Post Partum Contraception: Awareness and Willingness to Use by Antenatal Attendees in A Third Level Health Facility, Southern Nigeria

Background: The contraceptive prevalence of Nigeria is low. Post partum contraception (PPC), especially in the immediate post period, may improve our contraceptive prevalence rate. Objective: To determine the level of awareness and willingness to use post partum contraception by antenatal attendees of the University of Port Harcourt Teaching Hospital (UPTH). Methods: This is a cross-sectional questionnaire-based prospective study in consented antenatal attendees of the UPTH between the 1st of June and 31st of August 2020. Pretested questionnaires were administered on the respondents by trained assistants. Their socio-demographic data and information on their awareness and willingness to use post partum contraception were entered into excel spread sheet and analyzed with SPSS version 20.0. Chi-square test of variables were done and P<0.05 was taken as significant. The results were presented in tables of frequencies and percentages. Result: Two hundred and seventy-one antenatal attendees of the UPTH participated in this study. Their mean parity was 2.65 with a standard deviated of 1.25. Of the total number of respondents, 299(99.26%) had at least a secondary education, 156 were aware of post partum contraception; giving a prevalence of 57.56%. Two hundred and six (76.01%) expressed willingness to use post partum contraception if counseled and offered. Husbands support for the use of contraception was 69.37%. Conclusion: There was poor awareness of post partum contraception in the UPTH antenatal attendees. However, the expression of willingness to use this method of contraception was high.


I. INTRODUCTION
Antenatal care is a period when set of organized interventions are carried out to cater for the health of woman and her fetus for ultimate safe delivery outcome; and also prepare the couple for other needed necessary care in the post partum period. Family planning, one of these needed necessary care, is therefore an essential component of the antenatal care and the post partum period up to but not limited to the 1 st one year.
Family planning (FP) is defined as the prevention of unintended pregnancy following the first year of childbirth [1]. Contraception allows the couple the human right potential to decide if and when to have children and hence attain their desired family size.
With the stress of labour/delivery, psychological and financial strain among others, most women would prefer deferring the next pregnancy to such a time that allows their full recovery from the toll of immediate past delivery experiences [2]. Therefore, early initiation of FP in the post partum period is crucial to guaranteeing health and wellbeing of the mother and their babies bearing in mind that this period poses additional risk with adverse reproductive outcome to the mother [3].
Unfortunately, more than 200million women in Africa who want to avoid/prevent pregnancy are not using any form of modern contraceptive [3]. More importantly, in the post partum period, about 95% of women do not desire pregnancy in the 1 st 12 months of delivery but up to 70% of them are not using contraception.
Though these women do not desire pregnancy in the post partum period, many of them initiate sexual intercourse early post-delivery. In Enugu, [4], showed that 68.9% resumed coitus within 6 weeks of delivery while only 14.7% of them used modern contraception.
Other studies at Ibadan and Kano by [5], [6] showed 36.4% and 66.9% of the women respectively had resumed coitus within 6weeks of delivery while only 20.7% and 65.5% respectively used any form of contraception.
In a meta-analysis report, Tsegaye et al. in Ethiopia gave a prevalence of post partum contraception (PPC) of 48.11%, education being the most important predictive factor to its use [7].
Preconception care, and especially, the ANC remains a critical time to counsel expectant mothers and indeed couples on PPC benefits [7], [8].
Study by [9] and Ethiopian work by [10] showed that antenatal counseling for PP contraception increased willingness to use contraception by 91.5% in the counseled group as against 68.7% who indicated interest in the control group; while in the later, it showed contraceptive uptake of 78.38% in the counseled group as against 13.40% in the parturient who were not counseled for PP contraception. The effect of PPC showed in Yaprak et al. study that majority of participants still used traditional method of contraception in spite of counseling in the post partum period [11]. However, immediate PP counseling on contraception reported by Kasemiss in his study, 73.7% in the counseled group and a lower 42.6% in the control accepted PPC [12].
The post partum family planning remains the ideal time to improve on CPR as suggested by various reviews [1], [4]. There is therefore the need to evaluate the awareness and willingness to use post partum family planning by the UPTH antenatal population; hence this study.

II. METHODOLOGY
This study was conducted in the antenatal clinic of the UPTH. This hospital is located in the outskirt of Port Harcourt, an ancient oil rich cosmopolitan city of Nigeria. It provides general and specialize care to Risers State and its adjoining states.
It was a prospective cross-sectional questionnaire-based study in women attending antenatal care at the UPTH between the first of June and 31 st of August 2020. Pretested questionnaires were administered on consented respondents by trained assistant who supervised the process of data collection.
The socio-demographic characteristics, awareness, and willingness to use post partum contraception and reasons for not wanting to use it were captured on excel spread sheet and analyzed using SPSS version 20.0. Chi-square was used to test variables for significance and P value of 0.05 at 95% confidence interval was adjudged significant. Result was presented in tables of frequencies and percentages. Ethical approval for the study was obtained from the UPTH/ethical committee.

III. RESULTS
From the result of the two hundred and seventy-one antenatal women who responded in this study, 145 (53.51%) were in the 25-34 age range, 215 (79.34%) were multiparous; the parity mean was 2.65 with a standard deviation of 1.25. Most of them, 269 (99.26%) had at least secondary education (p value >0.05 for education, Table V) and 168 (61.99%) were Pentecostal. See Table I. Table II, showed that a good number of these women have heard of contraception and knows its benefits; 257 (94.83%) and 234 (86.35%) respectively. In 188 (69.37%) of the women, the husbands supported contraception. About half 156 (57.56%) of the respondents have heard of post partum contraception during the antenatal sessions (Table III); but only 67 (24.72%) of this number had heard of immediate post partum contraception (Table II). Two hundred and six (76.01%) of the women expressed the willingness to use post partum contraception if counseled and the method offered, while the remaining 65 expectant mothers who declined were mainly either undecided or gave religion as a reason for the non-acceptance (Table IV).

IV. DISCUSSION
Antenatal care and family planning are some of the important pillars of safe motherhood. Antenatal care period therefore remains a very useful time to introduce/remind mothers or couples on the need to limit or space their children (family planning) [10].
In this study, most of the participants were young nulliparous women with at least a secondary education. This means that they will appreciate counseling given on the need for family planning [7], [8]. A high percentage of these women (94.83%) are aware of contraception and knows its benefits (86.35%). This means that even before becoming pregnant, the basic knowledge about contraception in general was high.
Studies have shown there is direct relationship between contraceptive knowledge and use before pregnancy and in the post partum period [9], [13]. It is therefore expected that participants in these studies will invariably indicate high willingness to use contraception in their post partum period if adequately counseled; since their preconception contraceptive awareness was high. This will be in agreement with studies done by [l3], [17] among others. This is more so, considering that 69.37% of the respondents have their spouse support as husband's awareness and support for contraception has shown to improve uptake even in the post partum period [14], [15].
Only about half (57.56%) of the attendees have heard of post partum contraception; but only one quarter (24.72%) of this number has heard about immediate post partum contraception. However, 76.01% of these respondents were willing to use this method if offered. The poor awareness of and high willingness to use post partum contraception by participant if offered suggests a grossly inadequate counseling during the period of antenatal care.
From the level education and average parity, these women have a high pedigree to accepting post partum contraception [7]. More importantly adequate counseling has equally proven to increase the uptake of contraception generally and post partum contraception in particular [9], [12] bearing in mind that the post partum period is a very important opportunity to counseling these women to accepting contraception [9], [12] and preventing accidental/unintended and possibly unwanted pregnancy and its sequelae [1], [2] the poor counseling situation revealed in this study becomes very worrisome.
The very low level of one-on-one counseling, as shown by 12.20% and 4.5 direct counseling by the nurses and doctors respectively are even more disturbing. This level of counseling is needed to consolidate on the general talk (lecture) given during the antenatal sessions [16], [17].
This situation calls for serious concern considering the fact that a reasonable number of these women resume intercourse early in the post partum period (within the first 6weeks) [4], [6] with most of them not using any form of contraception [4], [5], [18]- [20]. There is therefore need for an organized strategic interventional counseling that will enable the women make the necessary informed choice of contraception. This will ultimately increase the already high expression of willingness to use PPC by the women in this study.
Topping the list for reasons in declining PPC contraception are, being undecided and religion. This has been shown by several studies [21]- [24]. However, while these studies point more on religion and fear of side effects, most respondents in this study are undecided, which is in keeping with poor/inadequate counseling so far established in this study. As contraceptive prevalence of Nigeria remains disturbingly low [25] there is need to strategically address the various obstacles to accepting contraception, especially post partum contraception, in these women most of whom do not need pregnancy at this point in time.

V. CONCLUSION
There is poor awareness of post partum contraception among University of Port Harcourt Teaching Hospital antenatal population. However, their willingness to use this method of contraception is high. Grossly inadequate counseling on post partum contraception during antenatal care services must be addressed to improve post partum contraceptive acceptance.

VI. LIMITATION
The study focused on the UPTH, a referral centre.

VII. RECOMMENDATION
A widespread study in the subject matter involving the State is needed. This will be useful in policy formulations on family planning at the state level and by extension the country at large. More importantly, emphasis should be laid on adequate counseling on this method of contraception during the antenatal care to get the women well informed on this method of contraception so that they will key into it.