Knowledge of Postpartum Women about Modern Contraceptive Methods and Attitudes towards its Utilization in Debre Tabor Town, Northwest Ethiopia: A Community-Based Cross-Sectional Study

Background: The postpartum period is a crucial time to prevent short inter-pregnancy interval and unwanted pregnancies. Although it is the most ideal period to create awareness on postpartum mothers’ about knowledge and attitudes contraceptive methods; it is often neglected part of the continuum of care. Therefore, t his study aimed at assessing postpartum mother’s knowledge and attitudes of modern contraceptive methods towards its utilization. Methods: A community-based cross-sectional study was conducted on 552 postpartum mothers at Debre Tabor town from September 20, 2018 to October 20, 2018. A cluster sampling technique was used to select the study participants. Data were entered into Epi info version 7 and analyzed by SPSS version 20 software. Multivariable logistic regression model was fitted to identify associated factors. Results: The overall prevalence of good knowledge and favorable attitude towards modern contraceptive methods was 57.6% (95% CI: 53.3%, 61.6%) and 40.6% (95% CI: 36.8, 44.6) respectively. Higher education [


Introduction
Family planning (FP) is the ability of individuals and couples to anticipate and attain their desired number of children, and it is highly related to the spacing and timing of their births which is achieved through the use of contraceptive methods.It is also a way of thinking and living that is adopted voluntarily upon the basis of knowledge, attitude, and responsible decisions by individuals and couples (1).
Family planning is a means of promoting the health of women and families, and it is part of a strategy to reduce the high maternal, infant and child mortality.Besides, it is also the most effective measure to control high population growth (2).
For this reason, information about FP should be made available and actively promoted its accessibility to all individuals desiring them (1).
Family planning is a priority area in the to-do lists of the government of Ethiopia; because it is one of the strategies of the government to improve maternal and child health.The newly launched health service development plan (HSDP) IV and the SDG (sustainable development goal-7) are aiming at expanding quality FP services to improve the health of mothers, neonates, children, adolescents, and youths(30) (3).The Ethiopian Federal Ministry of Health (FMOH) has undertaken different initiative measures to reduce maternal mortality.From those initiatives, the most important one is delivery of family planning service at all levels of the health care system (1).However, 22% of mothers have unmet need for modern family planning methods (4).Addressing the unmet need for modern contraceptive methods will have an immediate impact in decreasing unintended pregnancies whose outcome could be postpartum hemorrhage or unsafe abortion, both which are direct causes of maternal mortality (1,4).
In Ethiopia, the prevalence of children born less than two years after their siblings is 22% (4).Short birth intervals are associated with harmful outcomes for both newborns and their mothers, such as preterm birth, low birth weight, and death (5-7)(5-7) (5)(6)(7).The postpartum period is the most crucial time to maintain the ultimate health of a woman and her newborn.It is also the time of opportunity to provide contraceptive methods for decreasing the risk of short inter-pregnancy interval and unwanted pregnancies.Assessing postpartum mothers' knowledge and attitude towards modern contraceptives, which would prevent mothers and their families from the consequences of shortly spaced pregnancies, is a way to improve its utilization.
Lack of adequate data on knowledge and attitude about modern contraceptive methods in the populations impede the effort to improve the practice (8).Knowing the common misconceptions about each contraceptive method helps to address concerns and fears of mothers to the specific method (1) Studies in Ethiopia showed that utilization of postpartum family planning methods was low (9).This was because of different reasons like having no knowledge about family planning methods, their unfavorable attitude towards it, its contradiction with their religious beliefs, and their desire to have many children.(9,10).Even though most postpartum mothers know the names of modern contraceptive methods(4), they do not know when they would start contraceptive methods, time of pregnancy after discontinuation of contraception, whether the mother may become pregnant whilst in breast feeding and before the beginning of menstruation.According to a study done in Somali region, the prevalence of attitudes of mothers towards modern contraceptive methods was 51% (11).In addition, women who report familiarity with contraceptive were found to be having misinformation (12).Increasing women's knowledge and improving their attitude on postpartum modern contraceptive methods is essential to improve their quality of life.Therefore, this study is aimed at assessing knowledge of postpartum modern contraceptive methods and attitudes towards its utilization in Debre Tabor town, Northwest Ethiopia.

Method Study Design, Setting and Period
A community-based cross-sectional study was conducted from September 20 to October 20, 2018 in Debre Tabor town.Debre Tabor town is the capital city of South Gondar zone Am-  13).(52) The town has one referral hospital, three health centers, and six health posts serving the community.

Study Population
All women who gave birth in the past six to twelve months of the time of the study in Debre Tabor town were the source population, and this population within the selected clusters was the study population.Mothers who were critically ill throughout the data collection period were excluded.

Sample Size Determination and Sampling Procedures
The sample size (n) which was required for this study was determined by using a single population proportions formula by considering the assumptions: postpartum mothers who had good knowledge was 68.2% (9), a margin of error (d) = 5%,and a 95% level confidence.

= = 334
Where n= required sample size, = level of significant, z= standard normal distribution curve value for 95% confidence level= 1.96, p= proportion of mother's knowledge about postpartum modern contraceptive methods, d= margin of error.
The final sample size was 552 including the design effect of 1.5 and a 10% non-response rate.Design effect of 1.5 was used in case of cost minimization rather than 2. Debre Tabor town has six urban "kebeles" (which are the smallest administrative unit in Ethiopia) and three "kebeles" were selected randomly (kebele 1, kebele 2, and kebele 5).A house-to-house visit was carried out in the selected clusters to identify eligible mothers.All eligible mothers in the selected clusters were interviewed with the assumptions of homogeneity of participants in Debre Tabor town.

Operational Definitions
Extended postpartum period: the period between six to twelve months of delivery (14).

Good knowledge:
Mothers who have a score of greater or equal to the mean value and above from variables which assessed modern contraceptive methods were considered having good knowledge (15).
Poor knowledge: Mothers who have a score of less than the mean value from variables which assessed modern contraceptive methods were considered having poor knowledge (15).

Favorable attitude:
Mothers who have a score of greater or equal to the mean value and above from variables which assessed modern contraceptive methods were considered having favorable attitude (16).

Unfavorable attitude:
Mothers who have a score of less than the mean value from variables which assessed modern contraceptive methods were considered having unfavorable attitude (16).

Data Collection Tools, Procedures and Quality Control
Data was collected using a face-to-face intervieweradministered structured questionnaire adapted from different literatures (9,(13)(14)(15).The questionnaire had four parts: the socio-demographic, reproductive and maternity health service, knowledge, and attitude.A total of 11 questions were prepared to assess mother's knowledge.Women were asked if they know 1) family planning methods used for postpartum mothers; 2) mother become pregnant whilst breastfeeding; 3) a woman should start contraception before the menstruation begins; 4) IUCD can be used to prevent pregnancy after delivery; 5) IUCD can be used during breastfeeding period; 6) after IUCD removal a woman may get pregnant immediately; 7) implants be used to prevent pregnancy after delivery; 8) after removal of implants a woman can get pregnant immediately; 9) after permanent contraceptive a woman can't become pregnant; 10) a woman during breastfeeding period can use COC; 11) injectable contraceptive (DEPO) be used to prevent pregnancy after delivery.The possible answers were yes or no.A score of 1 was given for a "yes" and a score of 0 was given for a "no" responses.
Eight questions were prepared to assess attitude of mothers towards modern contraceptive methods.Mothers were asked if they agree 1) without family planning, a Postpartum woman can get pregnant within 6 weeks; 2) if the menses is not started after delivery, a woman will not get pregnant; 3) PPFP  Above half of the respondents knew postpartum women can start contraceptives before the beginning of menstruation.
One-fourths (26.8%) of the mothers knew that IUCD can be used by breastfeeding mothers.Nearly half (47.1%) of the participants knew that after permanent contraceptive a woman may not become pregnant (Table 3).Injectables (84.4%), pills (74.3%), and implants (60.3%) were the most known contraceptive methods by the study participants (Figure 1).

Factors Associated with Knowledge of Postpartum Mothers on Modern Contraceptives
On the bivariable regression analysis, the factors found to be significantly associated with knowledge of mothers on modern contraceptive methods were educational status of the mother, mothers ever discuss with their husband about contraceptive methods, attend PNC, having prior information about modern contraceptive methods after delivery of the last child, and history of modern contraceptive utilization before the delivery of the last child.
After controlling the effect of other variables, educational status, mothers ever discuss with their husband about contraceptive methods, and history of modern contraceptive utili-

Discussion
Improving women's knowledge and attitude towards modern contraceptive methods is indispensable to enhance the practice of postpartum contraceptives.
Accordingly, this study found that the overall knowledge of women on postpartum modern contraceptive methods was 57.6%with 95% CI (53.4,61.6) which is in line with a study conducted in Northwest Ethiopia that was 60.1% (10).How-ever, the finding of this study was lower than a study conducted in Eastern Ethiopia which shows an 68.2% of them had good knowledge (9).This may be due to the difference in In this study, the level of mother's good knowledge about postpartum modern contraceptives was higher than the study conducted in Northwest Ethiopia(17)(16) (13).This may be due to the difference in the study population.The previous study was done in all reproductive-aged mothers, but this study was conducted on postpartum mothers.
In this study, the educational status of women was found to be a predictor of mother's knowledge of postpartum contraceptive methods.Those mothers who attend primary and above education were 2.15 times more likely to have good knowledge of postpartum modern contraceptive methods compared to those women who did not attend formal education.This study is supported by a study conducted in Northern India (18).This could be due to the fact that educated mothers may get information about contraceptive methods from different sources like by attending maternal health services and other reproductive issues.They are also able to retain the information they attained.In this regard, concerned bodies should set multimodal strategies specific to women's educational status, so that they improve their knowledge of reproductive health and appropriate health-seeking practices towards themselves.
The odds of having adequate knowledge of postpartum modern contraceptive methods among women who have ever discussed with their husbands about contraceptive methods were two times higher compared with those who had poor knowledge.This could be justified as a discussion for contraceptive methods with partners may increase the chance to share different information and get the freedom to do any maternal and reproductive health services.From this finding, we can deduce that encouraging women to participate in household decision-making matters and maintaining a habit of shared decision with sexual partners will have a paramount importance to the improvement of women's knowledge of reproductive health, thereby improving the actual utilization of modern contraceptive methods to prevent unwanted and mistimed pregnancies.
History of modern contraceptive utilization before the delivery of the last child was also another important factor for mothers' knowledge of modern contraceptive methods.
Those mothers who have ever used modern contraceptive methods before the delivery of the last child were nearly two times more likely to have had good knowledge of postpartum contraceptive methods as compared to their counterparts.
This could be due to the fact that women who have ever used contraceptive methods might discussed and share ideas about different contraceptive methods with health professionals and maintain a positive mind set towards the use of the contraceptive methods repeatedly.Thus, healthcare providers and other relevant stakeholders have to give adequate counseling, and also must advocate about the importance of using modern contraceptives and the negative impacts of short interpregnancy interval to the mother as well as to the newborn.
This study found that the attitude of mothers towards modern contraceptive methods was 40.6% with 95% CI (36.8, 44.6).
The finding is lower than studies conducted in Eastern Ethiopia and Khatamendu, Nepal (17,19).These differences might be due to the dissimilarity in socio-demographic and cultural characteristics.The other difference of this study from a study conducted in Nepal might be the result of the tool used to measure the outcome variable and study design.
In this study, the questions were prepared on five Likert scales (strongly disagree, disagree, neutral, agree and strongly agree).. Mothers in the age groups of 25-34 were 58% decreased to have had a favorable attitude compared to mothers in the age group of 18-24 years old.This may be due to the fact that at this age group women are eager to have more children, , and consequently, may develop negative attitude towards modern contraceptive utilization.
This study declared that having prior information about contraceptive methods before the delivery of the most recent child was 1.73 times more likely to have had a positive attitude towards postpartum contraceptive method utilization.
This may be due to having prior information which help women to have sufficient knowledge and outweigh the advantages and disadvantages of using contraceptive methods; thus develop a favorable attitude through time.In this case, information regarding reproductive and sexual health which, particularly, reaching out to the modern contraceptive method in health institutions using different mass media and/or social media will have a great role in building adequate knowledge of modern contraceptives.This will ultimately reduce the maternal and neonatal mortality that will happen due to short inter delivery interval.
Lastly, adequate knowledge of postpartum modern contraceptive methods is found to be a significant factor associated with the mother's attitude towards postpartum modern contraceptive methods utilization.Those women who had good knowledge were 3.49 times more likely to have had a favorable attitude towards postpartum modern contraceptive methods.This is because knowledge is an entry point for any behavior and health service-related practices.Also, knowledgeable women have better retaining and comprehension skills about maternal and reproductive health-related activities compared to women who have poor knowledge.

Limitation of the study
This study recognized possible limitation that should be considered when interpreting the results.Since the study was cross -sectional design, it does not permit to establish cause-effect relationships.

Conclusion
More than half of the respondents had good knowledge about modern contraceptive methods and about two fifth of the re- Consent for publication: Not applicable As a result, studying knowledge and attitude of postpartum mothers tell us what they know and how they feel about modern contraceptives.The majority of MNCH services are conducted before and within the first six months of the postpartum period.These MNCH services are an opportunity to improve the mothers' attitude and knowledge of modern contraceptive methods.At the time of antenatal care (ANC), labor and delivery, postnatal care, and immunization service, women may get more information about modern contraceptive methods.So, it is a good opportunity to assess the knowledge and attitude of postpartum mothers to improve the utilization of modern contraceptives.
will affect the health of children; 4) postpartum family planning does not help women to start sexual intercourse immediately; 5) postpartum family planning cannot expose to urinary tract infection; 6) IUCD does not affect any day-to-day activity; 7) male sterilization does not affect the desire of sexual activity; 8) IUCD does not affect any sexual activity and desire.A score of 1 was given for correct answers and a score of zero was given for incorrect answers.Two fourth-year midwifery students and a BSc graduate in midwifery were recruited for data collection and supervision respectively.The questionnaires were prepared in English and translated into Amharic and translated back to English to keep the consistency of the questionnaire.A pre-test on 28(5%) of the sample was done at Woreta town.One day training was given about the overall data collection process for both the data collectors and the supervisor.During the data collection period, questionnaire was checked for completeness daily by the supervisors, and corrective measures were taken on spot.Data Processing and AnalysisThe data were entered into EPI Info version 7 and exported to SPSS version 20 software for analysis.Binary logistic regression was used to identify factors associated with knowledge and attitudes of modern contraceptive methods.Variables having with a p-value of less than or equal to 0.20 was fitted in the multivariable logistic regression models for controlling the possible effect of confounders.The variables which have independent association with knowledge and attitudes of postpartum mothers about modern contraceptive methods were identified based on the odds ratio with 95%CI, and p-value less than or equal to 0.05 were considered to determine statically significant association.

Figure 1 :
Figure 1: Type of contraceptives known by postpartum mothers in Debra Tabor town, South Gondar zone, Northwest Ethiopia 2018.
the study subjects.The previous study was done on postpartum mothers at the end of twelve months of delivery.This may increase repetitive contacts in MNCH services; which provide the chance to get more information about family planning methods.The other reason perhaps is the increase of knowledge about postpartum contraceptive users at the end of twelve months.In other words, through time mothers may get different information about contraceptive methods.
Abbreviation ANC: antenatal care, AOR: adjusted odds ratio, CI: confidence interval, COC: combined oral contraceptives, COR: crud odds ratio, FP: family planning, IUCD: intra-uterine contraceptive device, MCH: maternal and child health, PNC: postnatal care, PPFP: postpartum family planning, SPSS: statistical package for social scientists, WHO: world health organization Declaration Ethics Approval and Consent to Participate This study was conducted under the declaration of Helsinki.

Table 2 ) . Table 2 :
Repr oductive and Mater nity Health Ser vice-Related Characteristics of Mother at Debre Tabor Town

Table 5 ). Factors Associated with Attitude of Postpartum Mothers on Modern Contraceptive Methods
planning methods among mothers whose educational status of high school and above were 2.15 times [AOR: 2.15 (95% CI: 1.36, 3.4)] more likely to have good knowledge than who did not attend formal education.Mothers who were ever discuss with their husband about contraceptive methods were 2.15 [AOR: 2.152 (95% CI: 1.48, 3.14)] times more likely to CI: 1.19, 2.53)] times more likely to have favorable attitude than those who does not had information about contraceptives.Lastly, mothers who had good knowledge about contraceptives were 3.5[AOR: 3.493 (95% CI: 2.37, 5.15)] times more likely to had favorable attitude than those who had poor knowledge.(Table6).

Table 3 :
Knowledge of Women in the Postpar tum Per iod on Moder n Contr aceptives in Debr e Tabor Town,

Table 4 :
Attitudes Bivar iable and Multivar iable Logistic Regr ession Analysis of Factor s Associated with Knowledge of Postpar tum Mothers about Contraceptives in Debre Tabor Town, South Gondar Zone, Northwest Ethiopia, 2018 (n= 552) of Women in the Postpar tum Per iod on Moder n Contr aceptive Methods in Debr e Tabor Town, Northwest Ethiopia, 2018 (n= 552)

After delivery of the last child do you get information about FP
Notes: * p-value <0.05, ** p-value ≤0.001

Table 6 :
Bivar iable and Multivar iable Logistic Regr ession Analysis of Factor s Associated with Attitude of Postpar tum Mothers about Modern Contraceptives in Debre Tabor Town, South Gondar Zone, Northwest Ethiopia, 2018 (n= 552)