Patterns and predictors of contraceptive use among post-caesarean women in Sierra Leone: insights from a five-year longitudinal study

This five-year longitudinal study in Sierra Leone reveals that while modern contraceptive use among post-caesarean women reaches 48.5% at five years, it is significantly influenced by increased health system contact, specifically higher antenatal care attendance and receiving contraceptive offers before discharge, whereas delivery at tertiary facilities is associated with lower uptake.

The Gist

Imagine a woman in Sierra Leone who has just undergone a major surgery to deliver her baby: a Caesarean section. This is a high-stakes moment. Just like a car that has been in a serious accident and needed a major repair, her body needs time to heal, and the risk of complications if she gets pregnant again too soon is very high.

This study is like a five-year follow-up report on what happened to 1,000+ of these women after their surgery. The researchers wanted to answer one big question: Did these women get the "tools" they needed to space out their future pregnancies, and what helped or stopped them from getting those tools?

Here is the story of the paper, broken down into simple parts:

1. The Problem: The "Too Soon" Trap

In Sierra Leone, having a baby via C-section is risky. If a woman gets pregnant again before her body is fully ready (less than two years later), it's like trying to drive a car with a fresh, unhealed engine. It can lead to dangerous breakdowns (complications) or even a crash (maternal death).

The best way to avoid this is Family Planning (contraception). It's the "speed limit" that keeps the engine safe. However, despite the government offering free healthcare, many women leave the hospital without these tools.

2. The Investigation: A Five-Year Journey

The researchers acted like detectives, tracking these women for five years. They looked at:

• Who they were (age, education, wealth).
• Where they had their surgery (small local clinics vs. big city hospitals).
• What happened during their hospital stay (did a nurse talk to them about birth control?).

3. The Big Findings: What Worked and What Didn't

The Good News:
By the end of five years, nearly half (48.5%) of the women were using modern contraception. This is actually higher than the national average for all women in the country. It suggests that women who have had a C-section are very motivated to protect their health.

The "Magic" Moments (Predictors of Success):
Think of these as the keys that unlocked the door to family planning:

• The "Frequent Flyer" Effect: Women who visited the doctor more than twice during their pregnancy were almost twice as likely to use contraception later. It's like going to the gym regularly; the more you interact with the system, the more you learn and the more likely you are to stick to the plan.
• The "Before You Leave" Gift: If a doctor or nurse offered them a contraceptive method before they were discharged from the hospital, they were 2.5 times more likely to use it. It's like being given a map and a compass right before you start a long hike, rather than waiting until you're lost in the woods.

The Surprising Hurdle:

• The "Big Hospital" Paradox: You might think going to a big, fancy city hospital (tertiary facility) would be better. But the study found the opposite! Women who delivered at these big hospitals were less likely to use contraception.
  • Why? Imagine a busy airport terminal. The big hospitals are so overwhelmed with patients that the staff is running on a treadmill. They are skilled, but they are so busy that they don't have time to sit down and have a deep, personal conversation with every patient. The "personal touch" gets lost in the crowd.

4. The Changing Tools: From "The Ring" to "The Chip"

The study also looked at which tools women chose, and the preferences changed over time like fashion trends:

• Year 1: The most popular tool was the IUCD (a small T-shaped device inserted into the uterus). It was like the "instant fix" because doctors could put it in right while the woman was still on the operating table.
• Year 5: The IUCD usage crashed (dropped to less than 1%). Why? Many women stopped using it because of side effects (like cramping or bleeding). It's like buying a car that gets great gas mileage but has a very uncomfortable seat; eventually, people stop driving it.
• The New Favorite: By year five, Implants (a tiny rod placed in the arm) became the most popular choice. They are discreet, long-lasting, and don't have the same side effects as the IUCD for many women.

5. The Takeaway: What Should We Do?

This paper is a call to action for doctors and hospitals. It tells us that connection is key.

• Don't just treat the surgery; treat the future. Doctors need to talk to women about birth control before they leave the hospital.
• Big hospitals need to slow down. Even if you have the best equipment, if you don't have time to talk to the patient, the message doesn't get through.
• Keep the conversation going. Visiting the doctor multiple times during pregnancy builds trust and keeps the topic of family planning on the table.

In a nutshell:
This study shows that while Sierra Leone is making progress, we need to stop treating family planning as an "extra" service and start treating it as a standard part of the healing process. If we give women the right tools and the right advice before they leave the hospital, we can save lives and keep mothers safe for the long haul.

Technical Summary

1. Problem Statement

Context:
Caesarean deliveries are associated with significantly higher rates of maternal morbidity and mortality compared to vaginal births. Short birth intervals (less than 24 months) following a caesarean section increase the risk of severe complications, including uterine rupture and placenta accreta. Despite Sierra Leone's high maternal mortality ratio (547 per 100,000 live births) and the availability of free family planning services under the Free Health Care Initiative, the modern contraceptive prevalence rate (mCPR) remains low (29%), with a stagnated unmet need of 25%.

Research Gap:
While postpartum family planning (PPFP) is a recognized strategy, uptake remains critically low (4% in PPFP programs). There is a lack of longitudinal data specifically tracking contraceptive behaviors and predictors among women who have undergone caesarean delivery in Sierra Leone over an extended period. This study aims to fill that gap by assessing uptake patterns and identifying factors influencing modern contraceptive use within five years post-caesarean.

2. Methodology

Study Design:
A secondary analysis of data from a prospective, multicentre, five-year observational cohort study.

Population and Setting:

• Original Cohort: 1,274 women who underwent caesarean delivery between October 2016 and May 2017.
• Sites: Nine hospitals across Sierra Leone (4 district, 1 regional, 1 national referral, and 3 private non-profit facilities) covering Northern, Eastern, Western, and Southern provinces.
• Inclusion/Exclusion: Included women of all ages with fetal weight >500g. Excluded cases with hysterectomy, maternal death, loss to follow-up, or data entry errors.
• Final Sample: 1,044 women with complete data were included in the analysis.

Variables:

• Primary Outcome: Utilization of modern contraception (condoms, DMPA, implants, IUCD, pills, or bilateral tubal ligation) at one and five years post-delivery.
• Independent Variables: Maternal age, parity, education, marital status, number of antenatal care (ANC) visits, perinatal death, facility type, wealth quintile, and whether a contraceptive method was offered during admission.

Data Collection & Analysis:

• Follow-up: Home visits conducted at 30 days, one year, and five years post-delivery.
• Statistical Analysis: Complete-case analysis using R (v4.4.0). Bivariable and multivariable logistic regression were used to calculate Crude Odds Ratios (COR) and Adjusted Odds Ratios (aOR) with 95% Confidence Intervals (CI). Statistical significance was set at p < 0.05.

3. Key Contributions

• Longitudinal Insight: Provides rare five-year longitudinal data on contraceptive trajectories specifically for post-caesarean women in a low-resource setting.
• Method-Specific Trends: Highlights a dramatic shift in method preference, moving from Intrauterine Contraceptive Devices (IUCD) to implants over time.
• Systemic Predictors: Identifies specific health system factors (ANC attendance, facility type, and provider counseling) that significantly influence uptake, offering actionable targets for policy intervention.

4. Key Results

Contraceptive Uptake Trends:

• Overall Uptake: 48.5% of women were using modern contraception at five years, which is notably higher than the national average of 29%.
• Method Shift:
  • IUCD: Dominant at Year 1 (40.3%) but declined sharply to 0.8% by Year 5 (p < 0.001).
  • Implants: Increased significantly from 24.7% at Year 1 to 45.6% at Year 5 (p < 0.001).
  • DMPA: Data was missing for Year 1 but captured at Year 5.

Predictors of Contraceptive Uptake (Multivariable Analysis):

• Antenatal Care (ANC): Women attending >2 ANC visits were nearly twice as likely to use contraception compared to those with fewer visits (aOR 1.96; 95% CI 1.19–3.23).
• Provider Counseling: Being offered a contraceptive method before discharge significantly increased uptake (aOR 2.44; 95% CI 1.05–6.40).
• Facility Type: Delivery at a tertiary/regional facility was associated with a 47% reduction in the odds of contraceptive uptake compared to district or private facilities (aOR 0.53; 95% CI 0.34–0.83).
• Non-Significant Factors: Age, parity, education level, marital status, and wealth quintile did not show statistically significant associations in the adjusted model, though wealth showed a positive trend in the crude analysis.

5. Significance and Implications

Clinical and Policy Implications:

• Integration of PPFP: The strong association between ANC attendance and uptake suggests that integrating family planning counseling into routine antenatal care is a critical leverage point.
• Discharge Counseling: The finding that offering a method before discharge doubles uptake underscores the need to institutionalize "postpartum family planning" counseling as a standard discharge protocol, especially given that 17% of mothers in Sierra Leone miss the 48-hour postnatal check.
• Addressing Tertiary Facility Gaps: The lower uptake in tertiary/regional hospitals likely stems from high patient volumes and reduced provider-patient interaction time. Interventions must focus on optimizing counseling workflows in high-volume referral centers.
• Method Counseling: The rapid discontinuation of IUCDs (likely due to side effects) and the rise of implants suggest a need for better counseling on method-specific side effects and long-acting reversible contraception (LARC) management to prevent early discontinuation.

Conclusion:
The study concludes that while contraceptive uptake among post-caesarean women in Sierra Leone is higher than the national average, significant gaps remain. Strengthening provider-client interactions, particularly during antenatal care and pre-discharge, and addressing systemic bottlenecks in tertiary facilities are essential to sustaining contraceptive use and reducing maternal mortality. Future research should employ qualitative methods to understand the specific reasons for method discontinuation.