Barriers and enablers to utilisation of postpartum long-acting reversible contraception in Eastern Uganda: a qualitative study

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We explored the enablers and barriers to utilisation of postpartum long-acting reversible contraceptives in Eastern Uganda. Methods We conducted a qualitative study in two districts of Eastern Uganda. We had 39 interviews. We conducted 20 in-depth interviews and three focus group discussions with postpartum women, male partners, health workers, and village health team memberss. Our study was grounded in the COM-B framework, and the transcripts were analysed thematically. Results The use of immediate postpartum long-acting reversible contraception (LARC) was majorly hindered by both incapabilities and limited opportunites in the health system and patient factors. System factors included lack of healthcare provider-initiated counselling for postpartum contraception, overburdened healthcare workers, and shortage of Postpartum Family Planning commodities and sundries. Patient factors included limited knowledge (lack of awareness for postpartum contraception), misconceptions (perceived body fragility, need to fully recover and for menses to resume after delivery), fear of side effects, men had fear of infidelity, lack of agency to ask for health education and poor health seeking behaviours. The enablers for immediate postpartum LARC included positive attitudes towards contraception, preference for contraceptive implants over intra uterine devices (IUD) at the 6-week postpartum period, resumption of sex and menses, partner support, and perceived effectiveness of postpartum contraception. Participants thought that sensitization about LARC through health education and outreach visits, male involvement through ANC appointments and male village health teams, and switching between family planning methods could improve uptake of immediate postpartum LARC. Conclusion Inadequate knowledge and skills on postpartum family planning services(PPFPs) and lack of health education by health workers and misconceptions with poor partner support majorly led to low utilisation of postpartum family planning services in this setting. Scaling up effective, low cost and innovative ways to provide PPFP services such as video counselling may improve the use of immediate postpartum LARCs. As well as actively promoting the provision of intergrated services along the continuum of maternity care. immediate postpartum Long acting reversible contraception Uganda modern contraceptives Antenatal intra uterine devices implanon Figures Figure 1 Introduction After childbirth, almost all (95%) women wish to delay or prevent future pregnancies ( 1 ). Despite their overwhelming desire and motivation to delay or prevent future pregnancies, only 10% of women use modern contraceptives in the postpartum period ( 2 ). The unmet need for family planning is noted to be highest among postpartum women than in the general population ( 1 ). The low utilisation of postpartum contraceptives predisposes women to short interpregnancy intervals, and unwanted pregnancies; many of which end up as unsafe abortions, which are associated with adverse maternal, perinatal and infant outcomes including death ( 3 ). Specifically, a short interpregnancy interval is associated with low birth weight, preterm birth, small for gestation age, and poor neonatal survival rates, and very often death for both mother and baby ( 3 ). Short birth intervals affect the woman’s ability to engage in income generating activities leading to social economic deprivation ( 4 ). In low- and middle-income countries, few women receive counselling regarding family planning during antenatal and postnatal care which underscores the limited opportunities available for women to be informed about postpartum family planning ( 1 ). Similarly, there are many missed opportunities to counsel and provide postpartum family planning along the continuum of maternal and child health services ( 5 ). In Uganda, 41% of women who were not using family planning reported not receiving counselling regarding family planning during their visit to the health facility ( 6 ). Despite the fact that the Ministry of Health guidelines encourage provision of integrated services at all levels which has increased rates of health facility deliveries, 90% women still leave health facilities after childbirth without receiving postpartum contraceptives ( 6 ). The high number of women who do not return to the health facility for postnatal care attendance highlights a missed window Postpartum contraception confers benefits of convenience, ease of insertion/provision, and increased utilisation of modern contraceptive services ( 7 ). However, in Africa among the few women who opt for postpartum family planning, more than 90% of women preferred to use short-term contraceptives (oral or injectable contraceptives) ( 1 ). The problems of inconsistent and early discontinuation inherent in short-term contraceptives undermine their effectiveness in providing long-term contraception in the postpartum period ( 8 ). The long-acting reversible contraceptives (LARCs), including implants and intrauterine devices, remedy the need to rely on the user ( 7 ). LARC provide highly effective, efficacious, safe and long-term contraception for postpartum women ( 7 ). Several quantitative studies have assessed demographic predictors of post-partum contraception use ( 2 , 9 , 10 ) and use of LARCs ( 11 ), but these do not provide information on how to improve the provision of post-partum contraception services. Several qualitative studies have explored the views of Ugandan men and women about contraception in general, but no specific findings have been reported about post-partum contraception ( 12 – 14 ). A qualitative study has explored barriers to the utilisation of immediate postpartum contraception for women in South-Western Uganda( 15 ), but this setting is different from ours. The study was conducted to gain insight into the barriers and enablers for utilization of post-partum LARC within Mbale and Budaka districts. Methods Study design We conducted a descriptive qualitative study. The study was grounded on the COM-B theoretical framework ( 16 ). This framework involves the capability (physical & psychological), opportunities (physical & social) and motivation (reflective and automatic) to postpartum LARC use (behaviour) ( 16 , 17 ). Capability to use postpartum contraception includes psychological capability (knowledge and attitudes) and physical capability (e.g., skills for inserting IUDs and implant, medical eligibility criteria) ( 16 ). The opportunities were categorised under physical (health system factors) and social (e.g., convenience and social acceptability), while motivation includes automatic (subconscious beliefs about family planning) and reflective or conscious motivations for postpartum family planning use ( 16 ). Study setting The study was conducted in different settings in Mbale and Budaka Districts in Eastern Uganda. This included antenatal and postnatal units of Mbale Regional Referral Hospital (MRRH), Busiu Health Centre (HC) IV and Budaka HC IV. Outside of the health facility settings, the study was conducted among residents in both town and rural areas of Mbale district (Busiu and Nakaloke) and a community in Budaka district. This enabled us to get a general representation from both the town and rural areas of Eastern Uganda. MRRH is a regional referral hospital with a large catchment area serving populations in Bugisu, Teso, Bukedi and Sebei sub-regions. The hospital provides a range of antenatal, intrapartum and postnatal services including postpartum family planning (PPFP) services. Study population and sampling procedure The study included pregnant women who were receiving antenatal care and postpartum women in MRRH, Nakaloke, Budaka and Busiu Health Center IV. Male partners of women who had just given birth were included in the study as well. Women who had delivered within the last six months were included in the study whether they were breastfeeding or not. Health workers at MRRH and Nakaloke HC III and village health teams (VHTs) from the community of Nakaloke subcounty and Budaka district were also included in the study. Women who were critically ill and those who were six months post-delivery were excluded from the study. We used maximum variation purposive sampling to select the study participants who could provide rich in-depth description of the phenomenon under study ( 18 ). The VHTs were used to identify the study participants from the community. Sampling was based on the principle of data saturation. In our study, data saturation was reached after 22 in-depth interviews (IDIs) with 11 women, four male partners, three VHTS and 4 healthcare workers. Three focus group discussions of 6–7 participants per group were conducted among pregnant women in antenatal clinic, postpartum women and the male partners. Data collection procedures and methods Semi-structured interviews were conducted using an interviewer administered guide. The questions for the guide were derived from the COM-B framework. The guide had questions about family planning in general (discussed family planning use with the male partner and ever used family planning). Women in postpartum clinic were asked whether they had been offered family planning in general and/or LARC immediately and/or within six months after child birth. The women were further probed for their perceptions, willingness to use PPFP, perceived enablers and barriers to use of immediate PPFP. Women who were not offered immediate PPFP after delivery were asked about their interest to receive counselling on PPFP, their intention to use contraception, perceived enablers and barriers to contraception use and their preferred method of PPFP. The format of questions for male partners and pregnant women was similar to that used for women in the postpartum period. The interviews were conducted by DA, BN, PN, (female midwives with a degree in midwifery), FO & DN, (female medical officers) and JW & SW (male midwives with degree in midwifery) who spoke the native languages of the study participants (Luganda, lugwere, lumasaba). Data collection was between April and December 2023. The in-depth interviews lasted 25 to 80 minutes, while the FGDs lasted from one hour and 30 minutes to two hours. Note-taking was done during the interview to capture impressions. Data analysis and rigor of the study Interviews were audio-recorded on a digital voice recorder. All voice recordings were carefully transcribed verbatim by DA, BN, PN, FO, and SW and they also translated to English by a native of the local languages (Lumasaba, Luganda, and Lugwere). The Atlas.ti.9 was used in the analysis. Braun and Clarke’s thematic analysis involving six step process was used ( 19 ). This involved familiarization with the transcripts, identification and development of codes. Coding was developed iteratively to add new emerging concepts. The codes were combined into themes and subthemes that represent the perceived barriers and enablers of post-partum contraception. We used the COM-B framework to organise our results, by assigning each each theme to the appropriate component in the COM-B model. Details in Fig. 1. Trustworthiness and rigor of the study findings was maintained through triangulation of data sources (pregnant women, postpartum women and male partners), study sites (hospital and community setting), and data collection methods (in-depth interviews and focus group discussion)( 18 ). Male interviewers were used to interview male partners, while female interviewers were used to interview women. The interviews were conducted by midwives which ensured credibility of the findings ( 18 ). Data analysis was conducted by three persons (AK, DA, & BN) to ensure the trustworthiness of the findings. We have used direct quotes from the participants to reinforce the confirmability of the study findings. Ethical considerations The study obtained ethical clearance from the Busitema University Research and Ethics Committee (BUREC NO. BUFHS-2023-51). Written informed consent was obtained from the study participants while administrative clearance was obtained from all the units where the study was conducted. All the participants enrolled into the study were above 18 years and received modest compensation of 20,000 Ugandan shillings (approximately £5) as per the guidance from the Busitema University Research and Ethics Committee. Participants (three in number) who requested to use postpartum LARC method were referred to family planning services. Results We interviewed 39 participants. 20 of these were in-depth interviews ( nine postpartum mothers, three male partners, one ANC mother, four health workers and three VHTs) and three FGDs where one was with six antenatal mothers, another with seven postpartum mothers and one with six men whose partners were in the postpartum period. Among the indepth interviews, we interviewed 3 couples. None of the participants declined to enroll in the study. The age range of the most participants was 20 to 35 years(n = 31), while the majority were of formal education (n = 37) and were peasants (n = 20). Most of the participants were of the Bagisu ethnic group, had one to three children (n = 14) and delivered from a health facility (n = 31). Table 1 Characteristics of participants Characteristics Postpartum Women (N = 16) Antenatal women (N = 07) Men (N = 09) Health workers (N = 4) Village health teams (N = 3) Age < 20 01 00 00 00 00 20–35 15 07 06 03 00 ¬ 35 00 00 03 01 03 Marital Status Single 00 00 00 01 00 Married 16 07 09 03 03 Education level No education 02 00 00 00 00 Formal education 14 07 09 04 03 Occupation Peasant 12 04 04 00 00 Housewife 03 01 00 00 00 Teacher 01 00 00 00 00 Self employment 00 02 03 00 00 Motorcyclist 00 00 02 00 00 Nurse/ Midwife 00 00 00 04 00 Village health team 00 00 00 00 03 Ethnic Group Bagwere 04 00 04 02 03 Bagisu 03 06 05 02 00 Baganda 00 01 00 00 00 Place of Delivery Home 01 00 00 00 00 Health facility 15 07 09 04 03 Parity 1–3 10 05 03 02 01 4–6 04 02 06 02 02 > 7 02 00 00 00 00 Enablers and barriers to uptake of immediate postpartum LARC We identified 3 themes which were enablers, barriers, and recommendations. These had sub-themes which were structured around the COM-B model. The enablers and barriers were aligned into capability, opportunities, and motivation of behaviour. Table 2 Applying the COM-B model to explore the barriers, facilitators and recommendations to uptake of immediate postpartum LARC. Com-B domain Sub-domain Barriers Enablers Recommendations Capability Psychological • Lack of knowledge, • Misconceptions, (need to wait for menses, effect of birth trauma on use of LARC, perceived body fragility immediately after birth, Religious beliefs). • lack of sexual intimacy after delivery • Differing fertility goals, • Knowledge on LARCs • Need to resume intimacy with their partners • having attained a desired family size, conceiving too soon, • sensitization by health workers while in health facilities • community sensitization by health workers and VHTs. Physical • Unaware and unskilled health workers in offering LARC services. • Health workers have skills to offer the LARCs • Training Midwives to enhance their skills in PPFP. Opportunity Physical • Lack of health worker-initiated family planning services, • overburdened health workers, • Shortage of equipment used to offer LARCs and stock outs of LARCs . • Availability of PPFP LARC. • Lobby for LARC from other health facilities. Social • Harsh workers • Lack of partner support • lack of agency to ask for health education. • Good attitude of health workers • Joint decision-making to take up FP • Partner support • Provision of privacy and confidentiality to women • Offering FP counselling during ANC visits and at postnatal units. Motivation Automatic • Negative influence of the care taker about use of LARCs. • Lack of male involvement. • Positive attitude towards couple counselling and FP use, • Positive influence by partners, family members, and health workers. • Male involvement in ANC couple counselling on FP. • Recruitment of male VHTs • male involvement in ANC and other health services, sensitization by expert clients. Reflexive • Fear of infidelity, • side effects, • Discomfort of procedures of LARCs • Negative experience • Educated mothers • Long duration of action, approval to the utilization of LARC, • preference of LARC. • Sensitization, need for individualized FP, • Sensitization by use of poster images about PPF and media. Theme 1: Capability Women`s capability to take up immediate PPFP was hindered psychologically and physically. Sub-theme A: Psychological capability The following factors psychologically impeded the women`s capability to uptake of immediate PPFP; Lack of knowledge, Misconceptions, (need to wait for menses, effect of birth trauma on use of LARC, perceived body fragility immediately after birth, Religious beliefs), lack of sexual intimacy after delivery, Differing fertility goals. Limited Knowledge and misconseptions Due to limited knowledge on PPFP, many participants developed misconceptions about PPFP methods. This therefore would affect their psychologically capablilty of deciding to take up the PPFP. We identified misconceptions and fear of side effects, differing fertility goals, need for menses to return, lactation amenorrhea, birth trauma after delivery, inexperience in use if the IUD, perceived body fragility, perceived women`s role in the family and fear of side effects as hinderances to uptake of PPFP. Misconceptions The utilisation of LARC especially IUD was hindered by the misconceptions surrounding IUD use. The misconceptions regarding the use of IUDs and implants included interference with sexual intercourse, disappearance in the body, causing weight gain, excessive bleeding and infertility. Women thought that insertion of the IUD required measurement of the length of partners’ penis. “Yes, women always complain. That if they insert that coil, it disappears in your body; that it kills off eggs (ova) in a burnt manner….that it …goes up to the heart. (23year old postpartum woman). “if it( the IUD) starts to harm me during sexual intercourse, then I feel pain, I start to ask myself that what is it? Or sometimes then we divorce” (53 year old Male partner) “That coil me I hear the people who go for it say that they measure the length of your husband’s penis and they say that if you go for that coil you do not have to cheat, that when you cheat you get problems because men are not the same (in terms of the length of the penis) and that the coil is not good.” ( 27year old postpartum woman) Misconception for the need to wait for menses and lack of sexual intimacy The use of LARC in the immediate postpartum period was perceived to be irrelevant since the menstrual periods had not yet returned. Women thought that absence of menses meant that they could not conceive, while others thought that LARC uptake in the immediate postpartum period was only relevant for those whose menses had returned early. Return of menses was also key for women who thought that LARC would cause amenorrhea. Some women wanted to know when their menses would return after birth, and so, were reluctant to use family planning methods which would interfere with the return of their menses. “Yes I cannot accept because if you do not see the period and you get like that family planning injection, you will be without having your periods you will not understand yourself. It needs you first menstruate and see that period. I first see the menstrual blood before (getting a method)” (27 year old postpartum woman). The idea of using postpartum LARC immediately after childbirth was foreign to some women and male partners because of the lack of intimacy at this period. “…as the husband I cannot be with her intimately immediately after birth…. So, at least I wait for her to return to her normal way. When she bleeds following birth, time comes and she is dry [lochia stops], but even if she is dry as the partner you can give her another one week before you can resume your game [sex]” (38 year old male partner). Misconception for the need to recover and body fragility after delivery Immediate postpartum LARCs, especially the intrauterine device, were perceived to add more pain to those who experienced a traumatic delivery. Women, therefore, preferred to first recover from the birth trauma before taking up any method. “ there for me, basing on what(having a painful vaginal tear repair after birth) i went through, I feel that you be adding me more pain(if you insert a coil immediately after child birth). Yes, in the process of putting it. You be when you are still fresh, like there they have vaginally repaired them, those one who are vaginally repaired. Ok the stitches be still painful then you add” (30year old postpartum woman) The capability to use LARC was crippled by the nearly universal disapproval of its use in the immediate postpartum period. Women and male partners were reluctant to use LARC immediately after birth because of the perceived need for the woman to fully recover from the after-effects of childbirth including that the woman was still weak to use LARC. Women thought that their bodies were still fragile to use family planning immediately after birth. The fact that women were still bleeding made women to be more hesitant to use IUD as it was thought to make bleeding worse. This was especially important given that women lacked enough blood during this postpartum period. The associated pelvic pain during postpartum, and still fresh vaginal tears and repairs hindered the insertion and use of IUD during the immediate postpartum period. “At least six weeks after birth. Immediately after birth I see she is still bleeding because she has just given birth, the “way” is still very wide,... So, if you put when the way is still wide, when it goes back to normal it might affect her” (38 year old Male partner) “…I cannot accept. the uterus can be when it has not yet gone back to its original position. And you are still over bleeding. And you do not know when that bleeding is going to stop, in what period. You may say that you insert it in then you bleed over and over. And you say, this thing is the one causing the bleeding. yes, so for me I cannot accept it(the IUD). (35 year old Pregnant woman attending ANC) Desire for a large family size The use of postpartum LARC was hindered by a desire for a large family size. Some women wanted to give birth until their ova were exhausted which hindered the use of postpartum IUD “There those who do not listen even if you tell them to (take-up FP), they just want to continue producing. Some, say let me produce the children until they get finished in the womb” (27year old postpartum woman) Sub-theme B: Physical capability Unaware and unskilled health workers in offering LARC services The unaware and unskilled health workers in offering PPFP services made women to be physically incapable to takeup PPFP. The reluctance of health workers to initiate postpartum LARCs contributed to skills and knowledge deficiency on postpartum LARC among men and women. Additionally, some midwives, nurses and village health teams were unaware of PPFP and unskilled in offering PPFP services. “I have always known that after birth, you wait for some time, they don’t give it to you immediately. I didn’t know that you could get it.” (22-year-old postpartum woman) Around me l have them (other nurses and midwives) but they are not confident (skilled). Me I feel there is a way they are not confident because every time a mother comes for IUD, when I am not there they wait for me (40 year Midwife ). Theme 2: Opportunity Sub-theme A: Physical Phyiscally, women lacked the opportunity to receive PPFP methods due to lack of health worker-initiated family planning services, overburdened health workers, shortage of equipment used to offer LARCs and stock outs of LARCs Lack of Health worker-initiated family planning services. All the mothers attended antenatal care, and only one of them delivered at home. The rest (n = 14) delivered from a health facility. Postnatal care was poorly attended except for the purpose of bringing the child for immunization. Despite skilled birth attendance in a majority of the study participants, the majority of them were not counselled for postpartum LARC during antenatal care and postnatal care. There was no mention of postpartum LARC in the majority of cases (n = 9) during antenatal and postnatal care, while in isolated cases, postpartum family planning was mentioned unintentionally and perfunctorily during history-taking in antenatal care. Most of these women who witnessed lack of initiated family planning services during their postpartum period lacked the opportunity to take up postpartum LARC methods. “No, she (health worker) didn’t talk about it at all. And still they just discharged us” (38 year old Male partner whose wife delivered from Busiu HC1V). “They don’t give it [family planning] to you immediately. I didn’t know that you can get it. After some time then you can go and get it. The health workers had never 22-year-old postpartum woman) Consequently, some women had never heard that family planning in general can be used in the immediate postpartum period. Paradoxically, healthcare workers misguided some women that they were not eligible for immediate postpartum LARC. “I have never heard that they put immediately after birth,…Yes, the health workers…then said, “but we cannot insert it (Implanon) in you right now [after abortion], go home and spend one month then you come back here and then we insert it in you.” ” (35 year old Pregnant woman attending ANC at Nakaloke HC III) Despite the lack of initiative to counsel and provide postpartum LARC on the part of the healthcare workers, women and male partners expressed palpable demand and interest to receive information and counselling regarding postpartum LARC. Participants thought that informing them about postpartum LARC would help them decide on whether to use LARC in the immediate postpartum period. “It is good [to receive health education during ANC] because I [will]know as a mother when I give birth, I need to go to the health worker and they give me family planning to use” (Postpartum mother currently user of implant) “Now there it needs when you… maybe teach us and we might also be happy or get responsible to see that we join family planning” (32 year old Postpartum mother with 12 children) Overburdened healthcare workers and lack of agency to demand for health education There was reluctance of women and their families to engage the healthcare providers regarding receiving information related to postpartum LARC. The healthcare workers were perceived to be so busy, very tired and unavailable to provide postpartum LARC, while the fear of burdening the authoritarian healthcare workers with need for postpartum LARC services further discouraged conversations regarding the utilisation of postpartum LARC. “Now, sometimes, the health workers may be busy…, she might be tired. So, you may fear to talk to them because they have worked the entire night, they are tired and they want to go and rest…..I fear to talk to them that is why I just keep quiet, .” (, 27year old postpartum woman). Lack of FP equipment and shortage of LARCs Stock outs of the postpartum LARCs hindered health workers from offering PPFP services. This was also associated with unavailability of equipment used to offer PPFP such as lignocaine, autoclave, and procedure couches. “here I cannot insert an IUD where there is no couch. There should be a couch because you have to put this mother in lithotomy position then you do it.” (38-year-old midwife) “ Only that sometimes when we have stock outs and maybe a mother has come, we don’t have lignocaine. We don’t have the gloves, we don’t have even syringes, no cotton, and sterility is a problem. Usually that’s what affects us as a facility.” (35-year-old Nurse) Sub-theme B: Social There were factors that socially denied women an opportunity to takeup PPFP. These included; harsh workers, lack of partner support, lack of agency to ask for health education. Harsh health workers Women missed the opportunity of taking up LARCs because some health workers communicated harshly to them and disrespected client rights to remove a method which was causing them significant side effects such as excessive bleeding, loss of appetite and losing weight. “Just she [health worker] became harsh. When she became harsh I saw ah-ah that I am not managing [to wait for family planning counselling].” ( 30 year old postpartum woman) Lack of partner support: The use of LARC immediately after childbirth was negatively affected by the male partner disapproval. The lack of involvement of male partners in the consenting and decision-making processes in addition to the misconceptions of the side effects of LARC made male partners reluctant to allow the use of LARC. “yes, what will you do? Now when the important thing you have to hide yourself (meaning to get implanon and not inform partner) and when you tell him, he does not accept.(30 year old postpartum mother) Receiving counselling and a method of postpartum LARC without the knowledge and approval of the husband highly caused marital conflicts. Women reported that some husbands disliked family planning services to the extent that they could divorce their wives if they took up any method. “When they reach there sometimes the health workers sensitize them and they get courage. Then she decides to take it. So, from there then she gets back, others [women] even divorce when the husband doesn’t agree with what she has done [taking up postpartum LARC].” (ID402, 23 year old postpartum woman) Failure to return for family planning services. Unavailability of men for male companionship during ANC visits Women noted that failure to receive family planning while in the hospital after delivery meant, they could not get time to come back because of their busy domestic duties at home. Additionally, having to wait long hours at the health facility in order to receive services also causes most mothers to not to seek or to delay seeking family planning services. Most men were not able to accompany their wives to health facilities due to their busy work schedules which reduced their opportunities to receive family planning counselling services. “For us we have a lot of work as mothers so you decide to go home and I will come back another day. Now when you reach home, you may be caught up with work, you say you will get time and go back to the health facility.” ( 27 year old postpartum woman) Me, I am a motorcyclist. I can wake up early morning and say let me go to work, I will come back and we go with my wife for the ANC appointment. Then time reaches when I have not yet come back from work, perhaps I might be still very far, therefore my wife comes alone to hospital. (61 year old FGD Male partner) Theme 3: Motivation Sub-theme A: Automatic; Women were automatically motivated not to utilize PPFP due to negative influence of the care taker about use of LARCs, lack of male involvement. Sub-theme B: Reflexive Fear of infidelity, side effects, Discomfort of procedures of LARCS, Negative experience reflexively motivates women not to take up PPFP were reflexive motivators to hinder uptake of PPFP. Fear of infidelity Women especially those with men having long distance jobs perceived that their husbands thought that the use of postpartum LARC would encourage them to have sexual relations with other men. “Now he might be thinking that if I go for family planning and yet he is not always around, I might cheat on him, you know how men can be, they might think you are here doing different things yet in actual sense you are doing your work and he thinks you are cheating that is why he does not want.” (ID103, 27 year old postpartum woman) Discomfort of procedures of LARCs methods: Barriers such as discomfort of the LARCs methods were discovered and these had code such as invasive removal of implants, side effects, and discomfort on insertion of the IUD, and implant. Women felt discomfort due to the invasive mode of removal of implants. Some women thought that inserting IUD immediately after birth was difficult, painful and uncomfortable for them. The mode of insertion of the IUD in the context of per vaginal bleeding made it more discomforting for the woman. “ Because of the way they insert it in down there. Yes, I see it is difficult/uncomfortable to be with…..Yes, in the process of putting it.” (30 year old postpartum woman) “The fear is during removal as you know some of us drink alcohol so they may give the drug to reduce pain and may not work so when they cut to remove you feel the pain”(28 year old FGD pregnant woman). Side effects Over-bleeding was the most common side effect reported to be experienced by women. They reported that they became dizzy whenever they over-bled especially using the implant method. Other side effects that were commonly experienced with implants included gaining weight and weight loss “Now I gave birth to him in 2018,(by then) that is when I used it but I did not use it to the end. It would make me bleed a lot, I would always feel dizzy so I used it for one and a half years after I came and it was removed.” (22 year old postpartum woman) “If they fit in you, it might accept(or work in) your body and then you fatten. The whole of you fattens and then someone thinks that you’re pregnant yet not. The second one, there is finishing two “weeks” while “bleeding” when you go to the hospital and they give some tablets then it stops..”(, 23 year old postpartum woman) However lack of sexual drive was reported by some women and associated it with feeling like a pregnant woman. “My wife was not having sexual desires. Then I asked her, “how come when we are in one bed when I want to have sexual relations you say you don’t have the sexual desire”,,, Then I said, “what can we do, we go and remove the method”(30 year old FGD Male partner). Enablers to utilisation of postpartum LARCs . Theme 1: Capability: Sub-theme A: Pyschological Knowledge on LARCs, need to resume intimacy with their partners, having attained a desired family size and conceiving too soon were factors that made women psychologically capable of taking up PPFP. Need to resume intimacy with their partners The recovery process also enabled return of menstrual periods which indicated to women the possibility of conception and the need for family planning. The return of menses was also accompanied by sexual resumption which women thought would put them at risk of pregnancy. “Now I knew that I was becoming fine/ fine and my husband could want to be intimate [have sexual relations]. So I knew I might conceive accidentally.” (22 year old postpartum woman) Having attained a desired family size Men and women whose marriages were old or had lasted long with evidence of grandchildren present were automatically motivated to take up postpartum LARCs due to having attained a desired family size. “Ok, for family planning, I want and I want it 100% because even the number of children is that one(enough), I have even started having grandchildren.” (, 32 year old postpartum woman with parity of 12) Conceiving too soon Willingness to and use of postpartum LARC was related to the need to promote child spacing and promote proper recovery from childbirth especially women who had complications during child birth. “She told me that it is true when you use family planning, you will space your children and even if you get pregnant again, these other children will not be sickly. If you do not space children they disturb you because they are always sickly and you will not be able to take care of them.” ( 22 year old postpartum woman). Sub-theme B: Physical Afew health workers had skills to offer the LARCs and this capability enabled them to offer PPFP. Theme 2: Opportunity Sub-theme A: Physical Physical opportunities such as availability of PPFP methods enabled women to take up PPFP. Sub-theme B: Social Good attitude of health workers, Joint decision-making to take up FP and partner support were social opportunites that facilitated uptake of PPFP. Joint decision making with a partner about family planning. Most women who received health education after birth regarding the importance of using postpartum LARC, the six weeks period enabled women to share the new information with their male partners, a step which was critical in joint decision making. Partner approval following joint decision as a couple was thought by both women and men to promote utilisation of LARC after six weeks, rather than immediately after birth, since women needed to first seek guidance and approval from their husband when they go back home after being discharged This motivated women to take up postpartum LARC. Relatedly, the utilisation of LARC in the six weeks was facilitated by the postnatal care services especially immunization which was thought to be suited for postpartum LARC. “So, if they give me something [health education] and then I come back after one and a half month, I come back and sit with my partner and explain to him that and we agree with each other. Then there is no problem.” (, 23-year-old postpartum woman) “The one and a half months (starting contraception 6 weeks after delivery) would be better for us the women….there on going back at one and a half month [for immunization], it’s better you receive it because you would have agreed with your partner.” (, 23-year-old postpartum woman) . Theme 3: Motivation Sub-theme A: Automatic Positive attitude towards couple counselling and FP use, positive influence by partners, family members, and health workers with male involvement in ANC couple counselling on FP automatically motivated women to take up PPFP. Positive attitude towards couple counselling and family planning use Women and male partners expressed palpable demand and interest to receive information and counselling regarding postpartum LARC. Participants thought that informing them about postpartum LARC would help them decide on whether to use LARC in the immediate postpartum period. Positive attitudes towards family planning use were related to receiving health education as a couple during antenatal care, positive nudging from grandmothers, and not experiencing the side effects purportedly reported among family planning methods. “Me it looks better if we are counselled when we are all together me and my wife, because we shall decide on one issue. And the questions that will be asked, we; my wife and I will be able to answer together. (30 year old FGD Male partner). “That one (Implant) is good I can put it, it does not have any problem. Okay there are those who say that when they put they bleed a lot but I have never tried it. But I see as if it is good.” ( 27 year old postpartum woman) Influencers for postpartum LARCs The subjective norms relating to recommendation to use of family planning in the postpartum period among the peers encouraged some women to use postpartum LARC. The healthcare provider had a strong influence to utilisation of postpartum family planning methods especially among women with childbirth complications. The family social circles, the grandmothers and other senior women further influenced women on the use of postpartum LARC. “Considering how the health workers explained to me that I should not conceive soon since my uterus is now very weak. I should take some time before producing again.” (ID102, 22-year-old postpartum woman) “I have seen from my sister, she delivered by C/S. She gave birth to twins and my mother looked at their income as a couple and it was not good so she told her if you do not space, you will not be in good conditions. So do not produce again soon..” ( 22-year-old postpartum woman) The society perceived that women`s primary role was to give birth while that of men was to provide for the family. This negatively influenced mothers by preventing them from taking up postpartum LARCs. They reported saying; “Some men say that they leave their women to produce because they(men) take care of the family.” (, 35year old Antenatal woman) Sub-theme B: Reflexive; We uncovered factors such educated mothers, long duration of action, approval to the utilization of LARC and preference of LARCs as reflexive motivators for utilization of PPFP. Long duration of action Women were motivated to take up postpartum LARCs because of their long duration of action and perceived effectiveness when used. Women reported that in cases of stockouts for short-acting reversible contraception methods at health facilities, those who already received the LARCs methods are already protected from conceiving and will not be affected by stock outs. “Because for the short acting methods, it's difficult. You might go to the hospital and…then that we are out of stock…And sometimes because of unavoidable issues the dates might reach when you’re not around….But with the other method (implants& coils) when they say that it’s 5 years it will be 5 .” (ID402, 23 year old postpartum woman) Preferences for contraceptive implants. The utilisation of LARC in the postpartum period was related to covert preferences for contraceptive implants. Some women were opposed to the use of the IUD and indicated that they would be willing to use contraceptive implants instead. The preferences for contraceptive implants were related to perceptions that the side effects were less for contraceptive implants especially those related to vaginal bleeding, interference with sexual intimacy with the male partner, and the effect on fecundity. Similarly, the misconceptions surrounding the use of implants were less for the IUD which provided a positive subjective norms and ambience favourable for use of postpartum contraceptive implants. Some of the women had used contraceptive implants before which promoted its use in the immediate postpartum period. The method of inserting contraceptive implants was also thought to be compatible with the immediate postpartum period as it was thought not to interfere with the healing and recovery process after childbirth. For the arm, it is also not bad. I see it does not cause difficulty….it is not like the coil….for it just, they put on the arm, then they treat you for just a short time. Few days it can be ok. You will be healed. Not like the other one (IUD), when you will be in pain. However, a few women preferred using the IUD due to its long term effectiveness compared to the implant. “ok, for me if they are to give me a method, truth they have to give me the IUD, I would want it; the one for the opening of the uterus (IUD). Why? Because it’s similar to the other one (implant - in being long acting compared to short acting methods). Reason being if they have fitted it (IUD) in you, for it, you have enough protection in your body and if you’re to be wherever. ( 23 year old postpartum woman) Women and men recommended sensitization by health worker, experienced clients and community outreaches on Postpartum Family Planning as ways to increase their capability to take up PPFP. Healthworkers reported that training on Postpartum Family Planning and borrowing PPFP methods from other health facilities during stockouts or shortages medical supplies would increase physical opportunities for women receive Postpartum Family Planning. Provision of privacy and confidentiality to women and offering Family Planning counselling during ANC visits and at postnatal units were recommendated as social opportunities for women to take up Postpartum Family Planning. Recruitment of male VHTs, male involvement in ANC and other health services were suggested to be automatic motivators for uptake of Postpartum Family Planning. Women were recommended not to take advice from negative peers and first try to take up a family planning method to get their own experience. This makes them exercise autonomy in using a method of family planning. The need for individualized FP, sensitization by use of poster images about PPF and media would reflexively motivate women to take up PPFP. Offering individualized counselling helps shy or fearful or low esteemed women to freely open up to health workers about their concerns on family planning. Discussion The study was conducted to explore the enablers and barriers to utilization of LARC among postpartum women. Our study findings underscore the lack of healthcare provider-initiated counselling and provision of LARC, limited knowledge of health workers, vhts, men and women, misconceptions of women and men, lack of partner approval, and shortages of PPFP commodities and sundries as the main barriers to uptake of postpartum LARC’s. These mainly affected the women`s capability in taking up the PPFP as well as lowering their opportunites to receiving PPFP services. The enablers to utilization of postpartum LARC included attainment of ideal family size, skilled health workers, positive attitudes and effectiveness of LARC. These motivated women, strengethed their capability and gave then an opportunity to take up PPFP. Our study has important implications to maximize missed opportunities for provision of postpartum LARC and reduce the high fertility rates in our settings. In LMIC only 13% of postpartum women use LARC ( 20 ). Despite women’s demand to be informed about postpartum LARC, participants in our study noted the lack of healthcare provider-initiated counselling and provision of postpartum LARC greatly hindered the utilization of LARC. This was compounded by the overstretched healthcare providers, lack of agency of women to request for postpartum contraception and the fragmented nature of healthcare services provision. The lack of healthcare provider-initiated counselling and provision may be related to the lack of integrated services. Similar studies in LMIC have also reported lack of integrated services and postpartum counselling as the main factors that hinder uptake of postpartum LARC ( 15 , 20 , 21 ). Overall, the increasing rates of health facility deliveries in Uganda presents an opportunity to scale up utilization of immediate postpartum LARC especially given the corresponding low attendance of postnatal care services ( 6 ). Our study notes that women were reluctant to come back to the health facility after delivery for family planning methods, a finding which was consistent with other studies ( 21 , 22 ). Therefore, identifying feasible ways of integrating immediate postpartum LARC into routine facility deliveries would tremendously improve the utilisation of immediate postpartum LARC’s ( 20 ). Limited knowledge and skills as well as misconceptions further affected the use of LARC in the postpartum period. It made women to lack the capability to take up PPFP. Participants thought that they needed to first recover from childbirth and resume their menses before using LARC. The shortages of PPFP methods and equipment with overburdened health workers hindered offering of PPFP. The perceived lack of sexual intimacy during this period and the role of breastfeeding further affected the use of immediate postpartum LARC. Our findings are consistent with studies in Africa which reported the role of resumption of menses in uptake of immediate postpartum LARC ( 22 , 23 ). This could be related to women’s perception that the risk of pregnancy was low during the period because menses had not yet returned and the perception that breastfeeding supresses return of fecundity( 23 , 24 ). Healthcare providers have been noted to perpetuate the misconception of the association of return of menses with return of fertility( 23 ). Therefore, it is important to counsel women and healthcare providers regarding the high risk of pregnancy given that ovulation may precede menses during postpartum period ( 23 ). Women in our study valued the need to recover from vaginal bleeding and their menses to resume after childbirth because modern contraceptives were thought to cause heavy bleeding. Therefore, it is important to address the existing limited knowledge and misconceptions surrounding postpartum use in an effort to promote uptake of immediate postpartum LARC. Poor partner support lowered women`s oportunites to takeup PPFP as well as demotivated them. This hindered the utilisation of postpartum contraception. The male partner disapproval of immediate postpartum LARC was related to misconceptions, and lack of involvement in decision making to use family planning. This was consistent with other studies from similar settings which cited lack of partner approval as a deterrent to uptake of immediate postpartum LARC ( 21 – 24 ). In patriarchal societies with deeply entrenched gender inequalities, the male partner makes all the decisions in the family including the reproductive health needs to use postpartum contraceptives ( 15 , 21 , 22 ). Women who desire to use PPFP may not accept it for fear of retribution, gender-based violence and reproductive coercion ( 21 , 25 ). Although male partners do not always escort their women for deliveries, their involvement is key in the uptake of immediate postpartum LARC ( 24 ). In our study, the poor utilization of LARC in the immediate postpartum period was related to misconceptions and fear of side effects, a finding which was similar to other studies ( 15 , 23 – 25 ). This was particularly important given the low utilization of LARC (1% for IUD) in the general population compared to other modern contraceptives (27% for injectables) ( 6 ). Although most women were opposed to using IUD in the postpartum period, some preferred to use contraceptive implants. The contraceptive implant was seen to cause fewer side effects, and could not interfere with the healing process after childbirth which suggests an opportunity to promote contraceptive implants in the immediate postpartum period. Relatedly, women were willing to use postpartum LARC after 6 weeks of childbirth, a finding which was consistent with a study in DR Congo and Burkina Faso ( 22 ). The six weeks period was perceived to allow them time to heal but was also thought to provide an opportunity to discuss and make a joint decision to use family planning with the male partner. Strengthening the interventions that promote utilization of immediate and 6 weeks postpartum services could play a critical role in the use of immediate postpartum LARC. Strengths and limitations Our study provides insight of the barriers and enablers to use of LARCs in the immediate postpartum period. We recruited participants from antenatal care, women who delivered in a health facility or home. We also included their male partners. The collaborative approach especially the approach to involve the participants in suggesting recommendations to improve uptake of immediate postpartum contraceptive was very empowering. Our study findings did not majorly differ from those of a similar study done in south western Uganda by Merlin et. al which could be a reflection from other regions of the country except for are few findings like fear to coomunicate to busy health and certain misconceptions by women. Therefore interventions to improve PPFP uptake could benefit women in the entire country. The study was limited to a small portion of eastern Uganda which was mainly Mbale and Budaka districts which might not reflect the entire eastern region. Conclusion The utilization of immediate postpartum family planning in Mbale Regional Referral Hospital was highly hindered by limited knowledge and skills among health workers and VHTs, misconceptions among women and men, poor partner support and lack of FPcounselling. Further research should be done to test the effectiveness of Integration of family planning services along the continuum of maternity care and the use of innovative low cost interventions such as videos for health education and counselling to increase utilization of immediate postpartum contraception. Declarations Consent for publication. The authors consent for publication. Availability of data and materials. Additional data and materials can be accessed on reasonable request from the corresponding author. Competing interests. The authors declare no competing interests. Funding. Funding provided by the Royal Society of Tropical Medicine and Hygiene (RSTMH) Authors’ contributions. AK, MW, DM, and MM did conceptualization, MW and DM provided the methodology; software, AK,DA, and RN did the formal analysis. AK and DA wrote the original draft manuscript, MD, MM,JE, MW, JNW, DA, SW, DN, PAMN,FO, JW, and AN, reviewed and edited, MW did visualization, MW, DM and MM did supervision, AK was project administrator, AK acquired funding. All authors have read and agreed to the published version of the manuscript. AK and DA had full access to all study data and took responsibility for the integrity of the data and the accuracy of the data analysis. Acknowledgment. We would like to acknowledge God, RSTMH for funding this study and the research mentee group or the moral support given during the study. We would also like to acknowledge the research assistants and participants who consented to be interviewed. We would like to thank them for willingly taking the time to provide the information and data needed to complete this study. References Pasha O, Goudar SS, Patel A, Garces A, Esamai F, Chomba E, et al. Postpartum contraceptive use and unmet need for family planning in five low-income countries. 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Jalinga Vuamaiku G, Epuitai J, Andru M, Aleni M. “I Don’t Support It for My Children”: Perceptions of Parents and Guardians regarding the Use of Modern Contraceptives by Adolescents in Arua City, Uganda. International Journal of Reproductive Medicine. 2023;2023. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Oct, 2024 Read the published version in Contraception and Reproductive Medicine → Version 1 posted Editorial decision: Revision requested 31 May, 2024 Reviews received at journal 31 May, 2024 Reviewers agreed at journal 25 May, 2024 Reviewers agreed at journal 22 May, 2024 Reviews received at journal 21 May, 2024 Reviewers agreed at journal 21 May, 2024 Reviewers agreed at journal 20 May, 2024 Reviewers agreed at journal 20 May, 2024 Reviewers invited by journal 20 May, 2024 Submission checks completed at journal 16 May, 2024 Editor assigned by journal 16 May, 2024 First submitted to journal 13 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4412393","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":306831644,"identity":"f79b52e8-534a-41d3-a8c9-885cc0d80772","order_by":0,"name":"Assen Kamwesigye","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, Mbale Regional Referral and Teaching Hospital, P.O. Box 921,","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Assen","middleName":"","lastName":"Kamwesigye","suffix":""},{"id":306831645,"identity":"79f4616d-355a-445d-8817-e4968679f943","order_by":1,"name":"Daphine Amanya","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYDCCAwxsDAlwXgUQMzM3kKLlDEgLIxFa4ICxDUzi18J3/OyxBw932Mjrtp89JvFzXm00fztQy4+KbTi1SJ7JSzdIPJNmuO1MXppk77bjuTMOMzYw9py5jVOLwYEcM4nEtsOM20AM3m3HchuAWpgZ2/BoOf8GpOW//TYgQ/LvnGO58wlquQG25UDiNiBDmrehJncDIS2SN96lAbUkJ2+78cbYWubYgdyNQC0H8fmF73zuMcmfbXa2287nGN58U1OXO+/84YMPflTg1sLAwANnsUgwMBwGsw7gUY+ihfkDA0MdfsWjYBSMglEwIgEAuZNjrTazy/0AAAAASUVORK5CYII=","orcid":"","institution":"Department of Community and Public Health, Busitema, Faculty of Health sciences, University, P.O. 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Box 1460,","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ritah","middleName":"","lastName":"Nantale","suffix":""},{"id":306831654,"identity":"fe59c073-ae4b-428f-863d-c98276d2c0fb","order_by":10,"name":"Agnes Napyo","email":"","orcid":"","institution":"Department of Nursing and Midwifery, Faculty of Health Sciences, P.O. Box 317, Kabale, University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Agnes","middleName":"","lastName":"Napyo","suffix":""},{"id":306831655,"identity":"7f801e78-67af-4090-a2bc-310ba3d13271","order_by":11,"name":"Julius N Wandabwa","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, Mbale Regional Referral and Teaching Hospital, P.O. Box 921,","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Julius","middleName":"N","lastName":"Wandabwa","suffix":""},{"id":306831656,"identity":"fb53c399-090c-4f82-87de-b380ebad9682","order_by":12,"name":"David Mukunya","email":"","orcid":"","institution":"Department of Community and Public Health, Busitema, Faculty of Health sciences, University, P.O. Box 1460,","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Mukunya","suffix":""},{"id":306831657,"identity":"b07d8865-01d6-4567-87ed-093d9f457fd0","order_by":13,"name":"Milton W Musaba","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, Faculty of Health Sciences, Busitema University, P.O. Box 1460","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Milton","middleName":"W","lastName":"Musaba","suffix":""},{"id":306831658,"identity":"ac28773b-425a-4b77-b330-26f03f50eaad","order_by":14,"name":"Merlin Willcox","email":"","orcid":"","institution":"School of Primary Care, Population Sciences and Medical Education, University of Southampton.","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Merlin","middleName":"","lastName":"Willcox","suffix":""}],"badges":[],"createdAt":"2024-05-13 09:55:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4412393/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4412393/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40834-024-00308-5","type":"published","date":"2024-10-10T15:57:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57448876,"identity":"2166648e-d216-42fc-9820-12414559377e","added_by":"auto","created_at":"2024-05-30 20:00:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":132709,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework to explore enablers and barriers to uptake of LARC adapted from the COM-B Model \u0026nbsp;(16).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4412393/v1/40e5c3e40471400df0418415.png"},{"id":66597531,"identity":"36e16005-8c8f-4df1-8f8e-ce75ec89c260","added_by":"auto","created_at":"2024-10-14 16:10:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1314493,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4412393/v1/8c2776c2-0dd2-486f-bb41-a6a2f58212da.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and enablers to utilisation of postpartum long-acting reversible contraception in Eastern Uganda: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAfter childbirth, almost all (95%) women wish to delay or prevent future pregnancies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite their overwhelming desire and motivation to delay or prevent future pregnancies, only 10% of women use modern contraceptives in the postpartum period (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe unmet need for family planning is noted to be highest among postpartum women than in the general population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The low utilisation of postpartum contraceptives predisposes women to short interpregnancy intervals, and unwanted pregnancies; many of which end up as unsafe abortions, which are associated with adverse maternal, perinatal and infant outcomes including death (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Specifically, a short interpregnancy interval is associated with low birth weight, preterm birth, small for gestation age, and poor neonatal survival rates, and very often death for both mother and baby (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Short birth intervals affect the woman\u0026rsquo;s ability to engage in income generating activities leading to social economic deprivation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn low- and middle-income countries, few women receive counselling regarding family planning during antenatal and postnatal care which underscores the limited opportunities available for women to be informed about postpartum family planning (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Similarly, there are many missed opportunities to counsel and provide postpartum family planning along the continuum of maternal and child health services (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Uganda, 41% of women who were not using family planning reported not receiving counselling regarding family planning during their visit to the health facility (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite the fact that the Ministry of Health guidelines encourage provision of integrated services at all levels which has increased rates of health facility deliveries, 90% women still leave health facilities after childbirth without receiving postpartum contraceptives (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The high number of women who do not return to the health facility for postnatal care attendance highlights a missed window\u003c/p\u003e \u003cp\u003ePostpartum contraception confers benefits of convenience, ease of insertion/provision, and increased utilisation of modern contraceptive services (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, in Africa among the few women who opt for postpartum family planning, more than 90% of women preferred to use short-term contraceptives (oral or injectable contraceptives) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The problems of inconsistent and early discontinuation inherent in short-term contraceptives undermine their effectiveness in providing long-term contraception in the postpartum period (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The long-acting reversible contraceptives (LARCs), including implants and intrauterine devices, remedy the need to rely on the user (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). LARC provide highly effective, efficacious, safe and long-term contraception for postpartum women (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral quantitative studies have assessed demographic predictors of post-partum contraception use (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and use of LARCs (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), but these do not provide information on how to improve the provision of post-partum contraception services. Several qualitative studies have explored the views of Ugandan men and women about contraception in general, but no specific findings have been reported about post-partum contraception (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A qualitative study has explored barriers to the utilisation of immediate postpartum contraception for women in South-Western Uganda(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), but this setting is different from ours.\u003c/p\u003e \u003cp\u003eThe study was conducted to gain insight into the barriers and enablers for utilization of post-partum LARC within Mbale and Budaka districts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a descriptive qualitative study. The study was grounded on the COM-B theoretical framework (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This framework involves the capability (physical \u0026amp; psychological), opportunities (physical \u0026amp; social) and motivation (reflective and automatic) to postpartum LARC use (behaviour) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Capability to use postpartum contraception includes psychological capability (knowledge and attitudes) and physical capability (e.g., skills for inserting IUDs and implant, medical eligibility criteria) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The opportunities were categorised under physical (health system factors) and social (e.g., convenience and social acceptability), while motivation includes automatic (subconscious beliefs about family planning) and reflective or conscious motivations for postpartum family planning use (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eThe study was conducted in different settings in Mbale and Budaka Districts in Eastern Uganda. This included antenatal and postnatal units of Mbale Regional Referral Hospital (MRRH), Busiu Health Centre (HC) IV and Budaka HC IV. Outside of the health facility settings, the study was conducted among residents in both town and rural areas of Mbale district (Busiu and Nakaloke) and a community in Budaka district. This enabled us to get a general representation from both the town and rural areas of Eastern Uganda. MRRH is a regional referral hospital with a large catchment area serving populations in Bugisu, Teso, Bukedi and Sebei sub-regions. The hospital provides a range of antenatal, intrapartum and postnatal services including postpartum family planning (PPFP) services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and sampling procedure\u003c/h2\u003e \u003cp\u003eThe study included pregnant women who were receiving antenatal care and postpartum women in MRRH, Nakaloke, Budaka and Busiu Health Center IV. Male partners of women who had just given birth were included in the study as well. Women who had delivered within the last six months were included in the study whether they were breastfeeding or not. Health workers at MRRH and Nakaloke HC III and village health teams (VHTs) from the community of Nakaloke subcounty and Budaka district were also included in the study. Women who were critically ill and those who were six months post-delivery were excluded from the study. We used maximum variation purposive sampling to select the study participants who could provide rich in-depth description of the phenomenon under study (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The VHTs were used to identify the study participants from the community. Sampling was based on the principle of data saturation. In our study, data saturation was reached after 22 in-depth interviews (IDIs) with 11 women, four male partners, three VHTS and 4 healthcare workers. Three focus group discussions of 6\u0026ndash;7 participants per group were conducted among pregnant women in antenatal clinic, postpartum women and the male partners.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection procedures and methods\u003c/h2\u003e \u003cp\u003e Semi-structured interviews were conducted using an interviewer administered guide. The questions for the guide were derived from the COM-B framework. The guide had questions about family planning in general (discussed family planning use with the male partner and ever used family planning). Women in postpartum clinic were asked whether they had been offered family planning in general and/or LARC immediately and/or within six months after child birth. The women were further probed for their perceptions, willingness to use PPFP, perceived enablers and barriers to use of immediate PPFP. Women who were not offered immediate PPFP after delivery were asked about their interest to receive counselling on PPFP, their intention to use contraception, perceived enablers and barriers to contraception use and their preferred method of PPFP. The format of questions for male partners and pregnant women was similar to that used for women in the postpartum period.\u003c/p\u003e \u003cp\u003eThe interviews were conducted by DA, BN, PN, (female midwives with a degree in midwifery), FO \u0026amp; DN, (female medical officers) and JW \u0026amp; SW (male midwives with degree in midwifery) who spoke the native languages of the study participants (Luganda, lugwere, lumasaba). Data collection was between April and December 2023. The in-depth interviews lasted 25 to 80 minutes, while the FGDs lasted from one hour and 30 minutes to two hours. Note-taking was done during the interview to capture impressions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis and rigor of the study\u003c/h2\u003e \u003cp\u003eInterviews were audio-recorded on a digital voice recorder. All voice recordings were carefully transcribed verbatim by DA, BN, PN, FO, and SW and they also translated to English by a native of the local languages (Lumasaba, Luganda, and Lugwere). The Atlas.ti.9 was used in the analysis. Braun and Clarke\u0026rsquo;s thematic analysis involving six step process was used (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This involved familiarization with the transcripts, identification and development of codes. Coding was developed iteratively to add new emerging concepts. The codes were combined into themes and subthemes that represent the perceived barriers and enablers of post-partum contraception. We used the COM-B framework to organise our results, by assigning each each theme to the appropriate component in the COM-B model. Details in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eTrustworthiness and rigor of the study findings was maintained through triangulation of data sources (pregnant women, postpartum women and male partners), study sites (hospital and community setting), and data collection methods (in-depth interviews and focus group discussion)(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Male interviewers were used to interview male partners, while female interviewers were used to interview women. The interviews were conducted by midwives which ensured credibility of the findings (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Data analysis was conducted by three persons (AK, DA, \u0026amp; BN) to ensure the trustworthiness of the findings. We have used direct quotes from the participants to reinforce the confirmability of the study findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003eThe study obtained ethical clearance from the Busitema University Research and Ethics Committee (BUREC NO. BUFHS-2023-51). Written informed consent was obtained from the study participants while administrative clearance was obtained from all the units where the study was conducted. All the participants enrolled into the study were above 18 years and received modest compensation of 20,000 Ugandan shillings (approximately \u0026pound;5) as per the guidance from the Busitema University Research and Ethics Committee. Participants (three in number) who requested to use postpartum LARC method were referred to family planning services.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe interviewed 39 participants. 20 of these were in-depth interviews ( nine postpartum mothers, three male partners, one ANC mother, four health workers and three VHTs) and three FGDs where one was with six antenatal mothers, another with seven postpartum mothers and one with six men whose partners were in the postpartum period. Among the indepth interviews, we interviewed 3 couples. None of the participants declined to enroll in the study. The age range of the most participants was 20 to 35 years(n\u0026thinsp;=\u0026thinsp;31), while the majority were of formal education (n\u0026thinsp;=\u0026thinsp;37) and were peasants (n\u0026thinsp;=\u0026thinsp;20). Most of the participants were of the Bagisu ethnic group, had one to three children (n\u0026thinsp;=\u0026thinsp;14) and delivered from a health facility (n\u0026thinsp;=\u0026thinsp;31).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostpartum Women (N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAntenatal women (N\u0026thinsp;=\u0026thinsp;07)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMen (N\u0026thinsp;=\u0026thinsp;09)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth workers (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVillage health teams (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026not; 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeasant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf employment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotorcyclist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse/ Midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVillage health team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnic Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBagwere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBagisu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of Delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEnablers and barriers to uptake of immediate postpartum LARC\u003c/h2\u003e \u003cp\u003eWe identified 3 themes which were enablers, barriers, and recommendations. These had sub-themes which were structured around the COM-B model. The enablers and barriers were aligned into capability, opportunities, and motivation of behaviour.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eApplying the COM-B model to explore the barriers, facilitators and recommendations to uptake of immediate postpartum LARC.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCom-B domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnablers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRecommendations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Lack of knowledge,\u003c/p\u003e \u003cp\u003e\u0026bull; Misconceptions, (need to wait for menses, effect of birth trauma on use of LARC, perceived body fragility immediately after birth, Religious beliefs).\u003c/p\u003e \u003cp\u003e\u0026bull; lack of sexual intimacy after delivery\u003c/p\u003e \u003cp\u003e\u0026bull; Differing fertility goals,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Knowledge on LARCs\u003c/p\u003e \u003cp\u003e\u0026bull; Need to resume intimacy with their partners\u003c/p\u003e \u003cp\u003e\u0026bull; having attained a desired family size, conceiving too soon,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull; sensitization by health workers while in health facilities\u003c/p\u003e \u003cp\u003e\u0026bull; community sensitization by health workers and VHTs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Unaware and unskilled health workers in offering LARC services.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Health workers have skills to offer the LARCs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull; Training Midwives to enhance their skills in PPFP.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Lack of health worker-initiated family planning services,\u003c/p\u003e \u003cp\u003e\u0026bull; overburdened health workers,\u003c/p\u003e \u003cp\u003e\u0026bull; Shortage of equipment used to offer LARCs and stock outs of LARCs .\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Availability of PPFP LARC.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull; Lobby for LARC from other health facilities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Harsh workers\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of partner support\u003c/p\u003e \u003cp\u003e\u0026bull; lack of agency to ask for health education.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Good attitude of health workers\u003c/p\u003e \u003cp\u003e\u0026bull; Joint decision-making to take up FP\u003c/p\u003e \u003cp\u003e\u0026bull; Partner support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull; Provision of privacy and confidentiality to women\u003c/p\u003e \u003cp\u003e\u0026bull; Offering FP counselling during ANC visits and at postnatal units.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Negative influence of the care taker about use of LARCs.\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of male involvement.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Positive attitude towards couple counselling and FP use,\u003c/p\u003e \u003cp\u003e\u0026bull; Positive influence by partners, family members, and health workers.\u003c/p\u003e \u003cp\u003e\u0026bull; Male involvement in ANC couple counselling on FP.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull; Recruitment of male VHTs\u003c/p\u003e \u003cp\u003e\u0026bull; male involvement in ANC and other health services, sensitization by expert clients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReflexive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Fear of infidelity,\u003c/p\u003e \u003cp\u003e\u0026bull; side effects,\u003c/p\u003e \u003cp\u003e\u0026bull; Discomfort of procedures of LARCs\u003c/p\u003e \u003cp\u003e\u0026bull; Negative experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Educated mothers\u003c/p\u003e \u003cp\u003e\u0026bull; Long duration of action, approval to the utilization of LARC,\u003c/p\u003e \u003cp\u003e\u0026bull; preference of LARC.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull; Sensitization, need for individualized FP,\u003c/p\u003e \u003cp\u003e\u0026bull; Sensitization by use of poster images about PPF and media.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Capability\u003c/h2\u003e \u003cp\u003eWomen`s capability to take up immediate PPFP was hindered psychologically and physically.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme A: Psychological capability\u003c/h2\u003e \u003cp\u003eThe following factors psychologically impeded the women`s capability to uptake of immediate PPFP; Lack of knowledge, Misconceptions, (need to wait for menses, effect of birth trauma on use of LARC, perceived body fragility immediately after birth, Religious beliefs), lack of sexual intimacy after delivery, Differing fertility goals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimited Knowledge and misconseptions\u003c/h2\u003e \u003cp\u003eDue to limited knowledge on PPFP, many participants developed misconceptions about PPFP methods. This therefore would affect their psychologically capablilty of deciding to take up the PPFP. We identified misconceptions and fear of side effects, differing fertility goals, need for menses to return, lactation amenorrhea, birth trauma after delivery, inexperience in use if the IUD, perceived body fragility, perceived women`s role in the family and fear of side effects as hinderances to uptake of PPFP.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMisconceptions\u003c/h2\u003e \u003cp\u003eThe utilisation of LARC especially IUD was hindered by the misconceptions surrounding IUD use. The misconceptions regarding the use of IUDs and implants included interference with sexual intercourse, disappearance in the body, causing weight gain, excessive bleeding and infertility. Women thought that insertion of the IUD required measurement of the length of partners\u0026rsquo; penis.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, women always complain. That if they insert that coil, it disappears in your body; that it kills off eggs (ova) in a burnt manner\u0026hellip;.that it \u0026hellip;goes up to the heart. (23year old postpartum woman).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;if it( the IUD) starts to harm me during sexual intercourse, then I feel pain, I start to ask myself that what is it? Or sometimes then we divorce\u0026rdquo; (53 year old Male partner)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;That coil me I hear the people who go for it say that they measure the length of your husband\u0026rsquo;s penis and they say that if you go for that coil you do not have to cheat, that when you cheat you get problems because men are not the same (in terms of the length of the penis) and that the coil is not good.\u0026rdquo; ( 27year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMisconception for the need to wait for menses and lack of sexual intimacy\u003c/h2\u003e \u003cp\u003eThe use of LARC in the immediate postpartum period was perceived to be irrelevant since the menstrual periods had not yet returned. Women thought that absence of menses meant that they could not conceive, while others thought that LARC uptake in the immediate postpartum period was only relevant for those whose menses had returned early. Return of menses was also key for women who thought that LARC would cause amenorrhea. Some women wanted to know when their menses would return after birth, and so, were reluctant to use family planning methods which would interfere with the return of their menses.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes I cannot accept because if you do not see the period and you get like that family planning injection, you will be without having your periods you will not understand yourself. It needs you first menstruate and see that period. I first see the menstrual blood before (getting a method)\u0026rdquo; (27 year old postpartum woman).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe idea of using postpartum LARC immediately after childbirth was foreign to some women and male partners because of the lack of intimacy at this period.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;as the husband I cannot be with her intimately immediately after birth\u0026hellip;. So, at least I wait for her to return to her normal way. When she bleeds following birth, time comes and she is dry [lochia stops], but even if she is dry as the partner you can give her another one week before you can resume your game [sex]\u0026rdquo; (38 year old male partner).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMisconception for the need to recover and body fragility after delivery\u003c/h2\u003e \u003cp\u003eImmediate postpartum LARCs, especially the intrauterine device, were perceived to add more pain to those who experienced a traumatic delivery. Women, therefore, preferred to first recover from the birth trauma before taking up any method.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo; there for me, basing on what(having a painful vaginal tear repair after birth) i went through, I feel that you be adding me more pain(if you insert a coil immediately after child birth). Yes, in the process of putting it. You be when you are still fresh, like there they have vaginally repaired them, those one who are vaginally repaired. Ok the stitches be still painful then you add\u0026rdquo; (30year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe capability to use LARC was crippled by the nearly universal disapproval of its use in the immediate postpartum period. Women and male partners were reluctant to use LARC immediately after birth because of the perceived need for the woman to fully recover from the after-effects of childbirth including that the woman was still weak to use LARC. Women thought that their bodies were still fragile to use family planning immediately after birth. The fact that women were still bleeding made women to be more hesitant to use IUD as it was thought to make bleeding worse. This was especially important given that women lacked enough blood during this postpartum period. The associated pelvic pain during postpartum, and still fresh vaginal tears and repairs hindered the insertion and use of IUD during the immediate postpartum period.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;At least six weeks after birth. Immediately after birth I see she is still bleeding because she has just given birth, the \u0026ldquo;way\u0026rdquo; is still very wide,... So, if you put when the way is still wide, when it goes back to normal it might affect her\u0026rdquo; (38 year old Male partner)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I cannot accept. the uterus can be when it has not yet gone back to its original position. And you are still over bleeding. And you do not know when that bleeding is going to stop, in what period. You may say that you insert it in then you bleed over and over. And you say, this thing is the one causing the bleeding. yes, so for me I cannot accept it(the IUD). (35 year old Pregnant woman attending ANC)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDesire for a large family size\u003c/h2\u003e \u003cp\u003eThe use of postpartum LARC was hindered by a desire for a large family size. Some women wanted to give birth until their ova were exhausted which hindered the use of postpartum IUD\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There those who do not listen even if you tell them to (take-up FP), they just want to continue producing. Some, say let me produce the children until they get finished in the womb\u0026rdquo; (27year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme B: Physical capability\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eUnaware and unskilled health workers in offering LARC services\u003c/h2\u003e \u003cp\u003eThe unaware and unskilled health workers in offering PPFP services made women to be physically incapable to takeup PPFP. The reluctance of health workers to initiate postpartum LARCs contributed to skills and knowledge deficiency on postpartum LARC among men and women. Additionally, some midwives, nurses and village health teams were unaware of PPFP and unskilled in offering PPFP services.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have always known that after birth, you wait for some time, they don\u0026rsquo;t give it to you immediately. I didn\u0026rsquo;t know that you could get it.\u0026rdquo; (22-year-old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAround me l have them (other nurses and midwives) but they are not confident (skilled). Me I feel there is a way they are not confident because every time a mother comes for IUD, when I am not there they wait for me (40 year Midwife ).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Opportunity\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eSub-theme A: Physical\u003c/h2\u003e \u003cp\u003ePhyiscally, women lacked the opportunity to receive PPFP methods due to lack of health worker-initiated family planning services, overburdened health workers, shortage of equipment used to offer LARCs and stock outs of LARCs\u003c/p\u003e \u003cp\u003e \u003cb\u003eLack of Health worker-initiated family planning services.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll the mothers attended antenatal care, and only one of them delivered at home. The rest (n\u0026thinsp;=\u0026thinsp;14) delivered from a health facility. Postnatal care was poorly attended except for the purpose of bringing the child for immunization. Despite skilled birth attendance in a majority of the study participants, the majority of them were not counselled for postpartum LARC during antenatal care and postnatal care. There was no mention of postpartum LARC in the majority of cases (n\u0026thinsp;=\u0026thinsp;9) during antenatal and postnatal care, while in isolated cases, postpartum family planning was mentioned unintentionally and perfunctorily during history-taking in antenatal care. Most of these women who witnessed lack of initiated family planning services during their postpartum period lacked the opportunity to take up postpartum LARC methods.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;No, she (health worker) didn\u0026rsquo;t talk about it at all. And still they just discharged us\u0026rdquo;\u003c/em\u003e (38 year old Male partner whose wife delivered from Busiu HC1V).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They don\u0026rsquo;t give it [family planning] to you immediately. I didn\u0026rsquo;t know that you can get it. After some time then you can go and get it. The health workers had never 22-year-old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eConsequently, some women had never heard that family planning in general can be used in the immediate postpartum period. Paradoxically, healthcare workers misguided some women that they were not eligible for immediate postpartum LARC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have never heard that they put immediately after birth,\u0026hellip;Yes, the health workers\u0026hellip;then said, \u0026ldquo;but we cannot insert it (Implanon) in you right now [after abortion], go home and spend one month then you come back here and then we insert it in you.\u0026rdquo; \u0026rdquo; (35 year old Pregnant woman attending ANC at Nakaloke HC III)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite the lack of initiative to counsel and provide postpartum LARC on the part of the healthcare workers, women and male partners expressed palpable demand and interest to receive information and counselling regarding postpartum LARC. Participants thought that informing them about postpartum LARC would help them decide on whether to use LARC in the immediate postpartum period.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is good [to receive health education during ANC] because I [will]know as a mother when I give birth, I need to go to the health worker and they give me family planning to use\u0026rdquo; (Postpartum mother currently user of implant)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now there it needs when you\u0026hellip; maybe teach us and we might also be happy or get responsible\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eto see that we join family planning\u0026rdquo; (32 year old Postpartum mother with 12 children)\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eOverburdened healthcare workers and lack of agency to demand for health education\u003c/h2\u003e \u003cp\u003eThere was reluctance of women and their families to engage the healthcare providers regarding receiving information related to postpartum LARC. The healthcare workers were perceived to be so busy, very tired and unavailable to provide postpartum LARC, while the fear of burdening the authoritarian healthcare workers with need for postpartum LARC services further discouraged conversations regarding the utilisation of postpartum LARC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now, sometimes, the health workers may be busy\u0026hellip;, she might be tired. So, you may fear to talk to them because they have worked the entire night, they are tired and they want to go and rest\u0026hellip;..I fear to talk to them that is why I just keep quiet, .\u0026rdquo; (, 27year old postpartum woman).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eLack of FP equipment and shortage of LARCs\u003c/h2\u003e \u003cp\u003eStock outs of the postpartum LARCs hindered health workers from offering PPFP services. This was also associated with unavailability of equipment used to offer PPFP such as lignocaine, autoclave, and procedure couches.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;here I cannot insert an IUD where there is no couch. There should be a couch because you have to put this mother in lithotomy position then you do it.\u0026rdquo; (38-year-old midwife)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eOnly that sometimes when we have stock outs and maybe a mother has come, we don\u0026rsquo;t have lignocaine. We don\u0026rsquo;t have the gloves, we don\u0026rsquo;t have even syringes, no cotton, and sterility is a problem. Usually that\u0026rsquo;s what affects us as a facility.\u0026rdquo; (35-year-old Nurse)\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eSub-theme B: Social\u003c/h2\u003e \u003cp\u003eThere were factors that socially denied women an opportunity to takeup PPFP. These included; harsh workers, lack of partner support, lack of agency to ask for health education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eHarsh health workers\u003c/h2\u003e \u003cp\u003eWomen missed the opportunity of taking up LARCs because some health workers communicated harshly to them and disrespected client rights to remove a method which was causing them significant side effects such as excessive bleeding, loss of appetite and losing weight.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Just she [health worker] became harsh. When she became harsh I saw ah-ah that I am not managing [to wait for family planning counselling].\u0026rdquo; ( 30 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eLack of partner support:\u003c/h2\u003e \u003cp\u003eThe use of LARC immediately after childbirth was negatively affected by the male partner disapproval. The lack of involvement of male partners in the consenting and decision-making processes in addition to the misconceptions of the side effects of LARC made male partners reluctant to allow the use of LARC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;yes, what will you do? Now when the important thing you have to hide yourself (meaning to get implanon and not inform partner) and when you tell him, he does not accept.(30 year old postpartum mother)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eReceiving counselling and a method of postpartum LARC without the knowledge and approval of the husband highly caused marital conflicts. Women reported that some husbands disliked family planning services to the extent that they could divorce their wives if they took up any method.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When they reach there sometimes the health workers sensitize them and they get courage. Then she decides to take it. So, from there then she gets back, others [women] even divorce when the husband doesn\u0026rsquo;t agree with what she has done [taking up postpartum LARC].\u0026rdquo; (ID402, 23 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFailure to return for family planning services.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eUnavailability of men for male companionship during ANC visits\u003c/h2\u003e \u003cp\u003eWomen noted that failure to receive family planning while in the hospital after delivery meant, they could not get time to come back because of their busy domestic duties at home. Additionally, having to wait long hours at the health facility in order to receive services also causes most mothers to not to seek or to delay seeking family planning services. Most men were not able to accompany their wives to health facilities due to their busy work schedules which reduced their opportunities to receive family planning counselling services.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;For us we have a lot of work as mothers so you decide to go home and I will come back another day. Now when you reach home, you may be caught up with work, you say you will get time and go back to the health facility.\u0026rdquo; ( 27 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMe, I am a motorcyclist. I can wake up early morning and say let me go to work, I will come back and we go with my wife for the ANC appointment. Then time reaches when I have not yet come back from work, perhaps I might be still very far, therefore my wife comes alone to hospital. (61 year old FGD Male partner)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Motivation\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSub-theme A: Automatic;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWomen were automatically motivated not to utilize PPFP due to negative influence of the care taker about use of LARCs, lack of male involvement.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSub-theme B: Reflexive\u003c/h3\u003e\n\u003cp\u003eFear of infidelity, side effects, Discomfort of procedures of LARCS, Negative experience reflexively motivates women not to take up PPFP were reflexive motivators to hinder uptake of PPFP.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eFear of infidelity\u003c/h2\u003e \u003cp\u003eWomen especially those with men having long distance jobs perceived that their husbands thought that the use of postpartum LARC would encourage them to have sexual relations with other men.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now he might be thinking that if I go for family planning and yet he is not always around, I might cheat on him, you know how men can be, they might think you are here doing different things yet in actual sense you are doing your work and he thinks you are cheating that is why he does not want.\u0026rdquo; (ID103, 27 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eDiscomfort of procedures of LARCs methods:\u003c/h2\u003e \u003cp\u003eBarriers such as discomfort of the LARCs methods were discovered and these had code such as invasive removal of implants, side effects, and discomfort on insertion of the IUD, and implant.\u003c/p\u003e \u003cp\u003eWomen felt discomfort due to the invasive mode of removal of implants. Some women thought that inserting IUD immediately after birth was difficult, painful and uncomfortable for them. The mode of insertion of the IUD in the context of per vaginal bleeding made it more discomforting for the woman.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo; Because of the way they insert it in down there. Yes, I see it is difficult/uncomfortable to be with\u0026hellip;..Yes, in the process of putting it.\u0026rdquo; (30 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The fear is during removal as you know some of us drink alcohol so they may give the drug to reduce pain and may not work so when they cut to remove you feel the pain\u0026rdquo;(28 year old FGD pregnant woman).\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eSide effects\u003c/h2\u003e \u003cp\u003eOver-bleeding was the most common side effect reported to be experienced by women. They reported that they became dizzy whenever they over-bled especially using the implant method. Other side effects that were commonly experienced with implants included gaining weight and weight loss\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now I gave birth to him in 2018,(by then) that is when I used it but I did not use it to the end. It would make me bleed a lot, I would always feel dizzy so I used it for one and a half years after I came and it was removed.\u0026rdquo; (22 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If they fit in you, it might accept(or work in) your body and then you fatten. The whole of you fattens and then someone thinks that you\u0026rsquo;re pregnant yet not. The second one, there is finishing two \u0026ldquo;weeks\u0026rdquo; while \u0026ldquo;bleeding\u0026rdquo; when you go to the hospital and they give some tablets then it stops..\u0026rdquo;(, 23 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever lack of sexual drive was reported by some women and associated it with feeling like a pregnant woman.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My wife was not having sexual desires. Then I asked her, \u0026ldquo;how come when we are in one bed when I want to have sexual relations you say you don\u0026rsquo;t have the sexual desire\u0026rdquo;,,, Then I said, \u0026ldquo;what can we do, we go and remove the method\u0026rdquo;(30 year old FGD Male partner).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eEnablers to utilisation of postpartum LARCs\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eTheme 1: Capability:\u003c/h2\u003e \u003cdiv id=\"Sec35\" class=\"Section4\"\u003e \u003ch2\u003eSub-theme A: Pyschological\u003c/h2\u003e \u003cp\u003eKnowledge on LARCs, need to resume intimacy with their partners, having attained a desired family size and conceiving too soon were factors that made women psychologically capable of taking up PPFP.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eNeed to resume intimacy with their partners\u003c/h3\u003e\n\u003cp\u003eThe recovery process also enabled return of menstrual periods which indicated to women the possibility of conception and the need for family planning. The return of menses was also accompanied by sexual resumption which women thought would put them at risk of pregnancy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now I knew that I was becoming fine/ fine and my husband could want to be intimate [have sexual relations]. So I knew I might conceive accidentally.\u0026rdquo; (22 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eHaving attained a desired family size\u003c/h2\u003e \u003cp\u003eMen and women whose marriages were old or had lasted long with evidence of grandchildren present were automatically motivated to take up postpartum LARCs due to having attained a desired family size.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Ok, for family planning, I want and I want it 100% because even the number of children is that one(enough), I have even started having grandchildren.\u0026rdquo; (, 32 year old postpartum woman with parity of 12)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eConceiving too soon\u003c/h2\u003e \u003cp\u003eWillingness to and use of postpartum LARC was related to the need to promote child spacing and promote proper recovery from childbirth especially women who had complications during child birth.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;She told me that it is true when you use family planning, you will space your children and even if you get pregnant again, these other children will not be sickly. If you do not space children they disturb you because they are always sickly and you will not be able to take care of them.\u0026rdquo; ( 22 year old postpartum woman).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme B: Physical\u003c/h2\u003e \u003cp\u003eAfew health workers had skills to offer the LARCs and this capability enabled them to offer PPFP.\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eTheme 2: Opportunity\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSub-theme A: Physical\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePhysical opportunities such as availability of PPFP methods enabled women to take up PPFP.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eSub-theme B: Social\u003c/h3\u003e\n\u003cp\u003eGood attitude of health workers, Joint decision-making to take up FP and partner support were social opportunites that facilitated uptake of PPFP.\u003c/p\u003e \u003cp\u003e \u003cb\u003eJoint decision making with a partner about family planning.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost women who received health education after birth regarding the importance of using postpartum LARC, the six weeks period enabled women to share the new information with their male partners, a step which was critical in joint decision making. Partner approval following joint decision as a couple was thought by both women and men to promote utilisation of LARC after six weeks, rather than immediately after birth, since women needed to first seek guidance and approval from their husband when they go back home after being discharged This motivated women to take up postpartum LARC. Relatedly, the utilisation of LARC in the six weeks was facilitated by the postnatal care services especially immunization which was thought to be suited for postpartum LARC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So, if they give me something [health education] and then I come back after one and a half month, I come back and sit with my partner and explain to him that and we agree with each other. Then there is no problem.\u0026rdquo; (, 23-year-old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The one and a half months (starting contraception 6 weeks after delivery) would be better for us the women\u0026hellip;.there on going back at one and a half month [for immunization], it\u0026rsquo;s better you receive it because you would have agreed with your partner.\u0026rdquo; (, 23-year-old postpartum woman)\u003c/em\u003e.\u003c/p\u003e\n\u003ch3\u003eTheme 3: Motivation\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eSub-theme A: Automatic\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePositive attitude towards couple counselling and FP use, positive influence by partners, family members, and health workers with male involvement in ANC couple counselling on FP automatically motivated women to take up PPFP.\u003c/p\u003e\n\u003ch3\u003ePositive attitude towards couple counselling and family planning use\u003c/h3\u003e\n\u003cp\u003eWomen and male partners expressed palpable demand and interest to receive information and counselling regarding postpartum LARC. Participants thought that informing them about postpartum LARC would help them decide on whether to use LARC in the immediate postpartum period. Positive attitudes towards family planning use were related to receiving health education as a couple during antenatal care, positive nudging from grandmothers, and not experiencing the side effects purportedly reported among family planning methods.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Me it looks better if we are counselled when we are all together me and my wife, because we shall decide on one issue. And the questions that will be asked, we; my wife and I will be able to answer together. (30 year old FGD Male partner).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;That one (Implant) is good I can put it, it does not have any problem. Okay there are those who say that when they put they bleed a lot but I have never tried it. But I see as if it is good.\u0026rdquo; ( 27 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eInfluencers for postpartum LARCs\u003c/h3\u003e\n\u003cp\u003eThe subjective norms relating to recommendation to use of family planning in the postpartum period among the peers encouraged some women to use postpartum LARC. The healthcare provider had a strong influence to utilisation of postpartum family planning methods especially among women with childbirth complications. The family social circles, the grandmothers and other senior women further influenced women on the use of postpartum LARC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Considering how the health workers explained to me that I should not conceive soon since my uterus is now very weak. I should take some time before producing again.\u0026rdquo; (ID102, 22-year-old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have seen from my sister, she delivered by C/S. She gave birth to twins and my mother looked at their income as a couple and it was not good so she told her if you do not space, you will not be in good conditions. So do not produce again soon..\u0026rdquo; ( 22-year-old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe society perceived that women`s primary role was to give birth while that of men was to provide for the family. This negatively influenced mothers by preventing them from taking up postpartum LARCs. They reported saying;\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Some men say that they leave their women to produce because they(men) take care of the family.\u0026rdquo; (, 35year old Antenatal woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme B: Reflexive;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe uncovered factors such educated mothers, long duration of action, approval to the utilization of LARC and preference of LARCs as reflexive motivators for utilization of PPFP.\u003c/p\u003e\n\u003ch3\u003eLong duration of action\u003c/h3\u003e\n\u003cp\u003eWomen were motivated to take up postpartum LARCs because of their long duration of action and perceived effectiveness when used. Women reported that in cases of stockouts for short-acting reversible contraception methods at health facilities, those who already received the LARCs methods are already protected from conceiving and will not be affected by stock outs.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because for the short acting methods, it's difficult. You might go to the hospital and\u0026hellip;then that we are out of stock\u0026hellip;And sometimes because of unavoidable issues the dates might reach when you\u0026rsquo;re not around\u0026hellip;.But with the other method (implants\u0026amp; coils) when they say that it\u0026rsquo;s 5 years it will be 5 .\u0026rdquo; (ID402, 23 year old postpartum woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePreferences for contraceptive implants.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe utilisation of LARC in the postpartum period was related to covert preferences for contraceptive implants. Some women were opposed to the use of the IUD and indicated that they would be willing to use contraceptive implants instead. The preferences for contraceptive implants were related to perceptions that the side effects were less for contraceptive implants especially those related to vaginal bleeding, interference with sexual intimacy with the male partner, and the effect on fecundity.\u003c/p\u003e \u003cp\u003eSimilarly, the misconceptions surrounding the use of implants were less for the IUD which provided a positive subjective norms and ambience favourable for use of postpartum contraceptive implants. Some of the women had used contraceptive implants before which promoted its use in the immediate postpartum period. The method of inserting contraceptive implants was also thought to be compatible with the immediate postpartum period as it was thought not to interfere with the healing and recovery process after childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor the arm, it is also not bad. I see it does not cause difficulty\u0026hellip;.it is not like the coil\u0026hellip;.for it just, they put on the arm, then they treat you for just a short time. Few days it can be ok. You will be healed. Not like the other one (IUD), when you will be in pain.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, a few women preferred using the IUD due to its long term effectiveness compared to the implant.\u003c/p\u003e \u003cp\u003e\u0026ldquo;ok, for me if they are to give me a method, truth they have to give me the IUD, I would want it; the one for the opening of the uterus (IUD). Why? Because it\u0026rsquo;s similar to the other one (implant - in being long acting compared to short acting methods). Reason being if they have fitted it (IUD) in you, for it, you have enough protection in your body and if you\u0026rsquo;re to be wherever. \u003cem\u003e( 23 year old postpartum woman)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWomen and men recommended sensitization by health worker, experienced clients and community outreaches on Postpartum Family Planning as ways to increase their capability to take up PPFP. Healthworkers reported that training on Postpartum Family Planning and borrowing PPFP methods from other health facilities during stockouts or shortages medical supplies would increase physical opportunities for women receive Postpartum Family Planning. Provision of privacy and confidentiality to women and offering Family Planning counselling during ANC visits and at postnatal units were recommendated as social opportunities for women to take up Postpartum Family Planning. Recruitment of male VHTs, male involvement in ANC and other health services were suggested to be automatic motivators for uptake of Postpartum Family Planning. Women were recommended not to take advice from negative peers and first try to take up a family planning method to get their own experience. This makes them exercise autonomy in using a method of family planning. The need for individualized FP, sensitization by use of poster images about PPF and media would reflexively motivate women to take up PPFP. Offering individualized counselling helps shy or fearful or low esteemed women to freely open up to health workers about their concerns on family planning.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study was conducted to explore the enablers and barriers to utilization of LARC among postpartum women. Our study findings underscore the lack of healthcare provider-initiated counselling and provision of LARC, limited knowledge of health workers, vhts, men and women, misconceptions of women and men, lack of partner approval, and shortages of PPFP commodities and sundries as the main barriers to uptake of postpartum LARC\u0026rsquo;s. These mainly affected the women`s capability in taking up the PPFP as well as lowering their opportunites to receiving PPFP services. The enablers to utilization of postpartum LARC included attainment of ideal family size, skilled health workers, positive attitudes and effectiveness of LARC. These motivated women, strengethed their capability and gave then an opportunity to take up PPFP. Our study has important implications to maximize missed opportunities for provision of postpartum LARC and reduce the high fertility rates in our settings.\u003c/p\u003e \u003cp\u003eIn LMIC only 13% of postpartum women use LARC (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Despite women\u0026rsquo;s demand to be informed about postpartum LARC, participants in our study noted the lack of healthcare provider-initiated counselling and provision of postpartum LARC greatly hindered the utilization of LARC. This was compounded by the overstretched healthcare providers, lack of agency of women to request for postpartum contraception and the fragmented nature of healthcare services provision. The lack of healthcare provider-initiated counselling and provision may be related to the lack of integrated services. Similar studies in LMIC have also reported lack of integrated services and postpartum counselling as the main factors that hinder uptake of postpartum LARC (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Overall, the increasing rates of health facility deliveries in Uganda presents an opportunity to scale up utilization of immediate postpartum LARC especially given the corresponding low attendance of postnatal care services (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Our study notes that women were reluctant to come back to the health facility after delivery for family planning methods, a finding which was consistent with other studies (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Therefore, identifying feasible ways of integrating immediate postpartum LARC into routine facility deliveries would tremendously improve the utilisation of immediate postpartum LARC\u0026rsquo;s (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLimited knowledge and skills as well as misconceptions further affected the use of LARC in the postpartum period. It made women to lack the capability to take up PPFP. Participants thought that they needed to first recover from childbirth and resume their menses before using LARC. The shortages of PPFP methods and equipment with overburdened health workers hindered offering of PPFP. The perceived lack of sexual intimacy during this period and the role of breastfeeding further affected the use of immediate postpartum LARC. Our findings are consistent with studies in Africa which reported the role of resumption of menses in uptake of immediate postpartum LARC (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This could be related to women\u0026rsquo;s perception that the risk of pregnancy was low during the period because menses had not yet returned and the perception that breastfeeding supresses return of fecundity(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Healthcare providers have been noted to perpetuate the misconception of the association of return of menses with return of fertility(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Therefore, it is important to counsel women and healthcare providers regarding the high risk of pregnancy given that ovulation may precede menses during postpartum period (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Women in our study valued the need to recover from vaginal bleeding and their menses to resume after childbirth because modern contraceptives were thought to cause heavy bleeding. Therefore, it is important to address the existing limited knowledge and misconceptions surrounding postpartum use in an effort to promote uptake of immediate postpartum LARC.\u003c/p\u003e \u003cp\u003ePoor partner support lowered women`s oportunites to takeup PPFP as well as demotivated them. This hindered the utilisation of postpartum contraception. The male partner disapproval of immediate postpartum LARC was related to misconceptions, and lack of involvement in decision making to use family planning. This was consistent with other studies from similar settings which cited lack of partner approval as a deterrent to uptake of immediate postpartum LARC (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In patriarchal societies with deeply entrenched gender inequalities, the male partner makes all the decisions in the family including the reproductive health needs to use postpartum contraceptives (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Women who desire to use PPFP may not accept it for fear of retribution, gender-based violence and reproductive coercion (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Although male partners do not always escort their women for deliveries, their involvement is key in the uptake of immediate postpartum LARC (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, the poor utilization of LARC in the immediate postpartum period was related to misconceptions and fear of side effects, a finding which was similar to other studies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This was particularly important given the low utilization of LARC (1% for IUD) in the general population compared to other modern contraceptives (27% for injectables) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Although most women were opposed to using IUD in the postpartum period, some preferred to use contraceptive implants. The contraceptive implant was seen to cause fewer side effects, and could not interfere with the healing process after childbirth which suggests an opportunity to promote contraceptive implants in the immediate postpartum period. Relatedly, women were willing to use postpartum LARC after 6 weeks of childbirth, a finding which was consistent with a study in DR Congo and Burkina Faso (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The six weeks period was perceived to allow them time to heal but was also thought to provide an opportunity to discuss and make a joint decision to use family planning with the male partner. Strengthening the interventions that promote utilization of immediate and 6 weeks postpartum services could play a critical role in the use of immediate postpartum LARC.\u003c/p\u003e"},{"header":"Strengths and limitations","content":"\u003cp\u003eOur study provides insight of the barriers and enablers to use of LARCs in the immediate postpartum period. We recruited participants from antenatal care, women who delivered in a health facility or home. We also included their male partners. The collaborative approach especially the approach to involve the participants in suggesting recommendations to improve uptake of immediate postpartum contraceptive was very empowering. Our study findings did not majorly differ from those of a similar study done in south western Uganda by Merlin et. al which could be a reflection from other regions of the country except for are few findings like fear to coomunicate to busy health and certain misconceptions by women. Therefore interventions to improve PPFP uptake could benefit women in the entire country. The study was limited to a small portion of eastern Uganda which was mainly Mbale and Budaka districts which might not reflect the entire eastern region.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe utilization of immediate postpartum family planning in Mbale Regional Referral Hospital was highly hindered by limited knowledge and skills among health workers and VHTs, misconceptions among women and men, poor partner support and lack of FPcounselling. Further research should be done to test the effectiveness of Integration of family planning services along the continuum of maternity care and the use of innovative low cost interventions such as videos for health education and counselling to increase utilization of immediate postpartum contraception.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional data and materials can be accessed on reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding provided by the Royal Society of Tropical Medicine and Hygiene (RSTMH)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAK, MW, DM, and MM did conceptualization, MW and DM provided the methodology; software, \u0026nbsp; AK,DA, and RN did the formal analysis. \u0026nbsp; AK and DA wrote the original draft manuscript, \u0026nbsp;MD, MM,JE, MW, JNW, DA, SW, DN, PAMN,FO, JW, and AN, reviewed and edited, MW did visualization, \u0026nbsp;MW, DM and MM did supervision, \u0026nbsp;AK was project administrator, AK acquired funding. \u0026nbsp;All authors have read and agreed to the published version of the manuscript. AK and \u0026nbsp;DA had full access to all study data and took responsibility for the integrity of the data and the accuracy of the data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge God, RSTMH for funding this study and the research mentee group or the moral support given during the study. We would also like to acknowledge the research assistants and participants who consented to be interviewed. We would like to thank them for willingly taking the time to provide the information and data needed to complete this study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePasha O, Goudar SS, Patel A, Garces A, Esamai F, Chomba E, et al. Postpartum contraceptive use and unmet need for family planning in five low-income countries. Reproductive health. 2015;12(2):1-7.\u003c/li\u003e\n\u003cli\u003eNakaggwa F, Kimuli D, Kasule K, Katwesige JF, Kintu D, Ssempebwa R, et al. Postpartum family planning uptake in Uganda: findings from the lot quality assurance sampling survey. Contraception and Reproductive Medicine. 2023;8(1):44.\u003c/li\u003e\n\u003cli\u003eWHO. Report of a WHO technical consultation on birth spacing. Rep a WHO Tech Consult Birth Spacing. 2005;13:1-44.\u003c/li\u003e\n\u003cli\u003eCheslack Postava K, Winter AS. Short and long interpregnancy intervals: correlates and variations by pregnancy timing among US women. Perspectives on sexual and reproductive health. 2015;47(1):19-26.\u003c/li\u003e\n\u003cli\u003eSserwanja Q, Mukunya D, Nabachenje P, Kemigisa A, Kiondo P, Wandabwa JN, et al. Continuum of care for maternal health in Uganda: a national cross-sectional study. PLoS One. 2022;17(2):e0264190.\u003c/li\u003e\n\u003cli\u003eUBOS. GOVERNMENT OF UGANDA Uganda Demographic and health survey. 2016-2017.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project. Family Planning: A Global Handbook for Providers (2018 update). Baltimore and Geneva: CCP and WHO, 2018.\u003c/li\u003e\n\u003cli\u003eSsebatta G, Kaye DK, Mbalinda SN. Early contraceptive implants removal and its associated factors among women using implants at a National Referral Hospital, Kampala Uganda. BMC Womens Health. 2021;21(1):399.\u003c/li\u003e\n\u003cli\u003eSileo KM, Wanyenze RK, Lule H, Kiene SM. Determinants of family planning service uptake and use of contraceptives among postpartum women in rural Uganda. Int J Public Health. 2015.\u003c/li\u003e\n\u003cli\u003eRutaremwa G, Kabagenyi A, Wandera SO, Jhamba T, Akiror E, Nviiri HL. Predictors of modern contraceptive use during the postpartum period among women in Uganda: a population-based cross sectional study. BMC Public Health. 2015;15:262.\u003c/li\u003e\n\u003cli\u003eAnguzu R, Tweheyo R, Sekandi JN, Zalwango V, Muhumuza C, Tusiime S, et al. Knowledge and attitudes towards use of long acting reversible contraceptives among women of reproductive age in Lubaga division, Kampala district, Uganda. BMC Res Notes. 2014;7:153.\u003c/li\u003e\n\u003cli\u003eMorse JE, Rowen TS, Steinauer J, Byamugisha J, Kakaire O. A qualitative assessment of Ugandan women\u0026apos;s perceptions and knowledge of contraception. Int J Gynaecol Obstet. 2014;124(1):30-3.\u003c/li\u003e\n\u003cli\u003eNalwadda G, Mirembe F, Byamugisha J, Faxelid E. Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives. BMC Public Health. 2010;10:530.\u003c/li\u003e\n\u003cli\u003eKabagenyi A, Jennings L, Reid A, Nalwadda G, Ntozi J, Atuyambe L. Barriers to male involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women\u0026apos;s perceptions in two rural districts in Uganda. Reprod Health. 2014;11(1):21.\u003c/li\u003e\n\u003cli\u003eWillcox M, King E, Fall E, Mubangizi V, Nkalubo J, Natukunda S, et al. Barriers to uptake of postpartum long‐acting reversible contraception: Qualitative study of the perspectives of Ugandan health workers and potential clients. Studies in family planning. 2019;50(2):159-78.\u003c/li\u003e\n\u003cli\u003eDe Leo A, Bayes S, Bloxsome D, Butt J. Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery. Implementation Science Communications. 2021;2(1):1-8.\u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.\u003c/li\u003e\n\u003cli\u003ePolit DF, Beck CT. Nursing research. Generating and assessing evidence for nursing practice. 2012;9.\u003c/li\u003e\n\u003cli\u003eClarke V, Braun V. Thematic analysis. The journal of positive psychology. 2017;12(3):297-8.\u003c/li\u003e\n\u003cli\u003eAsmamaw DB, Belachew TB, Fetene SM, Addis B, Amare T, Kidie AA, et al. Postpartum long-acting reversible contraceptives use in sub-Saharan Africa. Evidence from recent demographic and health surveys data. PLoS One. 2023;18(10):e0291571.\u003c/li\u003e\n\u003cli\u003eMemon ZA, Mian A, Reale S, Spencer R, Bhutta Z, Soltani H. Community and Health Care Provider Perspectives on Barriers to and Enablers of Family Planning Use in Rural Sindh, Pakistan: Qualitative Exploratory Study. JMIR formative research. 2023;7(1):e43494.\u003c/li\u003e\n\u003cli\u003eTran NT, Yameogo WME, Gaffield ME, Langwana F, Kiarie J, Kulimba DM, et al. Postpartum family-planning barriers and catalysts in Burkina Faso and the Democratic Republic of Congo: a multiperspective study. Open access journal of contraception. 2018:63-74.\u003c/li\u003e\n\u003cli\u003eGahungu J, Vahdaninia M, Regmi PR. The unmet needs for modern family planning methods among postpartum women in Sub-Saharan Africa: a systematic review of the literature. Reproductive health. 2021;18:1-15.\u003c/li\u003e\n\u003cli\u003eHarrison MS, Goldenberg RL. Immediate postpartum use of long-acting reversible contraceptives in low-and middle-income countries. Maternal health, neonatology and perinatology. 2017;3:1-9.\u003c/li\u003e\n\u003cli\u003eJalinga Vuamaiku G, Epuitai J, Andru M, Aleni M. \u0026ldquo;I Don\u0026rsquo;t Support It for My Children\u0026rdquo;: Perceptions of Parents and Guardians regarding the Use of Modern Contraceptives by Adolescents in Arua City, Uganda. International Journal of Reproductive Medicine. 2023;2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"immediate postpartum, Long acting reversible contraception, Uganda, modern contraceptives, Antenatal, intra uterine devices, implanon","lastPublishedDoi":"10.21203/rs.3.rs-4412393/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4412393/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eIn Uganda, women experience multiple missed opportunities to receive counselling for postpartum family planning services along the continuum of maternity care. We explored the enablers and barriers to utilisation of postpartum long-acting reversible contraceptives in Eastern Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study in two districts of Eastern Uganda. We had 39 interviews. We conducted 20 in-depth interviews and three focus group discussions with postpartum women, male partners, health workers, and village health team memberss. Our study was grounded in the COM-B framework, and the transcripts were analysed thematically.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe use of immediate postpartum long-acting reversible contraception (LARC) was majorly hindered by both incapabilities and limited opportunites in the health system and patient factors. System factors included lack of healthcare provider-initiated counselling for postpartum contraception, overburdened healthcare workers, and shortage of Postpartum Family Planning commodities and sundries. Patient factors included limited knowledge (lack of awareness for postpartum contraception), misconceptions (perceived body fragility, need to fully recover and for menses to resume after delivery), fear of side effects, men had fear of infidelity, lack of agency to ask for health education and poor health seeking behaviours. The enablers for immediate postpartum LARC included positive attitudes towards contraception, preference for contraceptive implants over intra uterine devices (IUD) at the 6-week postpartum period, resumption of sex and menses, partner support, and perceived effectiveness of postpartum contraception. Participants thought that sensitization about LARC through health education and outreach visits, male involvement through ANC appointments and male village health teams, and switching between family planning methods could improve uptake of immediate postpartum LARC.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eInadequate knowledge and skills on postpartum family planning services(PPFPs) and lack of health education by health workers and misconceptions with poor partner support majorly led to low utilisation of postpartum family planning services in this setting. Scaling up effective, low cost and innovative ways to provide PPFP services such as video counselling may improve the use of immediate postpartum LARCs. As well as actively promoting the provision of intergrated services along the continuum of maternity care.\u003c/p\u003e","manuscriptTitle":"Barriers and enablers to utilisation of postpartum long-acting reversible contraception in Eastern Uganda: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-30 20:00:46","doi":"10.21203/rs.3.rs-4412393/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-31T13:01:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-31T12:38:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200350578714601759471254425749127513582","date":"2024-05-25T19:09:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62568482520601724174184805839216145048","date":"2024-05-22T13:09:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-21T13:29:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"41372502622369418292937860051900555698","date":"2024-05-21T08:27:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301297432437855007730033365529229680563","date":"2024-05-20T22:13:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330593568260899520680460515238365702587","date":"2024-05-20T13:35:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-20T12:52:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-16T07:05:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-16T07:05:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Contraception and Reproductive Medicine","date":"2024-05-13T09:54:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"780c9c26-8cca-4961-8922-e2a566824d8b","owner":[],"postedDate":"May 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:07:14+00:00","versionOfRecord":{"articleIdentity":"rs-4412393","link":"https://doi.org/10.1186/s40834-024-00308-5","journal":{"identity":"contraception-and-reproductive-medicine","isVorOnly":false,"title":"Contraception and Reproductive Medicine"},"publishedOn":"2024-10-10 15:57:17","publishedOnDateReadable":"October 10th, 2024"},"versionCreatedAt":"2024-05-30 20:00:46","video":"","vorDoi":"10.1186/s40834-024-00308-5","vorDoiUrl":"https://doi.org/10.1186/s40834-024-00308-5","workflowStages":[]},"version":"v1","identity":"rs-4412393","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4412393","identity":"rs-4412393","version":["v1"]},"buildId":"veTbxFhMMB0_faC6-Wkog","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}