AOR: Adjusted Odds Ratio; ANC: Antenatal Care; COR: Crude Odds Ratio; ETB: Ethiopian Birr; FP: Family Planning; HCs: Health Centers; IUCD: Intra Uterine Contraceptive Device; LAM: Lactation Amenorrhea Method; PNC: Postnatal Care; PPFP: Postpartum Family Planning; SRS: Simple Random Sampling; SPSS: Statistical Software for Social Sciences; WHO: World Health Organization

A mother’s health has become one of the important agendas in the development of a nation. The postnatal period is especially critical for mothers as most deaths of mothers occur within this period. This time is an ideal time to deliver interventions that improve the health and survival of mothers. An important element that has been identified in women’s health care is sexual practice and family planning during the postpartum period [1,2]. In developing countries, the rapid population growth is attributed to high levels of fertility. Modern contraception has been proven as the most effective method for fertility reduction. Effective contraception also prevents unintended pregnancy and ensures adequate birth spacing. Pregnancy and child birth changes a woman’s priorities, attitudes, lifestyle, sexual behaviors, the decision for contraceptive uptake, and the preferred contraceptive method [3-7]. Postpartum family planning (PPFP) is defined as the prevention of unintended pregnancy and closely spaced pregnancies through the first 12 months following childbirth [5,6,8]. It is the initiation and use of contraceptives during the first year after delivery [9]. During postpartum period, Family planning (FP) can prevent about 30% of maternal mortality and 10% of child mortality if couples space their pregnancies more than 2 years apart. In contrary, closely spaced pregnancies within the first year postpartum increase the risks of preterm birth, low birth weight and small-for-gestational-age babies. The risk of child mortality is highest for very short birth-to-pregnancy intervals (i.e. less than 12 months). The timing of the return of fertility after childbirth is variable and unpredictable. Women can get pregnant before the return of menstruation [3,5,8,10,11]. Global and national policies have refocused attention on PPFP as an important intervention to ensure healthy outcomes for women and infants [12]. Uptake of PPFP remains low in sub-Saharan Africa and very little is known about how pregnant women arrive at their decisions to adopt PPFP [11]. The postpartum period is an important intervention for improving access to FP service. Postpartum women are among those with the greatest unmet need for FP. Significant factors influencing the uptake of FP are likely to be: level of education, antenatal and postnatal FP counseling, menses return, breastfeeding status, and return of sexual activity [13-18]. Modern contraceptive use by currently married Ethiopian women has steadily increased over the last 15 years, jumping from 6% of women using modern contraceptive method in 2000 to 35% in 2016 [19]. In Addis Ababa and Dire Dewa, 55% and 21% of childbearing women adopted modern Postpartum family planning (PPFP) respectively [20]. About 86% of the women in Ethiopia have an unmet need during their first year postpartum, but only 8% are using any method of family planning. Only 5% of women during the 12- month postpartum period desire another birth within two years [6,14,21-23]. Though the World Health Organization (WHO) recommends that pregnancies be spaced by at least 24 months, nearly half (47%) of postpartum women have short (<23 months) birth-topregnancy intervals in Ethiopia [6]. Resumption of sex exposes postpartum mothers to risk of unintended pregnancy even before return of menstruation after delivery. Nearly half, (47%), of women use contraceptive during the extended postpartum period. Among those, 10 (2.4%) women adopted family planning in the first 42 days after delivery, 76 (18%) during the first three months and 156 (37%) during the first six months after delivery. The most commonly used method during extended postpartum period was injectable, which accounts to 77%. Discussion with husband, knowledge of FP and use of antenatal care (ANC), postnatal care (PNC) and child immunization services was positively correlated with likelihood of using PPFP [24]. Many of the studies focus on the socio-economic, cultural and physical barriers which women need to overcome in order to adopt a method of contraception. However, less attention has been paid to FP uptake among postpartum women. Therefore, this study aimed to assess the prevalence and determinant factors of utilization of contraceptive methods among postpartum women in public health institutions Debre Berhan town, Ethiopia. The result of the study can be used to develop educational programs and effective PNC strategies on postpartum FP.

Study setting and participants

A facility-based cross-sectional study was conducted in public health institutions of Debre Berhan town from March 1-15, 2016. Debre Berhan town is a capital of North Shewa Zone of Amhara regional state, Ethiopia. The town is situated 130 kilometers to the Northeast of Addis Ababa, on the main route of the country’s corridor which connects the capital city of Ethiopia, Addis Ababa, with Tigray Regional State. There are one public referral hospital and three Health Centers (HCs) in this town. Around 250, 200, 70 and 30 mothers’ accessed service from Debre Berhan referral hospital, Kebele 04 HC, Kebele 07 HC and Kebele 08 HC respectively within 14 weeks postpartum since the previous year. The study participants were postpartum women who came for postnatal care (after six weeks postpartum) or brought their babies for immunization and/or come for family planning (within 14 weeks of postpartum). Critically ill women and those who didn’t consent for participation were excluded from the study.

Sample size and sampling technique

This study was done on 248 postpartum women. Sample size was determined using the single population proportion formula considering 95% confidence level, an expected proportion of women who resumed sexual intercourse within six weeks postpartum of 57.8% [1] and marginal error of 5%. Study participants were selected from all public health institutions in the town with proportional allocation to population size (i.e. client flow) using simple random sampling (SRS) techniques.

Data collection and study variables

Pre-tested interviewer-administered questionnaire was used to collect data. The questionnaire comprise of socio-demographic characteristics of the participant, maternal medical and obstetric history, postpartum sexual history, and postpartum family planning utilization. Questionnaire was adapted from previous literatures [1,25-27], and prepared in English and translated to Amharic. Completeness and consistency of data was checked on daily basis. The dependent variable was Postpartum family planning (PPFP). Resumption of sexual intercourse was defined as having the first penetrative sexual intercourse after childbirth. In this study postpartum is the period beginning immediately after the child birth and extending for about six weeks. Modern family planning includes male/female sterilization, pills, Intra Uterine Contraceptive Device (IUCD), Injectable, Implants, male/female condom, Lactation Amenorrhea Method (LAM), Emergency Contraception (EC).

Data management and analysis

Data was entered and cleaned using EpiInfo version 3.5.4 and analyzed by SPSS software version 20. Descriptive statistics were used to summarize findings: means and standard deviations for numerical variables, and frequencies along with percentages for categorical variables. The prevalence of early resumption of sexual intercourse was computed as the proportion of participants who resumed sexual intercourse before end of six weeks postpartum. Binary logistic regression was performed to determine the factors associated with PPFP. A crude odds ratio with 95% confidence interval was calculated for all variables included in the bivariate model. A multivariate analysis was performed to determine the independent effects of the explanatory variables. All variables found significantly associated at p-value<0.05 with postpartum family planning use in the bivariate analysis were selected for multivariate analysis. A 95% confidence interval that excludes the null value, 1, indicates statistical significance.

Participants socio-demographic characteristics

A total of 248 postpartum mothers were interviewed giving 100% response rate. Majority of the mothers (41.5%) belongs to 25-29 years age group with mean age of 27.40 (± 4.96 SD). Majority of the women, 209 (84.3%), were follower of Orthodox Christian by religion, and about 225 (90.7%) of the study participants were from Amhara by ethnicity. Of the study participants, 100 (40.3%) were housewife; 78 (31.5%) had attained elementary level of education; and 226 (91.1%) were married and in-union. About 184 (49.3%) had delivered their second child; and 243 (65%) of their spouses had attained secondary level of education (Table 1).

Table 1: Socio-demographic characteristics of the postpartum women in Debre Berhan town public health institutions, Ethiopia, May 2016.

Postpartum sexual characteristics of study participants

Overall, 63 (25.4%) postpartum mothers were reported resumption of sexual intercourse during the first six weeks after childbirth.

The earliest time was within the first week of postpartum. Majority of the women (92.3%) did not receive any advice about postpartum sexual intercourse (Table 2).

Table 2: Postpartum sexual characteristics of postpartum women in Debre Berhan town, public health institutions, Ethiopia, May 2016.

Postpartum family planning utilization

Out of 248 interviewed, 238 (96%) women had information (awareness) about family planning. But, only 82 (41.6%) women of those who had awareness started using contraceptive. Partners feeling towards the using of contraceptive method during postpartum period was found positive (Table 3).

Table 3: Postpartum family planning utilization by postpartum women in Debre Berhan town public health institutions, Ethiopia, May 2016.

The reasons why the women do not use postpartum contraceptive

Among the women who do not use contraceptive during postpartum period, most of them [197 (54.6%)] reason out using contraceptive is not necessary as they were not started sexual activity (Figure 1).

Figure 1: Reasons for why postpartum women do not use contraceptive methods in Debre Berhan town public health institutions, Ethiopia, May 2016.

Also only 21(8.7%) women have information about safe contraceptive method for lactating mothers.

Association between participants characteristics and contraceptive utilization during postpartum period

Starting sexual intercourse during the first six weeks postpartum was associated with the utilization of family planning during postpartum period.

Those women who resumed sexual intercourse during the first 6 weeks postpartum were used contraceptive methods two times than those who did not resume sexual activity.

Also the timing of resumption of sexual intercourse and return of menses were found to be associated with postpartum family planning utilization.

Women who had saw menses and started sexual intercourse during postpartum period were two times more likely to use postpartum family planning within the first six weeks than those who didn`t see menses and initiated sexual intercourse (Table 4 and Figure 2).

Figure 2: Flow chart indicating sample processes of postpartum women among Debre Berhan town public health institutions, Ethiopia, May 2016.

Table 4: Determinants of postpartum family planning utilization among postpartum women of Debre Berhan town, Ethiopia, May 2016.

This is a facility based cross sectional study in an attempt to assess postpartum family planning use during the first 6 weeks after child birth. The mean age of study subjects was 27.40 (± 4.96) with the youngest mother is 18 years and oldest being 42 years which almost similar with the study conducted in 6 Addis Ababa. Majority of study participants were Orthodox (84.3%) by religion and Amhara (90.7%) by ethnicity. Likewise, research conducted in Addis Ababa revealed similar findings [1]. Among 248 study participants, only 63 (25.4%) had resumed sexual intercourse during postpartum period within the first six weeks, which is lower compared to the result of the study done in Ethiopia [1] and Nigeria [25]. This may be attributed to over dominance of Orthodox religion followers of study participants and their strong adherence to their religion. But regarding the time of resumption of sexual intercourse, earliest time was within the first week which was similar with study done in Addis Ababa [1] but shorter compared to study conducted in Uganda [27] and Nigeria [25]. This difference may be attributed to cultural difference.

Women stated many reasons as to why they resumed sexual intercourse within 6 weeks of postpartum period. The demand by husbands (85.2%) was an important factor as reported by the women. It is so far higher than similar study conducted in Ethiopia [1] which was indicated to be 31.6%. The other reason for sexual resumption includes: feeling comfortable (54.5%), fulfilling cultural demands (28.4%). This is comparable with the result of the study done in Ethiopia [1] but higher than the result of the study conducted in Uganda [27]. This may be due to cultural differences. In this study significant number (21.0%) of mothers experienced some sort of health related morbidity including. This was similar to that study conducted in Ethiopia [1] and in Uganda [27] which was 21.1% and 22.2% respectively. Other studies conducted where also indicated similar finding [21,26,28]. On the other hand, the reasons stated for not resuming sex included: husband was away, religion expectation, no interest, poor self-image, not feeling good secondary to stitch or Cesarean section done, health profession advices, cultural prohibition, not start to see menstruation. These are similar reason listed in the study conducted in Ethiopia [1] and Uganda [27]. Religion expectation is the major reason why the women do not resume sexual intercourse during puerperium.

Only 7.7% ever received an advice from a health care provider about postpartum sexual activity which is lower compared to study conducted in Ethiopia [1]. Among study participants 41.6% were currently started using contraceptive methods. This result is comparable with the result of the study conducted in three African countries [29] but slight lower than the result of the study done in Ethiopia [1]. Resumption of sexual intercourse, time of initiation of sexual intercourse and return of menses were found to be significantly associated with postpartum family planning utilization by postpartum women. This association also shown in the study conducted in different African countries [21] and in Addis Ababa [1].

Only 25.4% of the study participants resume sexual intercourse within 6 weeks of postpartum. Postpartum family planning utilization is low in the study area. Injectable contraceptive methods were the most preferred choice among respondents in the study. Those who resumed sexual intercourse before 6 weeks and who had seen menses were more likely used postpartum contraceptive methods. Resumption of sexual intercourse, time of initiation of sexual intercourse and return of menses were found to be significantly associated with postpartum family planning utilization by postpartum women.

Family planning service providers and all health care providers should focus specifically on immediate postpartum contraception by providing health education on fertility return behaviors, benefits of breastfeeding in preventing unintended pregnancies within the first six months postpartum and initiation of contraception before the return of menses or resumption of sexual activity as conception could precede return of menses after delivery. Strengthening family planning counseling, integrating PPFP with maternal and child health service delivery and promoting PPFP should be recommended.

Derara Workineh and Takele Gezahegn conceived and designed the study. Derara Workineh, Takele Gezahegn, Tufa Kolola, Tigist Demissew, and Helen G Libanos were involved in the conduct, analysis, data interpretation, and report writing. Takele Gezahegn drafted the manuscript and reviewed, edited and finalized the manuscript. All authors have read and agreed to the final manuscript.

We are thankful to Debre Berhan University for material support and to Debre Berhan town public health institutions for their cooperation. We are also thankful to the study participants for their voluntary participation.

The authors declare no competing interest or no conflict of interest.

Ethical clearance was obtained from the Ethical Review Committee of Debre Berhan University, Institute of Medicine and Health Sciences. A formal letter was obtained from the department of Public Health, Debre Berhan University and Health Department of North Shewa Zone. All participants were given detail information about the purpose of the study, no names were used to report findings and informed verbal consent was obtained from all participants for their willingness to participate in the study.

There is limited literature about PPFP utilization. Also most of them are reports and reviews. This paper presents primary data about the utilization of PPFP. Postpartum family planning utilization is low. This indicates that much has to be done in the future to increase utilization and integration of PPFP with other services. Health education should be provided on fertility return behaviors, and initiation of contraception before the return of menses or resumption of sexual activity.