Family Planning Prevalence Among Postpartum Mothers Attending Child Welfare Clinics – A Sri Lankan Experience

Sir, 
 
One of the main reasons for seeking abortion in Sri Lanka is insufficient spacing between births.(1) This could be partly due to deficit in postpartum contraceptive services. A hospital-based study reported that at the time they leave the hospital, knowledge on the appropriate time to start a contraceptive method was poor among Sri Lankan mothers.(2) Even among those who are knowledgeable, the actual practices are unknown. Studies have demonstrated that antenatal programs that promote contraception are not effective to improve postpartum contraceptive prevalence.(3,4) The purpose of this study was to assess the prevalence of modern Family Planning (FP) methods among postpartum mothers in order to improve maternal and child healthcare service provision. 
 
A clinic-based, cross-sectional, descriptive study was conducted in the area of the medical officer of health, Beruwala. We interviewed all infant-mother pairs where infants were two months of age, attending child welfare clinics for the first dose of Diphtheria-Tetanus-Pertussis (DTP) during a period of two months. A cluster sampling technique was used to obtain the sample from 19 child welfare clinics. An interviewer administered questionnaire was used for data collection. Authors collected data during routine clinic visits. Ethical and administrative clearance was obtained from the National Institute of Health Sciences, Kalutara. 
 
All together 129 mothers were interviewed. Mean age of the study sample was 27 years with a standard deviation of 4.6. Median duration of the postpartum period was eight weeks. Sixty-four of the study sample were having their first child. The sample consisted of 58 (45%) Muslim mothers and 71 (55%) Sinhalese mothers. 
 
Family Planning (FP) prevalence among study participants was 41.1% (53). Out of the mothers who were not on FP, 22 (28.9%) had already decided on an FP method. Fifty-four mothers, 41.9%, neither used a family planning method nor had they decided on a method or when to start. All these 75 mothers who had already started and decided on an FP method had received domiciliary care (postpartum home visits by the public health midwife) and FP advice through the area public health midwife. 
 
Among those who had not decided on a method, 40 (74.1%) had no specific reasons for noncommencement, while 12 (22.2%) had not decided because of the inaccurate information received on FP. Nine mothers (16.7%) did not receive domiciliary care at all and only 33 (61.1%) received family planning advice from the area public health midwife. 
 
Use of an FP method was significantly associated with domiciliary postpartum care (Fishers exact test P = 0.009) and FP counseling (χ2 = 17.5, P < 0.001). Maternal age, ethnicity or number of children was not significantly associated with postpartum FP prevalence. 
 
The prevalence of modern methods used among the reproductive age group in Sri Lanka was 49.5% in 2000.(5) The prevalence of modern FP methods used among postpartum mothers in our study sample was below this national average. The study shows that all mothers who received domiciliary care had not received FP counseling. Divisional level health care managers should pay more attention to improve the quality of postpartum care in order to improve maternal and child health status.


Family Planning Prevalence Among Postpartum Mothers Attending Child Welfare Clinics -A Sri Lankan Experience
Sir, One of the main reasons for seeking abortion in Sri Lanka is insufficient spacing between births. (1) This could be partly due to deficit in postpartum contraceptive services. A hospital-based study reported that at the time they leave the hospital, knowledge on the appropriate time to start a contraceptive method was poor among Sri Lankan mothers. (2) Even among those who are knowledgeable, the actual practices are unknown. Studies have demonstrated that antenatal programs that promote contraception are not effective to improve postpartum contraceptive prevalence. (3,4) The purpose of this study was to assess the prevalence of modern Family Planning (FP) methods among postpartum mothers in order to improve maternal and child healthcare service provision.
A clinic-based, cross-sectional, descriptive study was conducted in the area of the medical officer of health, Beruwala. We interviewed all infant-mother pairs where infants were two months of age, attending child welfare clinics for the first dose of Diphtheria-Tetanus-Pertussis (DTP) during a period of two months. A cluster sampling technique was used to obtain the sample from 19 child welfare clinics. An interviewer administered questionnaire was used for data collection. Authors collected data during routine clinic visits. Ethical and administrative clearance was obtained from the National Institute of Health Sciences, Kalutara.
All together 129 mothers were interviewed. Mean age of the study sample was 27 years with a standard deviation of 4.6. Median duration of the postpartum period was eight weeks. Sixty-four of the study sample were having their first child. The sample consisted of 58 (45%) Muslim mothers and 71 (55%) Sinhalese mothers.

Letters to Editor
Family Planning (FP) prevalence among study participants was 41.1% (53). Out of the mothers who were not on FP, 22 (28.9%) had already decided on an FP method. Fifty-four mothers, 41.9%, neither used a family planning method nor had they decided on a method or when to start. All these 75 mothers who had already started and decided on an FP method had received domiciliary care (postpartum home visits by the public health midwife) and FP advice through the area public health midwife.
Among those who had not decided on a method, 40 (74.1%) had no specific reasons for noncommencement, while 12 (22.2%) had not decided because of the inaccurate information received on FP. Nine mothers (16.7%) did not receive domiciliary care at all and only 33 (61.1%) received family planning advice from the area public health midwife.
Use of an FP method was significantly associated with domiciliary postpartum care (Fishers exact test P = 0.009) and FP counseling (χ² = 17.5, P < 0.001). Maternal age, ethnicity or number of children was not significantly associated with postpartum FP prevalence.
The prevalence of modern methods used among the reproductive age group in Sri Lanka was 49.5% in 2000. (5) The prevalence of modern FP methods used among postpartum mothers in our study sample was below this national average. The study shows that all mothers who received domiciliary care had not received FP counseling. Divisional level health care managers should pay more attention to improve the quality of postpartum care in order to improve maternal and child health status.

Future of Community Medicine in India
Sir In spite of the impressive advances made in the field of Community Medicine in India, there is considerable confusion over its role in the future. As you have rightly pointed out in your editorial by Rajesh Kumar (Academic Community Medicine in 21 st Century: Challenges and Opportunities), academic growth in this subject can take either of these two directions, namely, Family Medicine or Public Health. The basic shortcoming of public health in India, which we feel, is that those with training in public health are not in the position to make decisions. As conventionally in the government setup these crucial positions are handled by bureaucrats and ministers who do not have the training or experience in public health.
It is surprising to us that in these times of rapid growth, when we are continually made to believe that we are becoming superpowers, the health situation in our country is so dismal. That no effort is being made to correct this state of affairs is evident in the amount of funding which the government provides for our health.