Components of contraceptive counselling postpartum women receive during antenatal and postnatal health care services: A qualitative approach

Contraceptive counselling is seen as a major part of public health care, maternal and child health care. Therefore, antenatal and postnatal periods are regarded as the appropriate opportunities for women to receive education on contraceptives. However, not much attention has been given to the contents, materials used and frequency of the contraceptive education women receive as this is critical in understanding the contraceptive behaviour of these women. Against this backdrop, this study explores the components of contraceptive counselling postpartum women receive when they attend antenatal and postnatal health care services in order to provide insights into the various contraceptive counselling given to postpartum women who attend antenatal and postnatal clinics. The study uses exploratory methodological approaches, where qualitative data were collected through individual in-depth interviews. Thirty women of the age 20-35 years attending antenatal and postnatal clinics were interviewed at the University of Ghana Hospital and Achimota Hospital. The analysis shows that women were counselled on the direct and indirect benefits of contraceptive uses, the various types of contraceptives and duration of use. The study further found the use of teaching materials such as audio visuals and leaflets during counselling sessions. However, less education was provided on the possible side effects of using contraceptives. The study therefore recommends continuous education on the benefits of contraceptives as well as possible side effects of these contraceptives to achieve higher contraceptive use.

Introduction

Counselling in general and contraceptive counselling, in particular, is often seen as a major part of public health care as well as maternal health care. The impact of these counselling sessions on health care utilisation is varied [1,2]. During counselling sessions, education is given on issues ranging from breastfeeding, personal hygiene, nutrition, birth spacing, method use, vaccination and immunization and the counselling normally lasts for 30 to 45 minutes.

The prenatal and postnatal period is often regarded as the appropriate period for women to receive contraceptive counselling because these periods are highly associated with women frequently contacting the health systems [3]. Further, offering contraceptive counselling during these periods is vital because pregnancy and child birth may influence a woman’s preference for contraception [4]. Furthermore, one of the essences of offering contraceptive counselling during postpartum period is to ensure that postpartum women have some level of understanding of the safety, efficiency and possible side effects of these methods of contraception. Also, contraceptive counselling has resulted in an increase in the intention and actual use of contraceptives [5-10]. Thus, antenatal and postnatal period creates a good opportunity to women and health providers not only to discuss the importance of contraception during postpartum but the implications for its use [11].

The effective provision of contraceptive services has been considered as one of the means through which the rates of unplanned pregnancies can be reduced and prevent induced abortion [8,12,13]. However, there are still uncertainties with regard to the timing and the content of the counselling session [5,14]. There are also uncertainties regarding whether the provision of contraceptive counselling during antenatal care is a good health intervention. Again, contraceptive counselling during the provision of antenatal and postnatal health care service suggests that, it is an important part of maternal health and contributes significantly to maternal wellbeing. However, not much attention has been given to the contents, materials use and frequency of the contraceptives education that women receive as this is critical in understanding the contraceptive behaviour of these women. On this backdrop of information, the aim of this study is to explore the components (contents, materials and frequency) of contraceptive counselling postpartum women receive during antenatal and postnatal health care services. This study will contribute to knowledge by providing insights into the various contraceptive counselling given to postpartum women who attend antenatal and postnatal clinics.

Method

Study design

The study used an exploratory design. Data were collected through the use of semi-structured interviews between June and August, 2017 in order to give respondents the chance to express their opinion to reach a deeper understanding of the subject matter [15].

Study settings

The study used two hospital settings for the qualitative data collection, specifically their antenatal and postnatal care units. The two hospitals selected the University of Ghana Hospital, Legon and Achimota Hospital, all located in the Greater Accra region of Ghana. The choice of these two hospitals settings was informed by the following: hospitals have well-organized antenatal and postnatal units, have a good record of antenatal and postnatal health care service utilisation, provide regular counselling sessions on contraceptives, family planning, personal hygiene, child care and nutrition and are easy to reach from the University of Ghana by the researcher (convenience sampling). For instance, University Hospital is located 2.5 kilometers from the University of Ghana and Achimota Hospital is 9.8 kilometers from University of Ghana.

Participants

Thirty participants were recruited from the two hospitals. This comprised nine women who used antenatal health care services only, six women who accessed only postnatal health care services and fifteen women who utilised both antenatal and postnatal health care services. These thirty participants were aged 20-35 years. Three categories of respondents were selected and these are as follows: only antenatal health care services users, only postnatal health care services users and users of both antenatal and postnatal health care services. Furthermore, the criteria for selecting participants using antenatal health care are: must be within the reproductive age of 15-49 years, must be in their last trimester of pregnancy, must have at least a child and should have attended antenatal for at least four times. Again, the study used the following criteria for selecting postnatal health care service users: must be within the reproductive age of 15-49 years, must be regular users of postnatal health care services, at least three visits and must have at least a child.

Ethical considerations

Ethics Review Committee (ERC) of the Ghana Health Service (GHS) approved the study with the reference number ‘GHS-ERC: 01/01/2017’. Authorisation and administrative clearance was further obtained from the authorities of the two selected hospitals (University of Ghana Hospital, Legon and Achimota Hospital). Also, written informed consent was obtained from the participants. The informed consent covers issues on the purpose of the study, confidentiality, benefits and possible risks associated with the study and voluntary participation.

Data collection

Data were collected in 2017. The interview structured questions on social and demographic data; this was followed by a semi-structured interview guide with open-ended questions. The main questions were: During any of your antenatal visits and/or postnatal visit, did a doctor, nurse or other health care worker talk to about contraception? What are the modes through which you receive contraceptive information during antenatal and/or postnatal visit? Have you been receiving contraceptive information anytime you go for antenatal clinics? If yes, how many times did you receive this information? Information was also collected on participants’ age, their educational level, their partner’s educational level, the number of children they have (parity), their religious affiliation and their ethnic background. All interviews were done in the English language and were tape-recorded after seeking permission from the participants and transcribed verbatim. Again, each interview lasted 20 - 30 minutes.

Data analysis

The collection and analysis of the data proceeded simultaneously for participants until meaning saturation was achieved [15]. Data were analysed using qualitative analytical software, called the Nvivo. However, the analysis at the initial stage comprises repeatedly reading through the interview transcripts and identifying new themes. To prevent forgetting vital details, transcription was done after the day’s interview. Again, thematic analysis was used in analysing the data. Data were analysed and presented in themes at three levels as global themes, organizing themes and basic themes [16]. The global themes are the first level of themes that encapsulate all perspectives under the subject matter (contraceptive counselling). The organization themes are the second level theme that summarizes underlining perspectives into two or more extracted text quotes from the transcripts and also reveals different views about the global theme. The basic themes are the third level themes that are captured as the extracted quotes from the transcripts.

Results

The results were presented in four sections. We began by illustrating the socio-demographic characteristics of the respondents as presented in table 1. Subsequently, the results have been presented as: a) contents of contraceptive information given during antenatal and postnatal health care service delivery; b) material used during contraceptive counselling at antenatal and postnatal clinics; and c) frequency of contraceptive counselling during antenatal and postnatal health care service delivery.

Components of contraceptive counselling

This section discusses the various components of contraceptive counselling that users of antenatal and postnatal health care service receive. The themes investigated were: contents of the counselling, frequency of contraceptive counselling and materials used during counselling sessions.

Contents of contraceptive counselling

The contents of contraceptive counselling basically cover what is contained in the contraceptive/ family planning messages and advice given to pregnant and postpartum women during antenatal and postnatal health care delivery. Relating to the theme on contents of contraceptive counselling, nine contents were mentioned by the participants both at the antenatal and postnatal health care units. These were ‘prevention of unplanned pregnancy’– which was mentioned by ten participants (four from the antenatal unit and six from the postnatal unit); ‘prevents STIs’–mentioned by three participants (two from the antenatal unit and one from the postnatal unit). The other contents mentioned were long-acting and short-acting contraceptive methods, good child spacing and child care practices, ensuring good maternal health and reducing the risk of short pregnancy intervals.

Further, prevention of unplanned pregnancy and the reduction of risk associated with short pregnancy intervals were the dominant basic themes identified in the analysis. The participants indicated that they were counselled that using contraceptives after birth will help prevent any unwanted/unplanned pregnancy. Others also mentioned that they were told that getting pregnant in quick succession is dangerous and using contraceptives is a sure way to avoiding that risk. During the interview, some participants stated the information they received when they were given counselling on contraception.

“Oooh, errr they tell us that using contraceptive is good and it will help us to avoid unwanted pregnancies and problems that come with pregnancies” (User 11- both antenatal and postnatal health care services).

“What they tell us is to do family planning; they tell us to take care of yourself to avoid unwanted pregnancy and some measures you should take to avoid unplanned pregnancies” (User 7- only antenatal health care services).

“When we use them [contraceptives] it helps us to prevent unwanted pregnancy and it is good for our health” (User 3- only postnatal health care services).

“I remember they said condom can prevent both pregnancy and STI and pills can only prevent pregnancy” (User 6- both antenatal and postnatal health care services).

Another content of contraceptive counselling that was mentioned was long acting and short acting methods of modern contraception. During the in-depth interviews, the respondents mentioned various types of modern contraceptives that were usually discussed with them during contraceptive sessions. They mentioned that counsellors talked to them about condoms, intrauterine device (IUD), pills, injectables, implants, female sterilization, and norplants. They also stated that education is given on how to use these contraceptive methods and the duration of use. The following quotes from the qualitative interviews tend support to this:

“We have different types, some are injectables, others are inserted into your private part and in your arm and we also have condoms. They also talk to us about the jadelle, and the pill. I also know we have some methods you can use for 6 months and others for 5 years” (User 4- only antenatal health care services).

“Eiiii, mmmm, she told us about condoms, the pill, and the one that you take injections and also the one they will put into our private part and arm. She also said you can use some of them for long period like 6 months to 2 years, and others too for a short period like 2 months, that is all I can remember” (User 15- both antenatal and postnatal health care services).

The third content found during the interview was good child spacing and child care practices. The respondents reported that they were told using contraceptives ensures good spacing of children since they are not likely to get pregnant soon after birth. They also mentioned that you have enough time to take good and proper care of your child since you don’t have to worry about pregnancy again.

“They tell us we will have time to take care of our babies because we don’t have to worry about pregnancy” (User 2- only postnatal health care services).

“They educate us on contraceptives. It helps us and we will know how to at least space the children” (User 9- only antenatal health care services).

“Yes, so that after birth, you can space your child, and you will have knowledge about not giving birth to unplanned children” (User 5- only antenatal health care services).

The other contents of contraceptive counselling identified were prevention of sexually transmitted infections (STIs), ensuring good maternal and child health. Some respondents noted that the counsellors stressed the importance of using contraceptives to prevent the risk of getting infected with sexually transmitted infections and also indirectly to ensure both mother and child are healthy.

“They tell us about the contraceptives that it helps prevent STIs, and to delay the pregnancy and is good for the health of the mother and the babies” (User 12- both antenatal and postnatal health care services).

“I also remember they told us that some contraceptives help in preventing sexually transmitted infection” (User 2- both antenatal and postnatal health care services).

“They tell us it [contraceptives] is good for our health and make our babies too healthy, it can make your baby grow healthy, and you have time for your baby” (User 4- only postnatal health care services).

Frequency of contraceptive counselling

With regard to the theme on the frequency of contraceptive counselling during antenatal and postnatal health care service delivery, three basic themes were mentioned by the respondents. These were ‘rarely’, ‘sometimes’ and ‘very often’. That is, the number of times women have received contraceptive counselling from their previous to their current antenatal and postnatal health care use. It is also important to note that contraceptive counselling is done in group sessions during the provision of antenatal and postnatal health care services. Further, this contraceptive counselling session is not done in isolation but along with other sessions such as nutrition, personal hygiene and pregnancy and child care practices. Women who mentioned that they received contraceptive counselling “rarely” during antenatal and postnatal visits was one of the basic themes identified. This means that they have received contraceptive education only once in their antenatal and postnatal health care use. They said that the midwife had told them about things other than contraception. This theme appeared in three narratives of the in-depth interviews conducted.

“Oooh no, I don’t, sometimes when I come for antenatal they talk to us about other things like the things we will go through during pregnancy and how to deal with them, it is not every time that they talk to us about contraceptives” (User 8- only antenatal health care services).

“Oooh no, like I said before, only once and it was an NGO which came and talked to us about it” (User 1- only antenatal health care services).

“Mmmm, they talked to us about it only once as far as I can remember” (User 1- postnatal health care services).

The second theme identified is women who mentioned they received contraceptive information “sometimes”. This involves women receiving education on contraceptive two times during their visit to antenatal and postnatal health centres; however they said that they need more education on contraceptives. This was the most dominant basic theme which appeared in nine narratives of the interview.

“Errrh, no please, but I remember during my first pregnancy and I came for antenatal, they talked to us two times” (User 3- only antenatal health care services).

“Oooh, since I started coming here, this is the second time they talk to us about it, but I think they have to talked to us more about it” (User 5- only post natal health care services).

“Oooh, since I came here for check-ups, this is the second time they have talked to us about it” (User 6- only postnatal health care services).

Another theme found in the analysis is women who indicated that they receive contraceptive information “very often” any time they utilise antenatal and postnatal health care services. Thus, women said that they received contraceptive advice from midwives three or more times during their visit to antenatal and postnatal health centres.

“Every time I come to antenatal they talk to us about it” (User 9- only antenatal health care services).

“Errr, this is the third time, they talk about it, sometimes when we come here, they only talk about the food we have to eat, how to take care of ourselves and the other things” (User 12- both antenatal and postnatal health care services)

“Mmmm, this is the third time they have talked to us about it” (User 8- both antenatal and postnatal health care services).

Materials used during contraceptive counselling

Concerning the theme on materials used to educate women on contraceptives during antenatal and postnatal health care service provision, four basic themes were identified in the analysis. These are ‘leaflets’, ‘papers and documents, ‘pictures’ and ‘no materials’. Most of the women reported that no materials were specifically used when providing them with information on contraceptives. In other words, the respondents mentioned that during contraceptive counselling sessions, the midwives/counsellors do not use any materials when educating them on contraceptives. They just give them group talks on family planning without referring to any books and documents.

“Errr, they did not use any books, the nurse just comes and talks to us, and when we don’t understand anything we ask questions” (User 10- both antenatal and postnatal health care services).

“They just talk to us; they did not use any materials in educating us about contraceptives” (User 3- only antenatal health care services).

Others also said that during the group session on contraceptives, the midwives usually show them pictures of the various types of modern contraceptives and how they are used. Thus, pictures of methods like the pill, injectables, IUD, female sterilisation, condoms, and implants are shown to them during counselling sessions as well as how to effectively use them. They, however, mentioned that the pictures are not always used during contraceptive counselling sessions.

“Errrh, I remember they showed us some pictures of contraceptive methods, but at other times they use nothing, they just talk to us” (User 5- only antenatal health care services).

“Errrh, sometimes they show us pictures and at other times they use nothing, they just talk to us” (User 7- only antenatal health care services).

“Mmmm, she has shown us some pictures of the family planning and how we can use it, yes she shows us pictures” (User 3- only postnatal health care services).

Another basic theme under materials used during contraceptive counselling sessions at antenatal and postnatal health centres is the use of leaflets/fliers. This was mentioned by only one respondent during the in-depth interview. This happened when a non-governmental organisation came and talked to them about contraceptives and shared leaflets/fliers to them to read. This suggests that during contraceptive group counselling sessions at antenatal and postnatal health centres, leaflets/fliers are not often used in educating women on contraception.

“Oooh, the people who came to educate us were from an NGO, they brought some materials with the methods and their pictures, I even have it in my bag [Respondent shows interviewer the material-leaflet/flier,]” (User 9-both antenatal and postnatal health care services).

Last but not least is the use of papers and documents as materials for contraceptive counselling during antenatal and postnatal health care provision. The respondents mentioned that sometimes midwives/nurses use papers and other documents when talking to them about contraceptives. Thus, the papers serve as a guide to them in educating them on contraceptives.

“They only hold documents and papers when teaching us about contraceptives” (User 13- both antenatal and postnatal health care services).

“They only hold a book when they talk to us about it [contraceptives]” (User 14- both antenatal and postnatal health care services).

Discussion

The content of contraceptive counselling antenatal and postnatal health care users receive includes but not limited to types of modern contraceptives, duration of use and benefits of contraceptives. For instance, respondents mentioned both long-and short-acting methods such as the pill, IUD, condoms, injectables, female sterilisation and implants. They also said that the purpose and the effectiveness of these modern contraceptive methods were discussed with them by midwives during group counselling sessions. This probably suggests that counselling pregnant and postpartum women on the various types of contraceptive methods is essential for making good reproductive health decision and increasing control over their sexual and reproductive health. This helps these women to build on their existing knowledge on types of contraceptive methods, the specific purpose they serve and their efficacy. It also offers them the opportunity to ask questions and seek clarification on some misconceptions they might have concerning the method types. Again, group counselling on types of contraceptive methods offer women the opportunity to share experiences and learn from others’ experiences as far as contraception is concerned.

Duration of contraceptive use was another content of the counselling they received when using the maternal health care services. They mentioned that some contraceptive methods can be used for a long periods of time for example two years, while other methods can be used for a short period for example two months. It was revealed from the interviews that these contraceptive counselling sessions do not take place very often. The women mentioned that they receive much more education in other modules (personal hygiene, best child care practices, nutrition and pregnancy care precaution) when they use antenatal and postnatal health care services relative to education on contraception. It is important to note that receiving counselling on the duration of efficacy of contraceptive methods is critical in women deciding to limit births, stop child bearing and other fertility decisions. Studies have indicated that duration of a method use largely influences the family planning and sexual and reproductive health decisions women take [17-19]. For instance, a study in Bangladesh found that women chose the norplant contraceptive method because of its longer duration (5 years) of use and effectiveness it has [18]. Another study in Indonesia, also established that women opted for long-acting methods like the norplants after they have received counselling on the methods and were more satisfied with the method [17].

Further, the direct and indirect benefits of contraceptive use were part of the counselling they received. These benefits positively affect the health of the newborns and their mothers by ensuring good child spacing, reduce risk of short pregnancy intervals, prevents unplanned pregnancies, prevents risk of contracting sexually transmitted infections as well as ensuring good maternal and child health. Other studies have highlighted the importance of giving family planning counselling to women during pregnancy and postpartum periods [10,20,21]. A study in Sri Lanka indicated that during antenatal health care use, midwives and other health personnel educate pregnant women on risks and benefits of using contraceptives after birth [10]. Again, an in-depth interview conducted in Switzerland revealed that the general benefits of contraception, according to the respondents were spacing births, avoiding unplanned pregnancy and protection from sexually transmitted infections [20]. The findings in this study support the assertions and outcomes from these other studies that have been described above. It must, however, be pointed out that, the respondents did not mention any form of risk/side effects of contraceptives as part of the counselling they receive during antenatal and postnatal health care use.

Another important outcome from the interview is the kinds of materials midwives/counsellors use during group counselling sessions. The dominant issue that emerged from the interview (for both antenatal and postnatal health care users) was the fact that during the group sessions on contraception, most of the midwives/counsellors do not use any form of materials as reference. However, pictures and info-graphics of various modern contraceptive methods are sometimes showed to them during these group sessions. Studies on contraceptive counselling have established that using materials such as counselling guide/manual, flipcharts, leaflets, drawing, audio, visuals, and info-graphics determines the quality of counselling clients receive [22-25]. These studies have argued that the use of these materials as part of the counselling process has some merit in ensuring the provision of quality contraceptive counselling. Thus, it allows clients to visualise and hear the contraceptive information in order to make informed decisions that meet their sexual and reproductive health needs. The use of materials during counselling also enables clients to receive well organised information on the efficacy, use and possible risk of the contraceptive methods. This study, however, found that most of the counselling sessions lacked the use of relevant materials. This seems to suggest that the provision of effective counselling on contraception during antenatal and postnatal health care might be undermined. This may also negatively affect how these women understand contraceptives and how to effectively use them.

Conclusion

The qualitative results of this study have provided insight into the contraceptive counselling (The contents, the frequency and the materials used) postpartum women receive during antenatal and postnatal health care attendance. More specifically, the study findings indicated that women are educated on the direct and indirect benefits of using modern contraceptives, the number of times women receive counselling as well as the materials used during antenatal and postnatal health care use. Thus, policies and programmes that will encourage women to be in regular contact with the health care delivery system to be well informed and educated on contraception as well as increase their use of contraceptives should be implemented. More structural programmes should be put in place to ensure that more time is allocated to contraceptive counselling during antenatal and postnatal health care delivery. This is important for women to have better understanding of the efficacy, effectiveness, benefits and possible side effects of using modern contraceptives. This recommendation is necessary because the study results show that contraceptive counselling is not offered very often during antenatal and postnatal health care service delivery.

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