Postpartum family planning is an initiation of family planning services within the first twelve months following childbirth . It is aimed at preventing closely spaced and unintended pregnancies . Poor utilization of postpartum modern contraceptives has been associated with unintended pregnancies, induced abortions and increased risk of maternal morbidity and mortality worldwide including Tanzania . Low use of postpartum contraceptives also result to short interpregnancy intervals which increases the risk of induced abortions, miscarriage, preterm births, neonatal and child mortalities, still births and maternal depletion syndrome .
Worldwide, about 213.4 million women get pregnant every year, approximately 40% are unintended, of which about 50% end up with induced abortions, and 13% miscarriages . In Africa about 54 million women become pregnant annually, where 19.1 million of them are unintended, resulting to 33% of abortions . In Tanzania about 2 million women become pregnant every year with an estimate of 1 million are unintended pregnancies . In 2013, about 405,081 cases of induced abortions were reported in Tanzania among women of reproductive age .
Several studies have reported low uptake of modern contraceptives in Tanzania    . The low contraceptive use has been attributed to desire to conceive in the near future, fear of side effects, lack of freedom to stop the method without involving the health provider, lack of knowledge about the method and its availability ; misconceptions, poor accessibility of the method, limited skills among health care providers in modern contraceptive insertions , and concerns about the effectiveness of the methods in preventing pregnancy . However, none of these studies have been conducted in the pastoral communities to investigate awareness and uptake of postpartum modern contraceptives where most of women have less contact with health care providers. This exposes these women at risk of unplanned pregnancies.
Postpartum women are at high risk of unplanned pregnancies, especially in their first year after delivery. Adoption of postpartum contraceptives leads not only to reduction in unplanned pregnancies, but also it improves maternal and child well-being due to optimal birth spacing. These serious problems could be avoided by the use of modern family planning methods within the immediate or extended postpartum period. Previous investigators have demonstrated that spacing pregnancies for at least two years apart in the developing world could reduce maternal mortality by more than 40% and under five mortality by 31% .
The reduction of maternal deaths, prevention of unintended and too-early pregnancies is of public health priority in Tanzania. This can be scaled up through counseling on contraceptive methods during prenatal and throughout postpartum periods  . The government of Tanzania has made efforts to ensure that postpartum family planning services are integrated in the reproductive and child health services. The National Family Planning Coasted Implementation Program (NFPCIP-2009) plan was also set to identify resources and actions required to make family planning services accessible to all women of reproductive age in order to achieve at least 60% of contraceptive prevalence by 2015. According to the TDHS 2015-2016 report, this national target has not been met as the contraception prevalence for married and unmarried women of child bearing age stands at 32% and 46% respectively .
Although efforts has been made in terms of increasing access to maternal and child care services, no significant improvement has been observed in postpartum contraceptive use within the first year after delivery . Postpartum women still have highest unmet need for family planning in Tanzania ranging from 40% - 75% as compared to 22% - 35% of the general population . In Geita region among predominant pastoral communities where this study was conducted, the modern contraceptive use is low as 13%, unmet need for family planning is 35% and total fertility rate is 5.5 . Little is known about awareness on postpartum modern contraceptives use and factors influencing its uptake. This study aimed to assess awareness on postpartum modern contraceptive use and its associated factors among women of reproductive age in Bukombe District.
2.1. Study Design and Setting
A community based cross-sectional study was conducted in a predominant pastoral communities of Bukombe district in Geita region in north-western Tanzania from May-June 2018. Bukombe district is among of the 5 districts of Geita region which is located in the lake zone. It has a population of 224,542, 17 wards; 122 villages, an average of house hold size of 5.9 and fertility rate of 5.5 . Geita is one of the regions with poorest indicators with regards to maternal and new born health in Tanzania. Businesses, small farming and mining are the main activities in the region.
2.2. Study Population and Sampling Method
All women of reproductive age (15 - 49 years) were included. We excluded women who were non-residents in past 6 months and those who had hysterectomy. Multistage sampling process was used to select the study participants. The first stage involved purposive the selection of two divisions out of three divisions in Bukombe district based on their large population sizes. The second stage involved selection of 3 out of 17 wards. Proportionate to size sampling guided selection of wards from each division. The third stage involved random selection of three villages from each of the selected wards where 9 villages were selected. At each village three hamlets were randomly selected and women of reproductive age who gave birth in past one year from the selected hamlets as identified by local leaders were eligible to participate and were invited to participate.
2.3. Data Collection Method and Tool
A standardized questionnaire was used to collect data from the study participants through face to face interview. The information collected include: social demographic characteristics, children and reproductive health history and contraceptive methods availability, use and preferences. Seven research assistants employed to assist the data collection (i.e. medical doctors, nurses and social scientists). Research assistants received one day training session involving briefing on the purpose of the study, meaning of terms used in the study and the importance of maintaining ethical standards during data collection process. Prior the data collection, the pilot study was conducted in the nearby community outside the study area to test the validity and reliability of the questionnaire.
2.4. Study Variables
The main outcome variable was postpartum modern contraceptives use. The independent variables include; socio-demographic variables such as religion, marital status, education level, employment status and income. Reproductive health variables such as parity, live children, age of the last born, desired number of children, desired birth interval, mode of delivery and place of last delivery were also explored.
2.5. Ethics Consideration
Ethical clearance was obtained from Kilimanjaro Christian Medical University College Research Ethics Committee. Permission to carry out the study was obtained from Geita region and Bukombe district administrative authorities. Written consent was obtained from every participant. Anonymity was maintained by using unique identifiers instead of names to maintain confidentiality. Participation was voluntary and the participant’s right to withdraw from the study without giving any reason was explained.
2.6. Statistical Analysis
Data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 21. Continuous variables summarized using measure of central tendency and their respective dispersion. Categorical variables were summarized by proportions and frequencies. Odds ratio and 95% confidence interval used for factors associated with modern contraceptive use among postpartum women were estimated in multivariable logistic regression model. A p-value of less than 5% was considered significant.
3.1. Characteristics of the Study Participants
A total of 511 women of reproductive age were studied. The mean (SD) age was 26.48 (6.79) years. Majority 361 (70.7%) were aged between 25 to 34 years. More than half 304 (59.5) of the participants were involved in pastoral and farming activities, with majority 310 (60.6%) had primary school education level (Table 1).
Table 1. Study participants characteristics (N = 511).
3.2. Reproductive Health Characteristics of Study Participants
Majority 379 (76.4%) of the participants had desire to have more than five children. Majority 307 (72.2%) wanted to delay the next birth by at least 3 years. Three quarter 384 (75.1%) of the respondents reported to have not resumed menstruation at the time of the study. More than half 225 (44%) reported ever use of modern contraceptive (Table 2).
3.3. Awareness and Prevalence of Modern Contraceptive Use
Most (97.3%) of the participants were aware about modern contraceptives. More than half 225 (44%) reported ever use of modern contraceptive. The prevalence of postpartum modern contraceptives was 61 (11.9%) (Table 2).
3.4. The Common Contraceptive Methods Used among Postpartum Women
The most frequently reported modern contraceptives were implant (54%) and injectable (30%) while pills (8%), female sterilization (4%), intra uterine device and male condoms (2%) were infrequently reported (Figure 1).
3.5. Factors Associated with Postpartum Modern Contraceptive Use
In bivariate analysis, some sociodemographic variables such as area of residence (crude odds ratio [COR], 1.85, 95% CI: 1.21 - 3.41) and occupation (COR = 2.09, 95% CI: 1.38 - 3.41) were significantly associated with postpartum contraceptive use. This association remained significant in multivariable analysis where occupation (AOR = 2.34, 95% CI: 1.31 - 2.28) and living in urban (AOR = 1.84, 95% CI: 1.20 - 3.79) increased women’s likelihood of using postpartum contraceptives (Table 3).
In addition, some reproductive factors such as age of last born, desired birth interval and resumption of menstrual were also significantly associated with post-partum contraceptive use in bivariate analysis. After adjustment, last born aged 3 - 4 months (AOR = 3.30, 95% CI: 1.11 - 9.85) and started menstrual periods (AOR = 9.23, 95% CI: 3.60 - 23.72) were associated with modern contraceptive use (Table 4).
3.6. Challenges Related to Modern Contraceptive Use during Postnatal Period
A number of challenges were reported to hinder the use of postpartum modern contraceptives. These include fear of side effects (40%), poor knowledge about contraceptives (29%), husband restrictions to their wives to use contraceptives (20%), Distance to the health facility (9.2%) and availability of contraceptives methods was infrequently reported (2.1%) (Figure 2).
In this study the prevalence of postpartum modern contraceptive use was low as
Table 2. Reproductive health characteristics of study participants (N = 511).
Table 3. Socio-demographic characteristics associated with postpartum modern contraceptive use (N = 511).
11.9%. Factors such as mother’s occupation, area of residence, age of last born and resumption of menstrual were significantly associated with postpartum contraceptive use.
The prevalence of postpartum modern contraceptive use in our study was lower compared with the national prevalence of 19% . The lower prevalence of postpartum contraceptives use in the study area could be explained by high proportion of home deliveries (61%), coupled with poor attendance to postnatal
Table 4. Reproductive health characteristics associated with postpartum modern contraceptive use (N = 511).
care in the first 2 days (13%) in the study area . These leads to missed opportunities for postnatal contraceptive counseling. The postpartum contraceptive use in our study is also lower compared to 28%that was reported in Uganda
Figure 1. The common contraceptive method among postpartum women (N = 61).
Figure 2. Challenges of postpartum modern contraceptive use.
. The difference in prevalence could be due to the fact that the postpartum women in the former studies were highly motivation to use family planning methods. Our finding suggests that facility delivery remain an important windows of opportunity to provide access to family planning messages and to offer women various contraceptive methods. Therefore, this finding underlines the needs for integration of services within the public sector in order to take advantage of other service delivery to increase the uptake modern contraceptive during the critical postpartum period.
In the present study, the highest proportion of postnatal mothers uses implant contraceptives. This might be due to the fact that implant is not user dependent and may not easily seen by partners . But may also be partly explain women’s lack of decision making power over their contraceptive choice or their partners’ influence . Our finding is in contrast with studies in Ethiopia and Malawi which showed injectable was the most preferable contraceptive   . The difference of these findings may be explained by difference in social cultural factors between the two populations. This suggests the need for more emphasize in long acting contraceptives counseling as this will be preferable in this setting where women have little contact with health care providers.
There is a wide variation between developed and developing countries in using some types of contraceptives whereby oral pills and female sterilization are mostly preferred in the United States ; while in India male condoms were mostly preferred . Oral pill, injectable and male condoms are more common in Africa and Europe whereas long-acting and permanent methods are more common in Asia and Northern America. Injectables are common in Eastern Africa, Southern Africa, South-Eastern Asia and in some of the poorest countries in Latin America and the Caribbean . The difference could probably be due to social-cultural, economic and geographical variations.
In this study we found that, women’s occupation was a significant factor for postpartum modern contraceptives use. Mothers who owned business had 2 times higher odds of using the contraceptives as compared to those in other occupation such as famers and daily walkers. The probable explanation for observed association could be that, mothers who are involved in business activities make an interaction with many people who could have acquired the necessary knowledge to empower them with positive attitude towards the contraceptive use compared to their counterparts in others groups. This finding is consistence with a previous study in Ethiopia . The similarities in finding could be due to social cultural factors and the study settings as these studies were conducted among urban residents and rural residents (predominately pastoral).
We found a significant difference in contraceptive use between Urban and Rural dwellers. Women residing in urban two-fold higher odds of using post-partum contraceptives compared to rural dwellers counterparts. Our finding is consistent with previous studies done in five low income countries . The possible explanation could be that urban women have better access to information, education and health facilities than rural women.
Women whose menses returned after birth had 9 fold higher odds of using post-partum modern contraceptive compared to women on amenorrhea. This finding could be supported by the fact that women may be aware of fertility return when menses resumed. Amenohorric women would perceive less vulnerable to get pregnancy by assuming that amenorrhea would protect against pregnancy irrespective of the postpartum duration. Similar finding was reported in Kenya .
The present study also showed that a woman who’s their last born aged four to six months had higher odds of using contraceptives compared to other ages. The probable explanation to the observed association could be that most of mothers started to experience menstrual resumption at the third and fourth month after delivery.
This study revealed that fear of side effects, poor knowledge about contraceptives, husband restrictions in using contraceptives were the most hindering factors for post-partum contraceptive use. In addition, distance to health facility and availability of the method was among the challenges to use postpartum contraception. This finding is consistent with previous studies done elsewhere  . The fear of side effect might be based on their personal experiences or those other women they know or simply on unfounded perception. Some of the women attribute changes in their menstrual cycle to development of diseases in the reproductive system such as uterine fibroids. Prolonged and irregular vaginal bleeding has serious socio-cultural implication for many women.
4.1. Study Limitations
Issues of sex and contraceptive use could be a limitation as respondents may be reluctant to provide certain information they consider to be personal. However, we attempted to minimize its effect by assuring the participants that their responses could not be traced to them but only used for scientific purposes. This assurance might have encouraged majority of women to provide answers that reflects their reproductive behavior. The cross-sectional design of this study limited the ability to understand patterns of use or non-use across individuals over time as well as the causal effect relationship.
The postpartum modern contraceptive use in the study area is still low as 12%. The most preferred contraceptive was implant. Occupation, place of residence, age of the last born and menses resumption were associated with modern contraceptive use. Fear of side effects was the most prevalent challenge on contraceptive use.
Adequate counseling on modern contraceptive use (including side effects) during antenatal care, immediate post-delivery and throughout post-partum period is warranted. Provision of better access to information, education and health facilities in rural area may improve uptake of postpartum contraceptives.
This work was supported through the DELTAS Africa Initiative grant # DEL-15-011 to THRiVE-2. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust grant # 107742/Z/15/Z and the UK government. The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, Wellcome Trust or the UK government.
Our sincere gratitude also goes to all women who participated in this study, administrative staff in Geita region, Bukombe District and respective villages for their cooperation and support during the study period.
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