Investigación original / Original research
Initiation of effective postpartum contraceptive
use in public hospitals in Guatemala

Edgar Kestler,1 Maria del Rosario Orozco,2 Silvia Palma,2and Roberto Flores 2 Suggested citation
Kestler E, Orozco MR, Palma S, Flores R. Initiation of effective postpartum contraceptive use in publichospitals in Guatemala. Rev Panam Salud Publica. 2011;29(2):103–7.
Low frequency of effective contraceptive use remains a challenging problem. This article examines the frequency of effective postpartum contraception and the methods
used before discharge in public hospitals in Guatemala. It also discusses the need to implement
best practices in providing family-planning and contraceptive services.
Methods. In March 2006, a surveillance system was implemented to collect data on the initia-
tion of effective contraceptive methods. Postpartum women were monitored in 34 public hospitals.
Univariate and bivariate analyses were performed, and a chi-square test for linear trends was used
to compare female surgical sterilization rates after vaginal delivery and cesarean section.
Between 1 March 2006 and 31 December 2008, of the 218 656 women who had a postpartum event, 31% received an effective contraceptive method before hospital discharge.
The frequency of initiation of effective postpartum methods varied across hospitals. Hospital
results were consistent with national data on women of reproductive age. Among women who
underwent surgical sterilization, differences between those who had delivered vaginally and
those who had a cesarean section were statistically significant.
The overall frequency of initiation of effective postpartum contraceptive use is low in public hospitals in Guatemala. It is higher, however, in hospitals at lower health carelevels with strong community ties. Routine data collection revealed specific areas for improve-ment, particularly the need to enhance health providers’ knowledge of medical eligibility crite-ria for effective contraceptive use postpartum. The priority is to promote the provision of high-quality family-planning and contraceptive services in Guatemala’s public health system. Key words
Postpartum period; contraception behavior; family planning services; Guatemala.
the lowest in the region—to 71% in Costa in 2008 (2). Nevertheless, there are sig- Center for Epidemiological Research in Sexual andReproductive Health, Hospital General San Juan de Dios, Guatemala City, Guatemala. Send corre- tive services at all public health facilities spondence to: Edgar Kestler, ekestler@ciesar.org.gt (2). In Latin America, the overall use of Ministry of Health of Guatemala, Vice Minister ofHospitals, Guatemala City, Guatemala.
Rev Panam Salud Publica 29(2), 2011 Kestler et al. • Initiation of postpartum contraceptive use in Guatemala ery (9%) and after cesarean section (19%) ceived as a failure to uphold this funda- and details about the effective contracep- tive method chosen after counseling. Staff Data analysis
tral office by fax, email, or personal deliv- were done with Epi Info 2000 and Excel.
The statistical software StatsDirect 2.4.5 was used to calculate the chi-square test and entered into Epi Info 2000 by trained for linear trends to assess the statistical significance of differences between vagi- born. Second, it prevents high-risk preg- were discussed with each hospital’s rep- minate unwanted pregnancies, therebyreducing maternal mortality and mor- Availability of methods
bidity and secondary infertility (5).
the basis for preventing maternal mortal- are available at service delivery points, cesarean sections, took place. Of all post- ica, with trends that have not changed in size that increased use of effective con- mortality rates—that is, high-risk preg- bined oral contraceptive (norgestrel, 0.3 deliveries, 29% received and initiated an cated, type 1, class A, style 3, size 1).
use after vaginal delivery increased from MATERIALS AND METHODS
ods are available in Guatemala’s public contrast, the share of effective contracep- Data collection
specific abortion data are not included in Hospital location
derwent voluntary surgical sterilization, order by health care level, the 34 public hospitals include 6 regional hospitals, 15 considered in this report, with the excep- tion of two referral teaching hospitals in reported very low rates of effective con- traceptive provision after vaginal deliv- Rev Panam Salud Publica 29(2), 2011 Kestler et al. • Initiation of postpartum contraceptive use in Guatemala TABLE 1. Postpartum use of effective contraceptive method by type of hospital, Guatemala,
nally, at district hospitals, 20% of womenwho had delivered vaginally received dergone cesarean sections (Table 3).
Number of deliveries (vaginal and cesarean section) Number of women provided contraception before DISCUSSION
Frequency (%) of effective contraceptive method at hospital discharge (95% confidence interval) Number of women provided contraception before reported in 2008 (2). According to the re- Frequency (%) of effective contraceptive method at hospital discharge (95% confidence interval) Number of women provided contraception before Frequency (%) of effective contraceptive method at hospital discharge (95% confidence interval) condom (3%), IUD (2%), and male surgi-cal sterilization (1%) were the least fre-quently used.
did not influence initiation of effective sterilization after a cesarean section in- the study, linear trends for female surgi- natural method at hospital discharge.
level hospitals, and 41% at district hospi- cal sterilization postpartum were statisti- tals. Post-cesarean section use of effec- cally significant (chi-square test for lin- ear trend P = 0.0001) (Table 2).
because of their relatively higher typical- use failure rates postpartum, as it is quite tion were more likely to receive surgical livered vaginally. At regional hospitals, surgical sterilization after vaginal deliv- use of female surgical sterilization after study, the use of female surgical steril- at the Ministry of Health consists ofnorgestrel (0.3 mg) and ethinyl estradiol(0.03 mg) [Lo-Femenal and Perla], butaccording to WHO it is contraindicated TABLE 2. Effective contraceptive use postpartum in public hospitals, Guatemala, 2006–2008
postpartum (8). According to contracep-tive eligibility criteria, the method falls There are also theoretical concerns about a Chi-square test for linear trend P < 0.0001.
tion, affecting the duration of breastfeed- Rev Panam Salud Publica 29(2), 2011 Kestler et al. • Initiation of postpartum contraceptive use in Guatemala TABLE 3. Postpartum use of effective contraceptive methods by type of public hospital, Guate-
mala, 2006–2008
out evaluations and on-site visits to re-view monthly records of deliveries.
tries like Guatemala will have to improve provision and use of effective contracep- tive methods. The surveillance system es- tablished to systematically collect infor- useful tool for health personnel. Most im- portantly, it can also identify weaknessesin training, equipment, and supplies andcontribute to improving the health of the ing and the newborn’s growth. It is cru- also offers guidelines on the best ways to mala. It is urgent that health authorities ceptive choice and contribute to the sus- bility criteria for choosing contraceptive about contraceptive use at private or so- cial security hospitals. In addition, it pre- vise national guidelines on medical eligi- sents data on the initiation of effective bility criteria for contraceptive use.
done within 10 min after expulsion of the discharge, but it does not provide follow- Acknowledgments. This publication
all obstetric events at all public hospitals ized, and scientifically accurate informa- can be dispelled by the fact that Ministry port provided by the Erik E. and Edith H.
1. Ministerio de Salud Pública y Asistencia So- 5. World Bank, World Development Report. In- 9. Treiman K, Liskin L, Kols A, Rinehart W.
cial; Instituto Nacional de Estadística. En- “IUD’s an update.” Population Reports, Se- cuesta Nacional de Salud Materno Infantil ries B. Baltimore: Johns Hopkins School of (ENSMI) 2002. Ciudad de Guatemala, Guate- 6. Bill and Melinda Gates Foundation, Cuer- Public Health, Population Information Pro- navaca Public Health Institute, California 2. Ministerio de Salud Pública y Asistencia So- 10. Finger WR. IUD insertion timing vital in post- cial; Instituto Nacional de Estadística. En- health initiative: strategic assessment of ma- partum use. Network. 1996;16(2):21–2.
cuesta Nacional de Salud Materno Infantil ternal, neonatal and reproductive health in 11. Johns Hopkins Bloomberg School of Public Mesoamerica: current situations and trends.
Health, Center for Communication Programs.
Guatemala: MSPAS; 2009. Pp. 80–90.
Cuernavaca, Mexico: National Institute of IUD toolkit. Available from: http://www.
3. Stover J, Ross J. How increased contraceptive k4health.org/toolkits/iud. Accessed 30 No- use has reduced maternal mortality. Avail- 7. Kestler E, Valencia L, Del Valle V, Silva A.
Scaling up post-abortion care in Guatemala: tion/publications/contraceptive/2005_World_ initial successes at national level. Reprod 8. World Health Organization. Medical eligibil- 4. Center for Reproductive Law and Policy. Family ity criteria for contraceptive use: a WHO fam- planning in Guatemala. A fundamental right ily planning cornerstone, 4th ed. Geneva: Manuscript received on 16 February 2010. Revised ver- not fulfilled. New York: CRLP; 2000. Pp. 100–17.
sion accepted for publication on 5 November 2010.
Rev Panam Salud Publica 29(2), 2011 Kestler et al. • Initiation of postpartum contraceptive use in Guatemala Objetivo.
La baja frecuencia del uso de métodos anticonceptivos eficaces sigue siendo un arduo problema. En este artículo se analiza la frecuencia con que se adoptaun método de anticoncepción eficaz durante el puerperio y los diferentes métodos an- Inicio de un método
ticonceptivos empleados antes del egreso de los hospitales públicos de Guatemala.
anticonceptivo eficaz durante
También se analiza la necesidad de mejorar las prácticas de los servicios de planifica-ción familiar y anticoncepción.
el puerperio en hospitales
En marzo del 2006, se implantó un sistema de vigilancia para recopilar públicos de Guatemala
datos sobre el inicio de métodos anticonceptivos eficaces. Se hizo un seguimiento de
mujeres durante el puerperio en 34 hospitales públicos. Se llevaron a cabo análisis de
una sola variable y de dos variables, y se utilizó la prueba de la chi al cuadrado de las
tendencias lineales con objeto de comparar las tasas de esterilización quirúrgica fe-
menina después del parto vaginal y la cesárea.
Entre el 1 de marzo del 2006 y el 31 de diciembre del 2008, de las 218 656 mujeres a las que se les hizo un seguimiento durante el puerperio, en 31% se
inició un método anticonceptivo eficaz antes del alta hospitalaria. La frecuencia de
inicio de un método anticonceptivo eficaz en el puerperio varió entre los diferentes
hospitales. Los resultados hospitalarios concordaron con los datos nacionales sobre
las mujeres en edad fecunda. En las mujeres que se sometieron a esterilización qui-
rúrgica, las diferencias entre las que habían dado a luz por vía vaginal y las someti-
das a una cesárea fueron estadísticamente significativas.
En general, existe una baja frecuencia de inicio de un método anti- conceptivo eficaz durante el puerperio en los hospitales públicos de Guatemala. Sinembargo, es mayor en los hospitales de inferior nivel de atención de salud cuyosvínculos con la comunidad son intensos. La recopilación sistemática de datos revelóque determinadas áreas debían ser objeto de mejora, en particular era necesario me-jorar el conocimiento de los proveedores de servicios de salud en materia de criteriosmédicos sobre la indicación del uso de un método anticonceptivo eficaz durante elpuerperio. La promoción de la provisión de servicios de planificación familiar y anti-concepción de alta calidad en el sistema de salud pública de Guatemala constituyeuna prioridad.
Palabras clave
Período de posparto; conducta anticonceptiva; servicios de planificación familiar;Guatemala.
Rev Panam Salud Publica 29(2), 2011

Source: http://www.ciesar.org.gt/es/archivo/saludMaterna/planificacionFamiliarContracepcion/Initiation%20effective%20postpartum%20contraceptive%20use%20in%20public%20hospitals%20in%20Guatemala.pdf


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