Determinants of immediate postpartum long acting reversible contraceptive utilization among women who gave birth in public health facilities in northwest Ethiopia: unmatched case-control study design

Getachew Asmare Adella; Getiye Kibret Abtew; Mihiret Tesfaw Gellaw; Gizachew Ambaw Kassie; Molalegn Mesele Gesese; Endeshaw Chekol Abebe; Misganaw Asmamaw Mengstie; Mohammed Abdu Seid; Sefineh Fenta Feleke; Tadesse Asmamaw Dejenie; Berihun Bantie; Yenealem Solomon; Melkamu Aderajew Zemene; Anteneh Mengist Dessie; Denekew Tenaw Anley; Wubet Alebachew Bayih; Natnael Amare Tesfa; Natnael Atnafu Gebeyehu

doi:10.12688/f1000research.147605.1

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Research Article

Determinants of immediate postpartum long acting reversible contraceptive utilization among women who gave birth in public health facilities in northwest Ethiopia: unmatched case-control study design

[version 1; peer review: 1 approved with reservations]

Getachew Asmare Adella ¹, Getiye Kibret Abtew², Mihiret Tesfaw Gellaw³, [...] Gizachew Ambaw Kassie¹, Molalegn Mesele Gesese⁴, Endeshaw Chekol Abebe⁵, Misganaw Asmamaw Mengstie⁵, Mohammed Abdu Seid⁶, Sefineh Fenta Feleke⁷, Tadesse Asmamaw Dejenie⁸, Berihun Bantie⁹, Yenealem Solomon¹⁰, Melkamu Aderajew Zemene¹¹, Anteneh Mengist Dessie¹¹, Denekew Tenaw Anley¹¹, Wubet Alebachew Bayih¹², Natnael Amare Tesfa¹³, Natnael Atnafu Gebeyehu⁴

Getachew Asmare Adella ¹, Getiye Kibret Abtew², [...] Mihiret Tesfaw Gellaw³, Gizachew Ambaw Kassie¹, Molalegn Mesele Gesese⁴, Endeshaw Chekol Abebe⁵, Misganaw Asmamaw Mengstie⁵, Mohammed Abdu Seid⁶, Sefineh Fenta Feleke⁷, Tadesse Asmamaw Dejenie⁸, Berihun Bantie⁹, Yenealem Solomon¹⁰, Melkamu Aderajew Zemene¹¹, Anteneh Mengist Dessie¹¹, Denekew Tenaw Anley¹¹, Wubet Alebachew Bayih¹², Natnael Amare Tesfa¹³, Natnael Atnafu Gebeyehu⁴

PUBLISHED 18 Apr 2024

Author details Author details

¹ School of Public Health, College of Health Science and Medicine,, Wolaita Sodo University, Sodo, Ethiopia
² Department of MCH, South Wello Zone Health Office, Dessie, Ethiopia
³ Reproductive Choices, MSIE, Sodo, Ethiopia
⁴ School of Midwifery, College of Health Science and Medicine,, Wolaita Sodo University, Sodo, Ethiopia
⁵ Department of Biochemistry, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
⁶ Unit of physiology, Department of Biomedical Science, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
⁷ Department of Public Health, College of Health Sciences, Woldia University, Weldiya, Ethiopia
⁸ Department of Medical Biochemistry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
⁹ Department of comprehensive Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
¹⁰ Department of Medical Laboratory Science, College of health Sciences,, Debre Tabor University, Debre Tabor, Ethiopia
¹¹ Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
¹² Department of Maternal and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
¹³ School of Medicine, College of Health Science, Woldia University, Weldiya, Ethiopia

Getachew Asmare Adella
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Getiye Kibret Abtew
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Mihiret Tesfaw Gellaw
Roles: Data Curation, Formal Analysis, Methodology, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Gizachew Ambaw Kassie
Roles: Conceptualization, Investigation, Methodology, Software, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Molalegn Mesele Gesese
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Resources, Software, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Endeshaw Chekol Abebe
Roles: Data Curation, Investigation, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Misganaw Asmamaw Mengstie
Roles: Data Curation, Funding Acquisition, Project Administration, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Mohammed Abdu Seid
Roles: Data Curation, Funding Acquisition, Investigation, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Sefineh Fenta Feleke
Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Tadesse Asmamaw Dejenie
Roles: Data Curation, Funding Acquisition, Investigation, Project Administration, Resources, Validation, Visualization, Writing – Review & Editing

Berihun Bantie
Roles: Conceptualization, Formal Analysis, Methodology, Software, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Yenealem Solomon
Roles: Data Curation, Funding Acquisition, Investigation, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Melkamu Aderajew Zemene
Roles: Conceptualization, Formal Analysis, Software, Supervision, Writing – Review & Editing

Anteneh Mengist Dessie
Roles: Formal Analysis, Investigation, Methodology, Software, Supervision, Validation, Writing – Review & Editing

Denekew Tenaw Anley
Roles: Conceptualization, Formal Analysis, Methodology, Validation, Visualization, Writing – Review & Editing

Wubet Alebachew Bayih
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Visualization, Writing – Review & Editing

Natnael Amare Tesfa
Roles: Data Curation, Funding Acquisition, Investigation, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation

Natnael Atnafu Gebeyehu
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

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Abstract

Background

The aftermath of childbirth plays a vital role in addressing unmet family planning requirements and is instrumental in mitigating the risks associated with pregnancies that are closely spaced. Recognizing factors that indicate immediate postpartum utilization of long-acting reversible contraceptives is essential for crafting focused initiatives. This helps meet unaddressed family planning needs and contributes to the reduction of maternal and child mortality rates in the country. Therefore, this research aimed to pinpoint factors influencing the utilization of long-acting reversible contraceptives immediately after childbirth among women delivering in public health facilities in northwest Ethiopia.

Methods

A facility-based unmatched case-control study was carried out, involving 342 postpartum women (comprising 108 cases and 216 controls) who delivered in public health facilities in northwest Ethiopia. Data collection involved employing a structured interviewer-administered questionnaire, and binary logistic regression analysis was conducted. The statistically significant association between independent factors and the outcome variable was assessed using the adjusted odds ratio with a 95% confidence interval, considering a p-value less than 0.05.

Result

The educational status of women at secondary level and above (AOR=2.314, 95% CI=1.645-5.043), adherence to ANC follow-up (AOR=2.930, 95% CI=1.829-4.769), lack of desire to have a child (AOR=1.421, 95% CI=1.026-2.006), receiving counseling (AOR=3.029, 95% CI=2.085-5.988), and possessing knowledge (AOR=1.642, 95% CI=1.086-3.186) were identified as significantly correlated with immediate postpartum LARC utilization at p <0.05.

Conclusion

In this investigation, the utilization of immediate postpartum long-acting reversible contraceptives (LARC) was significantly linked to women’s educational attainment, attendance at antenatal care (ANC), their desire for additional children, counseling, and knowledge about immediate postpartum LARC. To promote family planning in the postnatal phase, it is recommended to prioritize maternal education, offer comprehensive counseling and health education, and enhance adherence to targeted ANC services.

Keywords

Long-acting reversible contraceptive, postpartum, immediate, factors, Ethiopia

Corresponding author: Getachew Asmare Adella

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Adella GA et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.

How to cite: Adella GA, Abtew GK, Gellaw MT et al. Determinants of immediate postpartum long acting reversible contraceptive utilization among women who gave birth in public health facilities in northwest Ethiopia: unmatched case-control study design [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:297 (https://doi.org/10.12688/f1000research.147605.1) First published: 18 Apr 2024, 13:297 (https://doi.org/10.12688/f1000research.147605.1) Latest published: 18 Apr 2024, 13:297 (https://doi.org/10.12688/f1000research.147605.1)

Introduction

Maternal health remains a prominent global concern due to the fact that pregnancy and childbirth are the leading causes of morbidity, mortality, and impairment among women of reproductive age.¹ Worldwide, there were 121 million unintended pregnancies, with an annual rate of 64 per 1000 women.² This prevalence is more pronounced in Sub-Saharan Africa (99 per 1000 pregnancies) and notably in Ethiopia (100 per 1000).³ The World Health Organization (WHO) recommends a minimum interpregnancy interval of two years.⁴ Brief intervals between births heighten the risk of health problems for both the mother and child, including preterm birth, low birth weight, small for gestational age, an elevated likelihood of chronic malnutrition, stunted growth, and child mortality.⁵^,⁶ If a pregnancy occurs within six months of a preceding delivery, the risk of low birth weight and prematurity doubles, while children born within 24 months of a previous birth are 60% more likely to experience infant mortality compared to those born more than 24 months apart.⁷

The period following childbirth is pivotal for addressing unfulfilled family planning requirements and minimizing the likelihood of pregnancies occurring in quick succession.⁸ Fertility can resume as early as 45 days after birth for non-breastfeeding women,⁹^,¹⁰ and it may occur before the return of menstruation in those who do not exclusively breastfeed.¹¹ Employing family planning during the postpartum phase enables women to space their births by a minimum of 24 months, leading to a 30% reduction in maternal mortality and a 10% decrease in child mortality.¹²

Counseling and provision of long-acting reversible contraception (LARC), encompassing intrauterine devices (IUDs) and subdermal implants, possess several attractive qualities, such as a high retention rate and enhanced protection against unintended pregnancy.¹³^,¹⁴

In Sub-Saharan Africa, there is a persistent low utilization of postpartum contraception.¹⁵ DHS data from 21 low- and middle-income countries, gathered between 2005 and 2012, revealed that a substantial majority (95%) of women within 0-12 months postpartum expressed a desire to avoid pregnancy in the next 24 months, yet less than one-third (31%) were actively using any contraceptive method. Additionally, around half (61%) of postpartum women faced challenges in accessing family planning services.⁸^,¹⁶ Despite this, there exists a notable unmet need for family planning during the postpartum period, ranging from 32 to 62% in low and middle-income countries.⁹^,¹⁷^,¹⁸

Due to the limited acceptance of postpartum family planning (PPFP), the key factors influencing PPFP acceptance include the level of education, perinatal family planning, counseling, resumption of menstruation, breastfeeding status, return of sexual activity, concerns about side effects, and a perceived low risk of pregnancy.¹⁹

Numerous investigations have revealed that socio-demographic factors, including women’s age, marital status, educational attainment, place of residence, and religious affiliation, influence the acceptance of long-acting reversible contraception (LARC) in diverse contexts.²⁰^–²³ Additional studies have indicated that factors such as secondary and higher education, communication with the husband, return of menstruation, antenatal care (ANC) follow-up, awareness of modern family planning methods, and receiving family planning counseling during ANC are predictors of postpartum contraceptive utilization.²⁴

Countless investigations have additionally discovered reproductive health factors like fertility intention, parity, and desire for FP as influencers of LARC method uptake and contraceptive use in general. In plenty of other study results, the reproductive health contributing factors with LARC use were identified as parity, desired family size, women who gave birth prematurely, previous history of abortion, women who had ever experienced an unwanted pregnancy, and women who had visited a clinic in the previous year for FP services.²⁵^–²⁹

Up to now, research in Ethiopia has primarily examined the prevalence of postpartum family planning utilization, particularly intrauterine contraceptive devices (IUCD). The factors influencing immediate postpartum family planning utilization, specifically long-acting reversible contraceptives, remain inadequately understood across Ethiopia. The identification of predictors for immediate postpartum use of long-acting reversible contraceptives is crucial for the development of more targeted programs, addressing unmet family planning needs, and mitigating maternal and child mortality in the country. Consequently, the objective of this study aims to ascertain the determinants of immediate postpartum utilization of long-acting reversible contraceptives among women delivering in public health facilities in northwest Ethiopia.

Methods

Study setting and period

The research was carried out in the Kelela district of northwest Ethiopia between May 15 and July 10, 2022. Situated 565 km away from Addis Ababa, the capital city of Ethiopia, the district is home to a projected total population of 169,187 in 2022, with 82,902 (49%) being females. The reproductive age group comprises 19,067 women, and an estimated 823 women are expected to give birth each month. Within the district, there is one public hospital, 9 health centers, and 33 health posts. According to the Kelela district health office annual report for 2022, there are 10 public health facilities offering immediate postpartum long-acting contraceptive services.

Study design

A facility-based unmatched case-control study design was conducted.

Population

Source population

All women in the postpartum period who delivered in the public health facilities of the Kelela district throughout the study duration.

Study population

For Cases: All women in the postpartum phase who gave birth in designated public facilities during the study timeframe and opted for a long-acting reversible contraceptive device within the initial 48 hours following vaginal delivery or after the expulsion of the placenta before uterine closure in the case of intra-cesarean deliveries.

For controls: All women in the postpartum period who delivered in the identical public health facilities but refrained from utilizing the postpartum long-acting reversible contraceptive device.

Inclusion and exclusion criteria

Inclusion criteria

Women in the postpartum phase who delivered through any method in the chosen public facilities were encompassed.

Exclusion criteria

Exclusion criteria for the study comprised women who delivered through any mode in designated public facilities but did not meet the World Health Organization’s medical eligibility criteria for the postpartum long-acting reversible contraceptive device during the investigation period.³⁰

Sample size determination, technique, and procedure

The sample size was calculated using the two population proportion formula in Epi Info software Version 7. The calculation took into account the following assumptions: 95% confidence interval, 80% power, a 1:2 ratio of cases to controls, counselled by a healthcare provider as the exposure variable, 26.4% of PPIUCD users and 43.2% of nonusers with exposure,³¹ and a 10% nonresponse rate as compensation for both groups. As a result, 342 postpartum women were included in the study (114 cases and 228 controls). Ten public health facilities in the study area provide immediate postpartum long-acting reversible contraception (LARC) services, with approximately six of them chosen using simple random sampling methods. The average monthly case flow was calculated using the number of immediate postpartum LARC utilisations per three months obtained from each selected public health facility’s quarterly report. Cases were identified by asking whether they used IUCD or implants after delivery and crosschecking their charts, and they were selected consecutively. Once cases were identified consecutively, two controls were chosen using simple random methods to increase the power of the study.

Data collection tools, measurements, and quality control procedures

To gather data, a structured interviewer-administered questionnaire was utilized, adapted and refined from various literature sources.³¹^–³⁸ Prior to distribution, a panel of experts in the field assessed its content validity. Additionally, a 5% sample size test was conducted in the Legambo district, and modifications were made based on expert feedback and pretest results. The questionnaire’s reliability was assessed through a reliability analysis, revealing a Cronbach’s Alpha exceeding 0.7, indicating internal consistency in the responses. To ensure uniformity, it was initially crafted in English, translated into a local language, and then back-translated into English.

The survey consisted of sections covering socio-demographic details, obstetric and reproductive care elements, knowledge, attitudes, and family planning topics. Six diploma midwives were designated as data collectors, and two BSc midwives were appointed as supervisors. A two-day training session was conducted for both data collectors and supervisors to instruct them on questionnaire administration and collection procedures. Prior to data entry, a thorough check for completeness was carried out on the questionnaire.

Long-acting reversible contraceptives are contraceptive options with durations of effectiveness spanning from 3 to 12 years (including intrauterine devices and implants), and fertility typically resumes shortly after their removal.

Immediate postpartum long-acting reversible contraceptive (LARC) utilization refers to the practical application of long-acting reversible contraceptive devices (such as IUCD and implants) within the initial 48 hours after childbirth and before the discharge to home, irrespective of the mode of delivery.

Women who received counseling on immediate postpartum long-acting reversible contraception (LARC) are those mothers who were informed by healthcare providers about the advantages, potential side effects, or recommended duration of using immediate postpartum LARC during antenatal care (ANC), the latent phase of labor, and/or the immediate postnatal period.

Knowledge of immediate postpartum long-acting reversible contraception (LARC) was determined by adding the responses to all seven knowledge-related questions regarding immediate postpartum LARC. Each correct answer was assigned a score of “1,” while an incorrect answer received a score of “0.” Consequently, participants who achieved a score equal to or higher than the mean value of the cumulative knowledge assessment questions were categorized as having good knowledge, whereas those who scored below the mean were considered to have poor knowledge.

The attitude-related inquiries were evaluated using a Likert scale consisting of nine items, graded on a 5-point scale from strongly disagree to strongly agree, with scores ranging from 1 to 5. Individuals who obtained scores equal to or higher than the mean value of the total attitude-related questions were categorized as having a positive attitude, while those with scores below the mean were deemed to have a negative attitude.

Data processing and analysis

The information was encoded and inputted into Epi-Data version 3.1, followed by exportation to SPSS version 25.0 for analysis. Descriptive statistics, such as frequency, mean, percentages, and standard deviations, were computed, and the findings were presented in tables. A binary logistic regression was carried out. Variables with a P-value of 0.2 were taken into account for multivariable logistic regression to manage potential confounding effects. The backward likelihood ratio method was used for multivariable logistic regression to control potential confounders. To assess multicollinearity, a correlation analysis between independent variables was conducted. Ultimately, the adjusted odds ratio with a 95% confidence interval was determined to evaluate the strength of the association, and a p-value less than 0.05 was utilized to ascertain the existence of a significant relationship between factors and outcome variables.

Ethical approval and consent to the participant

Ethical approval was obtained from the Institutional Review Board of Wolaita Sodo University with approval number and date RCSPG-179/14, May 15/2022 respectively. Additionally, a permission letter was granted by the Kelela district health office. Prior to the interview, participants were presented with the consent form, and written consent was obtained from each individual. Participants were assured that they had the option to skip any questions they were not comfortable answering, either partially or entirely, and that they could discontinue the interview at any point. The confidentiality of individual information was safeguarded by refraining from recording any identifying details.

Results

Socio-demographic characteristics of the study participants

This research involved 324 women who had recently given birth, comprising 108 individuals with specific conditions and 216 without. The overall response rate was 94.7%. The reason for non-responding was, no time, not interested. The average age of the participants was 27.69 years, with a standard deviation of 6.25. About 66(61.1%) of cased women and 149(69.0%) of controlled women lived in the rural area and 73(66.7%) of cased women and 148(68.5%) of controlled women were Muslim religious followers. About 101(93.5%) cased women and 194(89.8%) controlled women were married. Regarding the educational status of women, 62(28.7%) and 28(13.0%) of controlled women were unable to read and write and above the secondary level of education respectively. Also, 22(20.4%) and 32(29.6%) of husband-cased women were unable to read and write and were above the secondary level of education respectively (Table 1).

Table 1. Sociodemographic characteristics of respondents in northwest Ethiopia (N=324).

Variables	Category	Utilization of IPPRLAC
		Cases (n=108) n (%)	Controls (n=216) n (%)
Age	15-24	38(35.2%)	68(31.5%)
	25-34	55(50.9%)	114(52.8%)
	35-44	15(13.9%)	34(15.7%)
Residence	Urban	42(38.9%)	67(31.0%)
Residence	Rural	66(61.1%)	149(69.0%)
Marital status	Single	7(6.5%)	22(10.2%)
Marital status	Married	101(93.5%)	194(89.8%)
Religion	Muslim	73(67.6%)	148(68.5%)
Religion	Orthodox	35(32.4%)	68(31.5%)
Educational status of women	Unable to read and write	24(22.2%)	62(28.7%)
	Able to read and write	27(25.0%)	68(31.5%)
	Primary (grade 1-8)	36(33.3%)	58(26.9%)
	Secondary and above	21(19.4%)	28(13.0%)
Occupation of women	Housewife	64(59.3%)	145(67.1%)
	Merchant	23(21.3%)	31(14.4%)
	Government employee	11(10.2%)	22(10.2%)
	Others	10(9.3%)	18(8.3%)
Educational status of husband	Unable to read and write	22(20.4%)	42(19.4%)
	Able to read and write	25(23.1%)	78(36.1%)
	Primary (grade 1-8)	29(26.9%)	52(24.1%)
	Secondary and above	32(29.6%)	44(20.4%)
Occupation of husband	Farmer	59(54.6%)	126(58.3%)
	Merchant	19(17.6%)	46(21.3%)
	Government employee	25(23.1%)	33(15.3%)
	Others	5(4.6%)	11(5.1%)

Obstetric and reproductive characteristics

About 43(39.8%) of cased women and 114(52.8%) of controlled women had more than five family sizes.in addition, 68(63.0%) of cased women and 108(50.0%) controlled women had more than five live child. From live children, 28(26.9%) in the case group and 61(28.2%) in the control group were only females. Regarding birth interval, 27(25.0%) were in the case group and 54(25.0%) in the control group spaced more than 36 months. About 85(78.1%) of cased women and 175(81.0%) of controlled women had the plan to have a child. From those, 70(64.8%) of cased women and 135(62.5%) of controlled women prefer to have a male child. About 56(51.9%) of cased women and 115(53.2%) of controlled women husbands were the sole decision maker to have the child in the future. About 101(93.5%) cased women and 200(92.6%) controlled women had ANC follow-up, of those, 40(37.0%) of cased women and 68(31.5%) of controlled women had more than four visits. Seventy-eight (72.2%) of cased women and 144(66.7%) of controlled women were counseled about immediate postpartum LARC (Table 2).

Table 2. Obstetric and reproductive characteristics of respondents in northwest Ethiopia (N=324).

Variables	Category	Utilization of IPPRLAC
		Cases (n=108) n (%)	Controls (n=216) n (%)
Total family size	≤2	24(22.2%)	49(22.7%)
	3-4	41(38.0%)	53(24.5%)
	≥5	43(39.8%)	114(52.8%)
Number of total live children	≤2	15(13.9%)	38(17.6%)
	3-4	25(23.1%)	70(32.4%)
	≥5	68(63.0%)	108(50.0%)
Sex status of live children	Male only	29(26.9%)	54(25.0%)
	Female only	28(25.9%)	61(28.2%)
	Both male and female	51(47.2%)	101(46.8%)
parity of the respondent	Premipara	25(23.1%)	50(23.1)
parity of the respondent	Multipara	83(76.9%)	16676.9%)
Birth interval by months	<24 months	52(48.1%)	94(43.5%)
	25-36 months	29(26.9%)	68(31.5%)
	>36 months	27(25.0%)	54(25.0%)
Do you have no plan to have a child?	Yes	85(78.7%)	175(81.0%)
Do you have no plan to have a child?	No	23(21.3%)	41(19.0%)
Sex status of the child women's desire	Male	70(64.8%)	135(62.5%)
Sex status of the child women's desire	Female	38(35.2%)	81(37.5%)
Decision maker for the planned child	Myself	17(15.7%)	32(14.8%)
	Husband	56(51.9%)	115(53.2%)
	Joint decision	35(32.4%)	69(31.9%)
Was the current child wanted?	Yes	72(66.7%)	147(68.1%)
Was the current child wanted?	No	36(33.3%)	69(31.9%)
History of abortion	Yes	9(8.3%)	34(15.6%)
History of abortion	No	99(91.7%)	182(84.3%)
Did you have an ANC visit for the current birth?	Yes	101(93.5%)	200(92.6%)
Did you have an ANC visit for the current birth?	No	7(6.5%)	16(7.4%)
Number of ANC visits	Once	10(9.3%)	17(7.9%)
	Twice	27(25.0%)	51(23.6%)
	Three times	24(22.2%)	64(29.6%)
	Four and more times	40(37.0%)	68(31.5%)
Mode of delivery	Spontaneous delivery	82(75.9%)	163(75.5%)
	Instrumental delivery	15(13.9%)	46(21.3%)
	Cesarean delivery	11(10.2%)	7(3.2%)
Counseling about immediate postpartum LARC	Yes	78(72.2%)	144(66.7%)
Counseling about immediate postpartum LARC	No	30(27.8%)	72(33.3%)
Time of counseling	During ANC visit	16(20.5%)	30(20.8%)
	During the latent 1^st stage of labor	2(2.6%)	8(5.6%)
	During PNC	16(20.5%)	33(22.9%)
	Multiple counseling	44(56.4%)	73(50.7%)

Knowledge and attitude about immediate postpartum LARC

A majority of participants in both the case and control groups exhibited insufficient knowledge and a pessimistic attitude regarding immediate postpartum Long-Acting Reversible Contraception (LARC), as depicted in Figure 1.

Figure 1. Knowledge about and attitude toward immediate postpartum LARC among postpartum women in northwest Ethiopia.

Immediate postpartum LARC utilization

Eighty-five (78.7%) of cased women and 167(77.3%) of controlled women ever used family planning before the last pregnancy. The injectable contraceptive emerged as the most frequently utilized birth control method in both the case and control groups, as indicated in Table 3. Currently, only 108(33.3%) of women used immediate postpartum LARC (Figure 2). The most common reason for not using immediate postpartum LARC had no information, husband refusal, and desire to have a child, 38.9%, 20.8%, and 18.1% respectively (Figure 3).

Table 3. History of family planning use among postpartum women in Northwest Ethiopia.

Variables	Category	Utilization of IPPRLAC
		Cases (n=108) n (%)	Controls (n=216) n (%)
Ever used family planning before the last pregnancy	Yes	85(78.7%)	167(77.3%)
Ever used family planning before the last pregnancy	No	23(21.3%)	49(22.7%)
Type of modern family planning ever used (more than one answer possible)	Pills	6(7.1%)	12(7.2%)
	Injectable	53(62.4%)	108(64.7%)
	Implants	21(24.7%)	36(21.6%)
	IUCD	5(5.9%)	11(6.6%)

Figure 2. Immediate postpartum LARC use among postpartum women in Northwest Ethiopia.

Figure 3. Reasons for not utilizing immediate postpartum LARC among postpartum women in northwest Ethiopia.

Predictors of immediate postpartum long-acting reversible contraceptive utilization

Every sociodemographic, obstetric, and reproductive-related factor, along with knowledge about and attitude towards immediate postpartum Long-Acting Reversible Contraception (LARC), were included in the bivariable logistic regression. All variables met the assumptions of binary logistic regression, and those with a p-value ≤ 0.25 were incorporated into the multivariable logistic regression model. Ultimately, it was determined that women’s educational status, attendance at antenatal care (ANC), desire for childbirth, counseling on immediate postpartum LARC, and knowledge about immediate postpartum LARC were significantly linked to the use of immediate postpartum LARC at a significance level of p < 0.05.

Women with a secondary education or higher demonstrated 2.314 times greater likelihood of using immediate postpartum Long-Acting Reversible Contraception (LARC) compared to those who were unable to read and write (Adjusted Odds Ratio = 2.314, 95% Confidence Interval = 1.645-5.043).

Women possessing adequate knowledge about immediate postpartum Long-Acting Reversible Contraception (LARC) exhibited a 1.642 times higher likelihood of using it compared to those with insufficient knowledge (Adjusted Odds Ratio = 1.642, 95% Confidence Interval = 1.086-3.186).

Women who received counseling had a 3.029 times greater likelihood of using immediate postpartum Long-Acting Reversible Contraception (LARC) compared to those who did not receive counseling (Adjusted Odds Ratio = 3.029, 95% Confidence Interval = 2.085-5.988).

Women who attended antenatal care (ANC) for the current delivery had a 2.930 times higher likelihood of using immediate postpartum Long-Acting Reversible Contraception (LARC) compared to those who did not have ANC follow-up (Adjusted Odds Ratio = 2.930, 95% Confidence Interval = 1.829-4.769).

Women who expressed no desire to have a child exhibited a 1.421 times higher likelihood of using immediate postpartum Long-Acting Reversible Contraception (LARC) compared to those who had a desire to have a child (Adjusted Odds Ratio = 1.421, 95% Confidence Interval = 1.026-2.006) (Table 4).

Table 4. Predictors of immediate postpartum LARC use among postpartum women in Northwest Ethiopia.

Variables	Utilization of immediate postpartum LARC		COR(95% CI)	AOR(95% CI)	p-value
	Cases	Controls
Marital status
Single	7	22	0.611(0.253-1.479)	0.880(0.992-1.432)	0.210
Married	101	194	1	1
Sex of the child women desire
Male	70	135	1.105(0.683-1.789)	1.687(0.902-2.430)	0.740
Female	38	81	1	1
Residence
Urban	42	67	1.415(0.874-2.293)	1.602(0.439-3.240)	0.190
Rural	66	149	1	1
Educational status of women
Unable to read and write	24	62	1	1
Able to read and write	27	68	1.026(0.536-1.962)	1.420(0.752-2.966)	0.810
Primary education	36	58	1.603(0.855-3.006)	1.829(0.998-3.010)	0.631
Secondary and above education	21	28	1.937(1.025-4.406)	2.314(1.645-5.043)	0.002
Knowledge
Good	40	82	0.961(0.596-1.550)	1.642(1.086-3.186)	0.000
Poor	68	134	1	1
Attitude
Positive	44	89	0.981(0.613-1.569)	1.539(0.887-2.983)	0.108
Negative	64	127	1	1
Being counseled about immediate postpartum LARC
Yes	78	144	1.300(1.083-2.159)	3.029(2.085-5.988)	0.000
No	30	72	1	1
ANC follow up
Yes	101	200	1.154(1.060-2.896)	2.930(1.829-4.769)	0.031
No	7	16	1	1
Desire to have no child
Yes	85	175	0.8669(0.488-1.535)	1.421(1.026-2.006)	0.003
No	23	41	1	1
Total family size
≤2	24	49	1.299(0.712-2.369)	1.839(0.833-2.944)	0.184
3-4	41	53	2.051(1.198-3.512)	2.550(0.989-3.939)	0.219
≥5	43	114	1	1

Discussion

This research aimed to uncover the factors influencing the use of immediate postpartum Long-Acting Reversible Contraception (LARC) in postpartum women in northwest Ethiopia. The results indicated that factors such as a lack of desire to have a child, attainment of a secondary education or higher, attendance at antenatal care (ANC) follow-up, receiving counseling about immediate postpartum LARC, and possessing good knowledge about immediate postpartum LARC were identified as key determinants influencing the utilization of immediate postpartum LARC.

Women with a secondary education or higher were 2.314 times more likely to use immediate postpartum Long-Acting Reversible Contraception (LARC) compared to those who were unable to read and write. This finding aligns with studies conducted in the west Gojjam zone, south Gondar zone, Bale zone, Hawassa, Ethiopia, Uganda, India, low-income countries, and low and middle-income countries.²⁴^,³¹^–³³^,³⁶^,³⁹^–⁴⁴ One plausible explanation is that an increase in women’s educational attainment tends to positively influence healthcare-seeking behavior. Additionally, heightened education levels enable women to comprehend the advantages and drawbacks of contraceptives, providing them with accurate information about fertility and contraception. Empowering maternal education, therefore, plays a crucial role in enabling informed decision-making regarding fertility and contributes to improved maternal and child health.

The likelihood of using immediate postpartum Long-Acting Reversible Contraception (LARC) was 1.642 times higher among women with good knowledge about immediate postpartum LARC compared to those with poor knowledge. This observation aligns with studies conducted in Bahir Dar, West Arsi, Addis Ababa, Ethiopia, India, and low-income countries.²⁴^,³²^,³⁷^,⁴⁵^–⁴⁷

Additionally, the odds of utilizing immediate postpartum LARC were 3.029 times higher among women who received counseling compared to those who did not. This finding is consistent with studies conducted in the Sidama zone, West Gojjam zone, Hawassa, South Gondar zone, Bahir Dar, Addis Ababa, Ethiopia, and low and middle-income countries.²⁴^,³¹^–³³^,³⁶^,⁴³^,⁴⁶^,⁴⁸^,⁴⁹ According to the World Health Organization (WHO), postpartum family planning counseling is ideally initiated during antenatal care (ANC), offering an opportune time to counsel women. However, counseling during early labor and immediately postpartum is also deemed acceptable. Another potential rationale is that counseling enables women to receive accurate information about immediate postpartum LARC, potentially altering their attitudes and behaviors by dispelling rumors and misconceptions that could impede the acceptance of immediate postpartum LARC.

The likelihood of utilizing immediate postpartum Long-Acting Reversible Contraception (LARC) was 2.930 times higher among women who attended antenatal care (ANC) for the current delivery compared to those who did not. This finding is consistent with research conducted in the south Gondar zone, Bale zone, Bahir Dar, Ethiopia, low and middle-income countries, USAID findings from 17 countries, and USAID DHS Comparative Reports, India, and Egypt.²⁴^,³¹^,³²^,⁴³^,⁴⁴^,⁴⁹^–⁵⁴ The observed association could be attributed to the recommendation of focused antenatal care, which includes counseling about contraceptive methods during ANC follow-up. The increased frequency of ANC follow-ups, typically three times, may provide pregnant women with opportunities for discussions about immediate postpartum LARC and other contraceptive methods. Healthcare providers, during these interactions, often clarify misconceptions about immediate postpartum LARC. Therefore, delivering effective contraceptive counseling during ANC visits has the potential to address any misperceptions and motivate women to accept the use of immediate postpartum LARC.

The likelihood of utilizing immediate postpartum Long-Acting Reversible Contraception (LARC) was 1.421 times higher among women who expressed no desire to have a child compared to those who desired childbirth. This finding aligns with studies conducted in Hawassa City and the Sidama zone.³⁶^,⁴⁸ The overarching objective of family planning programs is to assist women who wish to delay or avoid childbearing in achieving these stated fertility goals. This approach offers the additional advantage of affording mothers sufficient time to recover from the physical stress of one pregnancy before embarking on the next, allowing for adequate lactation periods. Consequently, promoting healthy timing and spacing of pregnancies presents an opportunity to positively impact maternal health and newborn outcomes.

Limitation of study

The cross-sectional nature of the study inherently constrains the ability to establish the causal relationship between dependent and independent variables. Additionally, due to its quantitative approach, the study does not delve into participants’ profound emotions regarding acceptability, reasons for refusal, or beliefs about immediate postpartum Long-Acting Reversible Contraception (LARC), as would be possible in a qualitative approach. Moreover, the research was exclusively carried out in public hospitals, limiting the applicability of the findings to women who gave birth at home, in health centers, or private health institutions.

Conclusion

In this study, we identified factors that significantly influence the utilization of immediate postpartum Long-Acting Reversible Contraception (LARC). Educational attainment, attendance at antenatal care (ANC), desire for additional children, counseling, and knowledge about immediate postpartum LARC were found to be significantly linked to the use of this contraceptive method. The research aimed to pinpoint the determinants of immediate postpartum LARC among postpartum women in northwest Ethiopia. The results indicated that factors such as a lack of desire for additional children, a secondary education or higher, ANC follow-up, counseling on immediate postpartum LARC, and possessing good knowledge about it were key determinants influencing its utilization.

Hence, it is crucial to prioritize the empowerment of maternal education, provide comprehensive counseling on immediate postpartum Long-Acting Reversible Contraception (LARC) during any interaction, and reinforce adherence to focused antenatal care (ANC) attendance. These efforts are essential in encouraging women to adopt contraception during the postnatal period, contributing to overall improvements in maternal and child health. Additionally, emphasizing health education and communication becomes paramount for enhancing women’s understanding of immediate postpartum LARC utilization.

Ethical approval and consent to the participant

Ethical approval was obtained from the Institutional Review Board of Wolaita Sodo University with approval number and date RCSPG-179/14, May 15/2022 respectively. Additionally, a permission letter was granted by the Kelela district health office. Prior to the interview, participants were presented with the consent form, and written consent was obtained from each individual.

Authors’ contribution

Each author significantly contributed to the conception and design, data acquisition, or analysis and interpretation of the data. They participated in drafting the article or made substantial revisions to ensure intellectual integrity. All authors consented to submitting the work to the present journal, provided final approval for the version intended for publication, and committed to being accountable for all aspects of the study.

Data availability

Underlying data

Figshare: Determinants of Immediate Postpartum Long Acting Reversible Contraceptive Utilization among Women Who Gave Birth in Public Health Facilities in Northwest Ethiopia: Unmatched Case-control Study Design. https://doi.org/10.6084/m9.figshare.25050845.v1.⁵⁵

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Reporting guidelines

Fishare: Online resource for STROBE Checklist for case control study. https://doi.org/10.6084/m9.figshare.25478374.v1.⁵⁶

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgment

We express our sincere gratitude to the College of Health Science and Medicine at Woliata Sodo University for granting us ethical clearance. Additionally, we extend our heartfelt thanks to the study participants for their cooperation during the data collection process.

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