Clinician and policymaker perspectives on the barriers and enablers to implementing and scaling up integrated postpartum intrauterine contraceptive services within maternity care in Nepal: a qualitative study

Abstract

Background: Integrating postpartum family planning services within maternity care, specifically counselling about family planning and postpartum intrauterine contraceptive device (PPIUCD) insertion, may help reduce unintended pregnancies and related complications. This study explored factors affecting the implementation and scale-up of integration of these services within maternity care in Nepal from the perspectives of healthcare providers and policymakers.

Methods: For this qualitative study, we conducted in-depth, semi-structured interviews remotely with healthcare providers and policymakers across all seven provinces of the Nepali maternal healthcare sector until theme saturation was achieved. Potentially eligible participants were invited through publicly available e-mail addresses, personal contacts, snowball sampling, and social media advertisements. Respondents were assessed for eligibility and subsequently recruited. The Consolidated Framework for Implementation Research and Theoretical Domains Framework guided our inquiry and analysis. We transcribed the interviews verbatim, translated the transcripts into English and analysed them using thematic analysis.

Findings: Based on 26 interviews, we identified five major barrier themes relating to care recipients, healthcare providers, health facilities and the health system. The themes included: (i) the perceived inadequate awareness and low desire for PPIUCDs among care recipients, (ii) PPIUCD-specific issues, (iii) inadequate capacity and capability to deliver the services, (iv) inadequate investment and priority, and (v) contextual factors such as pelvic inflammatory diseases and hygiene considerations. Some contrasting views were reported between healthcare providers and policy participants. Policy participants emphasised insufficient efforts by healthcare providers to provide counselling and PPIUCD, while healthcare providers identified PPIUCD-related issues (e.g., complexity of the insertion procedure) as a significant barrier hindering their efforts. Both healthcare providers and policy participants identified inadequate investment in and priority on integrating postpartum contraceptive services, including PPIUCD, as another important factor. Participants indicated that there is an urgent need to implement effective integrated counselling and contraception services.

Interpretation: Greater investment is needed to address multilevel barriers to implementing and scaling up integrated postpartum family planning services, particularly PPIUCD insertion within maternity services in Nepal. Priority should be given to health education for care recipients and the community, capacity building (ensuring care providers are capable), and upgrading of health facilities.

Funding: Monash International Postgraduate Research Scholarship and Monash Graduate Scholarship.

Keywords: Barriers; Enablers; Family planning; Nepal; PPIUCD; PPIUD; Postpartum contraceptives; Postpartum intrauterine contraceptive devices; Qualitative study.

Fig. 1

Overview of Consolidated Framework of Implementation Research (CFIR) and Theoretical Domains Framework (TDF) domains.

Fig. 2

The recruitment process for the research.

Fig. 3

Summary theoretical domains and constructs mapped to the themes relevant at different level of implementation. The figure depicts relevant theoretical domains and constructs mapped to themes originated in our data relevant at different level of implementation components.