Post Cesarean section family planning

Sinnar University

Faculty of Medicine

Obstetric & Gynecology Board

Post caesarean section family

planning

Prepared By:

Dr. Samir Abd Elrhman Gorashi

M.B.B.S University of Khartoum

Assisted professor faculty of medicine

Sinnar University

Contents I

List of table II

List of figure III

List of abbreviations IV

English abstract V

CHAPTER ONE

Introduction 1 Literature review 5Objectives 13

CHAPTER TWO

Methodology 14CHAPTER THREE

Results 16

CHAPTER FOUR

Discussion 36Conclusions 38

Recommendations 39References 40

List f Tables

Distribution of study population

according to age Table1


according to residence Table2


according to level of education Table3


according to parity Table4


according to occupation Table5

Distribution of study population according to husband education

Table

6Distribution of study population according to economic status

Table7


according to source of knowledge Table8

Distribution of study population according to identification type of

contraceptive

Table9

Distribution of study population according to common type of contraceptive used

Table10

Distribution of study population according to reasons for choosing a

particular contraceptive

Table11

Distribution of study population according to husband attitude towards contraceptive

Table12

Distribution of study population according to get pregnant type of

contraceptive used

Table13

Distribution of study population according contraceptive used

prescribed by who

Table14

Distribution of study population according to reasons for not visit family planning centre post

Table15

puerperium Distribution of study population according to difficulties to use

contraceptive

Table16

Distribution of study population according to associated medical disease

Table17

List of Figures


according to age Figure 1


according to residence Figure 2


according to level of education Figure 3


according to parity Figure 4


according to occupation Figure 5

Distribution of study population according to husband education

Figure 6

Distribution of study population according to economic status

Figure 7


according to source of knowledge Figure 8

Distribution of study population according to identification type of

contraceptive

Figure 9

Distribution of study population according to common type of contraceptive used

Figure10

Distribution of study population according to reasons for choosing a

particular contraceptive

Figure11

Distribution of study population according to husband attitude towards contraceptive

Figure12

Distribution of study population according to get pregnant type of

contraceptive used

Figure13

Distribution of study population according contraceptive used

prescribed by who

Figure14

Distribution of study population according to reasons for not visit family planning centre post

puerperium

Figure15

Distribution of study population Figu

according to difficulties to use

contraceptive re16

Distribution of study population according to associated medical disease

Figure17

LIST OF ABBREVIATION

Cu-T Copper-T

DMPA Depot Medroxy Progesterone Acetate

EBF Exclusive Breast Feeding

EE Ethinyl Estradiol

FSH Follicle Stimulating Hormone

GnRH Gonadotropin Releasing Hormone

IUD Intra uterine device

LH Luteinizing Hormone

LAM Lactational Amenorrhoea Method

ML Cu-T Multi loadCopper-T

ME Mestranol

NFP NaturalFamily Planning

NET-EN Norethisterone enanthate

OC Oral Contraceptive

PID Pelvic Inflammatory Disease

POP Progesterone Only Pill

STIs Sexually Transmitted Infections

WHO World Health Organization

ENGLISH ABSTRACT

Objective:- The aim of this study to study the

situation of post caesarean section family

planning in Sinnar teaching hospital.

Methodology: - Descriptive cross sectional hospital

based study among women in Sinnar teaching

hospital. Data collected through designed

questionnaire include: - Socio-demographic

characters, obstetrics characters, knowledge and

attitude towards contraception and post

puerperium counseling regarding contraception

used.

Result:-A total of 946 women interviewed in

postnatal clinic, 325(34.4%) had before unplanned

pregnancy, their reason not used contraception198

(60.9%) and failure of contraception 137(39.1%).

The majority of women want space between

deliveries 798(84.4%), women in this study get

their knowledge about contraceptive from health

worker 322(34%), friends 212(22.4%), and Radio

203(21.5%). Most common type of contraceptive

known to women oral pills 216(22.8%) followed by

the IUCD 201(21.2%). Oral pills the common used

contraceptive 216(24.5%), their reason for that

safe and easy to used 319(33.7%). Husband had not

care about contraceptive used by his wife

402(42.5%). Contraceptive used describe by

doctors 403(42.6%) and friends 367(38.8%). The

majority of couple not counseled about

contraceptive 648(68.5%). Most of difficulties

face used of contraception financials problem

397(41.97%).

Most of the women had no associated disease

630(66.59%), had hypertension 162(17.13%), and

had diabetes mellitus 136(14.38%).

Conclusion: - There was high rate of unplanned

pregnancy, which put the women at risk. Most

women preferred traditional method, husband play

minor role in decided to use contraceptive. The

majority of women not counseled about

contraceptive in postnatal clinic, financial

problem face the women to get contraceptive.

INTRODUCTION

A person quality of life depends not only on good

healthy physical well being but on variety of

other circumstances these include: family

stability and harmony, the welfare of children

and freedom to enjoy various activities

including: leisure educational or community

pursuit. Family planning can influence nearly all

of these aspects of life ranging from those that

are strictly personal such as individual's health

to factors that are shared by relationships with

the others(1) . The most important problem of

human being today is not infectious diseases but

population. The world problem now is higher than

at any time in its history(2). Statistics showed

that the population of the world was about 1

billion in 1850 eighty years later in 1930 the

number of population doubled. On 1976 it had

doubled again and today it is more than 6

billions. Increase in the population has been

deemed the most important socio-economic and

cultural phenomenon in recent decades. The

ramification of population increase constitutes

serious threat (3.) A country with population

greater than its socio-economic resources can

support would be faced with many problems both

cultural and socioeconomic which in turn would

influence its independence. Family planning is

now accepted as an important health measure of

maternal health and its important contributor to

any effort aiming at the improvement of the

status of women (4).

Both men and women have the right to be informed

and have access to save, effective, affordable

and acceptable method of family planning of their

choice (5).

Since 1960s family planning programs have helped

women around the world to avoid 400 million

unwanted pregnancies (6). As a result many women's

lives have been saved. Therefore, family planning

helps reducing maternal morbidity and mortality

besides high risk pregnancies. Moreover, it

enables women to space out their pregnancies.

Further it gives the parents the chance to give

better care for their children and family .For

these reasons family planning is an important

strategy in promoting maternal and child

health(7).

Today an estimated 350 million couples worldwide

lack access to an effective and affordable family

planning method (8). Family planning does more

than help couples limit their family size , it

safe guards individual health and rights ,

preserve natural resources and can improve the

economic outlook for families and

communities .Family planning also saves lives up

to one third of all maternal illnesses could be

prevented if women had access to contraception (9).

At least 200 million women want to use effective

and safe family planning method but they are

unable to do so because they lack access to

information and services or the support of their

husbands and communities. Therefore the need for

family planning is growing so fast and it is

estimated that the unmet need will grow by 40% by

the next 15yrs (10, 11). Funding is decreasing and

the gap between the need and the available

resources is increasing (12).

Unmet need is defined as the percentage of fecund

married women who are not using an appropriate

method of contraception even though they don’t

want to get pregnant (13,14).

At present time family planning in the third

world countries is well established and is

progressing toward helping family's regulate

their reproductive lives (15). There is evidence

that sporadic cases of family practice in Sudan

had been known since the late 1950s.However,

services were initiated in 1965 and 1985 were

integrated into primary health care system(16,17).

In Sudan use of contraception was reported by 8%

of women but this figure differs according to

education levels of wealth back ground (18). The

most popular method of contraception in Sudan is

the contraceptive pills which is used by almost

one in twenty married women (19).

In Sudan maternal mortality is one of the highest

rates in the world. (1107 death / 100,000 live

birth)(20) .

Despite challenges in providing optimal

counseling effort, the antenatal health care

delivery settings would seem to be an ideal time

to conduct post partum contraceptive counseling.

Based on the result of case-control studies done

in U k , it is found most of women post caesarean

section used oral contraception because easy to

used and available, and can be used for long

duration without complication(21).

Knowledge and attitude towards post partum

counseling a community based study in Northwest

Ethiopia conclude that most of women used the

long term contraception like injection, Marina

and Implanon(21).

OBJECTIVES

General Objectives:

To study the situation of post c/s family

planning in Sinnar teaching hospital.

Specific Objectives:

1.To determine unmet need for family planning

in patients with post caesarean section.

2.To determine women knowledge, attitude

towards post caesarean

Section contraception

3-To determine family planning utilization

rate .

4-To identify the suitable method of

contraception for post caesarean section

women.

5-Explain the benefits of birth spacing.

METHODOLOGY

(1) Study design:

This is a descriptive cross-sectional hospital

based study.

(2) Study Area : Sinnar Teaching Hospital

antenatal clinic.

(3) Study Period : From August 2013 to January

2014.

(4) Study Population:

Sudanese women post caesarean section attending

in the Antenatal clinic at Sinnar Teaching

Hospital for contraception

(5)Sample size.

Sample size will be calculated with the help

of the formula:

N=z²(pq)

d²

Where:

N=sample size

Z=Coefficient level at 1.96 (95%).

P= Prevalence.

q= (p-1)

d= error 5%

Sample size is estimated to be( 1000) Sudanese

women .

(6) Data collections:

Data will be collected by a questionnaire this

will include close-ended questions covering the

following:

(7) Data analysis:-

Data will be analyzed using SPSS Computer

Program.

(8) Exclusion Criteria:-

Refusal of Sudanese women to participate in the

study.

(9) Ethical approval:-

Written consent should be optional from the

manager of Sinnar Teaching Hospital antenatal

clinic. Women will be informed that their

participation is voluntary.

RESULTS

The interviews were conducted between 1st of

August 2013 to 1st of January 2014. The

participants' were sampled when women post

caesarean section they attended post natal clinic

at Sinnar teaching hospital, and accepted to

participate. The results were represented in

three major sections: Socia-demographic

characteristics, Obstetrics characteristics,

Knowledge and attitude regarding contraceptive

used. A total of 946 pregnant women interviewed.

Women with an unplanned pregnancy were 325(34.4%)

while women with planed pregnancy were

621(65.6%)). Those who had unplanned pregnancy

before, (60.9%) of them did not use

contraceptives and the rest (39.1%) due to

failure of contraceptives.

The majority of women agreed with spacing between

deliveries 798(84.4%), only 115(12.2%) did not

agree, while 33(3.4%) don’t know.

Couples who were counseled for contraceptive

before were 298(31.5%) and those not counseled

were 648(68.5%).

Women who visited the family planning center

postnatal before were 432(45.7%) and those did

not were 514(54.3%).

Women who knew the benefits and side effects of

contraceptives were 325(34.4%) and those did not

know were 621(65.6%) .

Table 1: shows the age of the study group, less

than 20 years old 93(9.9%), between (20-40) years

old 748(79%) and more than 40 years old

105(11.1%).

Table 2: shows the residence of the study

population, rural 332(35.1%), urban 225(23.8%)

and suburban 389(41.1%).

Table 3: shows the Level of education of the

study population, illiterate 30(3.2%), Khalwa

21(2.2%), primary school 266(28.1%), secondary

school 502(53.1%), university graduate 86(9.1%)

and postgraduate 41(4.3%).

Table 4: shows the parity of the study group,

para one 212(22.4%), multipara 452(47.8%) and

grandmultipra 282(29.8%).

Table 5: shows the occupation of the study group,

housewife 575(60.78%), laborer 132(13.95),

employee 186(19.66%) and professional

53(5.61%).

Table 6: shows the husband education of the study

group, illiterate 121(12.8%), Khalwa 103(10.9%),

primary school 210(22.2%), secondary school

439(46.4%), university graduate 42(4.4%) and

postgraduate 31(3.3%).

Table 7: shows the economic status of the study

group, high 96(10.2%), moderate 420(44.4%), low

319(33.7%) and very low 111(11.7%).

Table 8: shows the study population get their

source of knowledge from, Radio 203(21.5%),

Television 188(19.9%), friend 212(22.4%), health

worker 322(34%) and news paper 21(2.2%).

Table 9: shows the identification types of

contraception study population know, coitus

interrupts 212(22.4%), safe period 197(20.8%),

IUCD 201(21.2%), implants 111(11.7%), injection

193(20.4%), oral pill232 (24.5%), sperm suicide

21(2.2%), condom 83(8.8%), vaginal barrier

11(1.2%), sterilization 101(10.7%) and IUS

71(7.5%).

Table 10: shows the most common type of

contraceptive used by the couple, coitus

interrupts153 (16.2%), safe period 167(17.7%),

pills216 (22.8%), injection 183(19.4%), IUCD

100(10.6%) and condom 22(2.3%).

Table 11: shows the reasons for choosing

particular contraceptive, safe and easy

319(33.7%), husband preference 152(16.1%),

advised by doctors or friends 227(23.9%), has no

complications 270(28.5%) and the only known to

the women 91(9.6%).

Table 12: shows the husband attitude towards

contraception, positive 359(37.9%), against

185(19.6%) and don’t care 402(42.5%).

Table 13: shows those get pregnant during

contraception use, coitus interrupts 87(28.9%),

safe period 177(58.8%), pills 21(6.9%) and condom

16(5.4%).

Table 14: shows contraceptive used that

prescribed by: doctors 403(42.6%), midwife

77(8.1%), used alone 99(10.5%) and friends

367(38.8%).

Table 15: shows their reasons for not visiting

family planning centre post puerperium, not

interest 148(28.8%), not told to came back after

puerperium 182(35.4%), financial problem

96(18.7%) and no needs to came 88(17.1%).

Table 16: shows difficulties to used

contraception, financial 397(41.97%), religious

154(16.28%), husband attitude 172(18.18%) and

accessibility 223(23.57%).

Table 17: shows associated medical disease, heart

disease 11(1.16%), diabetes mellitus 136(14.38%),

hypertension 162(17.13%), thromboembolism

7(0.74%), and no associated disease 630(66.59%).

Table 1: Distribution of study population

according to age-:

PercentFrequency Age 09.9%093 ≤2079.0%74820 -4011.1%105 >40100%946Total

Table 2:- Distribution of study population

according to residence-:

Percent Frequency Residence 35.1%332Rural

23.8%225Urban

41.1%389Suburban

100%946Total


according to level of education:-

Percent Frequency Level of

education

03.2%030Illiterate

02.2%021Khalwa 28.1%266Primary school 53.1%502Secondary

school 09.1%086University

graduate 04.3%041Postgraduate 100%946Total


according to parity-:

Percent Frequency Parity 22.4%212Prim Para

47.8%452Para 2- 5

29.8%282Para > 5

100%946Total


according to occupation:-

Percent Frequency Occupation 60.78%575Housewife

13.95%132Laborer

19.66%186Employee

05.61%053Professional

100.00%946Total


according to husband education-:

Percent Frequency Husband

education

12.8%121Illiterate 10.9%103Khalwa 22.2%210Primary school 46.4%439Secondary

school 04.4%042University

graduate

03.3%310Postgraduate 100.0%946Total


according to economic status-:

Percent Frequency Economic status 10.2%094High

33.7%319Moderate

44.4%420Low

11.7%111Very low

100.0%946Total


according to source of knowledge-:

Percent Frequency Source of

knowledge

21.5%203Radio 19.9%188Television 22.4%212Friend 34.0%322Health worker 02.2%021News paper

100.0%946Total


according to identification of types of

contraception the women know:-

Percent Frequency Type of

contraception 24.5%232Oral pills 22.4%212Coitus interrupts 21.2%201IUCD 20.8%197Safe period 20.4%193Injection 11.7%111Implant 10.7%101Sterilization 08.8%083Condom 07.5%071 IUS 02.2%021Sperm suicide 01.2%011Vaginal barrier


according to contraceptive used by the women or

husband:-

Percent Frequency Type of

contraceptive 22.8%216Oral pills 19.4%183Injection 17.7%167Safe period 16.2%153Coitus interrupts 10.6%100IUCD 02.3%022Condom

100.%946Total


according to reasons for choosing a particular

contraceptive:-

Percent Frequency Reasons 33.7%319Safe and easy 28.5%270Has no complication 23.9%227Advised by doctor or

friend 16.1%152Husband prefers 09.6%091The only known to the

women


according to husband attitude towards

contraceptives-:

Percent Frequency Husband

attitude 37.9%359Positive 19.6%185Against

42.5%402Don’t care 100%946Total


according to contraceptive used before getting

pregnant:-

Percent Frequency(n=301

) Contraceptive

used 28.9%087Coitus

interrupts 58.8%177Safe period

other NFP 06.9%021Oral pill

05.4%016Condom 100%301Total


according to source of contraceptive used-:

Percent Frequency Prescriber 42.6%403Doctors

38.8%367Friends 10.5%099Used alone 08.1%077Midwife 100%946Total


according to reasons for not visiting family

planning center postnatal-:

Percent Frequency(n=5

14) Reasons

35.4%182Not told to came

back after

puerperium

28.8%148Not interested

18.7%096Financial problem

17.1%088No need to came

back 100%514Total


according to difficulties to use contraceptives:-

Percent Frequency Difficulties 41.97%397Financial 23.57%223Accessibility 18.18%172Husband

attitude 16.28%154Religious

100%946Total

Table 17: Distribution of study population

according to associated medical diseases:

Medical disease Frequency Percent

Heart disease 011 01.16%

Diabetes mellitus 136 14.38%

Hypertension 162 17.13%

Thromboembolism 007 00.74%

No associated disease 630 66.59%

Total 946 100.0%

Figure 1:

Age

9.90%

79%

11.10%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

>20 20 - 40 >40

Figure 2:

Residence

35.10%

23.80%

41.10% Rural Urban Suburban

Figure 3:

Level of Education

9.10%

4.30% 3.20% 2.20%

28.10%

53.10%

IlliterateKhalwaPrim ary schoolSecondary schoolUniversity graduate Postgraduate

Figure 4:

Parity

22.40%

47.80%

29.80%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Prim para Para 2 - 5 Para > 5

Figure 5:

Occupation

60.78%

13.95% 19.66%

5.61%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Housewife Laborer Em ployee Professional

Figure 6:

Husband Education

12.80%

10.90%

22.20%

46.40%

4.40%

3.30%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00%

Illiterate

Khalwa

Prim ary school

Secondary school

University graduate

Postgraduate

Figure 7:

Econom ic status

10.20%

33.70%44.40%

11.70%HighM oderateLowVery low

Figure 8:

21.50%

19.90%

22.40%

34%

2.20%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00%

Radio

Television

Friend

Health worker

News paper

Source of know ledge

Figure 9:

Type of contraception know n by the w om en

20.40%

11.70%

10.70%

8.80%7.50%

2.20% 1.20%

24.50%

22.40%

21.20%20.80%

Oral pills Coitus interruptsIUCD Safe period Injection Im plant Sterilization Condom IUS Sperm suicide Vaginal barrier

Figure 10:

Contraceptive used by the w om en

22.80%

19.40%

17.70%

16.20%

10.60%

2.30%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00%

Oral pills

Injection

Safe period

Coitus interruptus

IUCD

Condom

Figure 11:

Reasons of used particular contraceptive

33.70%

28.50%

23.90%

16.10%

9.60% Safe & easy

Had no com plication

Advised by doctor orfriendHusband prefers

The only known to thewom en

Figure 12:

Husband attitude

37.90%

19.60%

42.50%

0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%

Positive Against Don’t care

Figure 13:

Contraceptive used before getting pregnant

58.80%

6.90%5.40%

28.90%

Coitus interruptsSafe periodOral pillCondom

Figure 14:

42.60%

38.80%

10.50%

8.10%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00%

Doctors

Friends

Used alone

m idwife

Sources of contraceptive used

Figure 15:

Reasons for not visiting FPC postnatal

35.40%

28.80%

18.70%

17.10%Not told Not interestedFinancial problemNo need

Figure 16:

Difficulties to used contraception

41.97%

23.57%18.18% 16.28%

0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%

Financial Accessibilty Husband attitude Religious

Figure 17:

Associated m edical disease

1.16% 14.38%

17.13%

0.74%66.59%

Heart diseaseDiabetes m ellitusHypertensionThrom boem bolismNo associated disease

DISCUSSION

Counseling for contraception applies discussion

of contraceptive needs, taking into account

reproductive goals and protection against

sexually transmitted diseases, information and

counseling about methods, their effectiveness

rates, and side effects, short- and long-term

method choices, assurance of contraceptive

resupply & access to follow-up care.

Postpartum contraception is the initiation and

use of family planning methods in the first six

weeks after delivery to prevent unintended

pregnancy particularly in the first 1-2 years

after childbirth, when another pregnancy can be

harmful to the mother or a breast feeding baby.

Unplanned pregnancy in this study is high

(34.4%), this well increase women risk of

complication of pregnancy, repetitive delivery

stress on women health and the effect on her baby

and breast feeding, and will increased chances of

unsafe abortion. The majority of the women

(60.9%) not used modern, but using natural method

(safe period and coitus interrupts) and those

used contraceptive (39.1%) are not using it

regularly. Here came the role of post partum

counseling about contraceptive and used

appreciated one for the women.

A similar study done in India found that

unplanned pregnancy was (45.5%), mainly due to

traditional and community believes, contraceptive

make infertility (34).

Health worker, friends and mass media are main

source of knowledge for women about

contraception.

This in contrast to study in Ethiopia where the

source of knowledge was midwives and friends

respectively (35).

Oral contraceptives most common contraceptive

known to all women followed by IUCD and

injection, this result similar to a study in

India and Ethiopia but in contrast to study done

in Ireland in which most common contraceptive

used was condom, sperm suicide and vaginal

barrier, these methods women had low knowledge

about it because not commonly used or accepted in

Sudan (34, 35, 36).

Most common methods of contraceptive used by the

women in this

study were oral pills (24.5%), followed by

coitus interrupts (22.4%) and safe period. Last

two methods an unsafe and not accurate if not

used properly. This explains why unplanned

pregnancy increased in number. The reasons for

women to use a particular contraceptive, safe and

easy (33.7%) and had no complication (28.5%).

This result is similar to India study, where

their reasons safe and easy to use.

The husband had major role in post partum

contraceptive to choose with his wife and discuss

the complication but in this study the husband

attitude is negative or does not care (42.5%) (34).

In this study found most of contraceptive

prescribed by doctors (42.6%) and near friends

(38.8%). This result in contrast to Ethiopia

study where used alone most common (34%) (35)

Regarding counseling of both couple post natal

about contraceptive, most of them were not

counseled (68.5%) and only (31.5%) counseled,

this similar to India and Ethiopia study (34, 35).

More than half of the women did not visit post

natal family planning centre, a (54.3%) of them

because they have not been told to come back

after puerperium.

Most of the women (65.6%) did not know the

benefits and the side effects of contraceptive

use. This result is better than in Ethiopia and

India study, but in contrast to Ireland study all

the women know the side effect and the benefit of

the contraceptive used(34,35).

The difficulties face the use of contraceptive by

the women was financials problem in the most of

women (41.97%) and in according accessibility

(23.57%).

Most of the women in this study (66.59%) used

contraception and had no associated medical

problem.

CONCLUSIONS

The study show a relatively high unplanned

pregnancy, due to poor counseling and

communication for family planning, the husband has

no role in improving utilization of family

planning. Most of women do not visit post natal

care centre routinely in spite of presence of

family planning and post natal clinic, there is no

detailed counseling for both couple.

RECOMMONDATIONS

♦ Involve both couple in post natal counseling.

♦ Details information about contraception must

be given for both

couple.

♦ Told women to came routinely to post natal

clinic.

♦ Attempts should be made to overcome the

resistance expressed by men for family

planning methods besides involving them in

the whole process of family planning.

♦ Extensive collaboration, with different

media means: TV, radio,

presses to deliver message to women

about the important of post

natal counseling.

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Post Cesarean section family planning

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