Postpartum Family Planning Utilization and Associated Factors among Women who Gave Birth in the Past 12 Months, Kebribeyah Town, Somali Region, Eastern Ethiopia

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Introduction Background
Postpartum family planning is defined as the prevention of unintended pregnancy and closely spaced pregnancies through the first 12 months after childbirth [1]. Therefore, the first year after a woman has given birth is a crucial period for the uptake of contraceptives to prevent unintended pregnancy [2]. Consequently, contraceptive use by women during this period is low, resulting to unintended pregnancies and unwanted childbearing [3].
Although the majority of postpartum women indicate a desire to delay a next birth, but family planning methods are often not offered to, or taken up by women after delivery or in the first year of postpartum [4,5].
Globally, family planning is recognized as a key life-saving intervention for mothers and their children [6]. On the other hand, short inter-pregnancy intervals can result negative health outcomes such as maternal anaemia; low birth weight, and neonatal/infant mortality [7]. Furthermore, short birth intervals adversely affect the health of mothers and the survival of their children. In addition, the risk of the death of a child increases if the interval between the birth of the child and the previous birth is less than 24 months [8].
World Health Organization advises an interval of at least 24 months before mothers attempt to become pregnant in order to reduce the risk of adverse maternal, prenatal and infant outcomes [9]. For example, when a mother becomes pregnant shortly after childbirth, she is more likely prone to develop complications including spontaneous abortion, postpartum bleeding, and anaemia. Secondly, the new born could be born with low birth weight and/or preterm. Thirdly, the index child might receive inadequate care and support which, thereafter, could lead to vulnerabilities to disease and malnutrition [10,11].
Therefore, the postpartum period is important period for Prevention, early diagnosis and treatment of complications of mother and infant, including the prevention of vertical transmission of diseases from mother to infant, Referral of mother and infant for specialist care when necessary, Counseling on baby care, Support of breastfeeding, Counseling on maternal nutrition, Counseling and service provision for contraception, birth spacing and the resumption of sexual activity and Immunization of the infant [12].
Therefore, ensuring access to preferred contraceptive methods for women and couples is essential to securing the well-being and autonomy of women by preventing pregnancy related health risks in women, Reducing infant mortality, Empowering women and enhancing education, Reducing adolescent pregnancies and Slowing population growth [13].
Generally, as the first pillar of safe motherhood and an essential component of primary health care, contraceptive utilization plays a key role in reducing maternal and new-born morbidity and mortality by preventing unintended pregnancy and close birth intervals [10].
This study will help health planners and health professionals in planning and providing more efficient postpartum family planning services. It also hopes that results of this study will serve as spring board for further researches in the field to enhance postpartum family planning utilization. The research finding also will help Kebribeyah Woreda health office to mobilize and sensitize the community to increase the uptake of postpartum family planning utilization for the wellbeing of mother and child health.

Conceptual frame work
The conceptual frame work was used in this study adapted from different related literature. First section covered socio demographic factors, the second were reproductive history related factors, the third, were knowledge and attitude; and the others section were health service related factors and decision making of postpartum women for contraceptive ( Figure 1).

Methods and Materials
This study was conducted in Somali region, Kebribeyah town from October 10 to October 30, 2015. Kebribeyah town (study town) is 50 km away from Jigjiga in the eastern part of the county. Based on 2015 population projection by the Central Statistical Agency (CSA), the Somali Region has a total population of 5,453,000, consisting of 2,820,321 men and 2632679 women. Kebribeyah town has four kebeles with the total population of 32,623 and women of reproductive age were about 7454 (22.85%) and estimated live birth is about 1109 (3.4%) (Woreda health office, 2015). Community based cross-sectional study design was employed. Single population proportion formula was used to calculate the sample size considering the following assumptions: prevalence of postpartum contraceptive utilization in North West Ethiopia, Dab at district which was 38.7% were considered [14]. Almost 95% confidence level, 3% margin of error was used to increase sample size and 5% non-response rate were considered.
Since our source population were 1109, which were <10,000 so we need to use correction formula. And the final calculated sample size was 529 and by considering 5% of non-response rate and the final sample size were 556 postpartum women. After conducting a rapid census to obtain the lists of household with postpartum women, Proportional allocations for each kebeles were made according to their respective postpartum women. Households with eligible study participants were selected by simple random sampling method through house-to-house visits ( Figure 2). The tools have nine pages; five of the sections were tries to cover: socio demographic characteristics, reproductive histories related factors, knowledge and attitude related factors, and health service related factors, discussion and approval of postpartum family use. Data collection tool were structured and interviewer administered questionnaires via face to face interview were employed. The questionnaire adapted from instruments that were applied in different studies related to family planning utilization [15][16][17].
Postpartum women's attitudes related factors were measured by five point likert scales (1 for strongly disagree, 2 for disagree, 3 for neutral, 4 agree and 5 for strongly agree) and knowledge was measured by mean knowledge from knowledge measuring question.
The study used household survey questionnaire as principal data collection tools. Data collectors were four female grade ten complete were participated. All the data collectors and supervisor were oriented for one day. The orientations were focus on familiarization of the tool, provision of the guidance on how to fill the questionnaire, how to approach the respondents, and how to capture the absentee. The orientations were facilitated by investigator himself to ensure proper communication of the questions, purpose and significance of getting appropriate information. The field works were supervised by the supervisor during data collection period closely.
The coded data were entered into Epi data version 3.1 and exported to SPSS version 20 statistical software package for analysis. Firstly, descriptive analyses (tables and graphs) were carried out for each of the variables. Secondly, bivariate analyses were done for the independent variables with the outcome variable to select candidate variables for the multivariate analyses. Variables having p-value ≤0.25 in the bivariate analyses were fitted into a multivariable logistic regression model to control the effects of confounding.
Finally variables which showed significant association with the dependent variable on the bivariate analysis were entered to multivariable logistic regression model to identify their association. Adjusted odds ratios with their 95% CI were calculated to determine the strength and presence of association. P-value of less than 0.05 was considered to declare significance.

Ethical Consideration
Ethical clearance was obtained from Jimma University, college of health science, Ethical Clearance Committee. Official letter of cooperation were also obtained from Somali regional Health Bureau and Woreda Health Office before the study has taken place both to ensure legitimacy and build trust with local kebeles and study communities.
Participation in this study was purely voluntary. Informed verbal consent was obtained from each respondent during the data collections and they were informed about purpose and benefit of the study along with right to refuse. Also by ensuring all collected information were kept confidentially.

Socio-demographic factors
Among 556 study participants, 545 postpartum women were interviewed, resulting in 98% response rates. The mean age of the respondent was 31 (SD + 7.4) and the minimum and the maximum age of the respondents were 15 and 45 years respectively.
The majority of the respondents 522 (95.8%) were married. The predominant ethnic group was Somali which is about 384 (70.5%) and the least one was Gurage which is 15 (2.8%) (

Reproductive histories related factors
About 46 (68.7%) started contraceptive between 2-3 months followed by 4-5 and at 6 month and above which is only eight respondents. Majority of the respondents 286 (82.4%) started sexual intercourse at seven weeks and above, followed by 54 (15.6%) at six weeks ( Table 2).

Variables Frequency Percentage
Number of pregnancy (n=545)

Assessment on attitude of postpartum women
The Mean attitudes of the respondents were 34.36 (SD + 6.5). Among the respondents, 278 (51%) had favorable attitude toward postpartum contraceptive utilizations (

Practice related factors
The prevalence of contraceptive utilization was found to be 67 (12.3%) among women in the postpartum period. The majority of respondents 46 (68.7%) started utilization of contraceptive between 2-3 months of postpartum and only 5 respondents used contraceptive within one months. Among the respondents (545) the intention of postpartum partum women used contraceptive were 214 (39.8%). The Intention for limiting and spacing were 62 (29.1%) and 186 (86.9%) respectively ( Figure 2).

Health service characteristics
The prevalence of antenatal care utilization were about 304 (55.8%), whereas, the prevalence of institutional delivery (both hospital and health centre) were 316 (58%).

Variables Frequency Percentage
Health facility in your town (N=545) Yes 545 100

Factors associated with postpartum contraceptive utilization
Variables such as: educational status of respondent, occupation of respondent, interval between birth, having ANC visit, counseled for FP at ANC, Place of delivery, counseled at delivery, having PNC visit, discussion with partner, husband decide, decide by themselves, start complementary feeding, number of pregnancy, PP duration, start of sexual intercourse, gestational age at ANC, good knowledge, favorable attitude were had significant association with postpartum contraceptive utilizations on bivariate analysis. Based on findings from the bivariate analysis, the following variables were included in multiple logistic regression models. Variables such as: occupation of the respondent, source of information about FP from health facility, start complementary feeding, counseling during ANC, counseling during delivery, husband decide, educational status of respondent, family size, ANC visit, favorable attitude, good knowledge, PNC visit, duration of postpartum. These fourteen variables were selected by checking their power.
In multivariate logistic regression analysis; predictors of postpartum family planning utilizations were, educational status of respondents, counseling for FP during delivery, counseling during ANC, duration of postpartum period, information about FP from health facility, favorable attitude. Women in the postpartum who were educated (literate) were three times more likely used postpartum contraceptive (AOR=3.37; 95% CI: (1.029-11.033)) as compared to illiterate. Women who had counseling during delivery (AOR=6.8; 95% CI: (1.875-24.492)) about nearly seven times more likely utilize postpartum family planning than their counter parts. Women with duration of postpartum 7-9 month nearly three times more likely utilize post postpartum family planning utilization than those less than three month (AOR=3.11; 95% CI: (1.011-9.670)). Postpartum women who had source of information about contraceptive from health facility were nearly four times more likely utilize postpartum contraceptive utilization than their counter parts (AOR=4.0; 95% CI (1.170-14.302)). Women who had ANC visit during pregnancy were almost 4 times more likely utilize post-partum contraceptive than women who didn't started ANC visit during pregnancy (AOR=3.9;95% CI: (1.234-12.065)).

Discussion
Postpartum family planning is the prevention of unintended pregnancy and closely spaced pregnancies through the first 12 months after childbirth [1]. Therefore, the first year after a woman has given birth is a crucial period for the uptake of contraceptives to prevent unintended pregnancy [2]. The prevalence of contraceptive utilization was found to be 67 (12.3%) among women in the postpartum period in Kebribeyah town which is slightly higher than Dab at district which is 10.3% [14]. This variation might be due to socio demographic, cultural, awareness and religious difference for the uptake of postpartum family planning use. However, this study is lower than the prevalence of postpartum contraceptive in Jimma Mana district town 48.4% [18]. This may be due to the temporal differences in the study periods and/or the fact that this study is done on women who are in the postpartum period when there is a high motivation to use family planning methods.
Injectable (38.8%) and pills (32.8%) were the commonly used methods. Moreover, implant accounted for 23.9% of the users. These degrees of preference were in line with study conducted in Gondar town [18]. This might be attributed to client's preferences for specific methods as well as the accessibility and availability of chosen methods.
In this study Postpartum women who had counseling during delivery were about more likely utilize postpartum family planning than their counter parts. This study is supported by across sectional survey conducted in Senegal stated that, those who received FP counseling at the time of delivery were more likely to use postpartum family planning than their counterparts [19]. This consistency might be due to women who were counseled during delivery would experience the pain as a result of frequent birth and the importance of having birth spacing for both the mother and new born. This can also attributed to the family planning advice received by the women at a health facility during delivery.
The findings suggest that facility delivery remain 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 service integration within the public sector in order to take advantage of the delivery to increase the uptake of family planning during the critical postpartum period.
Women in the postpartum whose duration of postpartum from 7-9 months was more likely utilize postpartum contraceptive than duration between 6 week and 3 month postpartum. This study was supported by recent cross-sectional study conducted in Gonder town [18]. The similarity could be supported by the fact that most women had resumed menses after 6 months and the period at which exclusive breast feeding stops and the women start to practice contraceptive utilizations.
Women who had ANC visit during pregnancy were more likely utilize post-partum contraceptive than women who didn't start ANC visit during pregnancy. This study was supported by cross sectional study conducted in Gonder town and Bahardar [15,18]. The reasons of consistency were women who had frequent visit during ANC had more exposure of information and had more awareness on birth spacing by the use of contraceptive after giving each birth. On the other hand, study conducted on North West Ethiopia Dab at district the utilization of antenatal care service was not found to be a significant predictor of the use of contraception in the postpartum period [14]. The difference between the two studies might be due to poor counseling during antenatal care visit on the importance of postpartum family planning use.
Women in the postpartum who had information about contraceptive from health facility were more likely to utilize postpartum contraceptive than their counter parts. Contrary to this finding study conducted in Uganda stated that women who had exposure to media on family planning were significantly more likely to use post-partum family planning [20]. The difference might be due to the credible source information might affect the utilization of postpartum contraception.
Postpartum women whose educational status was literate were more likely utilize postpartum contraceptive as compared to illiterate. Similarly study conducted in Uganda supported that woman's with primary or secondary educations were predictors' of modern PPFP utilizations. This similarity might be due to women attainment of educational level exposes to better understanding of the available methods of family planning during postpartum period. In addition, educations increase the level of awareness of family planning and to utilize the expedient method of family planning [20]. In contrary to this finding study conducted in Dabat district showed that significant association between husband's education and use of contraceptives among women. Higher education of husbands promotes the use of contraceptives in the extended post-partum period [21][22][23][24][25][26].
This difference might be due to husband's education was found significant in deciding use of family planning and importance of focusing on involving men in family planning because husbands do seem to play a role in deciding family planning methods for their wives [26][27][28][29][30][31][32].
However, it has the following limitations: Respondents had recall bias on certain variables, since the study is cross-sectional it shows only temporal relationships. Study participants were trained for only day and also Study includes only individual factors [41][42][43][44][45].

Conclusion
This study indicates that the prevalence of postpartum contraceptive utilization is low which about 12.3%. Factors such as, educational status of the respondents, source of information about contraceptive from health facility, counseling about FP during delivery, counseling at ANC, duration of postpartum, favorable attitude toward FP were factors positively predict postpartum contraceptive use. The Reason for non-users of contraceptives were religion forbids, wants to have many children, husband disproval, feeling not at risk due to breast feeding were the main factors.
Postpartum family planning utilization by the women during postpartum period is low and requires urgent and effective response by Kebribeyah woreda health office to enhance the uptake of postpartum contraceptive in through family planning education for the women as long term solution.

Recommendations
Woreda health office should work on health providers on counseling about FP during ANC, delivery, postnatal care to improve the utilization of contraceptives in the postpartum period. Empowering women through family planning education to utilize postpartum family planning and to bring behavioral change communications as a long term solution.
Health service providers should promote contraceptive utilization counseling during ANC, Delivery, and PNC at all level as short term solution. Health service providers should provide/promote contraceptive service during PNC for postpartum women. The researchers should investigate health service providers' related factors that hinder postpartum contraceptive uptake through qualitative study in the study area.