Barriers to Immediate Post-Partum Intra-Uterine Contraceptive Device Uptake among Mothers Delivering at Meru Hospital

Global contraceptive use is at 64%, Africa lagging behind at 33.4%. Kenya has an unmet need for family planning at 23%. Hormonal injections are the most used in Africa at 9.8% and Intra-Uterine Contraceptive Devices at 3.8%. Low uptake of 3.4% was reported in Meru Hospital and lack of literature on immediate Post Partum Intra Uterine Contraceptive Device (PPIUCD) uptake. Immediate Post Partum Intra Uterine Contraceptive Device is a long acting reversible contraceptive device inserted into the uterus immediately within 48 hours after delivery. The objective was to assess Barriers to Immediate Post-Partum Intra-Uterine Contraceptive Device uptake among Mothers delivering in Meru Hospital. Descriptive research design was used and a population of 289 mothers was targeted. Sample size of 74 respondents was selected using simple random sampling. Questionnaires and interview schedules were used to collect data. The collected data were entered and analyzed using Statistical Package for Social Science windows version 23.0. Descriptive analysis was used to obtain frequencies and percentages. Chi-square was used to test the relationship of study variables and presented in tables. The qualitative data were analyzed thematically. The findings revealed that provider related barriers such as none provision of the services and untimely counseling for the insertion had the highest impact to low uptake (57%). Clients lacked information where 68% reported that they were not counseled. Demographic and reproductive characteristics also played a role in low uptake. Using the chi square test, there was a significant relationship, P = 0.001 between young age of the mothers, unemployment (53%), low parity (56%) and low uptake. Preference for other alternative contraceptives (25.8%) such as hormonal methods was a barrier to the uptake. Therefore, barriers to PPIUCD uptake are provider related, alternative methods of contraception and client related such as lack of information, unemployment, young age and low parity. The How to cite this paper: Kirigia, C., Gitonga, L. and Muraya, M.M. (2019) Barriers to Immediate Post-Partum Intra-Uterine Contraceptive Device Uptake among Mothers Delivering at Meru Hospital. Open Journal of Obstetrics and Gynecology, 9, 312-325. https://doi.org/10.4236/ojog.2019.93032 Received: January 30, 2019 Accepted: March 1, 2019 Published: March 4, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
Global stabilization of population depends on successful reduction of obstacles to contraception services [1]. The obstacles must be identified for effective era- reduce maternal death in developing countries [2].
Two hundred and fourteen million women of reproductive age who want to avoid pregnancy in developing countries are not using a modern contraceptive method [3]. Contraception is the key to slowing unsustainable population growth and the resulting negative impact on the economy by having the desired number of children for every parent. In the Sub Sahara African, the contexts for population and family planning include weak policies supporting family planning and inadequate resources [4]. In contrast most countries in Africa, Latin America and Asia have strong policies that strongly support family planning programs in population control [4]. Global contraceptive use stands at 64%, with Africa lagging behind at 33.4%. The Pills and injections are the most commonly used in Africa at 8.7% and 9.8%, respectively (United Nations Department of Economic and Social Affairs (UNDESA), 2015). Intra Uterine Contraceptive Device (IUCD) utilization is at 3.8% while implants are at 2.3% and male condoms at 2.1%. Kenya has an unmet need for family planning at 23% (Kenya Demographic Health Survey (KDHS), 2014).
Despite PPIUCD having several benefits such as preventing unwanted pregnancies due to early resumption of sexual activities and unpredictable ovulation after delivery, its uptake is low. An uptake of as low as 3.4% was reported in Meru Hospital, out of target of more than 50%. The PPIUCD uptake was not well documented and there was little information on the factors that hinders its uptake. Moreover, studies on the use of immediate PPIUCD were limited in Kenya. The main objective of the study is to assess barriers to immediate Post The research findings serve as the source of knowledge to inform the hospital management on significant barriers to immediate PPIUCD uptake. The report provides an evidence base in problem solving related to PPIUCD family planning method. This helps in planning for interventions to increase from the low uptake of 3.4% to the hospital set target of 6% by the end of the year 2018.
According to a study on impact of health education on unmet needs of contraception in urban slums of Chandigarh India, lack of awareness of contraception methods contributes to low uptake of PPIUCD. Awareness here means that the mothers did not hear or see any advertisement about FP in the last 6 months or did not participate in any educational session about FP during last 6 months hence contributing significantly to low contraception uptake [5]. Lack of knowledge was also evident in Nyanza western Kenya in a study by Pauline et al. [6] who found that lack of contraception awareness and low uptake is related to none visit to antenatal clinic where education on family planning is mostly done.
Social demographic characteristic also contribute to low uptake. In a study on factors influencing contraceptive non-use among women of advanced reproductive age in Nigeria by Bola et al. [7] found that socio-demographic characteristics exert more influence on non-use. There was a significant relationship between non use and current young age where three-quarters of the non-users were 21 -30 years old related to the desire to get children early in marriage. None use was significantly influenced by woman's occupation as a housewife [8] in Nyanza western Kenya in a study on overcoming barriers to family planning through integration. As well, other studies revealed that the contraceptive use was found higher among employed women (67%) than that of unemployed women [9].
Reproductive characteristics of the mothers are some of the barriers to the uptake [10]. In a study of postpartum intrauterine contraceptive device acceptance between primiparous and multiparous women in a tertiary care centre, acceptance of PPIUCD was significantly higher in multiparous women than primiparous [10]. Number of living children, and child preference were found to be significantly associated with current use of contraception [9]. Cultural Norms,

Myths, Concerns and Miss Conceptions are other barriers.
Having bad belief about FP, e.g. loop can penetrate the heart, injection can cause infertility, pills can cause cancer, child-bearing is more comfortable at younger age, non-traditional methods of FP can harm the woman's health, are Open Journal of Obstetrics and Gynecology all related to culture [7]. Similarly in a study on barriers to modern contraceptive uptake among young women in Kenya by Rhoune et al. [11], revealed the main barrier to be a misconception from social networks that modern family planning causes infertility. In a study on midwives' views on PPIUCD [12] at nine wells hospital Dundee U.K, Lack of provider confidence, training and experience on insertion of PPIUCD is evident. It is the responsibility of a health care provider to ensure men's active involvement in reproductive healthcare which has shown to be positively associated with maternal and child health outcomes.
According to a study on Barriers affecting utilization of family planning services among rural Egyptian women by Eltomy et al. [1], the study explored the various types of reported barriers for both the discontinued group and the non-users. Service provider's negative attitude, shortage of staffs, protocols requiring woman to be on her period to start hormonal or IUCD methods contributed to low uptake. Concerning barriers related to the method by Bola et al. [7] more than half of the women who had discontinued using contraception had a desire to have a more effective method. This could be due to past experience of failure of the method or the presence of side-effects.

Study Site
Study was carried out in postnatal ward, maternity department of MH for a period of two months. The hospital is the main county referral hospital located in the urban part of the county at the outskirts of Meru town. Patients are referred from rural health facilities within the county for specialized services like obstetric and gynecological services and for attention by senior midwives among others. MH is a teaching hospital for students from various medical schools within the Mount Kenya region.

Study Design
A descriptive research design was used to determine answers to the study questions at MH in the months of June and July 2018. This was a social science research therefore need for descriptive answers to the study questions. The purpose of social science research is to explore, describe and explain a phenomenon [13].

Sampling Procedure
Due to few number of mothers inserted the device, a census was carried out for all mothers that were inserted. For non-inserted mothers group, a sample size of 74 respondents was used as a representative to the target population of 289 mothers. Respondents selection was done through simple random sampling procedure. The sample size was derived according to Nassiuma [14]. According to Nassiuma [14] coefficient of variation of at most 30% is acceptable in most surveys. In this study a coefficient of variation of 20% was used and a standard error of 0.02.
Nassiuma [14] gives the formula as follows; Sample size

Inclusion and Exclusion
Inclusion criteria depended on the mandatory characteristics that the subjects needed to have if they were to be included in the study. In this study the inclusion criteria was the mothers willing to participate in the study. Those who did not have the insertion and willing to participate were included to determine uptake barriers. Exclusion criteria were those characteristics that disqualified the subjects from inclusion in the study. In this study the exclusion criteria was those mothers who were not willing to participate in the study and those who had the insertion.

Data Collection Procedure
This study was carried out in postnatal ward, maternity department of MH for a period of two months. The Subjects consented before the interview and filled in the questionnaires with the assistance of the researcher where necessary. The consent followed a detailed explanation on the nature and purpose of the study.
Data collection was done in a private side room or a screened bedside depending on the client's general condition.

Data Collection Instruments
Data collection was carried out using structured questionnaires as the primary tools and interview schedules to gather qualitative and quantitative data. The questionnaires were divided into sections. Section A gathered the information Open Journal of Obstetrics and Gynecology

Pretesting
The data collection tools will be pretested at Embu level five hospital. The facility offers same services to mothers with similar characteristics to those in MH. Pretesting will be done in order to fish out wording issues and questions that are ambiguous and difficult to answer. 10% of the sample size will be interviewed during pretesting. This will also help the researcher estimate the length of time taken to fill one questionnaire and entire data collection period.

Establishing Reliability and Validity
Establishing reliability and validity is to determine repeatability and accuracy of data correction instruments respectively. To establish reliability, pretesting of the instruments was done using split-half reliability coefficient. To establish validity, a review of literature was done to compare and contrast the instruments with research findings from similar instruments in other studies. Moreover, consultations of experts from the department to judge and determine the completeness of the instruments was done.

Data Analysis
The collected data was entered and analyzed using statistical package for social science (SPSS) for windows version 23.0. Descriptive analysis was used to obtain frequencies and percentages. Chi-square was used to test the relationship of study variables. Interview schedules were analyzed thematically in relation to study objectives and the analyzed data presented in tables and narratives. Table 1 shows the demographic and reproductive characteristics of respondents.

Age
The mothers aged between 20 -30 years had the highest number (68%) of Open Journal of Obstetrics and Gynecology PPIUCD non uptake, followed by those above 30 years at 18%, 15 -19 years 9.5% and those below 15 years had the least number of uptake at 2.7%. this coincides with a study on factors influencing contraceptive non-use among women of advanced reproductive age in Nigeria by Bola et al. [7] found that; Socio-demographic characteristics exert more influence on non-use. There was a significant relationship between non use and current young age, Three-quarters of the non-users were 21 -30 years old related to the desire to get children early in marriage.

Parity
Most respondents were para 1 -3, 56%. Para 0 + 0 were 23.7%, more than para 3, were 20.3%. This affirms that acceptance of PPIUCD was significantly higher in multiparous women than primiparous in a study of postpartum intrauterine contraceptive device acceptance between primiparous and multiparous women in a tertiary care centre [10]. Number of living children, and child preference were found to be significantly associated with current use of contraception [9].

Employment Status
Most non users were unemployed 53.0%, followed by those who were self employed at 31.1%, and the least number of non users had salaried employment at 14.5%. This approves that non use was significantly influenced by woman's occupation as a housewife [7]. As well, other studies revealed that the contraceptive use was found higher among employed women (67%) than that of unemployed women [9].

Other Client, Provider and Method Related Barriers
Most respondents as shown in Table 2 who were the non users 57.0% were not given any information on PPIUCD. 32.1% were given information but refused to consent for insertion. 4.1% were informed and consented but the service was not offered to them. 4.1% had a problem therefore did not meet the insertion criteria. 2.7% consented, insertion done but unsuccessful while the other waited for the spouse to consult but did not come. It collaborates to a study on Barriers affecting utilization of family planning services among rural Egyptian women by Eltomy et al. [1], the study explored the various types of reported barriers for both the discontinued group and the non-users. Provider related barriers were reported barriers that lead to not using or discontinuation of FP methods which included service provider's negative attitude and shortage of staffs.
According to Table 3 the mothers who were given information on PPIUCD but did not consent for the services opted for alternative methods of family planning 25.8%. 2.7% had fears of myths and misconceptions, 2.7%, refused to consent because of staff negative attitudes, poor and services. 2.7% refused to consent because they had previous bad experience and side effects on this type of method, 1.4% was not married therefore they did not need family planning methods and the other 1.4% was on the basis of religion. 77% did not refuse to consent for the insertion. Similar to a study concerning barriers related to the method by Bola et al. [7] more than half of the women who had discontinued using contraception had a desire to have a more effective method.
In In Table 5 68% said that they were not given counseling services on PPIUCD insertion and the few who were counseled, it was done after delivery in postnatal ward 12.2%, during antenatal period was 6.8%, 5.4% was counseled on admission, 5.4%.   Lack of confidence, training and experience on insertion of PPIUCD is evident in a study on midwives' views on PPIUCD [12] at ninewells hospital Dundee UK [15]. In other respects, lack of enough providers or shortage of staffs contributed to delayed services in a study on midwives' views on PPIUCD [12] at nine wells hospital Dundee U.K.
This contradicts to a study concerning barriers related to the method by Bola et al. [7] more than half of the women who had discontinued using contraception had a desire to have a more effective method. This could be due to past experience of failure of the method or the presence of side-effects.

Conclusions and Recommendations
The identified barriers to PPIUCD uptake are provider related which include non-provision of contraception services and untimely counseling for PPIUCD insertion. Method related barriers include alternative methods of contraception related to previous bad experience and side effects. Client related barriers include lack of information on PPIUCD, young age, low parity and unemployment.
The following recommendations were made based on the research findings. 1) From the findings of the study, young age, low parity and unemployment contributed to low uptake of PPIUCD. Sensitization on this method of family planning should target this group of mothers who are young aged, those with low parity and the unemployed. Lack of knowledge on the availability of PPIUCD services influenced low uptake. Reproductive health department should put community based strategies in place to create awareness of PPIUCD services in the hospital, given that lack of awareness is a key barrier to the uptake. 2) According to the results, either non-provision of the services or untimely counseling for the insertion contributed to the low uptake of PPIUCD services. The hospital administration should ensure that continuous education and job training are done to the providers. Staff motivation and staffing issues should be addressed for improvement of service delivery given that providers played a major role in low uptake. a) less than 6 months ago b) more than 6 months ago c) can't remember d) never heard 12) a) Why was the insertion of PPIUCD not done to you after this delivery? i) I refused to consent for insertion ii) I was not given information on PPIUCD insertion iii) I had a problem therefore did not meet the insertion criteria iv) I was informed and consented but service not offered to me v) Others, specify b) In case you refused to consent, why?
i 6) What method have you been using before?