Introduction
Based on the mini 2019 Ethiopian Demographic and Health Survey analysis, the use of modern family planning is low. Overall, 41% of currently married women are using a modern method of family planning, and 1% are using a traditional method. Among the currently married women, the most commonly used methods are injectables (27%), implants (9%), intrauterine devices (IUD) (2%) and pills (2%).1 When we come to immediate postpartum family planning (IPPFP), it is even worse and out of a quarter of postpartum women who were counselled on contraception, only 13.6% received the contraceptive methods.2 As a result, the immediate postpartum long-acting reversible contraceptives (LARCs) use in sub-Sharan Africa (SSA) varies from 2% to 14%3 in general, and its use in Ethiopia varies from 11% to 17%4 5 in particular.
The unintended pregnancy rate remains higher, ranging from 64 to 91 pregnancies per 1000 women in developing regions compared with 35 pregnancies per 1000 women in developed regions.6 Waiting at least 24 months before attempting the next pregnancy was recommended as it is found to be a healthy time for pregnancy and as a result reduce the risk of adverse maternal, perinatal and infant outcomes.7 8 To decrease these risks, access to immediate LARCs is essential.8 9 LARCs are the ideal contraceptive methods for the prevention of the harmful consequences of unintended pregnancies in most women and adolescents as they are safe, effective and reversible.10 11 About 190 million women of reproductive age worldwide who want to avoid pregnancy do not use any contraceptive method and the unmet need for family planning in SSA is one of the highest, ranging from 20% to 26%.12 LARCs, which consist of implants and IUD, are the most effective modern family planning methods in tier one in addition to vasectomy and tubal ligation.13 14 Almost all postpartum women are medically eligible for LARCs.15 These methods have multiple advantages over other reversible methods as they do not require maintenance and their duration of action is long, ranging from 3 to 10 years once in place.16
The prevalence of LARCs use in SSA is one of the lowest, at 13.86% (11.18% for implant and 2.68% for IUDs).17 According to a United Nations study of 2015, worldwide, 57% of married women are using a modern form of contraceptives; and a recent study of 2019 showed, that only 15.5% of women worldwide use IUDs, and only 3.4% use subdermal implants. The common reasons for low uptake include misperceptions about the safety and efficacy of LARCs, perceived lack of consumer demand, inadequately trained providers and the relative complexity of providing LARCs compared with short-acting methods.18
Rapid population growth remains a major concern in many SSA countries.19 Women rely primarily on traditional and short-acting contraception, which is prone to incorrect or inconsistent use and failure.9 19 20 This leads to high maternal morbidity and mortality attributed to unintended pregnancies, short birth intervals and a higher risk of obstetric complications.21
A study in East Africa, in 2012, shows that access to FP services is particularly low among rural, less educated and poorer women. Furthermore, availability, perceived costs, lack of provider skills and misperceptions about modern contraceptives and their risks and benefits are barriers to uptake.22
A study done in Kenya in 2014, noted that only 3.4% and 9.9% of women seeking family planning methods use IUCD and implants, respectively. In Kakamega County, particularly, the report indicated that only 1% of the women use IUCD. This is very low given the advantages associated with LARC. Different reasons have emerged as to why the uptake is low but with no data to back up the statement.23
It is believed that health coverage and access to care have increased over the past decades, however, due to the poor quality of care, different sexual and reproductive healthcare targets could not be achieved, and as a result, associated morbidity and mortality could not be reduced. Even though LARCs commodities are free of charge and available in our hospital, it is only located at the family planning clinic in the outpatient department. As a result, the family planning commodities are not accessible to immediate postpartum women. Furthermore, there is a high turnover and lack of motivation among trained healthcare providers on family planning to provide immediate postpartum LARCs.
This study aimed to assess all fundamental barriers to immediate postpartum LARCs use and determine the effect of continuous quality improvement (CQI) using a plan–do–study–act (PDSA) based quality improvement model to increase the use of postpartum LARCs at Jimma University Medical Center (JUMC).
We presented here the changes made to increase the observed low utilisation of immediate postpartum LARCs use with the aim to increase from the baseline (6.9%) to CQI using the PDSA cycle to 30%.