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\begin{document}


\def\RunningAuthor{Dhanvarsha Sumaldha Subbiah Ramkumar et al.}
\firstPage{1597}
\articleType{Original Article}
\receivedDate{02 Mar 2021}
\acceptedDate{19 Apr 2021}
\revisedDate{07 Apr 2021}
\journalVolume{2021, 12}
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\journalDoi{ijrps.v12i2.4745}
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\title{A knowledge, attitude and practice study on awareness of contraception among postpartum women in a tertiary care centre}
\author{Sivasundari~Maharajan,  
            Dhanvarsha~Sumaldha~Subbiah~Ramkumar\textsuperscript{*}, 
            Perni~Navya~Sree~\\[5pt]{Department of Obstetrics and Gynaecology, Saveetha Medical College and Hospital, Chennai, Tamil Nadu {\textendash} 602105, India}}

\begin{abstract}
Despite being the first country to launch the National Family Planning Programme in 1952, India still lags behind in practising contraception. This study was conducted to assess knowledge, awareness and practice methods of contraception during the postpartum period. The study included 720 postpartum women; details including awareness and practice methods of contraception and factors affecting use by the postpartum women were obtained. Statistical analysis was done by using the chi-square test and percentage (\%). The mean age of postpartum women was 26.5 years, 28.19\% were literate between 9\ensuremath{^{th}} - 12\ensuremath{^{th}} grade, 96.94\% women were housewives. Among them, 56\% of women were aware of at least one contraception and correct usage. Among them, 98.01\% knew about sterilization. About 48.88\% of women were aware of more than one method of contraception. After counselling, 97.2\% of women were willing to use contraception. However, 2.78\% of patients chose abstinence. In our study, knowledge about contraception based on education and socio-economic status of women shows significant association (p-value {\textless}0.00001 for both). Health professionals should evaluate the level of awareness, create awareness and provide education regarding methods of contraception for use in the postpartum period to improve maternal and fetal outcome.  
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Contraceptive method,\newline Postpartum counselling,\newline Pregnant women,\newline Family planning
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Dhanvarsha~Sumaldha~Subbiah~Ramkumar~\\ Phone:\ +91-88703-66465~\\  Email:\ srds1006@gmail.com
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\section{Introduction}
Every woman has the right to protect and decide for her own health. \unskip~\citep{1088443:22094560} Women should be given the fundamental freedom to choose if and when she shall be a mother. \unskip~\citep{1088443:22094561} In this present era, even though a significant percentage of women are highly educated and work equally amongst men in all fields, a large percentage of women in rural areas are still illiterate or less educated and are economically dependent on their family \unskip~\citep{1088443:22094563}.

Contraception is a major component of reproductive health. \unskip~\citep{1088443:22094564} Despite the fact that India being the first country in the world to launch the National Family Planning Program in 1952, the country still lags behind in practising contraception and limiting their family size. 

Contraception during the postnatal period is very important for maternal and child health. Family planning can prevent more than 30\% of maternal deaths and 10\% of child mortality if the appropriate spacing between pregnancies is maintained. \ensuremath{^{}}

We have conducted this study to evaluate the knowledge, attitude and practise of contraception among the postpartum women who delivered in our tertiary care centre. 
    
\section{Methods}
A prospective, observational, hospital-based study was conducted on 720 postpartum women at the Department of Obstetrics and Gynaecology at our tertiary care centre between February 2020 and November 2020. The study was mainly aimed at evaluating the KAP on contraception use among postpartum women. 

The women were interrogated with a pre-structured questionnaire which included demographic data like age, education, parity, socio-economic status,  data on awareness about contraception. This study was initiated after clearance from the Institutional Ethics Committee of Saveetha Medical College and Hospital. An informed consent was obtained from the women, and confidentiality was ensured. 

Women who recently delivered were included in the study after obtaining informed consent. Women with pregnancy outcome as still, births or neonatal death and women who have undergone postpartum sterilization were excluded.

The knowledge about various methods of contraception was assessed. The women who were aware of at least one method and its correct method of use were considered aware of contraceptive method. 

They were counselled about various contraception methods available and allowed to choose a method of their choice for contraception. After adequate high-quality counselling given using the cafeteria approach, the method of contraception preferred was studied to assess the most common method of contraception chosen. 
    
\section{Results}
A total of 720 eligible postpartum women were included in the study. The mean age of postpartum women was 26.5 years. The majority of women, 60.43\% belonged to the age group of 25-34 years, 31.67\% belonged to 18-24 years and 7.9\% belonged to the 35-44 years age group.

About 70.14\% of women had more than one living child, and most of them (85\%) were housewives belonging to the lower middle class (SECIII) 59.30\%, followed by 15.70\% belonging to the upper-middle class (SECII). 

The majority of women were literate, 28.19\% between 9\ensuremath{^{th}} - 12\ensuremath{^{th}} grade, 27.91\% between 5\ensuremath{^{th}} - 8\ensuremath{^{th}} grade, 23.88\% {\textless}5\ensuremath{^{th}} grade, 16.94\% illiterate women and 3.05\% graduates or postgraduates. 

Predominantly 96.94\% were housewives, and 3.06\% women were employed currently (Table~\ref{tw-0da2da00ac08}).

Among 720 women, 56\% women were aware of at least one method of contraception and the correct method of use. About 44\% of women were unaware of at least one type of contraception (Figure~\ref{f-9ba5dc5a341c}).


\begin{table*}[!htbp]
\caption{\boldmath {Socio-demographic profile of participating women} }
\label{tw-0da2da00ac08}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.26869999999999997\linewidth-2\tabcolsep}p{\dimexpr.42260000000000005\linewidth-2\tabcolsep}p{\dimexpr.16259999999999998\linewidth-2\tabcolsep}p{\dimexpr.1461\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Characteristics &  & n=720 & \%\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.26869999999999997\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{Age (in years)}} &
  18-24 &
  228 &
  31.67\\
 &
  25-34 &
  435 &
  60.43\\
 &
  35-44 &
  57 &
  7.9\\
Parity &
  One live child &
  215 &
  29.86\\
 &
  More than one live child &
  505 &
  70.14\\
SEC* &
  Upper (I) &
  13 &
  1.81\\
 &
  Upper middle (II) &
  113 &
  15.70\\
 &
  Lower middle (III) &
  427 &
  59.30\\
 &
  Upper lower (IV) &
  95 &
  13.19\\
 &
  Lower (V) &
  72 &
  10\\
Education &
  Graduate or post graduate &
  22 &
  3.05\\
 &
  9\ensuremath{^{th}} - 12\ensuremath{^{th }}grade  &
  203 &
  28.19\\
 &
  5\ensuremath{^{th}} - 8\ensuremath{^{th}} grade &
  201 &
  27.91\\
 &
  {\textless}5\ensuremath{^{th}} grade &
  172 &
  23.88\\
 &
  Illiterate &
  122 &
  16.94\\
Occupation &
  Housewife &
  698 &
  96.94\\
 &
  Employed &
  22 &
  3.06\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{*SEC-socio-economic class according to Modified Kuppuswamy classification.}
    
\item{*p-value of {\textless}0.00001 with SEC and awareness}
    
\item{**p-value {\textless}0.00001 with literacy and awareness}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution of preference of various contraceptives among aware women} }
\label{tw-589844a5936b}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.6601\linewidth-2\tabcolsep}p{\dimexpr.33989999999999995\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Method of contraception & n=403 (\%)\\
\tblmidrule 
IUCD &
  347 (86.10\%)\\
Barrier method &
  345 (85.61\%)\\
Oral contraception pills (POP) &
  205 (50.87\%)\\
DMPA &
  164 (40.69\%)\\
Lactational amenorrhoea &
  22 (5.46\%)\\
Safe method &
  4 (0.99\%)\\
Sterilization &
  395 (98.01\%)\\
More than 1 contraception &
  197 (48.88\%)\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution of post counselling choice of contraception} }
\label{tw-2a24876b3904}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.57480000000000004\linewidth-2\tabcolsep}p{\dimexpr.42519999999999996\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Method of contraception & n (\%)\\
\tblmidrule 
IUCD &
  221 (30.69\%)\\
Barrier method &
  148 (20.56\%)\\
Oral contraception pills (POP) &
  72 (10\%)\\
DMPA &
  158 (21.94\%)\\
Sterilization &
  108 (15\%)\\
No method &
  20 (2.78\%)\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\bgroup
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\centering \makeatletter\IfFileExists{images/7f603dd8-ac56-4ae2-8780-24e6a7699ae6-u1.png}{\includegraphics{images/7f603dd8-ac56-4ae2-8780-24e6a7699ae6-u1.png}}{}
\makeatother 
\caption{\boldmath {Awareness about contraception}}
\label{f-9ba5dc5a341c}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/59c5bce2-39ec-4061-9df4-e5d946fafc41-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/59c5bce2-39ec-4061-9df4-e5d946fafc41-upicture2.png}{\includegraphics{images/59c5bce2-39ec-4061-9df4-e5d946fafc41-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Source of awareness}}
\label{f-cb55a79f7ab8}
\end{figure}
\egroup
Among the 403 women who were aware of at least one type of contraception, the majority were aware about the method of sterilization 98.01\%, IUCD was known to 86.1\%, barrier method (condom) was known to 85.61\%, hormonal contraceptive pills were known to 50.87\%, DMPA (injectable contraceptive) was known to 40.69\%, lactational amenorrhoea was known to 5.46\%, and safe method was known to 0.99\%. About 48.88\% of women were aware about more than one method of contraception (Table~\ref{tw-589844a5936b}).

After counselling by cafeteria approach, 97.2\% of women were willing to use contraception. Choices preferred were IUCD in 30.69\%, DMPA (injectable contraceptive) in 21.94\%, barrier method in 20.56\%, sterilization in 15\%, oral contraceptive pills in 10\%. However, 2.78\% of women did not want any method of contraception (Table~\ref{tw-2a24876b3904}).

Among the 55.97\% women who knew about contraception, 36\% know about the different methods via media, 45\% from the health care system (10\% via PHC workers), 19\% from family members (Figure~\ref{f-cb55a79f7ab8}).
    
\section{Discussion}
The ability of women to control their fertility is fundamental to women empowerment \unskip~\citep{1088443:22094661}.

``Ovulation can occur as early as 25 days post-partum among non-breastfeeding women, underscoring the importance of initiating contraception in the very early post-partum period'' \unskip~\citep{1088443:22094661}.

The statistics on contraceptive use among women in the extended post-partum period, i.e. one year period after the birth of a child, is of importance since a delay of use until the return of menstruation will subject women to the risk of unwanted pregnancy \unskip~\citep{1088443:22094663}.

Despite the fact that contraceptive use has increased, there still exists a gap between knowledge, attitude and practices of contraception use. An increased contraceptive use during the post-partum period reduces the rates of maternal and infant mortality \unskip~\citep{1088443:22094666}.

Furthermore, the largest proportion of women with an unmet need for contraception is found among those in their first year after childbirth. Thus in India, the higher proportion of unplanned pregnancies might be due to short birth intervals\unskip~\citep{1088443:22094661}.

In order to scale back the danger of adverse maternal, perinatal and infant outcomes, WHO (2006) recommended that the interval between a  birth and  an effort to  subsequent pregnancy should be 24 months \unskip~\citep{1088443:22094667}.

According to Demographic and Health Survey (DHS) data analysis from 17 developing countries, the danger of newborn and infant dying decreases with increasing birth interval lengths up to 36 months. In addition, short birth intervals ({\textless}24 months) also have a potential effect on the increased risk of maternal death and complications of pregnancies \unskip~\citep{1088443:22094670}.

According to a study by Upadhye et al., even though 92.5\% of women were aware about contraception, only 42.5\% practised contraception \unskip~\citep{1088443:22094671}. Among the 720 women enrolled in our study, 55.97\% were aware about various methods of contraception compared to 69\% from\unskip~\citep{1088443:22094672}.

In our study, the educational status of the women and socio-economic class were significant predictors of the level of knowledge about contraception. Association of higher education status with knowledge of spacing contraception has been observed by\unskip~\citep{1088443:22094673,1088443:22094674}.

Among the aware women, IUCD was known to 86.1\%, sterilization to 98.01\%, Oral contraceptive pills to 50.87\%, barrier method to 85.61\%, lactational amenorrhoea to 5.46\%, DMPA to 40.69\% and safe method was known to 0.99\%.  Kaushal SK et al. showed awareness around 92.5\% for IUCD, 97.1\% for pills, 8.6\% for DMPA \unskip~\citep{1088443:22094676}.

In this study, the main source of information was noted to be the health care system (45\%) and media (36\%), family members (19\%), which is in contrast to Hayat et al., where media was found to be the most common source of information \unskip~\citep{1088443:22094673}.

After contraception counselling, 97.2\% of women were willing to use contraception. However, 2.78\% of patients chose abstinence. In our study, knowledge about contraception based on the education of women and socio-economic status of the women shows significant statistical association (p-value of {\textless}0.00001 for both variables).

A significant association between contraceptive acceptance and type of family, socio-economic status and education was observed in a study conducted among women of reproductive age in rural Maharashtra \unskip~\citep{1088443:22094675}. Similar findings have been reported by other Indian studies \unskip~\citep{1088443:22094926,1088443:22094925}.
    
\section{Conclusions}
Health professionals should be able to evaluate the level of awareness about contraception among the postnatal women, create awareness on the need for an interval between pregnancies and provide high-quality education regarding different methods of contraception for use in the postpartum period to improve maternal and fetal outcome. 

\textbf{Ethical approval}

The study was approved by the Institutional Ethics Committee of Saveetha Medical College and Hospital

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study. 
    

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