Factors influencing utilization of intra-uterine device among postpartum mothers at Gombe Hospital, Butambala disrtict, Uganda

Abstract Abstract:  The most effective modern family planning method is long-acting reversible contraceptives (LARCs), including intra-uterine contraceptive devices (IUCD). It has multiple advantages over other reversible methods. Despite all known advantages of IUCD, its uptake is still low in Uganda. The purpose was to determine the factors influencing the utilization of intra-uterine contraceptive device among postpartum mothers. A facility-based cross-sectional analytical design was used. 202 Postpartum mothers were sampled and interviewed. Key informants interviews and FGDs were held. Out of 202 post-partum mothers, the prevalence of IUCD utilization was low at 16.3%. Knowledge level at was 55.9%. Education of mothers significantly influenced utilization (X2 (3) = 28.22, p = <0.001) with primary education and secondary education being 10 times more likely (COR = 9.67, 95%CI (2.639–35.411)) and 6 times more likely (COR = 6.17, 95%CI (2.234–17.023) to influence IUCD utilization, respectively. Occupation of mothers also influenced utilization (p < 0.000). Most of the mothers were skilled laborers and yet they were less likely to utilize IUCD compared to non-skilled counterparts (COR = 0.19 95%CI: 0.082–0.431). Culture influenced utilization of IUCD (X2 (1) = 18.22, p = 0.007). Healthcare providers should build the capacity of community health workers to promote effective community awareness about IUCD and its advantages. This will increase uptake.


PUBLIC INTEREST STATEMENT
The most effective modern family planning method is long acting reversible contraceptives (LARCs), which includes intra-uterine contraceptive devices (IUCD), among others. It has multiple advantages over other reversible methods. Most importantly, once in place, they do not require maintenance and their duration of action is long. IUCD has the following advantages; its contraceptive effect is quickly reversible following removal and has a longer duration of effectiveness of at least 12 years. Postpartum mothers require a range of effective contraceptive methods so as to avoid unintended pregnancies, within a short interval. Moreover, it is also said that the effectiveness, with correct and consistent use, of hormonal IUCD and copper IUCD is more than 99% for both. Therefore, it is important that IUCD is taken as priority family planning method to use in view of its advantages over other methods; its uptake is still low in Uganda. Unite for Sight (n.d.) argued that an estimated 830 women die of pregnancy-related causes each day, amounting to more than 300,000 deaths each year and that 99% of these deaths occur in low-and middle-income countries. However, access to family planning can greatly reduce these mortality rates. A study in 2012 found that contraceptive use caused a 44% reduction in maternal mortality in 2008 (Unite for Sight, n.d.). Similarly, according to United Nations Population Fund (UNFPA), approximately 808 women die every day from preventable causes related to pregnancy and childbirth, which is about one woman in every two minutes (United Nations Population Fund [UNFPA], 2020). Most of these deaths and injuries are entirely preventable.

Background to the study
Globally, the Total Fertility Rate (TFR) stands at 2.5 children per woman. Africa still has the highest fertility at 4.7 whereas Asia, Latin America and the Caribbean all have TFR of 2.2. Total fertility rate (TFR) of Oceania is 2.4 and for Europe, it is 1.6 while sub-Saharan Africa (SSA) has a TFR of five or more (United Nations [UN], 2015). In East Africa, the TFR remains high with 4.6 in Kenya and Rwanda, 5.4 for Tanzania, 6.2 for Uganda, and 6.4 for Burundi (Ministry of Health [MoH], 2014). The use of contraceptive methods has the potential to reduce TFR and help couples to decide freely and responsibly if, when and how many children to have (UN, 2015). It also improves healthrelated outcomes such as reduced maternal mortality and infant mortality (Bhutta et al., 2014), as well as school outcomes and economic outcomes, particularly for girls and women (Schultz & Joshi, 2013).
In Uganda in particular, the Total Fertility Rate (TFR) of 5.4 children per woman is attributed to low use of family planning services with a modern contraceptive prevalence of 35% (Uganda Bureau of Statistics [UBOS], 2016). It is accountable for the current estimated population of 34.6 million people and an unprecedented high population growth rate of 3% per annum as indicated in the national census report (UBOS, 2017). Certainly, uncontrolled births can destroy a nation's development aspirations and prevent its people from enjoying an improved standard of living (Michael, 2012).
According to the scholar (Michael, 2012), the Kahama district in the Shinyanga region had a Contraceptive Prevalence Rate (CPR) of 16%, which was far below the national average of 27%. Little was known on factors contributing to the low level of utilization of contraceptives that district, especially among women in stable marital relations. Promotion of contraception in countries with high birth rates is known to reduce poverty, hunger, and deter 32% of all maternal deaths and closely 10% of the childhood deaths (Tamrie et al., 2015).
The most effective modern family planning method consists of long-acting reversible contraceptives (LARCs) which include intra-uterine contraceptive devices (IUCD). This method has multiple advantages over other reversible methods. Most importantly, once in place, they do not require maintenance and their duration of action is long (Espey & Ogburn, 2011). Intra-uterine contraceptive has the following advantages; its contraceptive effect is quickly reversible following removal and has a longer duration of effectiveness of at least 12 years. It is completely good for breastfeeding post-partum women and safe for mothers where hormonal methods are contraindicated (ACCESS-FP J, 2008). The intra-uterine contraceptive device is a safe and highly effective contraceptive method (Getinet et al., 2014).
Postpartum women require a range of effective contraceptive methods so as to avoid unintended pregnancies, within a short interval, particularly the multi-year cost of the Copper T380A IUCD, as one of the most cost-effective contraceptive options (Kumar et al., 2014). Studies (Rutaremwa et al., 2015) have revealed that incidences of repeat pregnancy were reported among women who did not obtain IUCDs and instead opted for hormonal methods or used condom. This result, thus, recognizes the potential of IUCDs in preventing short pregnancy interval unlike the other contraceptives methods. Moreover, it is also said that the effectiveness, with correct and consistent use, of hormonal intra-uterine device and copper intra-uterine device is more than 99% for both. Similarly, their effectiveness, as commonly used, is still more than 99% (Unite for Sight, n.d). Therefore, it is important that IUCD is taken as a priority family planning method to use in view of its advantages over other methods.
Globally, the prevalence of Intra-uterine device (IUCD) is at 13.9%. The prevalence is at 17.5% in Asia, 11.9% in Europe, 6.5% in Latin America and the Caribbean, 4.7% in North America and 1.8% in Oceania. In Africa, it is at 4.6% and SSA accounts for 0.7%, Middle Africa at 0.2%, Northern Africa 19.8%, Southern Africa 1.2%, and West Africa at 0.5% (UN, 2013). However, studies are reporting a decrease or stagnation in the use of IUCDs in SSA (Darroch & Singh, 2013).
During the Family Planning (FP) 2012 London Summit, Uganda committed to achieving universal access to FP and increasing the modern contraceptive prevalence rate (mCPR), including IUCD, among married women to 50% by 2020 (MoH, 2014). This, therefore, calls for appropriate strategies that can trigger an update of Modern and Long Acting Reversible Contraceptives (MLARC) including IUCD among women.
In Uganda, contraceptive prevalence is dominated by injectable, male condoms, and other shortacting methods. The copper IUCD stands at 1.5% compared with 19% for injectable, 6% for implants, 1.9% for pills, among the married women while the majority (71.6%) account for lactation amenorrhea methods and other methods (Uganda Bureau of Statistics [UBOS] and ICF International Inc [ICF], 2017). A study in the Lubaga division, Kampala, found that IUCD use was at 1.8% and found to be the lowest among all other methods (Anguzu et al., 2014). Uganda still has one of the highest unmet needs at 28% for Family Planning in Sub-Saharan Africa (SSA) (MoH, 2016b).
Many postpartum women do not obtain contraception before their visit at 6-8 weeks, despite the big number of 41% attempting vaginal intercourse (McDonald & Brown, 2013). Postpartum women are among the groups that have the highest unmet need for FP (World Health Organization [WHO], 2013); yet highly effective Long Acting Reversible Contraceptives (LARC) like IUCD in the postpartum period has proven to prevent unintended and rapid repeat pregnancies (Teal, 2014). The high unmet need contributes to 43% of all unintended pregnancies in Uganda. There is, also, high discontinuation rate with 43% of the contraceptive users discontinuing with a year of debut mainly due to health concerns or fear of side effects or strong desire to return of fertility (MoH, 2016b). Contraceptive prevalence rate depends on education and counseling, access to information, family planning (FP) commodity security, availability of skilled staff, social and cultural factors (MoH, 2014). Patients and providers negative beliefs, male partner negative attitudes toward contraception and attitudes toward menstruation are among the many factors affecting the utilization of contraceptives, including IUCD (Unite for Sight, n.d).
Despite all the known advantages of IUCD, its uptake is still low in Uganda. Hence, conducting this study is helpful to assess the uptake, level of knowledge, socio-culture and health systems factors influencing utilization IUCD among postpartum women. Improving contraceptive use requires contextual understanding of the factors, but little is known about the contributing factors to the low IUCD utilization in Gombe hospital Butambala. Therefore, it's worthwhile to assess the demographic knowledge, socio-cultural, and health system related factors influencing utilization of IUCD among postpartum women attending services from Gombe Hospital.

Study area
The study was conducted in Gombe Hospital, Butambala district which is located 72 kilometers South of Kampala. The district is bordered by the districts of Mpigi, to the west Mityana to the north, and Masaka to the east. The district population was estimated to be 100,840 people with 50,082 males and 50,758 females with an annual growth rate of 1.3% and an average household size of 4.6. The hospital lies in the Gombe town council with a population of 15,553 with 7,583 Males and 7,970 females of which 3,142 are women of reproductive age (UBOS, 2017). See Figures 1 and 2 below for views of Gombe Hospital.

Broad aim
The study sought to determine factors that influence intra-uterine contraceptive device utilization among postpartum women attending service at Gombe Hospital.

Specific aims
The research had the following specific objectives; (1) To determine the prevalence of intra-uterine contraceptive device utilization among postpartum women attending services from Gombe Hospital.
(2) To assess the level of knowledge on Intra-uterine contraceptive device among postpartum women attending services from Gombe Hospital.
(3) To determine the socio-cultural factors that influence the utilization of intra-uterine contraceptive device among postpartum women attending services from Gombe Hospital.
(4) To determine the Health-system-related factors that influence the utilization of intra-uterine contraceptive device among postpartum women attending services from Gombe hospital.

Methods
Gombe Hospital, in Gombe town council, Butambala district, is 72 kilometers South of Kampala city, the capital of Uganda (UBOS, 2017). The study was a cross-sectional analytical design, both qualitative and quantitative mixed methods. It targeted postpartum mothers (15-49 years of age) attending healthcare services between 4th July and 16 August 2018. Postpartum mothers, attending the postnatal clinic, who took or never took family planning (FP) before were included. Mothers who delivered from the facility but never came for postnatal care within the study period were excluded from the study. Health-care providers working in the Family Planning Department were also included.
A sample of 202 mothers was randomly selected by systematic random sampling techniques. This sample was calculated using the known statistical formula (Yamane, 1967 as cited in (Singh & Masuku, 2014)). Two (2) health-care providers working in the family planning department were purposively sampled for key informant interview. Two Focus Group Discussion (FGD) with mothers were held. Hence, Face-to-face interview, key informant interview and FGDs were used to collect data.
A number of quality controls were taken care of, including training of research assistants and pre-testing of the tools. Data were entered in Statistical Package for Social Sciences (SPSS) for analysis. Qualitative data analysis was done through thematic and verbatim analysis following the verbatim transcriptions from the interviews.
Ethical approval was sought from the relevant authority of the faculty of health sciences at Uganda Martyrs University, guaranteeing the Institutional Review Board (IRB) endorsement. Other ethical considerations governing research on human subjects were well adhered to.

Prevalence of IUCD utilization among postpartum mothers
Of the 202 postpartum (PP) mothers, 11 of them were old users of IUCD and 22 mothers were new users of the method.

Figure 2. Uganda Muslim Supreme Council (UMSC) visits Gombe Hospital.
Prevalence was, thus, computed from the formula, n ¼ oldþnewusersofIUCD Therefore, the prevalence of IUCD utilization was at 16.3% among postpartum mothers.
Two key informants were asked about the utilization of IUCD in Gombe hospital. The two key informants agreed that the utilization of IUCD still remains low, which conforms to the finding on prevalence. For example; the respondent key informants reported as below; [. . .] Its utilization is not high because mothers believe it can cause bleeding, fibroids, cancer, can get out when in their periods, can travel to other parts of the body and can cause severe backache, [KI 1 14 August 2018].

Knowledge on IUCD among postpartum mothers
Postpartum women were asked if they knew about IUCD and Yes/No responses were elicited. 147 (72.8%) of the respondents self-reported that they were knowledgeable. Other specific questions on IUCD were asked, in a Likert scale, to ascertain their level of knowledge and 49(33.3%) of those who self-reported to be knowledgeable rated the method as good. 131(89.1%) agreed that IUCD is long lasting. Other details are shown in Table 2. Therefore, on overall, the level of knowledge was 55.9% In a qualitative interview, key informants (KI) were asked to suggest how IUCD utilization can be improved. They suggested health education to mothers on IUCD and community sensitization as appropriate. Others measures include; training midwives on immediate IUCD insertion and awareness creation about the availability of the method. The respondents reported as;

Socio-cultural factors that influenced utilization of IUCD
Bivariate logistic analysis and cross tabulation were done to determine the socio-cultural factors which influenced the utilization of IUCD among postpartum mothers. The results are shown in Table 3.

Social interaction (X 2
(1) = 18.01, p < 0.001), sources of information about IUCD (p = <0.001) and recommending use of IUCD to others (p < 0.000); all these influenced utilization as shown in Table  3 above. Postpartum mothers who received the information from their spouse were 4 times more likely to utilize IUCD compared to other sources (COR = 4, 95% CI (0.329-48.66).
Two focus group discussions (FGD) were held with mothers. Most of the participants in the two FGDs mentioned that they can recommend IUCD for others due to its effectiveness, long-term action and its reversibility nature.

Theme 1: Respondents can recommend the use of IUCD
For examples, the mothers had these to say; I would recommend one to use it because it works for a long period of time. It is a method that takes a long period of time with no repetitive side effects "Personally I did not get any problem". I was told IUCD s don't affect the effectiveness of ante retro viral therapy like some of the family planning methods [. . .] (FGD participant15 August 2018.)

Health-system factors that influenced utilization of IUCD
Bivariate logistic analysis and cross tabulation were done to determine the health-system factors which influenced the utilization of IUCD among postpartum mothers. The results are shown in Table 4.
The study found that receiving counseling on IUCD influenced utilization of the method among postpartum mothers (X 2 (1) = 0.315, p = 0.001) and that out of the 33 mothers who utilized IUCD, 28 (13.9%) had received counseling about the method. Availability of IUCD also influenced its utilization (p = 0.000). Out of the 33 mothers who utilized the method, 27 (13.4%) attributed it to the availability of IUCD in the facility. Believing that health-care providers had adequate knowledge of IUCD influenced its utilization (p = 0.001) as well as knowing that IUCD was free of charge (X 2 (2) = 6.053, p = 0.026).
In a qualitative interview with Key Informants (KI), they reported that despite health workers being formally trained in schools, some of them have inadequate knowledge and skills on IUCD and its insertion. They had these to say; I acknowledge the formal training conducted in schools, however it's insufficient hence resulting to incompetent health workers when it comes to issues of family planning especially IUCD. However, health workers are trained on job to improve their knowledge and skills though few are trained on it . . ..In case of staff rotation or transfer, the number of knowledgeable and skilled workers reduce hence affecting services delivery, [KI 1 on 14th 08.2018].
Majority of the staff though not all are knowledgeable because we had Implementing Partner (IP) trained us. It was an on-job training that helped health workers who had lost the   The multivariable analysis found social interaction and counseling on IUCD significantly influenced the utilization of IUCD (see Table 5).

Prevalence of IUCD utilization among postpartum mothers
Findings revealed that the prevalence of IUCD was low at 16.3%. This is above the national prevalence of IUCD among women of the reproductive age group which is at 1.1% (UBOS, 2017). However, this prevalence is not specifically for postpartum women. Despite the fact that the prevalence of IUCD in this study is more than that of the national level, utilization of IUCD is low compared to other family planning methods. Key informants reported that much as IUCD were not highly used by postpartum women, there was a slight improvement in IUCD utilization. These findings are similar to the study undertaken by other scholars (Anguzu et al., 2014) where IUCD utilization was found to be the least family planning method used. Similarly, another study conducted in Ethiopia among postpartum women showed that IUCD was the least, standing at 5.2% (Tefera et al., 2017). This study's findings contradict those of another study conducted in Turkey (Deveer, 2013), which revealed that IUCDs are the most commonly used modern contraceptive method in which out of 681 of the participants, 22.5% were using IUCD.

Knowledge on IUCD among postpartum mothers
Overall, knowledge of women on IUCD was 55.9%. There is generally a knowledge gap about IUCD and specifically on immediate post-partum IUCD insertion which could be attributed to low awareness and utilization, which may arise from inadequate counseling. This is in line with the study undertaken by another scholar who found out that women's knowledge of IUCD was low (Twesigye et al., 2016). This study finding contradicts with a study conducted in Ethiopia by Ali (2016) whose findings revealed that half of the women 63.8% had good knowledge of IUCD while 36.2% had low or poor knowledge on IUCD (Ali, 2016).

Socio-cultural factors that influence utilization of IUCD
Study findings indicated that postpartum mothers who attained a primary level of education were 4.38 times more likely to use IUCD compared to those with a tertiary level of education. It possible that women who are not educated, take seriously, counseling, and information provided by health workers. This might be due to the fact that their source of formal information may be solely from the health service providers, hence, influencing positively their decision-making. This result concurs with that conducted in a private health facility in Nigeria which found that postpartum women with no formal education or an only primary level were more likely to select the IUCD compared to those who had tertiary level of education (Eluwa et al., 2016). Other studies gave similar results (Bwazi et al., 2014). This findings conducted in Malawi revealed that husbands are the main decision makers especially on reproduction; thus, approval or disapproval of services determines the use or non-use of services by women (Bwazi et al., 2014).

Health-system factors that influence utilization of IUCD
This study revealed that counseling contributed to the utilization of IUCD and was statistically significant. Key informants reported that there was a slight improvement in IUCD uptake that had resulted from the intensified counseling. They also attribute the underutilization to the health-care providers who do not educate these mothers well. The study findings concur with those by Kumar et al. (2014) which revealed that many women who used IUCD reported that they had received counseling on the method from a qualified and dedicated counselor from a health facility prior to uptake. In one study, it was found that receiving health information after delivery (AOR = 3.57, 95% CI: 1.69, 7.53) was found to be statistically associated with postpartum care uptake (Kebede et al., 2019). Similarly, the study by Tefera et al. (2017), is also in support of this study finding. Their result revealed that mothers who were not counseled about IUCD were less likely to use the method compared to those who were counseled about the method. The finding reflects that provider's knowledge influences IUCD use. Finding is supported by another study conducted among Canadian women which recommended that providing education to health-care providers, women, and policy makers may overcome misperceptions about the use of IUCDs hence may help greater uptake (Hauck, 2015). Similar studies have been reported by other researchers elsewhere (Creanga et al., 2011). These are contrary to those studies by Jalang'o et al. (2017) where the majority of the women reported the major challenge was the frequent stock-outs at the facility (Jalang'o et al., 2017).

Conclusion
In summary, both prevalence and knowledge of IUCD among postpartum women were low. This was attributed to inadequate health education of mothers by the health workers and women's beliefs that they attributed IUCD to causing several complications like cancer, fibroids, and severe bleeding. Counseling and Social interaction were significant factors that influenced IUCD utilization, among others.