Assessement of Utilization and Satisfaction of the Immediate Postpartum Family Planning in the Teaching Hospital Sourô Sanou, Bobo-Dioulasso, Burkina Faso ()
1. Introduction
Immediate post-partum family planning (IPPFP) is a major component of childbirth care. In developed countries, contraceptive services are provided as an integral part of essential childbirth care. This contributes to the increased use of post-partum contraception, reducing unwanted pregnancies and ensuring adequate spacing between pregnancies [1] [2].
However, the success of family planning has not been equal throughout the world. In some countries, contraceptive use has remained low, or has increased only slowly over the years. In Africa, the efforts made in recent years in the field of maternal and neonatal health have produced encouraging results, due to effective interventions at both health facility and community level. However, despite the gradual decline in maternal and infant mortality indicators since 2005, efforts are still needed to achieve the targets set by the World Health Organization (WHO), including Burkina Faso [3].
Unplanned pregnancy is a source of major health and economic consequences in Burkina Faso including Bobo Dioulasso. It disproportionately affects households, increasing the risk of morbidity and mortality for both children and their mothers [3]. According to a consultation initiated by the WHO, after a live birth by natural means, the recommended interval before planning a new pregnancy is at least 24 months, in order to reduce health risks [4]. To avoid pregnancy within this timeframe, it is important to offer contraception immediately post-partum [5], in order to provide this service to recent mothers. The teaching hospital Sourô Sanou in Bobo-Dioulasso (CHUSS) has a wide choice of contraceptives available, as well as qualified providers, as part of the government’s free health care scheme for pregnant women and children under 5. Indeed, the post-partum period is a high-risk period for women who have not adopted an effective contraceptive method. Immediate postpartum family planning has been taking place at the CHUSS since April 2013 in order to offer this service to newborns before going back to continue the postnatal care at the health facility of origin.
In Bobo-Dioulasso, a study on the use of the postpartum intrauterine device at the maternity ward of the Sourô Sanou University Hospital (CHUSS) was carried out in 2017. It had concluded that postpartum family planning through the IUPP was a major opportunity to boost family planning (FP) and raise the level of contraceptive prevalence [6]. Indeed, the objective of the National Family Planning Plan of Burkina Faso (PNPF 2021-2025) is to increase the modern contraceptive prevalence rate (TPCm) from 31.9% in 2020 to 41.3% in 2025 [7]. However, the satisfaction of women using this method was not assessed. Therefore, there is a need to study the use and satisfaction contraceptive in Bobo Dioulasso, contributing to increasing the modern contraceptive prevalence rate to reach the target of 41.3% by 2025 [7]. This study aims to assess the utilisation and satisfaction of IPPFP in teaching hospital Souro Sanou, Bobo Dioulasso.
2. Methodology
2.1. Study Scope and Site
The site of the study was the Department of Gynecology, Obstetrics and Reproductive Medicine (DGOMR) in the teaching hospital Sourô Sanou (CHUSS). The DGOMR has three departments, including the obstetrics department, which is subdivided into three care units: the delivery room, the operating theatre and the post-natal and pathological pregnancy units. The physiological post-partum unit and the unit for recently operated women are attached to the gynecology department.
2.2. Type and Period of Study
This was a cross-sectional descriptive study carried out from September 1, 2019 to January 30, 2020.
2.3. Study Population
The target population consisted of women who had received counseling to choose an immediate postpartum contraceptive method between 10 minutes and 48 hours after delivery at the CHUSS maternity ward during the study period.
The source population consisted of women who had actually received a contraceptive method after receiving immediate postpartum contraception counseling at the CHUSS maternity hospital during the study period.
2.4. Inclusion Criteria
Patients included in the study were those who had given birth vaginally at the CHUSS maternity hospital during the study period and who had received a contraceptive method after immediate postpartum contraception counseling.
2.5. Sampling
Non-probability sampling consisted of including patients progressively according to their delivery and adherence to the study, until a representative sample size was reached. We calculated our minimum sample size (n), which here corresponds to the population who received FP counseling, using the SCHWARTZ formula:
t = Confidence level (standard value for 96% confidence level is 1.78).
p = The contraceptive prevalence rate for modern methods among women in union in Burkina Faso in 2019 is 26.9%.
m = Margin of error (estimated at 3% by default for our study).
This sample is the minimum size for our study population. The expected sample, in our context, was all deliveries registered from September 1st to November 30th, 2019, i.e. 1308 patients, 906 having given birth by vaginal delivery and 402 by caesarean section.
Of the 1308 patients who gave birth during the study period, we identified:
09 patients transferred to another department;
104 deliveries against medical advice;
212 women who refused to take part in the study;
130 deliveries not accessible after discharge for follow-up;
Out of a total of 853 births who received postpartum counseling, 559 refused to choose a contraceptive method after the counseling.
The following selection process yielded a final usable sample of 294 clients who had chosen a contraceptive method.
2.6. Sampling Techniques and Instruments
This was a survey in which data were collected first by direct semi-structured individual interviews and then by telephone calls between the second and sixth week after hospital discharge. They were then supplemented by a literature review based on the women’s registers and medical records. The data collected were recorded on a questionnaire.
2.7. Studied Variables
Contraceptive methods presented and selected: These methods were progestin-only oral contraceptives, implants, male or female condoms, the breastfeeding and amenorrhea method and the copper intrauterine device.
Follow-up: The elements evaluated were: 1) side effects, complications and time to onset, 2) discontinuation of the method and reason for discontinuation, 3) the replacement method chosen, 4) whether follow-up was regular or irregular, 5) degree and reason for satisfaction with the first and replacement methods used. Four levels of evaluation were retained: not at all satisfied, moderately satisfied, satisfied, very satisfied.
2.8. Data Collection Procedures
For clients with vaginal deliveries, postpartum contraceptive counseling took place in the delivery room ten minutes after delivery. Once an informed choice had been made, the contraceptive was offered to the client before she was allowed to leave the delivery room to be admitted to the physiological postpartum unit. In the case of Caesarean parturients, counseling took place during the first stage of labor. Pregnant women who came for a scheduled caesarean section were counselled in the waiting room before being admitted to the operating theatre. Thus, in the event of a confirmed preference for the intra-uterine device, it was placed intracaesarean. The other contraceptives chosen were administered in the care unit of newly operated women, before woman was discharged. For women undergoing emergency caesarean section and those with cervical dilatation of at least 4cm, counseling was performed postoperatively.
In this study, all women underwent a clinical examination one hour and thirty minutes after delivery. The aim was to ascertain the method chosen and to gather the woman’s immediate impressions of her current and previous methods. All these women received a second examination six hours after delivery, and before they were discharged, a telephone appointment was negotiated with each of them. This interview took place between the second and sixth week after discharge: the aim was to gather information on any side effects, as well as the level of satisfaction with the use of the method.
2.9. Data Analysis
Data was entered on a computer using EPI Data software version 3.1.1, using a specially designed mask. The data was coded alphanumerically to facilitate processing. Microsoft Office software versions Word and Excel 2013 were used to enter and present the results. Analysis was performed using SPSS software version 22. Positional parameters (mean and median) and dispersion parameters (standard deviation, minimum, maximum) were used to describe our sample.
2.10. Ethical Considerations
Each woman was asked to give free and informed verbal consent to participate in the study, and to provide a functional telephone number to be contacted upon discharge.
3. Results
3.1. Frequency
Out of a total of 853 deliveries who had received postpartum counseling, 294 had chosen and obtained a contraceptive method in the immediate postpartum period, i.e. 34.50%. Implants were adopted by 63.60% of patients who received counseling, followed by the intrauterine device (28.23%) and oral contraceptives (3.40%). Immediate long-acting reversible contraception (LARC), including the intrauterine device and implants, has been adopted by 270 customers.
3.2. Socio-Demographic Characteristics of Clients According to
Chosen Method
The implant was the method most chosen by clients in the 20 - 29 age group (35.03%). The choice made by clients according to age group is shown in Table 1.
Table 1. Distribution of births by contraceptive method and age group.
Method choose |
Age class (years) |
Total; n (%) |
<20; n (%) |
20 - 29; n (%) |
30 - 39; n (%) |
≥40; n (%) |
Implant |
33 (11.22) |
103 (35.03) |
49 (16.66) |
2 (0.68) |
187 (63.60) |
IUD* |
8 (2.72) |
35 (11.90) |
38 (12.92) |
2 (0.68) |
83 (16.80) |
CO** |
1 (0.34) |
8 (2.72) |
3 (1.02) |
4 (1.36) |
16 (5.44) |
LAM*** |
0 (0.00) |
3 (1.02) |
5 (1.17) |
0 (0.00) |
8 (2.72) |
Total |
42 (14.28) |
149 (50.68) |
95 (32.31) |
8 (2.72) |
294 (100) |
*IUD: intrauterine device; **CO: micro-dosed progestin oral contraceptive; ***LAM: Lactation amenorrhea method.
The implant was the method most chosen by clients with no formal education (40.47%). The choice made by clients according to level of education is shown in Table 2.
Table 2. Distribution of births by contraceptive method and level of education.
Method choose |
Level of education |
Total;
n (%) |
No in school;
n (%) |
Koranic;
n (%) |
Primary;
n (%) |
Secondary n (%) |
higher
academic level; n (%) |
Implant |
119 (40.47) |
2 (0.68) |
28 (9.52) |
22 (7.49) |
16 (5.44) |
187 (63.60) |
IUD* |
53 (18.02) |
2 (0.68) |
21 (7.14) |
4 (1.3) |
3 (1.02) |
83 (28.23) |
CO** |
5 (1.70) |
0 (0.00) |
5 (1.70) |
0 (0.00) |
0 (0.00) |
10 (3.40) |
LAM*** |
10 (3.40) |
0 (0.00) |
1 (0.34) |
2 (0.68) |
1 (0.34) |
14 (4.76) |
Total |
187 (63.60) |
4 (1.36) |
55 (18.70) |
28 (9.52) |
20 (6.80) |
294 (100) |
IUD: intrauterine device; **CO: micro-dosed progestin oral contraceptive; ***LAM: Lactation amenorrhea method.
Table 3. Distribution of women giving birth according to the contraceptive method chosen and their occupation.
Method choose |
Principal occupation |
Total;
n (%) |
Housewife; n (%) |
Employee; n (%) |
retailer;
n (%) |
Informal
sector worker
n (%) |
Student;
n (%) |
Implant |
129 (43.87) |
16 (5.4) |
6 (2.04) |
17 (5.78) |
19 (6.46) |
187 (63.60) |
IUD* |
66 (22.44) |
3 (1.02) |
8 (2.72) |
4 (1.36) |
2 (0.68) |
83 (29.93) |
CO** |
7 (2.38) |
0 (0.00) |
0 (0.00) |
3 (1.02) |
0 (0.00) |
10 (3.4) |
LAM*** |
11 (3.74) |
2 (0.68) |
0 (0.00) |
1 (0.34) |
0 (0.00) |
14 (4.76) |
Total |
213 (72.44) |
21 (7.14) |
14 (4.76) |
25 (8.50) |
21 (7.14) |
294 (100) |
IUD: intrauterine device; **CO: micro-dosed progestin oral contraceptive; ***LAM: Lactation amenorrhea method.
Implantation was the method most chosen by clients whose main occupation was housewife (43.87%). The choice made by customers according to their main occupation is shown in Table 3.
3.3. Time of Onset and Type of Side Effects
During in interviews with 290 clients 6 weeks after delivery, complaints were attributed to the side effects of the contraceptives utilization. Side effects related to the contraceptive method used were reported by 39 customers, or 13.26% of users interviewed by telephone.
Those using the implant were the most likely to report side effects (58.33%). The onset of these side effects was between 2 and 3 weeks after starting to use the method.
Table 4 lists all the side effects reported.
Table 4. Distribution of births according to signs considered to be side effects of the method used and their time of onset.
Time to appear (Days) |
Side effects depending on the contraceptive |
≤15 |
>15 |
TOTAL |
Copper intrauterine device; n = 83 |
|
|
|
Spotting |
0 |
1 |
1 |
Pelvic pain |
2 |
0 |
2 |
Cycle disruption |
0 |
1 |
1 |
Implant; n = 48 |
|
|
|
Breast pain |
4 |
6 |
10 |
Pelvic pain. |
6 |
15 |
21 |
Spotting |
8 |
20 |
28 |
Cycle disruption |
0 |
3 |
3 |
Oral contraceptive; n = 16 |
|
|
|
Spotting |
2 |
0 |
2 |
Pelvic pain |
1 |
1 |
2 |
Headaches |
4 |
1 |
5 |
Nausea |
1 |
2 |
3 |
3.4. Compliance with Methods Used
Prior to our study, 29.66% of clients (n = 253) had already used a contraceptive method. In 94.07% of cases (n = 238), they admitted that compliance with these methods was irregular. Regarding current contraception, all 294 (100%) said they were committed to regular follow-up.
3.5. Reasons for Abandoning the Chosen Method
A telephone interview 6 weeks after delivery was carried out with 290 clients. It revealed one case of abandonment of the contraceptive method chosen in the immediate post-partum period. This involved an intra-uterine device (IUD) placed per caesarean section. The client reported discomfort and spotting. She went to a private clinic where the IUD was removed.
3.6. Assessment of the Method
Level of and reasons for customer satisfaction with methods
The womens who declared themselves satisfied or very satisfied with the method used in this study accounted for 80.29%. Table 5 shows the level of satisfaction with previous versus current methods and the reasons for it.
Table 5. Distribution of birth attendants according to degree and reason for satisfaction with contraceptive methods, by method used.
Satisfaction |
Methods used |
Previously; n = 253 (%) |
Currently; n = 294 (%) |
Degree |
|
|
Not at all satisfied |
0.81 |
0.34 |
Moderately satisfied |
31.18 |
19.37 |
Satisfied |
65.99 |
70.29 |
Very satisfied |
2.02 |
10.00 |
Reason |
|
|
Rapid return to fertility |
22.22 |
10.38 |
Good accessibility |
22.13 |
14.02 |
Few/no side effects |
20.72 |
45.59 |
Personal convenience |
93.83 |
95.45 |
Easy to use |
61.21 |
84.43 |
Other |
3.92 |
7.55 |
4. Discussion
4.1. Description of Sample
In our study, the frequency of contraceptive use in the postpartum period was 34.50%. Using longitudinal data from Nairobi’s urban health and demographic surveillance system, Mumah et al. in 2015 found a postpartum contraceptive method adoption rate of 49% [8]. In Burkina Faso, according to the 2010 demographic and health survey, the prevalence of contraception in the postpartum period was 13% [9]. Zabre in 2019 in Bobo-Dioulasso, Burkina Faso, found a postpartum contraceptive method adoption rate of 21.40% [10]. Tran et al. in 2019, found a 29% [11] frequency of contraception in the postpartum period in Burkina Faso. The latter figure is lower than the results of our study. This could be explained by the fact that our study took place in a referral hospital, so all the contraceptive methods available under the free health care scheme in Burkina Faso were available, as were qualified providers. As a result, clients had access to many more qualified providers for family planning in the immediate postpartum period
4.2. Contraceptive Methods in the Immediate Post-Partum Period
4.2.1. Implants
Implants were chosen by 63.60% of patients. In the series, according to age, level of education and main occupation, the choice of implants was predominantly made by housewives (43.87%), clients with no education (40.47%) and clients in the 20-29 age bracket (35.03%). This rate is lower than that reported by Sawadogo in 2011 and Togbe in 2016 in Burkina Faso. For these two authors, implants were chosen respectively by 53% and 14.93% of female clients of all ages and educational levels [6] [12]. Young people’s enthusiasm for implants could be explained by their greater convenience of use and easy follow-up. This ease of use, together with the relative accessibility of the method, makes it popular with uneducated clients and housewives, who represent the majority of the working population in the city of Bobo Dioulasso.
4.2.2. The Intrauterine Device
The intrauterine device was chosen by 28.23% of patients in our study. This rate is comparable to that found by Togbe and Dembele in Bobo-Dioulasso, but also to that of Sawadogo and Lankoandé in Ouagadougou, Burkina Faso, who reported rates of 34.21% (Togbe) in the immediate postpartum period, 4.1% (Dembele), 47% (Sawadogo) and 2.15% (Lankoandé) respectively [6] [12]. Glazer et al. in 2011 in an urban hospital in the United States of America (USA) reported that 23% of women chose immediate post-placental IUD placement [13]. This choice is reflected in the fact that most of our customers prefer to use a long-acting contraceptive method.
4.2.3. Oral Contraceptives with Micro-Dosed Progestins
Low-dose progestin-only oral contraceptives were chosen by 5.44% of patients.
This rate is much lower than that found in Niger. Guengan in 2015, during the Demographic.
Health Survey (DHS) in Niger, found that from 1992 to 2012, the pill still accounted for twothirds of modern methods used [14]. According to our results, it is possible the daily intake of progestin-only oral contraceptives is paru constraining for our study population.
4.3. Satisfaction Levels of Clients Who Have Adopted a
Contraceptive Method
4.3.1. Time to Onset of Side Effects and Type of Side Effect
In our study, side effects appeared after 2 to 3 weeks of use in 13.26% of users. These results corroborate those found in the document issued by the Burkina Faso Ministry of Health in 2022, which states that although new users of FP methods are being recruited, 35% of them have stopped using their method for various reasons, 17% of which are linked to side effects [7].
4.3.2. Implants
Analysis of our results showed that 58.33% of women who chose the implant experienced various side effects. These side effects, documented by the manufacturer, included breast pain (20.83%), pelvic pain (43.75%), spotting (58.33%) and cycle disturbances (6.25%). Pelvic pain (31.25%) and spotting (41.66%) occurred within 4 to 6 weeks. These side effects are listed in the JADELLE package insert, which states that they may occur in more than 10% of users. Our results are therefore within the normal range, according to the manufacturer’s data. Analysis of our results from other studies carried out in other hospitals shows that they are comparable to those reported by Sawadogo in 2011 and Koné et al. in Burkina Faso. They reported side effects in 65.9% and 51% of clients respectively, with menstrual cycle disorders [12] [15].
4.3.3. The Intrauterine Device (IUD)
Four (4) customers (4.82%) were inconvenienced by the IUD.
This proportion is comparable to that found by Togbe and Dembele in Bobo-Dioulasso and Lankoandé in Ouagadougou, Burkina Faso, who respectively found 11 cases (1.1%) of side effects following IUD insertion in the immediate postpartum period (Togbe), 10 cases of expulsion (Dembele) and 08 cases of expulsion (Lankoandé) [6]. This rate is comparable to that of Mishra, Sujnanendra in 2014 in India, who found that out of a total of 3209 women, the proportion of clients with complications was 6% (IUD expulsion 1.2%, bleeding 3.2%, unseen thread problem 1.6%) [16]. These differences in our results could be explained by the larger sample size, and the longer duration of the study, which would be more important in the literature. This would have enabled us to obtain a larger, more representative sample, making the search for side effects much easier [3].
4.3.4. Monitoring the Methods Used
A total of 29.66% (253 clients) of the clients in our population had already used a contraceptive method prior to our study, but the follow-up of these methods was irregular. In our series, 6 weeks after discharge from hospital, all clients promised regular follow-up during the telephone interview.
However, in a study carried out in the USA, the American College of Obstetricians and Gynecologists found that, over a 12-month period, 86% of postpartum family planning (IPPFP) users were still using the method [17]-[19]. In an urban hospital in the USA, a study revealed that of 59 patients contacted 4 to 6 months after childbirth, 37% reported using a contraceptive method, while 29% of women said they were not using a contraceptive method [13]. Gurtcheff et al. in 2011 found data lower than ours, in fact 10% to 40% of women do not attend the postpartum visit [20]-[22]. Mishra in 2014 found, in a study carried out in India, that out of a total of 3209 women counseled on IPPFP, the proportion of clients lost to follow-up was 4%, but the proportion of clients followed up was 14% [16]. These results could be explained by the fact that our follow-up did not extend over time. In fact, the telephone appointments we had with clients who had not shown up for the 45th day appointment took place over a period of 6 weeks after the start of IPPFPIPPFP use.
4.3.5. Reasons for Abandoning the Initially Chosen Method
In our study, we noted 0.34% abandonment of the IUD due to discomfort or spotting. Our results are comparable to those of Sawadogo and Koné et al. in Burkina Faso. These authors found gynaecological or non-gynaecological health problems to be the reason for abandoning the contraceptive method in 46.7% [12], and 51.4% respectively [15]. Bonkian in Burkina Faso and N’Diaye in Mali found the desire for pregnancy to be the main reason for discontinuing contraception, with rates of 39.3% and 33.8% respectively [23] [24].
Our results are comparable to those found by Mumah et al. in Kenya, who found that almost half of women had abandoned a modern method within 12 months of starting to use it [8]. Our results could be explained by the fact that our post-partum follow-up only lasted six (6) weeks. A longer follow-up might have revealed other cases of method abandonment and the reasons for them.
4.3.6. Assessment of the Method
Level of satisfaction of customers who chose the methods and the reasons why More than two-thirds of clients who had received a contraceptive method in the immediate post-partum period during our study period said they were satisfied (70.29%), and 10% were very satisfied. The main reasons given were personal convenience (95.45%) and ease of use (84.43%). They had no plans to abandon or change their contraceptive methods. Implants were therefore the most widely used and preferred method in our study.
However, Peipert et al. in 2012 in a study conducted in the USA, demonstrated that women who used immediate long-acting reversible contraception, had the highest satisfaction rates and the lowest rates of unwanted pregnancies [25]. Another study conducted in Standfort, California, USA, showed that copper levonorgestrel intrauterine devices (IUDs) inserted immediately after vaginal delivery and during caesarean sections were associated with higher satisfaction and continuation rates at 6 - 12 months compared with IUDs placed at the postpartum visit (4 - 8 weeks after delivery), despite higher expulsion rates [26].
Kumar et al. in their 2014 study in India found proportions approaching our own. Almost all women (99.6%) were satisfied with the IPPFP at the time of insertion, and 92% were satisfied at the six-week follow-up visit. The IUD expulsion rate was 3.6% after six weeks’ follow-up [27].
Mumah et al. in 2015 found lower proportions than in our series in a study conducted in Nairobi. Indeed, almost half of women had abandoned a modern method within 12 months of starting use, and many were likely to switch to another method in the short term due to high methodrelated dissatisfaction [8].
In Kenya, Jalang’O et al. (2017) found that in focus group discussions, women remarked that the quality of services offered in public facilities was relatively good because they felt they were well advised [28].
Our results concerning the degree of satisfaction could be due to the quality of the counselling and care given within the framework of IPPFP. This is undoubtedly helped by the training in planning that is regularly given to health workers in our field of study.
4.4. Study Constraints and Limitations
The study focused on contraception in the immediate postpartum period, with an emphasis on satisfaction and follow-up regarding the use of contraceptive methods in the immediate postpartum period. The constraints observed during our study were, on the one hand, the fact that the interviewer was ourselves a health worker. As a result, the direct interview to collect data may have led some clients to deliberately evade certain questions or give misleading answers.
On the other hand, as this study was limited to patients who had given birth at the CHU Sourô Sanou maternity hospital during the study period, the results can only be extrapolated to the latter.
5. Conclusion
Immediate post-partum family planning is an essential component of maternal care. As a result, this period offers several advantages for the provision of services, particularly for IPPFP. Our study of contraception in the immediate post-partum period at the maternity ward of the Sourô Sanou University Hospital in Bobo-Dioulasso enabled us to make the following observations. Among the contraceptive methods adopted in the immediate post-partum period, implants were in first place. The majority of customers were satisfied with its use. To ensure acceptance of this policy, immediate long-acting reversible contraception (LARC) should be monitored in accordance with WHO recommendations.