Introduction

Globally, 121 million unintended pregnancies occurred at an annual rate of 64/1000 women [1]. This rate is higher in sub-Saharan Africa 99 per1000 pregnancy and in Ethiopia, 100 per1000 were unintended [2]. Met demand for family planning is one of the indicators in measuring the attainment of Sustainable Development Goal five and a strategy for reducing maternal, infant, and child mortalities by reducing unintended pregnancy [3]. Long-acting reversible contraception and comprehensive contraceptive counseling increase accessibility, have a high continuation rate, and provide greater protection against unintended pregnancy [4, 5]. Intrauterine devices (IUDs) are long-acting reversible contraceptive (LARC) family planning methods in which a couple uses them to limit or space the number of children they want to have through the use of contraceptive methods.

Immediate post-partum intrauterine contraceptive device (IPPIUCD) placement within 10 min after the expulsion of the placenta up to 48 h after delivery is a prevailing strategy that prevents unintended pregnancy with a high continuation rate [6]. Placement of the IPPIUCD is preferred because it does not interfere with breastfeeding and in addition breastfeeding can reduce early removal of IUCD as it reduces bleeding and pain [7, 8]. A short birth interval will be alleviated by using IPPIUD placement [9]. Women who may not return for the postpartum visit [10] and resume sex without using contraception [11], benefit from IPPIUCD. More than half of mothers resume sexual intercourse before 6 weeks postpartum [12, 13]. This is due to the low perception of the risk of pregnancy [12].

Acceptance is important for the utilization of any effective method of family planning. Acceptance and utilization of IPPIUD were higher for those mothers who had third-trimester visits [14]. Counseling is one of the tools to increase the acceptance of IPPIUCD [15]. Counseling about PPIUCD during antenatal care (ANC), spousal approval, having more than one child, and short-interval pregnancy favored the use of IPPIUCD [15]. In Ethiopia, despite several advantages and high effectiveness among the long-acting reversible contraceptives and existing additional opportunities from the increasing rate of institutional delivery for utilization of IPPIUCD, it utilization remains very low at 2% [16, 17]. The acceptance and utilization of IPPIUCD's in Ethiopia, particularly in the study area, is insufficient. Thus, this study aimed to assess the acceptance, utilization, and contributing factors of immediate post-partum IUCD among mothers coming for delivery service in Hawassa city.

Materials and methods

Study design, period, and setting

A facility-based cross-sectional study was carried out from January 1st to February 31st of 2020 in Hawassa City which is located 275 km south of Addis Ababa (the capital city of Ethiopia) on the Trans-African Highway 4 Cairo-Cape Town. Hawassa City is serving as the capital city of both Sidama regional state and southern nation national people regional (SNNPR). In Ethiopia including Hawassa city, all family planning methods and counseling services are offered for free. There are 12 public health facilities that provide delivery service in the city.

Study population

All postnatal mothers who gave birth at public health facilities of Hawassa city were considered as the source population while postnatal mothers who gave birth at selected public health facilities of Hawassa city during the study period were considered as the study population.

Eligibility criteria

Postnatal mothers who gave birth at immediate PPIUCD providing public health facilities of Hawassa city during the study period and residing for six months in Hawassa City were included. Mothers who were in poor health condition and did not fulfill the world health organization medical eligibility criteria for IUCD insertion were excluded.

Sample size calculation

The sample size (n) required for this study was determined using single population proportion formula (n = (Zα/2)2 p (1 − p)/d2)) by considering the following assumptions; the proportion of women who accepted post-partum IUCD use as 38% (p = 0.38) taken from a study conducted at Sidama zone health facilities [18], Za/2 = 1.96 (significance level at α = 0.05 with 95% confidence interval) and margin of error to be 5%. Adding a 10% non-response rate. Thus, a total of 398 sample sizes was obtained.

Sampling procedure

From all IPPIUCD service providing health facilities in Hawassa City, two hospitals (Hawassa comprehensive referral hospital and Adare general hospital) and three health centers (Adare, Millennium, and Alamura) were selected randomly. Then, the calculated minimum sample size was allotted by proportionate allocation based on a one-year delivery report, after calculating the average estimated monthly delivery in each health facility. Accordingly, a sample of 169, 168, 17, 26, and 18 were allocated for Hawassa comprehensive specialized hospital, Adare general hospital, Adare health center, Millennium health center, and Alamura health centers, respectively. Study participants were selected consecutively from each randomly selected health facility by considering their order of attendance at the delivery service to be random.

Study variables

Acceptance and utilization of immediate postpartum intrauterine contraceptive device were a dependent variable, while socio-demographic characteristics (age, marital status, place of residence, educational status, occupational status, husband occupational status, husband educational status, religion, and average monthly family income), reproductive health-related characteristics (gestational age, number of children, birth interval, birth plan for other children, future number of children, resumption of sexual and menstrual period following previous delivery), family planning related characteristics (counseling about IPPIUCD, use of F/P in the past, decision for modern contraception, and husband support to use family planning), health service utilization (ANC follow up, mode of delivery, types of delivery), and cognitive related factors (level of knowledge and attitude towards the use of PPIUCD) were independent variables of the study.

Operational definition

Acceptance of IPP IUCD

Woman’s verbal consent to use IUCD within 10 min to 48 h of delivery of placenta during the counseling of PPIUCD [19].

Utilization of IPPIUCD

Women who accepted PPIUD as a method of family planning and had actual PPIUCD insertion after the post-placental period or before they were discharged from the health facilities [18].

Knowledge

In this study, knowledge about immediate PPIUCD was measured by calculating the mean score of eight knowledge-related items and classifying them as good knowledge if the mother responded correctly greater than or equal to the mean score of knowledge questions or poor knowledge if the woman responded correctly less than the mean score of knowledge questions.

Attitude

In this study, attitude towards immediate PPIUCD use was measured by calculating the mean score of five attitude-related items and classifying them as positive attitude if the woman responded correctly greater than or equal to the mean score of attitude questions or negative attitude if the woman responded correctly less than to the mean score of attitude questions.

Data collection technique and quality

The data were collected using a face-to-face interview technique with a pre-tested structured questionnaire. The questionnaire was developed after reviewing different literatures [12, 13, 18,19,20]. Initially, the questionnaire was prepared in English and translated into Amharic by an expert, then back to English to check its consistency. Data were collected by five trained midwifery nurses in the postnatal room before discharge. During data collection, every collected questionnaire was checked daily by supervisors and investigators for completeness and consistency.

Data management and analysis

The collected data were entered checked its validity using EPI-Data version 7.2 and exported to STATA version14 software for editing, cleaning and analysis. Descriptive statistics were used to describe the characteristics of the study respondents by using means and standard deviations for numerical variables, frequencies along with percentages for categorical variables, tables and graphs. Bivariable and multivariable logistic regression analyses were used to identify influencing factors affecting the acceptance and utilization of IPPIUD. All explanatory variables in bivariable analysis with a p-value of less than 0.25 (p-value < 0.25) were selected as candidate variables for multivariable logistic regression analysis. The crude and adjusted odd ratios together with their corresponding 95% confidence interval were computed and interpreted accordingly. In the final model, the adjusted odds ratio (AOR) with their corresponding 95% confidence interval at a p-value of < 0.05 was used to declare a significant association. Hosmer–Lemeshow test was used to compare and rule out the goodness of fit of the models and it was non-significant. A multicollinearity test was conducted among independent variables and it was found not a problem.

Results

A total of 392 respondents were participated in this study yielding a response rate of 98.5%. the main reason for non-response was due to incomplete data on filled questionnaires and refusals of respondents to take part in our study.

Socio-demographic characteristics of mothers

The majority of the respondents 142 (36.2%) were within the age group of 20–25 years, with the mean (± SD) age of 25.18 (± 4.56) years. Most of the respondents 382 (97.9%) and 364 (92.9%) were married and urban dwellers, respectively. Half of the respondents were Protestant 223(56.9%) followed by Orthodox Christians 103 (26.3%) by their religion. Regarding their occupational status, 211 (54%) of respondents were housewives while 77 (17.6) were government employees. Of the total respondents, 148(38%) of them completed primary level of education while 141 (36.0%) of their husbands completed college and above level of education. Furthermore, 119 (30.4%) of their husbands were private employees by their occupational status (Table 1).

Table 1 Socio-demographic and economic characteristics among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020
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Reproductive health-related characteristics of mothers

The mean (± SD) number of living children was 1.77 (± 0.71) per respondent. One hundred eighty-four (46.9%) respondents had one to two children before this delivery while 150 (38.3%) of the hadn’t child. Birth intervals of more than three years were reported by 119 (30.4) respondents. Nearly half, (45.7%) of the respondents had the desire to have four children in the future and 237(67.7%) of respondents had a future birth plan after three years. Of all respondents who had an experience of delivery, 170 (72.6%) and 119 (51.1%) of them had sexual and menstrual resumption after 45 days of their previous delivery, respectively (Table 2).

Table 2 Reproductive health characteristics among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020
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Family planning-related characteristics of mothers

Of the total respondents, 312 (79.6%) had ever heard about IUCD. The majority of 241 (61.5%) respondents received counseling about IPPIUCD, of whom 160 (66.4%) were counseled during antenatal care (ANC). Most of the respondents 264 (67.7%) used family planning at any time in the past, of them 254 (96.2%) used it before to the current pregnancy. Two hundred one (58%) of respondents decided about modern contraception use with their husbands while 234 (60.9%) of respondents had partner support to use family planning (Table 3).

Table 3 Family planning-related history among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020
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Knowledge and attitude of mothers towards immediate PPIUCD usage

The knowledge mean score of the respondents was 2.6 (± 1.6) SD. About three fourth of respondents (74.7%) had poor knowledge about immediate PPIUCD. Regarding the attitude of mothers toward immediate PPIUCD use, 320 (81.6%) of them had a negative attitude (Fig. 1).

Fig. 1
figure 1

Level of knowledge and attitude towards immediate PPIUCD among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020

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Health service utilization-related characteristics of mothers

Of the 377 responders, antenatal care attendance was reported by the majority (96.2%), 198 (52.5%) of whom had their fourth ANC visit. Relating to the mode of delivery, about 259 (66.1%) of respondents were delivered through spontaneous vaginal delivery. During the study period, one out of ten current deliveries were unplanned (Table 4).

Table 4 Health service utilization among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020
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Acceptance and utilization of an immediate PPIUCD

The overall acceptance of immediate postpartum IUCD as a family planning method was found to be 16.4% (95% CI: 12.8, 20.2) while only 10.0% (95% CI: 7.0, 12.9) of respondents utilized immediate postpartum IUCD as a family planning method (Fig. 2).

Fig. 2
figure 2

Acceptance and utilization of IPPIUCD among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020

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Reasons for not using immediate postpartum IUCD

According to the results of this study, the main reason cited for rejecting immediate postpartum IUCD was a preference for another FP method 118 (36%) followed by lack of counseling 108 (32.9) while 19 (5.8%) of women have no reason (Fig. 3).

Fig. 3
figure 3

Reason for rejecting IPPIUCD among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020. NB Other; menstrual disturbance, husband refusal, No access

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Factors associated with acceptance and utilization of immediate post-partum IUCD

The assumptions of logistic regression were checked before conducting a regression analysis. In bivariable logistic regression analysis, seven variables with a p-value of less than 0.25 became eligible for multivariable logistic regression. After controlling for possible confounders in multivariable logistic regression (birth interval, plan to have another child, counseling about IPPIUCD, and attitude towards IUCD) were found to be associated with acceptance of immediate post-partum IUCD.

Accordingly, mothers having less than two years of birth interval increase the odds of acceptance for IPPIUCD by 2.7 times compared with mothers having three or more years of interval (AOR = 2.71; 95% CI (1.09, 6.72). Mothers with a plan to have another child were more than three times more likely to accept IPPIUCD (AOR = 3.32; 95% CI (1.45, 7.59) than mothers who did not have the plan to have another child. The likelihood of accepting IPPIUCD among mothers counseled about it was 3.79 times higher than among mothers not counseled about it (AOR = 3.79; 95% CI (1.67, 8.55), compared to their counterparts. Similarly, the odds of accepting IPPIUCD among mothers having a favorable attitude toward IUCD were six times higher than those of mothers with an unfavorable attitude toward IUCD (AOR = 6.43; 95% CI (3.26, 12.68) (Table 5).

Table 5 Factors associated with acceptance of immediate PPIUCD among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020
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Furthermore, in this study, husband support for family planning use, delivery time, and number of children had significant associations with the utilization of IPPIUCD. Accordingly, mothers who had husband support for family planning use were 3.28 times more likely to utilize IPPIUCD (AOR = 3.28; 95% CI (1.28, 8.41)) than their counterparts. Having delivery during the day increases the odds of utilizing IPPIUCD by 2.25 times (AOR = 2.25; 95% CI (1.06, 4.80) compared with mothers delivering during the night. Similarly, mothers who have more than three children are four times more likely to utilize IPPIUCD (AOR = 4.47; 95% CI (1.43, 13.91)) than those mothers with no children before this birth (Table 6).

Table 6 Factors associated with utilization of immediate PPIUCD among mothers delivered at public health facilities in Hawassa city, Ethiopia, 2020
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Discussion

Immediate postpartum IUCD use is an important approach to avoid unintended pregnancy and improve birth spacing. Hence, this study aimed to assess acceptance, utilization, and factors associated with immediate postpartum intrauterine contraceptive devices among mothers delivered at public health facilities in Hawassa city.

In this study, acceptance of immediate post-partum IUCD was found to be 16.4%. This finding is in line with previous studies conducted in Kenya [21] and the Bale Zone of Ethiopia [19], which reported magnitudes of 12% and 12.4%, respectively. This finding was also found to be low as compared to the studies done in India [22], Egypt [23], Rwanda [24], the Gamo Zone [25], and Sidama Zone [18], which reported acceptance rates of 36%, 28.9%, 67.8%, 35.6%, and 38.1%, respectively. The possible justification could be due to the difference in sample size and level of awareness among mothers. However, this finding was higher than the magnitude of acceptance reported in India [26] which was 8.6%. The possible reason might be due to differences in the study setting and interview period, as most of the women in India were interviewed in the antenatal period.

Results from this study provide an important understanding of the associated risk factors of acceptance of immediate PPIUCD. Accordingly, counseling about IPPIUCD, attitude towards PPIUCD usage, plan to have another child, and birth interval emerged as being independently associated with acceptance of immediate PPIUCD.

According to the current study, mothers who received IPPIUCD counseling had a four times higher likelihood of accepting IPPIUD than mothers who did not. This association was in agreement with a previous study conducted in four countries (India, Nepal, Sri Lanka, and Tanzania) [15], Indonesia [27], India [28], and Gamo Zone, Ethiopia [25]. The possible reason might be that counseling may increase knowledge about PPIUCD and improve the decision-making power of mothers. Supporting evidence is also shown by a study conducted in Pakistan [29] and Rwanda [4], where counseling for mothers during prenatal visits increased the awareness of mothers regarding the PPIUCD. It could also be explained during counseling, when health care providers may clarify misconceptions about PPIUCD and motivate the women to accept PPIUCD immediately after delivery.

The present study indicated that mothers with favorable attitudes were six times more likely to accept IPPIUCD compared with mothers with an unfavorable attitude. This goes with the previous evidence from Nepal [30] and Mekelle City, Ethiopia [31] that reported supportive attitudes as predictors of the acceptability of IUCD. This might be due to having a favorable attitude that may shape the mother's intention for postpartum IUCD willingness.

This study also showed that mothers having a birth interval of below 24 months increase the odds of accepting immediate PPIUCD by 2.7 when compared with mothers having a birth interval of above 36 months. This association agreed with previous studies conducted in Pakistan [29] and Tanzania [32] that found a greater likelihood of post-partum IUCD acceptance if there had been less than two years since the last birth. Additionally, this finding is supported by a study conducted in Rwanda [4, 24] that reports that fear of having an early or unwanted pregnancy was a reason for acceptance of immediate PPFP in 79% of respondents. This could be because mothers who had a short birth interval might require a long-acting and reliable method of contraception to attain optimal birth spacing and nurture their children. According to this finding, it is better to give due attention to a mother with a short birth interval (below 24 months).

Furthermore, the results of this study demonstrate that mothers who do not have a plan to have another child were three times more likely to accept immediate PPIUD than mothers who had a plan to have another child. This finding is supported by a study conducted in the Sidama zone [18], which showed increased use of immediate PPIUCD in mothers who do not have the plan to have another child than in mothers who had the plan to have another child. The possible reason might be that a mother without a plan to have additional children might have enough children, need enough time to recover from the physical stress of one pregnancy before moving on to the next, and have enough time for lactation, which prompted her to accept safe and effective long-acting immediate PPIUCD.

In our study, only 10% (95% CI: 7.0, 12.9) utilized immediate postpartum IUCD as a family planning method. This finding was in line with previous studies conducted in Chamblee, USA [8], 11.7%; India [33], 9.1%; Dila Town [34], 8.2%; and as low as related to magnitudes evidenced in China [35], 14.9%, Rwanda [4], 28.1%; Addis Ababa [37], 26.6%; Gamo Zone [25], 14%; and Sidama Zone [18], 21.9%. However, it was higher than the utilization reported in Kenya [21], Debretabor, Ethiopia [39], and Gojam, Ethiopia [40], which indicated magnitudes of immediate PPIUCD utilization of 5.1%, 1.65%, and 4.02%, respectively. The possible explanation for this discrepancy is variation in the integration of family planning with maternal and child-care services, geographic, socio-demographic, and reproductive characteristics. Furthermore, husband support for family planning use, delivery time, and number of children were significantly associated with utilization of immediate PPIUCD.

This study revealed that mothers with more than three children were above four times more likely to utilize immediate PPIUCD than their counterparts. Similar findings were reported by a study conducted in China [35], Nigeria [41], Rwanda [4, 21], and other parts of Ethiopia [34, 42, 43]. The plausible justification might be due to the fact that mothers who have a large number of children may be inspired to prevent additional pregnancies to limit their family size.

Husband support to use immediate PPIUCD is another variable that remained significantly associated with immediate PPIUCD utilization. Having husband support increases the odds of immediate PPIUCD utilization by 3.28 times compared to mothers lacking husband support. This evidence is comparable with previous studies done in Ghana [44], Addis Ababa [37, 38, 45], and the Gamo Zone (45). This could be a result of the fact that most Ethiopian women do not make decisions about family planning alone. This serves as a reminder that increasing the use of immediate PPIUCD requires incorporating the husband into reproductive health services.

Furthermore, this study indicated that mothers who delivered during the day were 2.25 times more likely to utilize immediate PPIUCD than those who delivered during the night. There is no study with a similar report to support this association, so it needs further study.

Finally, since this study used a cross-sectional design, it is impossible to determine the temporal link between exposure and outcome. Moreover, since the study was carried out in public health facilities, the findings may not adequately reflect the entire population in the city.

Conclusion

We found low acceptability and utilization of immediate PPIUCD. Counseling about IPPIUCD, attitude, the plan to have another child, and birth Interval were associated with acceptance of immediate PPIUCD, while husband support for family planning use, delivery time, and number of children had a significant association with utilization of immediate PPIUCD.

A low level of acceptability and utilization of immediate PPIUCD can be reduced by routine PPIUD counseling and encouraging couple-based family planning interventions. As a result, the government needs to develop strategies to increase partner involvement in decisions made on reproductive health, family planning in particular.

Finally, determinants of utilization of IPPIUCD are complex and cannot be recognized using quantitative approach only. Therefore, we also recommend conducting of further research using comprehensive qualitative approach to unearth reasons behind the decreased level of IPPIUCD utilization.