Determinants for Utilization of Post-Partum Intra-Uterine Contraceptive Device: A Cross-Sectional Study

Introduction:

India is facing population explosion with current growth rate of 1.19% (2016)^[1], the second most populated country in the world. Rising population and limited resources makes it important for India to take necessary steps to control the population growth of the country. As a result, India was the first country to start Family Planning programme in 1952^[2].

With rising number of institutional deliveries, Government of India (GoI) implemented a program to strengthen its post-partum family planning (PPFP) services. The first training for PPIUCD was given in 2009. The provision of PPIUCDs is being rapidly scaled up in India, with facilities in at least nineteen states offering the method in 2013.^[3]

The Total Fertility Rate (TFR) of India is 2.2 as per NFHS 4 and the unmet need in 12.9%. ^[4]There are around 25 districts in the state of Madhya Pradesh, which have high Total Fertility Rate. Sehore district of Madhya Pradesh is one of the 145 identified districts under "Mission ParivarVikas" as the TFR of Sehore is more than or equal to 3.0. These 145 districts spanning over seven high focus states, constitute around 28% of India's population, around 30% of maternal deaths and approximately 50% of infant deaths of the country.®

Postpartum period is a critical time when women are vulnerable to unintended pregnancy. Pregnancies taking place within 24 months of a previous birth have a higher risk of adverse outcomes like abortions, premature labour, postpartum haemorrhage, low birth weight babies, foetal loss and maternal death.

Demographic and Health Survey show that 40 percent of women in the first year postpartum intend to use a family planning (FP) method but are not doing so. Institutional deliveries have increased significantly all across the country, thereby creating opportunities for providing quality postpartum family planning services.

It is important to know about the satisfaction of beneficiaries with the service provision. Whether positive or negative their experiences and feedbacks are valuable. As India is striving to achieve replacement level fertility, it is crucial to focus on the quality of family planning services delivered.

Incorporating women's perspectives into contraceptive introduction strategies can help local family planning programmes to increase user satisfaction, improve continuation rates, and expand method use.

The purpose of the study was to assess the level of satisfaction amongst the acceptors of PPIUCD, identify the reasons for removal of PPIUCD amongst the beneficiaries,and to assess the quality of PPIUCD related counselling given to Antenatal women.

Results:

Results of PPIUCD service provision and beneficiaries' perspective:

The Mean age of beneficiaries included in the study was 23.69 years with the range of 18 to 40 years. Around 70% of the beneficiaries had education of secondary level and above, only 15.3% of the total acceptors of PPIUCD were uneducated. Moreover, higher acceptance was seen among the primiparous women as compared to multiparous.

shows the results for fertility intentions, counselling for family planning services, timing of counselling and its source and whether women were offered the basket of choices available to them.Our study result shows that contradictory to the ethics of offering the entire basket of family planning methods to the women, 79.6% of the were not informed about all the available methods for family planning.

Table 2 shows the details related to the decision maker for acceptance of PPIUCD, timing of decision making, adverse events experienced and its type, medical help sought for the adverse events, satisfaction with PPIUCD and reason of removal in case of the removal of PPIUCD. 45.1% of the beneficiaries were not asked of their willingness to get PPIUCD inserted.

The results in the study show that around 51.4% faced some or the other adverse effects like abdominal pain, irregular menstruation (including heavy menstrual flow or longer than normal duration of menstruation) and expulsion.

Table 3 shows the results of Chi Square test run between Level of Satisfaction amongst women who accepted PPIUCD and Education Level, Removal of PPIUCD, Women who experienced complication post PPIUCD insertion, the Decision Maker for acceptance and women who received counselling. We found statistically significant association between level of satisfaction and all the independent variables except level of education of the women.

Table 4 shows the results of Chi Square test between women who underwent removal of PPIUCD and dependent variables such as Parity, Women who experienced complication post PPIUCD insertion, the Decision Maker for acceptance and women who received counselling, Education Level and found a statistically significant association of PPIUCD Removal with Women who experienced complication post PPIUCD insertion, the Decision Maker for acceptance and women who received counselling.

As per the test results of Binary Logistic Regression with 'PPIUCD removal' being the dependent variable and Parity, Education level, Decision maker, Counselling, Experience of complication as Independent variables, it was found that the women who have experienced complication have 4.002 times higher odds of getting PPIUCD removed as compared to those who have not experienced any complications, keeping parity, decision making, education level, and counselling to be constant (p= <0.001, OR= 4.002). Also, the women who received counselling were 69.9% less likely to get PPIUCD removed as compared to those who did not receive counselling, keeping parity, decision making, education level, and experience of complication to be constant. (p= 0.003, OR= 0.301)

However, the results of binary logistic equation after adding Satisfaction level along with Parity, Education level, Decision maker, Counselling, Experience of complication as Independent variables, found that women with indifferent level of satisfaction are 62.3% less likely to get PPIUCD removed as compared to women who were dissatisfied after PPIUCD insertion, keeping Parity, Education level, Decision maker, Counselling and Experience of complication to be constant. (p= 0.020, OR= 0.377) Also, women who were satisfied with PPIUCD insertion are 97.4% less likely to get PPIUCD removed as compared to women who were dissatisfied after PPIUCD insertion, keeping Parity, Education level, Decision maker, Counselling and Experience of complication to be constant. (p= <0.001, OR= 0.026)

The classification table showed that there is almost 80% of correct classification of the data. The R2 showed that the model's fitness is good.

Results of 'Quality of Counselling' assessment: (Counselling for PPIUCD)

The common gaps observed during counselling were failure to encourage the women to explain her needs and concerns, lack of involvement of husband or family member during counselling session failed to explore the partner or family's knowledge regarding the return of fertility or benefits of spacing birth and their attitude regarding the use of family planning method.

Out of the entire set of information that the counsellor has to provide, the staff nurses disseminated the information partially. The women were informed about the benefits of spacing birth, the risk of pregnancy after the return of fertility. However, they were not offered the basket of family planning methods.

It was noticed that in all the counselling, the counsellor helped the women to arrive at a choice and gave her additional information if needed to arrive at a choice and supported her choice.

With the focus on counselling regarding PPIUCD, all the staff nurses evaluated the women's health if she can use the method safely, discussed the key information about PPIUCD such as its effectiveness and reversibility. But, not all the information regarding the advantages and specially the limitations and warning signs were disseminated.

Discussion:

The study findings show that the mean age of PPIUCD acceptors was 23.69 years; this was almost similar to the study done by Somesh Kumar et al where the mean age of the study participants was 24 years.^[3]

Ranjana et al in their study found that majority of the women accepting PPIUCD were literate. ^[6] In addition, Ashutosh Sharma and Vinita Gupta in their study found higher acceptance of PPIUCD amongst women having secondary level of education. ^[7] This is similar to the results found in our study, where only 15.3% of the women were uneducated. Others had gained some level of education with 70.2% of them having at least secondary education or above.

The study results show that more than half of the women who accepted PPIUCD were primiparous which is similar to the study done by RajniGautam et al where primiparous women showed highest percentage of acceptance.^[8]

All the women visiting the facility either for antenatal care or for institutional delivery should receive the counselling. Contradictory to this 29% of the beneficiaries reportedly received no counselling regarding family planning methods and specially regarding PPIUCD.

One of the purpose of the study was to know about the decision maker for accepting PPIUCD. However, 45.1% of the women responded that they were not asked about their willingness to adopt PPIUCD. They said that the insertion of PPIUCD was done without their knowledge and they were informed later about the insertion during their stay in the hospital. Few of the beneficiaries complained that insertion was done against their wish and the hospital staff informed that insertion of PPIUCD was compulsory for all the women coming for institutional delivery under the government scheme. The probable reason behind this could be to achieve the established goal of family planning and for earning the incentives. Moreover, even after the insertion, women were not given any information about the advantages adopting PPIUCD, its limitations regarding the protection from STIs and its adverse effects. While amongst the rest, majorly it was either the women alone or women with her family members who decided about the family planning method to choose. However, few women said it was their husband, mother-in-law, mother or sister made the decision. Another study also stated the higher acceptance of PPIUCD among the women who received support from family and husband for the same. ^[9]While assessing the quality of counselling, in only 33% cases staff nurse involved the partner or family member in the counselling and explored their attitude towards family planning.

In spite of multiple contacts of the women with the health care providers during her pregnancy, very few of them gained the information about family planning methods during ANC visits. The majority of the respondents in our study reported to have received counselling on the labour table after the delivery. For better acceptance of PPIUCD, the counselling should begin during the ANC visits to the facility. In the study done by R. Chauhan et al, 53% of the counselling were imparted during the antenatal period while only 9.8% of them were counselled after the delivery. ^[10] Scenario in this study was found to be very different, where 65.2% of the women received counselling after the delivery.

In 66.9% of the women responded that the source of information regarding PPIUCD were the staff nurses. This shows that staff nurses are the ones who play an important role in counselling the women for PPIUCD. However, we cannot ignore the role of front line workers (FLWs) as almost one-fourth of the beneficiaries reported to have received the information through ASHAs.

Although guidelines suggest that all women must ideally be informed about all the methods available for family planning. However, the study results show that 79.6% of the women were not made aware regarding the entire basket of family planning methods.

Kelly O' Hanley and Douglas H. Huber in their study mentioned that expulsion rates of 7-15% at six months can be expected.^[11] The current study shows the expulsion rate of 10.9%, which is almost similar to the study done by Manju Shukla et al where they reported expulsion rate of 10.7%.^[12]Another study reported higher expulsion rate of almost 18%.^[13]

The 12.9% of the women complained of abdominal pain and 21.9% of them experienced bleeding issues (either longer duration of menstruation or irregular menstruation) following PPIUCD insertion. This was dissimilar to the study done by Sudha C.P. et al where adverse effects such as abdominal pain and bleeding were reported by 8.3% and 6.7% of the women respectively.^[14]

The study findings show that 53.7% of the women never visited the facility for any of the three scheduled follow-ups after adopting PPIUCD for family planning. Many studies emphasize the importance of regular visits and early follow-ups to manage high expulsion rates by timely insertion of new IUCD or offering another method of family planning. ^{[15, 16]}

3 point Likert scale was used to measure the level of satisfaction amongst the beneficiaries of PPIUCD. 37.7% of the beneficiaries were dissatisfied with PPIUCD, 31.4% reported neither satisfaction or dissatisfaction while 30.9% of the women were satisfied by adopting PPIUCD. However, AashikaJanwadkar and Gulab Singh Shekhawat, in their study showed higher rate of satisfaction among the acceptors of PPIUCD.^[17]

One of the major reason observed for removal of PPIUCD was bleeding. There are many studies which also reported bleeding to be the main reason for removal.^[10,18,19]

While the other reasons of removal found in the study were abdominal pain in 19.2%, opting for another method of contraceptive in 16.6%, discomfort in 9.93%, family pressure in 7.9%, willingness to conceive in 7.9%. A Study by T.K. ShaanthyGunasing, mentioned that it was the partner or family member who played important role in making decisions regarding the method for family planning. [20]Thus as we found in the study, when the decision about PPIUCD insertion was made on the labour table without consulting the partner could result in early removal in case of partner's disagreement with the choice of method. Also, there are various misconceptions regarding PPIUCD such as it interferes with coitus. Thus, it is important to have partner's involvement during counselling.^[21]

Findings of quality of counselling assessment suggests that partner's involvement was missing during the counselling which is very crucial to improve the acceptance of PPIUCD in the community. In addition, not much information about the limitation and side effects of PPIUCD was given. This partial knowledge can be the cause for higher cases of removal seen in the study and could influence the level of satisfaction.

A dedicated cadre of family planning counsellors must be appointed at facilities having high delivery load (at least at CHC and District Hospital) so that we do not lose any opportunity to spread the word.Also, it is substantially important to focus on the timing of counselling. Efforts must be made to counsel all the women during their ANC visit and involve the partner or family member, this will give time to the women and her family to make informed choice. Refresher training must be imparted on regular basis to the staff nurses and others who undertake the job of counselling to adopt GATHER approach for family planning counselling.With proper counselling, higher level of satisfaction amongst the beneficiaries can be achieved.A proper counselling can give miraculous results and can improve the continuation rates by eliminating unnecessary cases of removal such as removal due to abdominal pain, bleeding and others which are curable.

Conclusion:

Government of Madhya Pradesh is making extreme efforts to reach the desired goal of replacement level fertility. With such low expulsion rates and an average level of satisfaction, we can conclude that PPIUCD can be the solution for developing countries like India that are facing population crises. The acceptance of PPIUCD can be improved by improving the quality of counselling. Higher acceptance of family planning methods specially during postpartum period can bring down the high maternal and neonatal mortality occurring due to great number of births within short intervals.