Introduction

Importance of family planning has been established as universal truth in order to put
break on ongoing uncontrolled world population growth. Besides the population
stabilization, family planning is essential to improve maternal and newborn survival
and health. Implementing effective family planning helps to prevent the maternal and
child death along with reducing the rate of unintended pregnancy, which has proven a
major issue worldwide.

During the year following the birth of a child, two in three women are estimated to
have an unmet need for contraception. Among the 12 countries in sub-Saharan Africa,
the postpartum unmet need was estimated at 73.8 percent compared to 62.3 percent in
six countries in Asia and 54.4 percent in seven countries in Latin America.(Figo,
2017)

In Nepal, some 25 percent of women had an unmet need for contraception, with 10
percent requiring it for spacing and 15 percent requiring it for limiting. Notably,
unmet need was higher among younger women than older women, ranging from 48
percent for women aged 15–19 years to 11 percent for women aged 45–49
years.(Central Bureau of Statistics, 2015)

If all currently married women who say they want to space or limit their children were
to use a family planning method, the contraceptive prevalence rate would increase to
77 percent. Currently, only 65 percent of the family planning needs of married women
are being met. (Ministry of Health (MoH) [Nepal], 2012)

Family planning is one of the priority programs of Government of Nepal, Ministry of

Health. It is also considered as a component of reproductive health package and
essential health care services of Nepal Health Sector Program II (2010‐2015),
National Family Planning Costed Implementation Plan 2015‐2021, Nepal Health

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Sector Strategy 2015‐2020 (NHSS) and the Government of Nepal’s commitments to
FP 2020.(Ministry of Health (MoH) [Nepal], 2016)

Country (Nepal) aims to increase demand satisfied for modern contraceptives from
56% (NDHS, 2011) to 62.9% and Contraceptive Prevalence Rate (CPR) for modern
methods from 47% in 2014 (MICS) to 50% by 2020. Likewise it aims to reduce
unmet need for FP from 25.2% in 2014 (MICS) to 22% which would allow the
country to achieve a replacement level fertility of 2.1 births per women by
2021.(Ministry of Health (MoH) [Nepal], 2015)

WHO Recommends a birth to pregnancy interval of at least 24 months in order to

reduce the risk of adverse maternal, perinatal and infant outcomes.(WHO, 2007)
Postpartum family planning and pregnancy spacing programs help women to achieve
those longer intervals. Postpartum intrauterine Device (PPIUCD) is one of the safest
contraceptive methods, which is inserted within 10 minutes after the expulsion of
placenta. It allows women to obtain safe, long-acting (up to 12 years), highly effective
yet reversible contraceptive protection that can be made readily available to women
delivering in health facilities.(Canning et al., 2016)

PPIUD does not interfere with breastfeeding, is safe for use by all women, including
HIV-positive women.(Canning et al., 2016) World Health Organization (WHO)
medical eligibility criteria state that it is generally safe for postpartum lactating
women to use a PPIUCD, with the advantages outweighing the
disadvantages.("Program Learning for Postpartum Intrauterine Contraceptive Device
(PPIUCD) Integration with Maternal Health Services: Programmatic Experience from
Multiple Countries | K4Health,")

One of the best, convenient and effective contraceptive methods for family planning
is Intrauterine Contraceptive Devices (IUCD). This method has been in practice since
long time. The modern IUCD is a safe, highly effective, long active and reversible.
Immediate post-placental insertion of PPIUCD is considered even more effective.
Many women also find the IUCD to be very convenient because it requires little
action once it is in place. (Thonneau & Almont, 2008)

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PPIUD was not very acceptable in our set up but it is a safe, highly effective, long
acting, cost effective method of contraception with very few side effects and no major
complication and contraindication. The feasibility of accepting PPIUD insertion can
increase with antenatal counseling and institutional deliveries. (Kanhere, Pateriya, &
Jain, 2015)

Awareness of the PPIUD among these women was very poor despite high acceptance.
The majority of the women had heard about the PPIUD from the antenatal clinic.
Parturient who had a short duration of their last child birth (2 years) had greater
acceptance of PPIUD.(Gautam, Arya, Kharakwal, Singh, & Trivedi, 2014)

PPIUCD was demonstrably safe, having no reported incidence of perforation with low
rate of expulsion, pelvic infection and missing threads. The Government of India is
now recommending post placental/ postpartum IUCD insertion because PPIUCD
were a safe and effective contraceptive method with no effect on lactation. The
Government of India is also providing this service free of cost to the patients. Thus,
we can conclude that PPIUCD is easily accessible, reversible and cost effective
contraceptive method for most postpartum women specially lactating women. (Swati
Singh, Malik, Ahalawat, & Taneja, 2015)

Despite these well-established benefits of PPIUD, its uptake continues to be low.

During the year following the birth of a child, 40% of women are estimated to have an
unmet need for contraception.(Rossier, Bradley, Ross, & Winfrey, 2015)

History of PPIUCD implication is very short in Nepal, awareness about it among

public is very low affecting its utilization. PPIUCD service was started in 2068 B.S. at
Paropakar Maternity and Women’s Hospital (PMWH), Thapathali, Tertiary Level
Hospital of Nepal. Data of PMWH points out that Uptake of PPIUCD was only 2.98
percent in fiscal year 2072/73 at PMWH. (PMWH, 2016) Government of Nepal has
revised the Maternal and Newborn Care Learning Resource Package for Skilled Birth
Attendants (2016) incorporating PPIUCD as its core skill to produce the skilled health
care provider.

The above mentioned conditions argue about the importance of family planning to
reduce unintended pregnancy thereby improving maternal and newborn survival and

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health. Different studies7-11,13,22-23,26 have concluded that PPIUCD is the safe,
convenient, effective postpartum contraception method but utilization is low.

In above context, this study is aim to assess the awareness and utilization of PPIUCD
among postnatal mothers at PMWH.

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 Literature review

World population grew to 7.06 billion in mid-2012 after having passed the 7 billion
mark in 2011. Developing countries accounted for 97 percent of this growth because
of the dual effects of high birth rates and young populations.("Fact Sheet: World
Population Trends 2012,") Demographic and Health Surveys in 52 countries between
2005 and 2014 reveal the most common reasons that married women cite for not
using contraception despite wanting to avoid a pregnancy.("Unmet Need for
Contraception in Developing Countries," 2016)

Women with unmet need for contraception rarely say that they are unaware of
contraception, that they do not have access to a source of supply, or that it costs too
much.("Unmet Need for Contraception in Developing Countries," 2016)

Every year, an estimated 74 million unintended pregnancies occur in developing

regions, the great majority of which are among women using no contraception or a
traditional method. If all unmet need for modern methods were met, 52 million of
these unintended pregnancies could be averted, thereby preventing the deaths of
70,000 women from pregnancy-related causes.(Susheela Singh, Darroch, & Ashford,
2014)

A prospective study conducted in a tertiary level hospital of India on “Immediate

Postpartum Intra Uterine Device Insertion” has concluded that Immediate postpartum
IUD insertion is a safe, convenient and effective method.(Sharma, Gupta, Bansal,
Sharma, & Tandon, 2017)

Post-placental insertion IUCD is a safe, highly effective, long acting, cost effective
method of contraception.(Katheit & Agarwal, 2016)

Postpartum insertion of IUCD is safe effective, feasible and reversible method of

contraception.(Gupta, Verma, & Chauhan, 2016)

PPIUCD is demonstrably safe, effective, has high retention rate.(Shah, Vora, Ankola,
& Amrutiya, 2016) The acceptance of PPIUCD was high in the parturients studied but
comparable to other studies done globally. Awareness of the PPIUCD among these
women was very poor despite high acceptance.(Ali, 2012)

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Knowledge and acceptance of postpartum insertion is very low among ante-natal
women; probably because the concept is new in the community. There is a strong
need to increase the knowledge and awareness about this by health education and
counseling. (Kathpalia & Mustafa, 2015)

Both the acceptance and actual insertion of IUCD were low probably because the use
of IUCD is a new concept in the community.(Mohamed, Kamel, Shaaban, & Salem,
2003)

IUCD acceptance was very poor in our study. People consult their relatives/friends
more than the healthcare providers in this regard, who tend to spread misconceptions.
Healthcare providers need to look into the matter seriously. Promotional activities
need to be focused on IUCD.(Gadre & Ahirwar, 2015)

We found low acceptability and uptake of PPIUCD among adolescent mothers.

Generally, there was lack of awareness and low prior use of the IUCD, lack of interest
in FP among sexually active adolescents, myths, misperception and fear of
complications cited as the barriers to use PPIUCD.(Yumbe, 2014)

The acceptance of long acting reversible contraceptives was very low. Supportive
attitude towards long acting contraceptives was the only factors that affect acceptance
of long acting contraceptive.(Gebremichael et al., 2014)

Acceptability of PPIUCD insertion was high in women counselled in antenatal period.

Hence, it is suggested that counseling for PPIUCD should start in antenatal period.
(Agarwal, Gupta, Sharma, & Arora, 2015)

In India for last few years acceptance of PPIUCD was significantly increased. Most
common reason behind this increased acceptance was PPFP counselling.(Manisha,
2016)

A number of studies and systematic reviews have evaluated the safety, efficacy and
acceptability of immediate postpartum insertion of IUDs (within 10 min of delivery of
the placenta) compared to delayed postpartum insertion (more than 10 min to 48 or 72
h following delivery) or interval insertion (after four or six weeks following
delivery.(Kapp & Curtis, 2009)

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Although the expulsion rate for immediate post-partum insertion was higher than for
interval insertion, the benefits of providing highly effective contraception
immediately after delivery outweigh this disadvantage, particularly in country where
women have limited access to medical care.(Shukla & Qureshi, 2012)

Immediate post-partum IUCD has high acceptability and more than 75% users are
satisfied and consider it as a contraceptive option. Post-placental insertion greatly
reduces the risk of subsequent pregnancy and eliminates the need for a return visit to
start contraception.(Trivedi, Kasar, Tiwari, & Sharma, 2014)

In a study on “Awareness and acceptance of contraceptive methods among post-

partum patients” done in India has shown that providing effective, high quality
antenatal and post-partum contraceptive counseling can reduce not only unintended
pregnancies but also induced abortions and decrease maternal morbidity and mortality
as a whole. (Patel, Pawani, & Patel, 2016)

With the high level of acceptance despite low levels of awareness, the government
needs to develop strategies to increase public awareness of the PPIUCD through
different media sources. It is also important to arrange training on PPIUCD in order to
increase knowledge and skills among healthcare providers.(Mishra, 2014)

Women who receive PPIUCD show a high level of satisfaction with this choice of
contraception, and the rates of expulsion were low enough such that the benefits of
contraceptive protection outweigh the potential inconvenience of needing to return for
care for that subset of women.(Kumar et al., 2014)

Despite wanting to space or limit pregnancies, nonuse of modern family planning

methods by women and returned fertility increased the risk of unintended pregnancy.
High unmet need for family planning in Nepal, especially in high risk groups,
indicates the need for more equitable and higher quality postpartum family planning
services, including availability of range of methods and counseling which will help to
further reduce maternal, perinatal, and neonatal morbidity and mortality in
Nepal.(Mehata et al., 2014)

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 Research Objectives

General objective:
• To assess the awareness and utilization of PPIUCD among postnatal mothers at
Maternity Hospital.

Specific Objectives:
• To assess the awareness on postpartum IUCD among postnatal mothers

• To find out the utilization of PPIUCD among postnatal mothers at PMWH.

• To explore the associated factors for selecting the PPIUCD among postnatal
mothers.

• To identify the barriers for non-utilization of PPIUCD among postnatal mothers.

• To evaluate the association between awareness and utilization of PPIUCD among

postnatal mothers.

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 Research Methodology

Study Design:
Descriptive design will be used for the study to assess the awareness and utilization of
PPIUCD among postnatal mothers in PMWH.

Study setting
Research will be conducted at the Paropakar Maternity and Women’s Hospital,
Thapathali, a Tertiary Level Maternity Hospital of Nepal. Popularly known as Prasuti
Griha in Nepali, it is the first and largest maternity hospital established in 2016 BS
(1959 AD). Being the central maternity and women’s hospital, it serves people from
all over the country. The hospital caters about 23,547 patients in indoors and 1,36,646
in OPD services. The total number of delivery in fiscal year 2072/73 was
18097.(PMWH, 2016)

‘Postnatal ward A’ of PMWH will be the area of study setting.

Study Population
The study population includes all women who gave birth through vaginal and
admitted to postnatal ward A during the study period.

Sample size:
Sample size will be obtained by the formula:

Sample size (n) = z2 x p x q / d2

Where,

n = sample size

z = At 95% confidence level z = 1.96 (2)

p = Prevalence of the variable (characteristics) in the postnatal mothers

d = margin of error set at 5%

q= (1-p)

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 The sample size is calculated based on the prevalence of PPIUCD users (2.98%)
among total normal delivery in Fiscal Year 2072/73 of PMWH.(PMWH, 2016)

Sample size (n) = 1.962 x 0.298 x 0.702

= 321.44
2
0.05

Total sample size is rounded off to 321.

Sampling technique-
Non probability purposive sampling technique will be use in the study.

Inclusion Criteria
All postnatal mothers who had gone through normal delivery process (vaginal) in the
hospital and admitted to ‘Postnatal Ward A’.

Exclusion Criteria:
Postnatal mother who had delivered baby by cesarean section.

Operational Definition
• Awareness: The fact or condition of being aware of postpartum intrauterine
contraceptive device

• Postpartum: The period after delivery of the products of conception until

6weeks.

• Postnatal Mother: Mother who has recently given birth.

• Normal Vaginal Delivery: Birth of baby through vagina following normal

birthing process.

• PPIUCD insertion: Insertion of the IUD during the postpartum period within 48
hours.

• Post placental insertion: Insertion of the IUD within 10 minutes following

delivery of placenta.

• Acceptance: To be convinced and agree to use PPIUCD.

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• Utilization: The number of clients who agreed to the method and actually had the
PPIUCD insertion.

• Maternity hospital: A hospital that provides comprehensive maternity care. In

this research, Paropakar Maternity and Women's Hospital (PMWH) is selected as
maternity hospital

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 Data Collection

Research Instrumentation
In order to collect data, a semi-structured questionnaire based on the objectives of
study will be used to extract information from the postnatal mother. Instrument will
be divided into three main sections:

• Part I comprises socio demography and obstetric related questions.

• Part II comprises the questions regarding existing knowledge on PPIUCD.

• Part III comprises the questions regarding utilization of PPIUCD.

Validity of the instrument will be established by consultation with research advisor,

subject experts and peers. Instrument will be created in English and then translated
into Nepali in order to get answers from candidates. Opinion from the Nepali
language expert and English language expert will be obtained for translation.

Pre- testing
Before conducting the study, Pretesting of the instrument will be conducted with 10%
of sample at same setting to increase reliability, sequencing and feasibility in
administration of instrument and will be excluded from the study.

Data Collection Procedure

The study will be carried out after obtaining ethical approval for research proposal
from the IRB of NAMS and PMWH. Permission from the respective authorities of
PMWH will be obtained prior to data collection.

Data collection will be done through interview process by researcher herself using
questionnaires and open ended questions. Basically following information will be
collected:

• Social demographic characteristics of the participants

• Obstetric and gynecological characteristics

• Previous contraceptive methods used

• Source of information and awareness of the PPIUCD

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• Reasons for acceptance or decline to PPIUCD

• Their further pregnancy desires.

• Information regarding PPIUCD utilization will be collected from the mother who
inserted PPIUCD.

• Complications experienced by mothers after utilizing PPIUCD.

Postnatal mothers, who are included in the study, will be briefed about the objectives
and process of the study and their informed written consent will be taken prior to the
data collection. This all will be done with maintaining privacy, confidentiality and
anonymity. The researcher will collect the data in 15-20 minute per respondent. To
meet the required number of participants (321) defined for the study, 12 respondents
will be taken daily in order to accomplish data collection task within given time frame
of one month.

As the daily average vaginal delivery at PMWH is much higher than 12, the sample
frame will be constructed on the basis of total number of normal vaginal delivery
record of 24 hours collected from maternal and newborn service centre and labour
room of PMWH. Data collection will be conducted in postnatal ward A and sample
will be chosen using simple random sampling technique with lottery method in order
to reduce bias.

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 Data analysis and Statistical analysis

The collected data will be checked thoroughly and shorted out accordingly. The
collected data will be analyzed to find out the association between socio-demographic
variables with awareness on PPIUCD and association between reproductive variables
with utilization of PPIUCD. Likewise, utilization of PPIUCD at PMWH will be
explored as well as the reasons for acceptance and decline to utilize PPIUCD will also
be assessed.

Shorted Data will be entered in MS Excel program and tabulated in Statistical

Package for Social Science (SPSS) version 17+ for analysis. The collected data will
be analyzed by using descriptive statistics such as frequency, range, mean and
standard deviation. The inferential data will be analyzed by using inferential statistics
like chi square test.

Findings will be presented in tables, figures, graphs and charts.

Dummy tables are presented below:

Table 1: Socio-demographic Information

Characteristics Awareness (n%) Utilization (n%)
Yes (n%) No Accepted Declined (n%)
(n%)
Age Distribution
<19
20-29
30-39
>40
Educational Status
No formal Education
Primary
Secondary
Higher Secondary
Above
Occupation
Housewife
Business

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Employed
Religion
Hindu
Buddhist
Christian
Muslim
Other
Table 2: Reproductive Information
Characteristics Awareness (n%) Utilization (n%)
Yes (n%) No (n%) Accepted (n%) Declined (n%)
Age at First Child Birth
<19
20-29
30-39
>40
Parity
1
2
3
4
>5
Last Child Birth (years)
0-2
2-3
3-4
>5
Future Pregnancy Plan
1-2 years
3-5 years
Not sure
No intention
Table 3: Contraceptive Method Used Previously
PPIUCD PPIUCD PPIUCD PPIUCD
Method used
Aware Non-aware Accepted Declined
DMPA
OCPs

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Male Condoms
Interval IUCD
Implants
Spermicidal
agents
Natural
Never used
DMPA = Depot Medroxy Progesterone Acetate
OCPs = Oral Contraceptive Pills
IUCD= Intrauterine Contraceptive Device

Table 4: Source of Awareness

Source No or Participants Percentage (%)
Media-TV/Radio/Social
Media/Print Media
Hospital/Health care
facilities
Neighbours/Relatives

Table 5: Acceptance and Decline of PPIUCD

Total number of participants No Percentage (%)
Accepted PPIUCD
Not Accepted PPIUCD

Table 6: Reason for Acceptance of PPIUCD

Reason for Acceptance No of Participants Percentage (%)
Free
Safe

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Long term
Reversible
Fewer clinic visits
Counseling
No interference with breast
feeding
Other

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Table 7: Reason for Decline of PPIUCD
Reason for Decline No of Participants Percentage (%)
Don’t know about PPIUCD
Need to discuss about partner
Partner and family refusal
Prefer to use another method
Satisfied with previous method
Fear of side effects
Interferes with sexual
intercourse
Religious Belief
No reason

Expected Outcome

The researcher will disseminate the findings of the study either through oral
presentation or publication.

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 Etihical Consideration

Ethical Issues
An informed written choice will be given to each client based on her full
understanding of study method and purpose. An informed written consent from
participants will obtained after providing adequate information about all aspects of
study. Privacy, confidentiality and anonymity will be given the highest priority and
will be maintained throughout the study by omitting the name or any other identity of
the respondents as well as by conducting the interview separately. Obtained data will
be used for research purpose only.

Ethical clearance
To maintain ethical soundness of the study, an ethical clearance will be obtained from
National Academy of Medical Science (NAMS). An official letter from NAMS Bir
Hospital Nursing Campus will be submitted to Paropakar Maternity and Women’s
Hospital (PMWH) in order to get ethical clearance from the respective authority.

Privacy, confidentiality and anonymity will be given the highest priority and will be
maintained throughout the study by omitting the name or any other identity of the
respondents as well as by conducting the interview separately. Obtained data will be
used for research purpose only.

19
 Informed Consent Form

Namaskar, My name is Babita Shakya. I am a student of Master in Nursing from

National Academy of Medical Sciences (NAMS), Bir Hospital Nursing Campus,
Gaushala, Kathmandu. I need your help to accomplish a research on “Awareness and
Utilization of Postpartum Intra Uterine Device among Postnatal Mothers”. This
research study is being conducted as a partial fulfillment of the requirement of Master
of Nursing Program and it has been approved by Institutional Review Board of
National Academy of Medical Sciences and Paropakar Maternity and Women's
Hospital.

Optimum privacy will be maintained and your identities will not be disclosed and all
the information gathered will be used only for this study purpose. I need your 10-15
minutes time for this task. You can answer only those questions which you feel
comfortable and you have full right not to answer particular question as well as
withdraw from this study at any time.

I request you to participate in this study by responding my questions.

Consent:

I …………………………………………….. have read/ have been told about the

contents of this form. I am clear and fully understand the content of this consent form
explained/written in it. I do not have any objection to use information gathered from
me. I have been guaranteed that my identity would not be disclosed at any point.

Hence, I give my permission to include me as the participant in this research study.

------------------------------
Participant’s signature
-------------------------------- Right Left
Investigator’s Signature
Date:
Code no: ……………………………..

20
Time Table

21
 Budget

Category Cost

Personnel Cost: Statistician 1x5daysx1000= Rs.5,000/-

Institutional Charge Rs.5,000/-

Translator cost Rs.5,000/-

Communication cost (Telephone) Rs. 2,000/-

Dissemination- Rs. 5,000/-

Stationary: Rs. 1,000/-

Photocopy: Rs. Rs 3/page x500 pages= Rs.1,500/-

Printing: Rs. Rs 5/pagex1000 pages= Rs.5,000 /-

Refreshment: Rs.50/day x 105days= Rs 5,250/-

Travel Expenses: Rs.40x 105days= Rs.4,200 /-

Total = Rs. 38,950/-

Contingency 5% : Rs.1,947/50

Grand Total= Rs.40,897/50

22
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Ali, R. A. M. (2012). Acceptability and Safety of Postpartum Intrauterine

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