Introduction of postpartum and post abortion family planning into three hospitals in South Sudan
Abstract
Introduction: Postpartum/post abortion family planning is a service provided for women who have given birth or had a spontaneous abortion. Due to low uptake of contraception in South Sudan, increasing contraceptive use is important to achieve Sustainable Development Goals.
Objective: To introduce postpartum/post abortion family planning to women who have delivered or undergone spontaneous abortion at Juba Teaching Hospital, Tambura Hospital, and Yei Hospital.
Method: This was a project initiated by Lund University in South Sudan as a part of a capacity building international training programme in sexual and reproductive health and rights. The aim was to introduce the use of postpartum/post abortion family planning and train health care providers.
Results: From the three hospitals, 1373 women who had delivered were counselled and 404 accepted postpartum contraceptives. Of 285 women who had had a spontaneous abortion and were counselled, 22 accepted contraceptives. During the project, 15 health providers were trained to promote and champion the use of postpartum and post abortion family planning provision.
Conclusion: This study shows that training of health care staff to advocate and promote postpartum/post abortion contraception is effective and can contribute to family planning services.
Keywords: postpartum, post abortion, family planning, contraceptives, South Sudan
Introduction
Postpartum/post abortion family planning is an important intervention for achieving overall family planning coverage. South Sudan has one of the lowest contraceptive prevalence rates (CPR) in the world standing at only 4.7%.[1] It also has one of the highest maternal mortality ratios (MMR) in the world at 789/100000 live births.[2] South Sudan has committed to working towards achieving Sustainable Development Goal (SDG) 3. Ensure healthy lives and promote wellbeing for all at all ages; specifically, to reduce MMR to less than 70/100000 live births (SDG 3.1). And ensuring universal access to sexual and reproductive healthcare services, including family planning[3] (SDG 3.7).
Contraceptive counselling in conjunction with delivery and post abortion care is an effective way of increasing the CPR and reducing MMR[4,5]. In the case of the three hospitals in our project, a recent survey of the care documented in the hospital registers showed that none of the women who had been in hospital for birth or post abortion care had received any kind of contraception or even been given any counselling or information about family planning. This clearly demonstrates a lack of an integrated and comprehensive reproductive healthcare service, lack of awareness about the importance of family planning as a woman’s right and a key measure to avert many unwanted complications. There is a lack of protocols and guidelines concerning postpartum/post abortion family planning.
This project came about as part of an international training facilitated by Lund University and funded by the Swedish International Development Cooperation Agency (Sida)[6] aimed to introduce postpartum/post abortion family planning to women who have delivered or undergone spontaneous abortion
Method
Three hospitals in different settings were selected as implementing centres: Juba Teaching Hospital (JTH), and Tambura and Yei Hospitals.
This project aimed to introduce the service to the three hospitals and to enthuse health care providers about the importance of postpartum/post abortion family planning. It also aimed to start family planning counselling during antenatal care visits, to increase the chances of enrolling more women to adopt contraceptive methods of their choice. We strongly encouraged involvement of male partners in the counselling, as they are influential in making decisions.
Juba Teaching Hospital is the main referral Hospital in South Sudan. It is a 580-bed facility, giving services to the estimated 13 million South Sudanese.[7] In the department of obstetrics and gynaecology there are 50 beds divided equally between the gynaecology and maternity wards. The department is staffed with 6 obstetricians & gynaecologists, 6 residents, 14 midwives, and 7 nurses. Around 8000 women deliver in the facility annually, and 2,000 women receive post abortion treatment every year. There is a family planning unit within the hospital providing contraceptives and family planning services to all women of reproductive age but this is not routine for postpartum or post abortion care.
Tambura Hospital is located in Tambura town, 582 km north-west of Juba. The catchment population is 200,000 and bed capacity is 88. In the maternity and gynaecology block there are 21 beds; attached to it is a family planning unit.
Yei Hospital is located in Yei town, 170 km south-west of Juba. It has a catchment population of 260,000 and bed capacity is 91; there are 32 beds for maternity and gynaecology, and attached to it is a family planning unit.
The primary target population of the project was all women who delivered or had post abortion care at these three hospitals. The secondary target population was the healthcare providers in these hospitals, who were trained on postpartum/post abortion family planning. Project activities are summarized in Table 1.
Table 1. Project activities
|
Activity |
Dates of implementation /duration |
|
1. Drafting checklist for collecting data from each client about receiving the service |
May 2019 |
|
2. Mapping of the facilities on the availability of all types of contraceptives |
3-4 June 2019 |
|
3. Training of 15 health care providers on counselling, increasing awareness and provision of various methods of contraception |
6-11 June 2019 (5 days) in Tambura Hospital 18-22 June 2019 (5 days) in Yei Hospital |
|
4. Provision of all types of contraception and adequate counselling of the clients about family planning |
12 June 2019 to date in Tambura Hospital 1 July 2019 to date in Yei Hospital |
|
5. Monitoring and follow up on the implementation of the project |
Ongoing process |
|
6. Presentation of the project outcome to the international training program (ITP SRHR) Lund University, and to other stakeholders |
November 2019 |
Results
Nine health workers were training in Tambura Hospital and six at Yei Hospital. These were two medical doctors, six midwives and seven nurses. The health-implementing partners in those hospitals facilitated the training within their budgeted funds allocated for family planning activities. In Juba Teaching Hospital, which was not supported by any health partners, staff working within the hospital family planning unit were given one day intensive training and tasked to implement and promote postpartum/post abortion family planning.
According to the three hospital registers, before the project, no women had received postpartum counselling or contraceptives after abortion. However, from June to October 2019, 1658 women were counselled on post abortion/ postpartum family planning.
During the intervention, 1373 women were counselled in the three hospital. Overall, 404 (29.4%) accepted contraceptives (Tambura 38.4%, Yei 20.0%, JTH 28.4%). See Figure 1 and Table 2.
Figure 1. Number of women counselled and accepting postpartum contraception in the three hospitals.
In the three hospitals, 285 women had post abortion care from June to October 2019. All were counselled on contraceptives but only 22 (7.7%) women agreed to use contraceptives. See Figure 2.
Figure 2. Number of women counselled and accepting post abortion contraception in the three hospitals.
The proportion of women who accepted to use postpartum contraceptives was higher in Tambura Hospital than Juba Teaching Hospital (28.4%) and Yei Hospital (20.0%). See Table 2.
Table 2. Prevalence of contraceptives use among women who delivered in the three hospitals
|
Hospitals |
Women who received postpartum family planning counselling n (%) |
Women who refused postpartum contraceptives n (%) |
Women who accepted contraceptives n (%) |
|
Tambura Hospital |
471(100) |
290 (61.5) |
181(38.5) |
|
Yei Hospital |
390 (100) |
312 (80.0 ) |
78 (20.0) |
|
Juba Teaching Hospital |
512 (100) |
367 (71.6) |
145 (28.4) |
|
Total |
1373 (100) |
969 (70.6) |
404 (29.4) |
The proportion of post abortion women accepting contraception was much lower in JTH (3.9%) than in Tambura (10.5%) and Yei (11.1%) hospitals. See Table 3.
Table 3. Prevalence of contraceptives use among women with post abortion care in the three hospitals
|
Hospital |
Women who received post abortion care and counselling n (%) |
Women who refused to use contraceptives n (%) |
Women who accepted contraceptives n (%) |
|
Tambura Hospital |
76 (100) |
68 (89.5) |
8 (10.5) |
|
Yei Hospital |
81 (100) |
72 (88.9) |
9 (11.1) |
|
Juba Teaching Hospital (JTH) |
128 (100) |
123 (96.1) |
5 (3.9) |
|
Total |
285 (100) |
263 (92.3) |
22 (7.7) |
Figure 3 shows the progesterone implant was the most popular method in the three hospitals, 49%, followed by progesterone injection (Depo-Provera). Intrauterine contraceptive devices (IUCDs) and oral contraceptives pills (OCPs) were much less popular.
Figure 3. The contraceptive methods chosen by the women in the three hospitals
Discussion
Nearly 30% of postpartum women counselled accepted contraception, whereas only 7.7% of women receiving post abortion care did. This is in line with the overall low CPR (4.7%) for South Sudan. Moreover, it could be attributed to strong cultural beliefs, lack of a law empowering women to take an informed decision to use family planning, and it could be due to inadequate counselling of the women.[7]
Figure 4. Victoria Kujang, a midwife at Yei Hospital counselling a mother. (Credit: Dr Benjamin B. Henry).
Almost all (94%) of the women who accepted contraception chose progestogen methods, implants (49%) and injections (45%). Women may feel comfortable using these two methods, as they are long-lasting (3-5 years and 3 months respectively), whereas OCPs need to be taken daily. IUCD had a low acceptance rate, possibly because the IUCD requires an intimate examination, an intrusive procedure, and the false belief that it may interfere with their sexual life. The prevalence of implant in this study is higher than the 20.8% reported in neighbouring Kenya.[8] This difference could be because the study population is not representative of the whole community of South Sudan. Also, in the case of Kenya, most women have personal control over their contraceptive choices besides having greater access to contraception. [9,10]
There was much lower uptake of contraception among women with post abortion care at JTH (3.9%), compared to 11.1% and 10.5% at Yei and Tambura Hospitals respectively. The variation between the three hospitals was attributable to the differences in the intervention carried out. The maternity staff in both Tambura and Yei Hospital were directly involved in the preparatory counselling and provision of contraceptives to women who had suffered abortions, or who had delivered, whereas at Juba Teaching Hospital family planning unit staff provided the service when called by the maternity staff. The interventions were different because the implementing partners supporting Tambura hospital and Yei Hospitals embraced the project and facilitated the training of obstetrics and gynaecology staff within their existing budgets, but this did not happen at JTH.
It was not a usual practice in these three hospitals to provide postpartum or post abortion family planning. The project brought benefits to the women that were counselled and accepted to take contraceptives. The project will attempt to sustain and improve the results through expanding the counselling to start in the third trimester during antenatal care, as this may give more opportunity for the woman to consider her options, to discuss the idea with her husband and decide on the type of contraception she would prefer. Moreover, continuing training and encouragement of the maternity and post abortion health care team as advocates of family planning education and counselling will try to ensure quality services flowing to the women.
Donors use the provision of family planning services as a performance indicator when evaluating implementing partners. Thus, as this project uses the same providers, the development and promotion of postpartum and post abortion family planning provision can be easily incorporated and would assist the partners to achieve their targets.
Males dominate decision-making in South Sudanese families; hence, some women were not able to access family planning, due to the absence of their partners at the time of counselling. Therefore, the project will continue engaging male partners through media, organized awareness programs, or through boma/village health teams. The education and engagement of community leaders and health workers at the community level is important in advancing family planning, as they are powerful in delivering messages related to health at the village levels.
Conclusion
Most of the project objectives have been achieved. Postpartum/post abortion family planning has substantially improved and made a contribution despite the challenges of the low uptake. Counselling capacity on contraceptive use and provision has significantly increased in the three hospitals.
References
- Kane S, Kok M, Rial M, Matere A, Dieleman M, Broerse JE. Social norms and family planning decisions in South Sudan. BMC Public Health. 2016;16:1183.
- World Health Organization, UNICEF, UNFPA, World Bank Group, United Nations Population Division. Trends in Maternal Mortality: 1990 to 2015. World Health Organization, Geneva; 2015;
- Ministry of Finance and Planning South Sudan, United Nations South Sudan. South Sudan Inaugural SDG Report. 2017.
- World Health Organization. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. World Health Organization, Geneva; 2011.
- Ceylan A, Ertem M, Saka G, Akdeniz N. Post abortion family planning counseling as a tool to increase contraception use. BMC Public Health. 2009; 9:20.
- Lund University. ADVANCED INTERNATIONAL TRAINING PROGRAMME ( ITP ) Sexual and Reproductive Health and Rights. 2020;
- United Nations Department of Economic and Social Affairs Population Division. World Population Prospects 2019: Data Booklet. United Nations, 2019;1–25.
- Kaneda T, Greenbaum C. Family Planning Data Sheet. Population Reference Bureau, Washington; 2019;1–17
- Tumlinson K, Pence BW, Curtis SL, Marshall SW, Speizer IS. Quality of care and contraceptive use in urban Kenya. Int Perspect Sex Reprod Health. 2015; 41(2):69–79.
- 10. Ochako R, Mbondo M, Aloo S, Kaimenyi S, Thompson R, Temmerman M, et al. Barriers to modern contraceptive methods uptake among young women in Kenya: A qualitative study. BMC Public Health. 2015; 15:118.
