The high rate of unintended pregnancy is said to be driving population growth, especially in sub-Saharan Africa where approximately one-half of all pregnancies are reported to be unintended, that is they came too soon or were unwanted . These pregnancies can be prevented with increased access to effective family planning (FP) methods. Research and interventions focus on improving access to FP services especially in the developing world where it is estimated that 222 million women are sexually active, want to delay or avoid a birth, and are not using modern FP (i.e., they have an unmet need for FP) . Women in their first year after childbirth have the highest unmet need for FP as more than two-thirds of these women want to delay their next birth but are not using any method [3, 4]. The postpartum period is an important intervention point for improving access to family planning services. This period is critical for two reasons: a) postpartum women have a high need for FP, and b) these women have multiple contacts with the health facility either for postnatal or child immunization visits.
Although the majority of postpartum women indicate a desire to delay a next birth, FP methods are often not offered to, or taken up by, women after delivery or in the first year postpartum [3, 5–7]. Based on the Health Belief Model, which has been widely used in the study of contraceptive use, perceived threat (perceived susceptibility and perceived severity), perceived benefits, cues to action, and self-efficacy are known to influence contraceptive behaviors [8–10]. Women must perceive their susceptibility to conception, the consequences of an unintended pregnancy, and the benefits of preventing such pregnancy to trigger their use of FP. The Health Belief Model was developed by Rosenstock in the early 1970s and is a cognitive interpersonal theoretical framework used in understanding the complex multidimensionality of contraceptive use decision-making [10, 11]. Earlier studies from sub-Saharan Africa demonstrate that the majority of women lack adequate knowledge of the return of fertility after birth with most of the women, as well as their providers, using resumption of menses as the measure of susceptibility or cue for FP use [4, 5, 7, 12]; these women are at risk of an unwanted or mistimed pregnancy. Seizing the opportunity to offer FP services to women in the postpartum period may result in a steeper increase in the uptake of FP methods and a reduction in unintended pregnancies.
The promotion of FP to delay conception after a recent birth is a best practice that can lead to optimal maternal and child health outcomes. In particular, short inter-pregnancy intervals can result in negative health outcomes such as maternal anemia, low birth weight, and neonatal/infant mortality [13–15]. In addition, short birth intervals are correlated with less breastfeeding of the child prior to the subsequent pregnancy; this may have implications on child health and mother-child bonding . Therefore, the promotion and use of FP for at least two years postpartum will prevent unintended pregnancies and ensure adequate birth intervals.
One way to increase access to FP services is through its integration with maternal and child health (MCH) services. Family planning can be integrated into MCH services at various intervention points. These points include: antenatal care, delivery, postnatal visits, and child immunization visits. To ensure that all postpartum women are reached, no matter their place of delivery, there is a need to integrate FP services into all of these points. Choosing to integrate at one point over the other may result in some women not being reached. For example, integrating only at delivery will miss women who did not deliver at the health facility. That said, comparative research is needed as to where it will be most effective to integrate these services especially for resource-constrained countries. Our study hopes to begin to fill this gap.
This study aims to assess the role of integrated MCH/FP services on use of postpartum family planning by: 1) examining women’s exposure to FP information and services at the time of delivery and at child immunization appointments, and 2) determining if these points of integration are associated with greater use of postpartum FP. Using the Health Belief Model as a theoretical framework [8–11], we assess the factors that influence postpartum FP use in urban cities in Senegal. We examine the association between exposure to FP information and services at the time of delivery and at a child immunization visit with current modern FP use among women who are up to two years postpartum. These MCH points of integration are important as they capture the overwhelming majority of women in urban Senegal where in 2010/2011, 93% of urban births in the five years preceding the survey were delivered in a health facility and 63% of 12–23 month olds were fully vaccinated . Senegal is an important setting for this type of study given that modern contraceptive method use is low overall (12% of married women report modern method use) and in urban areas (20%) .
Our focus on urban areas is due to the high rate of urbanization in sub-Saharan Africa which is said to result in concentrated poverty [18, 19]. This poverty has created an intra-urban disparity in maternal health care as urban poor women have limited access to maternal health services compared to their wealthier counterparts . The United Nations Population Fund (UNFPA) identifies reduction in rates of unwanted pregnancy as the most effective way to slow the rate of urban growth in the developing world . Assessing contraceptive use among urban postpartum women and investigating the extent of association with exposure to information and advice before, during and/or after delivery and during child immunization services will provide much needed information that will inform programs and policies targeted at increasing access to postpartum FP services and improved health outcomes for mothers and babies. We use recently collected household surveys and exit interviews with women of reproductive age in urban Senegal to assess the effect of integrated services on the prevalence of postpartum FP use.