Strengthened efforts in postpartum family planning (PPFP) is a key priority to accelerate progress in reproductive, maternal, newborn, and child health outcomes. In Rwanda, approximately 62% of women have unmet family planning needs in their first year after childbirth. This mixed methods secondary data analysis explores factors associated with PPFP uptake. Women (n=68) were surveyed at two time points to glean insights to the antenatal and postnatal care (PNC) experience. Additionally, a total of 202 participants consisting of 22 individual interviews with government and health officials and 16 focus group discussions with men (n=45), women (n=88) and community health workers (n=47) provided insights into current attitudes towards PPFP. Of 68 women surveyed, most (87%) reported not wanting another pregnancy within the next year; however, only half (53%) used PPFP. The partner (male) as the healthcare decision-maker was associated with PPFP uptake (p=0.04). Attitudes of men, women, and healthcare personnel towards PPFP were summarized in four themes: 1) PPFP purpose, 2) men’s participation in PPFP decision-making, 3) messaging platform effectiveness, and 4) PNC wait time. These results illustrate that a gap exists in the utilization of PPFP services. Partner (male) involvement, attendance to PNC services, and improved quality of PNC services may improve PPFP utilization in Rwanda.

This sub-analysis was conducted within the Preterm Birth Initiative (PTBi) Rwanda study, a collaboration among University of California San Francisco (UCSF), University of Rwanda, the Rwanda Ministry of Health (MOH), and the Rwanda Biomedical Center. As part of a cluster randomized control trial that is testing a group model of antenatal (ANC) and PNC service delivery (NCT03154177), questionnaires were administered to women at two time points – one during pregnancy (baseline) and one after delivery of the baby (follow-up). Data elements on PPFP uptake, respectful care, locus of control, and mental health status were abstracted from questionnaires completed between January 2017 to June 2018 (S1 Table).

PTBi conducted 16 focus group discussions (n=180) and 22 individual interviews for a total of 202 participants prior to trial initiation in May 2017 to inform design of the group ANC and PNC models. Participants were purposively selected to represent a variety of stakeholders and included district authorities, healthcare service providers, staff, patients, and patients’ partners (men). Focus group discussions and in-depth interviews were conducted in person and audio recorded in non-public settings, often in private rooms at health facilities in the local language, Kinyarwanda. For this study, interview responses that contained content related to PPFP were included.

For the quantitative component of this study, variables were defined by collated questions collaboratively selected by PTBi and are listed in the supporting information (S1 Table). Self-reported PPFP type was categorized as either more (sterilization, intrauterine device (IUD), sub-dermal implants, injectables) or less effective (condoms used alone, emergency contraception, or natural family planning) (Table 3).[29] Education level, occupation, household income, food security, and middle upper arm circumference (MUAC) were used as socioeconomic status indicators. A five-point Likert Scale was used for all questions to allow the participant to indicate the degree of agreeability or disagreeability to each statement, with the exceptions of one question on the locus of control questionnaire and one question on the Edinburgh postnatal depression scale which uses the 4-point standard. Selected survey questions, Chronbach’s alpha scores, respective predictors and outcomes, considerations to determine appropriate scoring of questionnaires, and methods to determine outcomes are detailed in S1 Table. We applied non-parametric and parametric testing for all bivariate analysis where appropriate. A p-value of <0.05 was considered statistically significant. RStudio 1.0.153 statistical software was used.

For the qualitative component of this study, a synthesis of interview and focus group discussion excerpts on the subject of PNC were used. These excerpts were utilized in lieu of full transcripts due to translation limitations. Themes were produced with an idiographic approach by secondary data analysis of the excerpts. Codes were created and refined through three iterations of discussion with the Rwanda PTBi team to ensure comprehensive identification of topics. Once codes and their associate definitions were finalized, codes were independently applied to transcripts in Dedoose 8.0.44. Themes and their supporting evidence were created individually by thorough review of the transcripts, framework, and the relationships captured across transcripts through the applied codes.