these services to mothers … I have no problem with it. (Participant 3, NO, 39, Female)

… really I feel if everyone is trained, they will be able to provide these services, like me when we were trained at Lira university, we were able to implement the service provision (Participant 1, ANO, 50, Female)

Drivers Related to Health Systems

Majority of participants identified availability of contraceptive commodities, adequate staffing with skilled personnel, training and motivation to be the drivers to uptake of PPMC. Providers highlighted that mentorship of provider and availing of commodities motivates staff to counsel women and provide the contraceptive method to them.

Mentorship … if not we need CMEs, to teach the staff working in this unit, it would help us a lot because the CPDs or CMEs reminds you on what you are to do because if they don’t do it, you cannot provide the services well. (Participant 4, EM, 25, Female)

Motivation of health workers like your supervisors here like the SPNO, the director, they can send us for trainings or workshops … it’s a motivation that gives us the encouragements to work. (Participant 3, NO, 39, Female)

I think if only midwives or health workers working in the OBGY could be given some orientation on how to help these mothers, training everyone to have the knowledge to help these mothers … (Participant 1, ANO, 50, Female)

… being a, referral hospital, all that we do depend on the facility, if they provide for us, like the IUDs we can provide them to those in need. (Participant 11, MO, Male 44)

Drivers Related to Recipient of Care

The most identified facilitators related to recipient of care (postpartum women) are knowledge of women, healthcare providers support, health education and counseling, male partners’ support. Participants affirmed that prior knowledge of women, proper education during hospital visit, and previous use of any IPPMC method by women are positive drivers of its uptake.

There are those who come when they have the knowledge but others you talk to them, they understand then they take the methods. (Participant 2, SANO, 57, Female)

… actually, it’s now when you health educate them they understand very well the advantages of using the method, they always accept to take them yeah … (Participant 4, ANO, 50, Female)

… for me how you talk to them matters, if you talk to them well, they will accept to consent to take up the service. (Participant 9, Enrolled midwife, 28, Female)

Those who take the methods majorly come when they know … especially the educated women, they come when they already know what they want so I think knowledge is very important. (Participant 7, Registered Midwife, 32, Female)

Negative Drivers (Barriers) to Uptake of Immediate Postpartum Modern Contraceptives Among Study Participants (N=15), March, 2024

Providers of Care Related Barriers

The following barriers; lack of information on the IPPPMC, lack of knowledge and skills of providers reflecting individual deficiencies in competence that may persist even after training, negative attitude of providers, work overload were identified by participants as providers related factors. Participants cited poor attitude of providers due to personal reasons like religion, coupled with work overload as negative drivers of uptake of IPPMC. They believed inadequate knowledge and skills of providers negatively affect its uptake as they may not be in position to properly counsel and provide a method to a woman immediately after birth.

Attitude of the nurses who are working here, some their attitudes are not good, sometimes when they (mothers) come and you tell them things like this like that, they get discouraged. (Participant 14, EM, 36, Female)

… we lack the knowledge in the provision of some of those methods, like IUD, they only train you when you are in family planning … so some of us lack the knowledge and skills to counsel and offer the IPPMC. (Participant 3, NO, 39, Female)

I told you as me … I will actually have a challenge of informing these mothers about the artificial methods because my religion doesn’t allow me to give artificial methods however, I can health educate them on the natural methods and whoever is able to take the natural method can take but not the artificial one that is as me and being a catholic. (Participant 2, SANO, 57, Female)

Health Systems Related Barriers

Most participants identified stock-outs of commodities, poor coordination, lack of in-service training, Inadequate staffing as barriers related to health system referring to limited opportunities for structured capacity-building. Most participants cited infrequent distribution of contraceptive stock, lack training and inadequate staffing to negatively influence uptake of IPPMC. They noted that these reasons can affect how they provide the contraceptives to women subsequently affecting its uptake.

…. I can talk to them but these patients would like to see the samples of those things physically., here we don’t have the commodities it is in family planning… (Participant 12, OBGY specialist, 51, Female)

… it is not there hmm … the commodities are with Family Planning team and they are the ones who come and give them here when we call them. (participant 10, EM, 28, Female)

If we had enough staff…, actually lack of staff in the unit, if we had enough staff, you can do certain things and leave others to attend other things (participant 11, MO, Male 44)

Skills can affect the provision … if health workers are not knowledgeable about the counseling and giving correct information to mothers, you cannot convince them to take up the service. (Participant 2, SANO, 57)

Recipient of Care Related Barriers

Most participants identified limited knowledge of women, religious and cultural beliefs, male partners objection, inadequate access to information as barriers related to the recipients of care. The key barriers to uptake of IPPMC by women could be attributed to their differences in religious beliefs, knowledge and social support majorly by spouses. Participants identified women societal negative influences as key barriers.

Actually, most of them lack the knowledge but when they come here we normally health educate them ……. and you know some religions are also against these methods and you find that some resist the family planning that we offer … (Participant 7, NO, 32, Female)

The first one I talked of is religion as I indicated like catholic religion is always against the artificial methods of family planning … (Participant 14, EM, 36, Female)

… things which they also fear is the influence from their other friends who have used these family planning, earlier some of them tell them you will over bleed or when you are in your periods you get some complications … it makes them resist to take the methods. (Participant 11, MO, Male 44)

… some of them say my husband is too tough which may not allow me to come for any modern family planning method … (Participant 1, ANO, 50, Female)

Discussion

We aimed to describe the drivers of uptake of immediate postpartum modern contraceptives by postpartum women in Lira city, northern Uganda. We found both positive and negative drivers of uptake of immediate postpartum modern contraceptives related to providers of care, health system and recipient of care.

Positive Drivers (Facilitators) to Uptake of Immediate Postpartum Modern Contraceptives by Postpartum Women in Lira City, Northern Uganda

This study found that the facilitators to uptake of immediate postpartum modern contraceptives related to the providers of care are knowledge and skills to provide the services, ability to counsel, training and, positive attitude. This could be because trained providers have the confidence and have their values clarified in the contraceptive provision. This finding is similar to other studies in Tanzania and northern Uganda, which found that increased confidence following training continuous on-site mentorship as a facilitator to immediate postpartum intrauterine device (IPPIUD) uptake.^23,24 This finding is also in agreement with a study in England, which attributed providers knowledge and skills in contraceptive counseling as major drivers to uptake.²⁵ The similarities here underscore the need for strengthening training in counselling and value clarification and attitude change among providers of care.

The health systems factors driving the uptake of immediate postpartum modern contraceptives identified in this study were availability of commodities, availability of trained skilled staff, and motivation of healthcare workers. This is because training and availing commodities to providers empower and motivates them to provide commodities as they would have the necessary skills and commodities to provide to women. This finding agrees with other studies in Rwanda and Lothian, which cited that training of health care providers and availability of the supplies and improved staffing enhance uptake of immediate postpartum modern contraceptives.^26,27 The consistency in this finding could be attributed to the general health system challenges in the developing world, calling for strengthening of immediate postpartum modern contraceptive supply chain, adequate staff training and motivation to achieve contraceptive uptake in the immediate postpartum period.

The main facilitators related to recipient of care include awareness among women, healthcare providers support, health education and counseling during antenatal, labour and delivery, and male partners’ support. This is attributed to the reality that supportive environment, clear and accurate information motivates women to take up immediate postpartum modern contraceptives. This result is consistent with a systematic review in Sub-Saharan Africa, which found contraceptive counselling during antenatal care, delivery and postnatal care to have a great positive impact on its uptake.^28,29 The findings here underscore the need of continuous provision of accurate information to women, male involvement as well as adequate counselling during antenatal care in order to scaleup immediate postpartum modern contraceptive uptake.

The findings in this study elucidates the context of health care providers, health-system-related and recipients of care-related factors driving the uptake of immediate postpartum modern contraceptives among postpartum women in Lira city, northern Uganda. It adds to the evidence needed to improve the uptake of immediate postpartum modern contraceptives in the region by addressing context-specific areas identified.

Negative Drivers (Barriers) to Uptake of Immediate Postpartum Modern Contraceptives by Postpartum Women in Lira City, Northern Uganda

This study found the barriers related to providers of care to be lack of knowledge and skills, negative attitude of providers. This finding could be attributed to inadequate training given to health workers during pre-service where emphasis is not put of IPPMC services, and those not working in family planning unit who do not undertake refresher training, lack of support supervision and lack of confidence of some health workers to provide the methods like the IUCD. This finding is similar to a study done in Central Uganda, which found incompetence of health workers, lack of training and negative attitude as the main barriers to provision and uptake of immediate postpartum modern contraceptives.³⁰ This finding also agrees with a study conducted in Tanzania, which identified health workers fear of provision, lack of confidence and demotivation as barriers to uptake of IPPMC.²³ This accentuates the need for value clarification and attitude transformation training (VCAT) to all in service healthcare providers and emphasizes mandatory contraceptive training to all students at health training institutions (schools).

The barriers related to health system constraints were stock-outs of commodities, lack of in-service training, inadequate staffing. This may be due to the inadequate funding, breakdown in the supply chain and lack of prioritization of contraceptive commodities. This finding is similar to a study in central Ugandan and in Acholi sub-region in northern Uganda, which found presence of few trained staff, inadequate trainings at schools as barriers to provision of immediate postpartum modern contraceptives.^24,30 The similarity in these findings could be attributed to the nature of investments governments put in training of health workers stressing the need to improve funding, stock or commodity availability for all contraceptive methods at all times and continuous medical education and in-service training to update providers knowledge on all contraceptive method provision.

In this study, the barriers related to the recipients of care were limited knowledge, religious and cultural beliefs, male partners objection, peer influence and fear of side effects. This may be due to inadequate focused health education during ANC, lack of male involvement, as well as inadequate advocacy and sensitization of religious and cultural leaders. This finding is in agreement with a study in Nepal, which revealed that husband’s preference, family, peer, social influence against contraceptive uptake in the immediate postpartum period.³¹ Similarly, a study in Kenya found none provision of services, untimely counseling, and lack of information from the mothers as barriers to uptake of IPPMC.³² This finding stresses the need to educate and advocate for involvement of male partners, cultural and religious leaders in understanding the role of contraceptive uptake in the development and the health of the population as their involvement have a bearing on women’s decision making in the society.

Study Strength and Limitations

The study offers an in-depth exploration of the drivers of uptake of immediate postpartum modern contraceptives from the providers of care who interface with the women and the healthcare system dynamics. By focusing on immediate postpartum modern contraceptive uptake in northern Uganda, the findings gained contextual relevance, underscoring the need to strengthen its provision to women in their immediate postpartum period. The choice of participants (healthcare providers) for qualitative study ensured rich information sought from the participants. However, limitations include the relatively small sample size of 15 participants, potentially constraining the generalizability of results. Also, geographical choice of Lira city may hinder capturing diverse regional context underscoring the need of a longitudinal approach to gain a wider insight.

Practical Implications

The findings in this study underscore the need to strengthen health system to provide appropriate solutions to issues that negatively affects uptake of immediate postpartum modern contraceptives by women. Policies must prioritize designing of appropriate protocols, in-service training as well as equipping facilities to provide contraceptives to women immediately after their delivery. Providing these interventions will enable equitable and timely access of contraceptives by women and this will in turn lead to the improvement of maternal health outcomes.

Conclusion

This study found quite a number of barriers and health system constraints related to commodity unavailability, lack of staff training, and inadequate staffing, knowledge gaps and skills gaps as well as negative attitude of providers were also identified, and limited knowledge, religious and cultural beliefs, male partners objection, inadequate access to information, peer influence and fear of side effects were key barriers from recipients of care. The major facilitators include availability of commodities, improving staffing level, staff training, and timely education and counselling of women. Timely education and counselling of women during antenatal visits, labour and delivery with accurate information to facilitate informed contraceptive decision. Prioritizing value clarification of all stakeholders. Provision of continuous medical education and refresher training of all healthcare workers involved in maternity care. Improve contraceptive commodity supply at service delivery points to mitigate stockouts of immediate postpartum contraceptive commodities.