Stakeholders’ perceptions of family planning programs during the COVID-19 period: A descriptive qualitative study

Abstract

Aim

The number of unintended pregnancies and the decreasing use of contraceptives during the COVID-19 pandemic are of particular concern to the national population and family planning program. The successful implementation of the family planning program cannot be carried out by the government alone. Still, it requires strong synergy with stakeholders. The difference in perceptions among stakeholders, acceptors, and the community about family planning is crucial, so qualitative research is needed to identify this matter. This study explores stakeholders’ perceptions of post-partum family planning programs and their barriers during the COVID-19 pandemic.

Method

This research uses a descriptive qualitative method, with participants consisting of family planning officers, cadres of family planning units, and the head of the family planning program. The data were collected through in-depth interviews and examined using content analysis.

Results

The results show that health workers and community leaders cooperated at the village and sub-district levels in realising the family planning programs. During the COVID-19 pandemic, services were stopped at the public health centre, especially long-term contraceptive method services. Stakeholders believe that barriers to the program's success include education level, negative perceptions, lack of training, and low trust in partners.

Conclusion

Cross-sectoral engagement is essential in increasing participation in family planning programs. Other critical success factors are support from husbands, community leaders, and local government.

Introduction

In early 2020, the COVID-19 outbreak was declared a world pandemic. In Indonesia, the National Agency for Disaster Management considered this situation an emergency before a presidential decree changed the status into a national disaster. As of April 2020, the virus had infected 2,900,422 people globally. In Indonesia, there were 8882 cases with 1107 recoveries and 743 deaths. Most confirmed cases were from productive age, amounting to 44%.¹

The National Population and Family Planning Board predicted an increase in unintended pregnancies in Indonesia and a decrease in contraceptive demand amid the COVID-19 pandemic. About 10% of users in 34 provinces in Indonesia experienced difficulty accessing family planning in March 2020. Women found it more difficult to access the family planning information and services they needed because healthcare facilities around the world redirected the resources to deal with COVID-19 pandemic.²

Every pregnancy should be planned and intended, but this is not always the case, especially during the COVID-19 pandemic. Therefore, it is important to plan pregnancy and determine the number of children from the beginning of marriage through family planning programs. One of the programs promoted by the government is post-partum family planning. Post-partum family planning includes using contraceptives immediately after delivery for up to six weeks (42 days).³ It is one of the strategic efforts to reduce infant mortality (IMR), maternal mortality (MMR), and total fertility rate (TFR), so post-partum family planning should be implemented as early as possible after baby delivery.^4,5

The family planning program is a national development program aiming to realise the prosperous Indonesian family goals.⁶ The successful implementation of the family planning program cannot be done by the government alone but requires strong synergy with stakeholders,^7,8 i.e., the community having legitimacy, power, and interest in the success of a program.⁹ These include family planning field officers, medical personnel such as doctors, nurses, village midwives in regional health centres and private clinics, cadres, and community leaders.¹⁰

A family planning program is built based on religious, demographic, and cultural considerations. In such a diverse backdrop, differences among stakeholders can emerge and become barriers to the success of a family planning program.¹¹ Perception is important as it determines impressions^12,13 and decisions. Understanding stakeholders’ perceptions and the barriers they face is needed to develop a culturally effective family planning program. This study aims to explore perceptions and barriers faced by stakeholders in family planning programs during the COVID-19 pandemic. The results of this study can help the national population and family planning board and related ministries to develop and implement appropriate interventions to improve the outcomes of the family planning program.

Method

This research uses a descriptive qualitative method. Data were collected from three regencies/cities in West Java, i.e., Bandung City, Bandung Regency, and Sumedang Regency, from November to December 2020. The ethics approval was granted by The Ethical Committee of Universitas Padjadjaran, with the reference number: 939/UN6/KEP/EC/2020.

Data were collected from in-depth interviews with stakeholders on their perspectives regarding post-partum family planning programs during the COVID-19 pandemic. The participants of this study were nine stakeholders of the family planning program: heads of the regional family planning program, family planning officers, and cadres of the family planning unit. The principal investigator conducted the interviews for about 45–60 minutes each. The interview process was carried out by telephone and in person recorded. The results of the interview were transcribed and then analysed. Qualitative data analysis was carried out through content analysis. The steps were unitising, sampling, recording or coding, reducing or simplifying data, and inferring (taking conclusions). The standardised construct analysis was based on the selected context and narrating the answers to the research questions. The aim is to map the stakeholders’ perceptions of post-partum family planning and its barriers.

Results

The results of this study provide an overview of the implementation of the post-partum family planning program, the barriers to increasing participation during the COVID-19 pandemic, and the solutions. This overview is depicted in four themes. The first theme is the implementation of the post-partum family planning program, called Bangga Kencana, which consists of three sub-themes: (a) cooperation between health workers and community leaders at the village and sub-district levels, (b) support from health cadres, community leaders, religious leaders in post-partum family planning, and (c) low coverage of the use of the long-term contraception method.

The second theme is the impact of COVID-19 on the implementation of post-partum family planning services, with three sub-themes: (a) challenges of post-partum family planning services in public health centres during COVID-19, (b) the implementation of health protocols, and (c) the use of online extension media (WhatsApp group). The third theme is the barriers and constraints in the implementation of post-partum family planning, with four sub-themes: (a) the community education levels, (b) the gaps between stakeholders’ expectations and health programs’ objectives, and (c) the negative perception toward using long-term contraception, (d) the absence of training on post-partum family planning for health workers, (e) the husbands’ attitudes toward family planning program.

The fourth theme is cross-sectoral expectations and support for the post-partum family planning program, with six sub-themes: (a) the need for sustainable collaboration, (b) the need for education and training for instructors and midwives, (c) the need for incentives/rewards for instructors, field officers, and cadres, (d) the need for a more attractive program, (e) instructors’ expectations of adequate facilities and infrastructure, (f) the expectation to subsidize the intrauterine device (IUD) contraception.

Discussion

The interview data show that there was cooperation between health workers and community leaders at the village and sub-district levels, such as midwife home visits to post-partum mothers, collaboration with related public health centres, the provision of integrated service posts, cadres, and family planning units and sub-districts. Meanwhile, the cooperation between family planning units and sub-branch includes monitoring post-partum mothers, counselling, and family planning participation campaign. In addition, the program implementation involved institutional collaboration, such as with the Indonesian Family Planning Association and the Indonesian Midwives Association.

“There are also programs that collaborate with Indonesian Family Planning Association with Indonesian Midwives Association” (P3.9)

Yunas and Nailufar¹⁴ explained that, in a family planning program delivery, certain goals could not be resolved without collaboration because a single party may not have sufficient capacity, resources, and networks. Cooperation can overcome this limitation and support common goal achievement. In the postpartum family planning program, the support at the village and sub-district levels was strong, which came from health cadres, religious and community leaders, and instructors.

“Religious or community leaders, is there any opposition about post-partum family planning? Everyone here supports.” (P1.9)

Tisnilawati⁶ stated that the lack of support from national, provincial, and municipal government stakeholders could reduce the quality of family planning programs. In rural areas, this is particularly needed because people may lack understanding, knowledge, and poor control over contraceptive use. Aside from governmental support, other stakeholders must be involved, including health workers, religious and community leaders, and users themselves.

Even with the cooperation and support, this study found that the use of long-term contraception methods was still low. Couples of reproductive ages used contraception but did not choose to use the long-term method. The most widely used contraceptives were injections, pills, and condoms. In addition, the contraception-use target set by spouses of fertile age (EFA) during COVID-19 was not achieved, unlike in the pre-COVID-19 time. Yunas and Nailufar¹⁴ found that at the village level, the use of long-term contraception was lower than national average. This can be related to the users’ level of education. Those with a higher level of education tend to choose to use long-term contraception.¹¹

Data shows that the family planning national targets had not been met (53.91%). According to research by Aqmal (2020), people may not participate in a post-partum family planning program because of their culture, beliefs, and perceived side effects. Other problems include a lack of socialisation, assistance, and cooperation with local communities or religious leaders.¹⁵

The COVID-19 pandemic reduced access to public health services, including family planning, because the resources were allocated to deal with the pandemic.¹⁶ The results showed that during the COVID-19 pandemic, there were restrictions on post-partum family planning program services at public health centres, especially long-term contraception services.

“During the COVID-19 pandemic, the long-term contraceptive method was limited to just five a day. Usually, there were no limits.” (P1.22)

The results also showed that health protocols were implemented to deliver post-partum family planning services. Users shifted to midwives because services in public health centres were limited to five. The health protocols include segregation between adults and children and check-up schedules.

“But yes, I manage it more (carefully) and organize what... the immunization, for example, I separate the babies, right, there are babies in the immunization, so (I) do not mix them with adults check-ups like family planning or pregnancy, so I just set the timing… adjust the timing so that it will not be too crowded, and people are mixed…” (P2.13)

The pandemic also made people use online media more extensively even though face-to-face meetings were still possible. Stakeholders felt in-person and online outreach was different.

“It's different, just strong, the value is met directly or not. Outreach through the media is different from direct outreach. This is recorded, we provide counselling, the person is not there, even though the message is delivered, but the value is different.”

Access to quality family planning services is important to achieve reproductive health goals. However, the services during the COVID-19 pandemic were limited due to limited supplies and personnel because most resources were concentrated on the pandemic.¹⁷ Therefore, COVID-19 might have reduced the success of family planning programs. However, counselling and services still need to be carried out based on the latest guidelines in the COVID-19 pandemic.¹⁶ The provision of communication, information, and education (CIE) materials and counselling related to reproductive health and family planning can be carried out online or by telephone consultation.¹⁸

Regarding the barriers, stakeholders believed that education level, different perceptions, unsupportive attitudes, no training, and doubts were the barriers in post-partum family planning programs.

“Many mothers. First, from the mother's capability, sometimes the community. The level of education is an influence, Ma’am. Sometimes we give some information that is easy to understand, some are old. Hegarmanah has a lot of inhabitants, so rumours can also quickly spread. But yes, it is (a problem with the) human resource, Ma’am.” (P1.5)

The statement shows that education is a predictor of participation in the family planning program. Maharani et al.¹⁹ stated that education shapes people's mindsets, attitudes, and life outlooks. Education helps people absorb information, including information about reproductive health and the benefits of using contraceptives.²⁰

Another barrier is the different perceptions between stakeholders and health programs regarding the implementation of post-partum family planning, especially about the timing.

“The use of contraception is following the actual recommendation. If the health recommendation is not 40 days, it can be okay.” (P8.9)

“One month apart, you have to be fast in family planning, whether you want injection or spiral-installed family planning.” (P4.3)

Perceptions are rooted in stakeholders’ knowledge. This study found that some people are unsupportive of using long-term contraception. Previous research has shown that this negative perception causes family planning programs to become unsustainable.²¹ Other than that, fear and costs also often cause misperceptions so that couples of reproductive does not support long-term contraception.

“Usually, they are afraid, ma’am. Those who just gave birth use IUDs. They are afraid… those who have recently given birth. So, they take injections or pills because they fear breast milk will be affected, so they mostly inject. But we try to direct them to the long-term contraceptive, of course.” (P1.2)

Another barrier, according to the stakeholders in this study, is the absence of training related to post-partum family planning for health workers in the community. Implementation of family planning programs in the community requires consultation with briefings or training for stakeholders and the community.²²

“There is no training.” (P7.11)

The final barrier observed in this study is the husbands’ doubts about the family planning program. Lette (2018), in her research, stated that if a husband hesitates and does not support his wife in joining a family planning program, the wife will be reluctant too.

“Yes, since being pregnant. So, the value is like this, Ma’am, her husband's view is that ‘ah it's not an officer of public health’ to me and Mrs Ani, that's the assessment. If it's not directly by the officer. What do they know?” (P7.13)

Aside from barriers, there were also expectations and support. Stakeholders in this study believed that there could be more cooperation across sectors, both government and non-government. Cross-sectoral engagement, such as family planning field officers, midwives, and health centres, is important to increase participation in post-partum family planning programs. In addition, support from husbands, community leaders, and local government is also needed.

“Maybe, yes, it is necessary. Currently, it's only with a village midwife, meaning the public health centre. It's already cross-sector (cooperation) to the public health centre, then we also need support from the village, Ma’am.” (P1.15)

The family planning program can be more effective if all parties take responsibility and support, especially the community leaders because they play a big role in conveying the importance of family planning programs to the community.¹⁰

The second expectation deals with the education and training for instructors and midwives related to post-partum family planning because continuous professional development is necessary for today's society.^8,23

“My expectation, Ma’am, is that there is training for the family planning unit. The second is the sub-section to convey the knowledge to the public with a source. Then, if possible, I want it once a month, or the officers do’blusukan’ (going around approaching the community at the grassroots level). So, the people are given a briefing, so they understand. The community is not the same, Ma’am, some are laymen, some (even asked) ‘What is family planning like this and like this’, now there are those who are still confused and don’t know what the benefits of family planning are, which are still common.” (P7.15)

The next thing that stakeholders expect is rewards or incentives for family planning instructors, field officers, and cadres because they could motivate people to do a better job.^24,25

“For cadres, at least the sub-section is equal to the family planning unit. Because we work hard here. The sub-section also works hard. We asked for data or something like this. We asked for data about the mothers from the unit first. I coordinated with Ms Nurmala, whose neighbourhood has a lot of mothers in labour. I’ve seen, for example, there are many neighbourhood clusters. We will see which Public Health Centre's schedule. We will immediately follow up with the sub-section, Ma’am. So, we don’t just go straight and look for them ourselves. We also used them (the data).” (P1.20)

The stakeholders also expected the programs to continue during the pandemic.

“Family planning services need to continue to be more frequent but not violating the health protocols. (The program should be) more often, and a lot more.” (P8.20)

Facilities and infrastructure in implementing family planning programs are important. To motivate the public to participate. These include complete contraceptive options, affordable distances, and costs for the community to participate in the family planning program.²⁰

“Adequate facilities and infrastructure (is needed).”

Government subsidies can also affect family planning participation in the community. Contraceptive costs significantly affect the choice of contraception.²⁰

This study analyses data from in-depth interviews about stakeholder perceptions and expectations on post-partum family planning. The results of this study are stakeholder perceptions regarding the implementation of the postpartum family planning program in Bangga Kencana. The findings reveal the impacts of COVID-19 on the performance of postpartum family planning, barriers and constraints, and expectations and support. Cross-sectoral engagement is essential in increasing participation in family planning programs. Other critical success factors are support from husbands, community leaders, and local government.

Conflict of interest

The authors declare no conflict of interest.