Knowledge, Attitude and Practices of Skilled Birth Attendants towards Immediate Postpartum Family Planning Services

Background: Postpartum Family Planning (PPFP) is one of the “High Impact Practices” to reduce maternal and infant mortality in Low and Middle-Income Countries (LMICs). Health Service Providers (HSPs) need to integrate these services as a core component of maternity services. This study aims to evaluate HSPs’ “knowledge, attitude and practices” regarding immediate PPFP. Method: A descriptive, cross-sectional study carried out in ten public sector secondary and tertiary hospitals in Karachi, Pakistan. Study participants were accredited Skilled Birth Attendants (SBAs) including doctors and nurse/midwives. Results were analyzed using “Statistical Package of Social Sciences (SPSS) version 19”. Results: A total of 237 SBAs were interviewed of which 141(59%) were doctors and 96(41%) were nurses/midwives. Almost equal percentage of doctors and nurses/ midwives were knowledgeable about PPFP. Out of the total, 72% SBAs (107 doctors and 63 nurse/midwives) were presently providing PPFP service. Supportive attitude towards PPFP was shown by 79(56%) doctors and 34 (35%) nurses/midwives. Nearly 30% of SBAs had misconception that religion prohibits FP practices. Of those who were not practicing PPFP the main reasons were time constraint and fear of introducing medical complication. Interestingly 30% of nurses/midwives were not allowed by the Head of the Obstetric Units to practice these services thus missing on the available resources for task sharing. Conclusion: PPFP should be mandatory component of maternity care and ongoing efforts are required for knowledge enhancement and behavior change of HSPs. Policy changes are also needed to decrease impediments at the PPFP service delivery level. Research Article Knowledge, Attitude and Practices of Skilled Birth Attendants towards Immediate Postpartum Family Planning Services Shazia Nasim Akbani1* and Sarah Saleem2 1MSc Health Policy and Management, Lecturer College of Health Sciences, University of Bahrain,


Introduction
Globally approximately 830 women die daily from avoidable reasons associated with pregnancy and childbirth. Approximately 99% of these maternal deaths occur in Low and Middle-Income Countries (LMICs) [1]. Short interval between pregnancies is proven by evidence to be one of the important contributors to maternal mortality [2]. World Health Organization (WHO) recommends "Healthy Timing and Spacing of Pregnancies (HTSP)" which is proven to improve https://www.peertechz.com/journals/archives-of-community-medicine-and-public-health Citation: Akbani  unplanned pregnancy. Hence, provision of contraception is important at the time of delivery [6].
Promoting HTSP by providing contraception at the time of childbirth is called immediate postpartum family planning which has been acknowledged as "High Impact Practices". Despite the evidence that PPFP can prevent more than 30% of maternal deaths and 10% of deaths in children [5], globally 61% of women are not using effective contraception within 24 months postpartum [3]. Studies show that socio-cultural infl uences, misconceptions about return of fertility and breastfeeding and lack of access to contraceptive services inhibit women from PPFP [7].
Pakistan, with estimated population of around 21 million [8], is the sixth highly populated country in the world. It has a low contraceptive prevalence rate of 34% with only 25% using a modern contraceptive method and there is 17% unmet need for FP [9]. In the fi rst year postpartum only 22% couples use any contraceptive method [10], making them vulnerable to unplanned pregnancies. As a result, approximately 34% births occurring within short interval of less than 2 years (10) causing adverse maternal, fetal and infant outcomes [11].
Childbirth taking place at health facility is an opportunity to provide PPFP, but this is not regularly followed at the hospitals in Pakistan [12]. The known barriers are client's lack of awareness or apprehension of side effects and non-availability of FP services at the place of delivery (Labor room/ operation theaters) [11]. Besides these factors, Health Service Providers (HSPs) are one major infl uencing factor in FP uptake [13].
HSPs, which are "skilled birth attendants (SBAs)" conducting delivery, can act as "gate keeper" and "decision-maker" to clients' choice of attaining PPFP services. Provider's outlook may be based on their knowledge, skills, attitudes, community environment and social will [14]. The personal, social and organizational biases of these essential partners limit clients' access to these interventions [14]. To maximize the role of service providers, it is fundamental to analyze SBAs knowledge, attitude and practices as these infl uence their support to PPFP [15]. Various studies have been carried out to ascertain "how" the service providers behave towards FP, but this study was conducted to understand "why" they have a certain attitude towards these highly sought services especially in postpartum period.

Study design
A descriptive, cross-sectional survey was conducted in July-Aug 2018.

Setting and sample
The study was conducted in Karachi, a metropolitan city in Pakistan which has diverse population of around 15 million [9]. Non-probability convenience sampling was done to select hospitals and participants. Ten public sector, secondary and tertiary care facilities were selected which cater to high volume of women from low socio-economic class [16].

Data collection
Prior to data collection ethical approval was obtained by the Ethics Review Committee of Aga Khan University, Karachi, Pakistan.
Data was collected from 237 SBAs by two study research assistants using a self-administered questionnaire which was prepared in English and translated in Urdu language. It was based on the review of literature and similar studies conducted elsewhere and was pilot tested to check for understanding and clarity [17,18].
Information about the demographic characteristics of HSPs was collected. Questionnaire assessed the knowledge of HSPs, their attitude and practices related to immediate PPFP.

Statistical analysis
Descriptive analysis of data was done for all the variables using "Statistical Package of Social Sciences (SPSS) 19 version".
Demographic information was analyzed in the form of frequencies and percentages. Knowledge of participants regarding immediate PPFP was assessed by assigning scores.
To the best of our knowledge no standard pretested scale was available to assess HSPs' knowledge regarding immediate PPFP methods. An arbitrary scoring system was developed after discussion with three experts: practicing Consultant Gynecologist and two Public Health specialists presently running postpartum family planning programs.
There were 15 questions in the knowledge component.
Rest of the questions were given weightage of one. B6 and B7 had four correct responses each. B8, B11, B12, B 13 and B 14 had one correct response each. Thus, the total score was calculated as 29 and the cut off for knowledge was set at 20. SBAs who scored 20/29 i.e. >69% were considered knowledgeable as was suggested by the experts.
Appropriate attitude was assessed by scoring 7 questions.

Appropriate practices were assessed by 10 questions in form of frequencies and percentages.
This study was a descriptive study and sample size was not Citation: Akbani  were not trained to provide these services. More than half of the SBAs (56%) had less than fi ve years' experience of working in Obstetrics and Gynecology unit, around a quarter (29%) had six to ten years' experience and 15% had more than 10 years' experience ( Table 1).

Knowledge of SBAs regarding immediate PPFP
The mean score on the knowledge component was 23.2 (with standard deviation 1.28), out of a possible score of 29.
It is encouraging to know that arou nd equal percentage of doctors and nurse/midwives were knowledgeable (Midlevel 90% vs doctors 87%) ( Table 1).
Results revealed that 57% SBAs were aware that after a live birth 24 months interval is recommended before next conception. Around 80% were aware that contraceptive method can be initiated immediately after delivery of placenta.
Regarding eligibility for immediate PPFP it was alarming to know that arou nd 50% of SBAs believed that primigravidas were not eligible. Most SBAs were aware of the contraceptive options for breast feeding mothers. Around two thirds of the providers agreed that long acting reversible contraceptives could be an alternate to permanent contraceptive methods ( Table 2).

Attitude of SBAs towards immediate PPFP
The analysis shows that 56% of doctors were in the category 'more supportive' towards PPFP, as compared to 35% of nurse/midwives. The supportive SBAs accepted that it is their responsibility to counsel clients and provide them with immediate PPFP. Amongs t those who did not support these services (52%), one third of the doctors and nearly half of the mid-level providers mentioned that counseling and giving contraception is time consuming. These SBAs did not favour adoption of immediate PPFP by primigravida. Nearly 30% of SBAs were reluctant in providing PPFP services due to misconception that religion prohibited FP practices. 22% SBAs thought that religion did not permit FP and 8% were unsure ( Table 3).
Out of the 67 (28%) SBAs who were not providing these services consid ered it time consuming and feared medical complications. Lack o f knowledge, skills and mentorship also acted as a barrier for SBAs (Table 5). It is interesting to note that 30% of nurse/midwives were not permitted by head of the departments to provide PPFP thus an opportunity of task sharing was missed.

Discussion
This study showed that majority of the service providers had not received pre-service FP training revealing the gap in their pre-service curriculum. Knowledge assessment of SBAs  [11]. Several studies have suggested that unmet need for FP is higher among uneducated, younger (15-19 years) women [18,22,23].
The self-imposed limitations of the SBAs based on a medical rationale which is not scientifi cally proven have been identifi ed as "medical barriers" in a study by Jane T. Bertrand (2015) [24].     [26]. Jane T. Bertrand (2015) suggests that provider bias should be analyzed at both service delivery and policy levels. Effective strategies need to be devised to overcome hinderances like lack of training, absence of commodities and legal permission to the providers [24].
One important fi nding in this study was that more than quarter of the nurses/midwives were not providing PPFP services as they were not permitted from head of departments. Similar hinderance is also highlighted in another study by Singh S, Darroch JE which says that the regulatory barriers inhibit nonphysician health care providers from providing PPFP services [22]. Shortage of HSPs is one of the factors hindering universal access to reproductive health. WHO has given recommendations for "Task shifting" to promote health-related behavior which includes postnatal care and family planning [27]. Task shifting is a way of effi ciently using resources (human and fi nancial) [28], by optimizing the role of health workers (doctors, nurses and midwives) to increase availability of reproductive health services [28]. It has been identifi ed that if doctors shift and/or share tasks with other cadres it can improve the provision of FP services [29]. Research has proved that when midwives can insert contraceptive implants and Intrauterine Devices (IUD) unintended pregnancies are reduced [28].
Though task sharing with mid-level providers is highly recommended globally [30], its implementation to increase access to healthcare provision is still awaited due to numerous barriers indicating that health system strengthening deserves primary focus [27]. Policy changes are needed at level of higher authorities to address this hinderance at the service delivery level. National guidelines or protocols based on WHO recommendations need to be developed with participatory consensus-driven processes. Its inclusion into national programmes and health care services depends on wellplanned implementation plan. Local professional societies may play an important role in changing the behavior of health care practitioners and to enable the use of evidence-based practices. This would then create an enabling environment for the implementation of best practices [28]. Specifi c focus is needed for continuous medical education and behavior change strategies to improve knowledge and skills of service providers and address their misconceptions.
Postpartum family planning has become part of the country's initiative to increase the uptake of family planning.

Conclusion
Postpartum family planning has to be a mandatory part of pre-service curriculum of all cadres of HSPs for their knowledge enhancement and behavior change. Need for continuing medical education opportunities related to family planning for the health service through refreshers and hands on trainings could not be over emphasized.
Policy changes are needed to decrease impediments at the PPFP service delivery level. National guidelines or protocols promoting task sharing/shifting based on WHO recommendations need to be developed and implemented to improve access to reproductive health services including PPFP.