Abstract

This research study is designed to examine the procedure of counseling faced by midwives in providing postpartum contraceptive counseling services to women in rural areas. A qualitative, inductive study was conducted with 20 midwives working in rural areas. The interviews had semi-structured questions. Thematic analysis was used for the analysis. The study \was conducted in a rural area of Lahore, Pakistan. This study showed that the current level of knowledge of midwives about contraception is adequate as they do not face any problem in giving counseling on contraception in rural areas. There is a great need for policymakers and field workers to better encourage spacing methods and couple incentives to embrace rural women.

Key Words

Contraceptive, Counselling, Procedure, Midwives 

Introduction

Reproductive health care addresses the reproductive processes, functions, and systems at all stages of life. The postpartum period is the crucial stage in the life of a woman since she will meet a health worker or a midwife for the first time if she belongs to a rural or backward area. It is therefore very important for a woman to have health counseling at this stage. Women can use contraception during this period if they want to avoid any mistakes with the consultation of health personnel (World Health Organization, 2007).

Contraception is a method to control pregnancy. Midwives are able to explain the contraceptive methods currently available, address the key advantages and disadvantages of these methods of contraception, classify contraceptive methods, understand when it is possible to start contraception after birth, implement contraception in consultations with pregnant and those women who have delivered, understand the use "Bridging Contraception" (Kolak et al. (2017).

A trained healthcare professional provides adequate care to a woman during work, like pre- and post-pregnancy. Skilled birth care is provided in a health facility or home setting, with the assistance of trained professionals including midwives, nurses, and doctors (Adatara et al., 2019).

Tabassum and Menhas in their research in 2014 discuss that Midwives play an essential role in providing health care services during the antenatal and postnatal period. They are experts in giving health care services. Social and cultural factors become a cause of maternal death mostly in village areas. The role of the CMW(Community midwives) has been established in various communities around the world for the enhancement of maternal health. Most of the midwives go to different accredited institutions to get trained. Midwives essentially play various many activities during schooling, to improve their skills. For good results of births, Midwives aided leads of birth. Midwives also play a very difficult role in the village side, where the hospitals are limited.

Kamran in a study conducted in 2015 sums up the problems and hindrances that come in the way of providing maternal healthcare facilities faced by midwives. They state that it is clearly evident that there is less awareness and information about contraception among rural women due to this midwives face many challenges while providing contraceptive counselling. Those challenges include the procedure of counseling (Qualification, Timings of counseling, targeted group, Training, Provision of contraceptives) and Significant challenges (Personal value of clients, Involvement of client's family, husband, mother-in-law, Contradictory role of community, Misconception about the use of contraception, Accessibility of contraception, Religious unacceptability of contraception).

Sarfraz and Hamid in their research (2014) found that due to community attitude, midwives face many complexities during fieldwork. Health departments give them proper training to provide health services. In rural settings, midwives are not properly trained by the health department due to insufficient facilities and a lack of resources. Therefore, the aim of this study is to obtain information about midwives' (dais) procedure of counseling rural women and to learn more about the characteristics and practices of those midwives during counseling on the use of contraceptives.




Objectives

The objectives of this study are the following:

1. To examine the family planning counseling practices by midwives.

2. To put forward suggestions to policymakers based on the study findings. 




Research Question

What are the experiences of midwives in providing postpartum contraceptive counseling services to women in rural areas? 




Significance of the Study

Nath and Islam (2015) state that the reproductive rights of a woman, including deciding the number, timing, and spacing of their babies, are absolutely essential to empowerment and equality for women. Hence counselling done during this period is very crucial and effective too. The most significant time for counseling is the postpartum period. Postpartum and post-abortion cycles are as significant for a woman as they are for many rural patients because in that time they come in contact with the midwives. 

In Pakistan, there is increasing awareness about the requirements for women regarding the use of contraceptive methods during the postpartum period. However, women with risk factors are also seeking midwives for contraceptive counseling as their beliefs about certain methods of contraception are not well understood in rural areas, rural midwives come across multifaceted and intimidating barriers to advise on the adaptation of modern contraceptives. Many factors like geographic, financial, cultural, and socio-economic lead, to the inability of midwives to provide guidance on using modern contraception. The challenges faced by midwives in rural areas in the practice of providing health services and guidance to rural females with related healthcare issues are significantly linked with cultural beliefs and faith. Therefore, the aim of this research is to obtain information about midwives' (dais) counseling of rural women and to learn more about the characteristics and practices of those midwives during counseling on the use of contraceptives.




Summary

This research examines the perspectives and views of midwives to provide rural women with postpartum contraceptive counselling; in Pakistan. Midwives talk with rural women and share their perceived obstacles when addressing contraceptive use after the postpartum period. Midwives encounter a lot of obstacles when providing contraceptive counseling in rural areas due to the factor of illiteracy among rural women that rural women's delay in seeking counseling. Village society and religious thought question them too (McCance & Cameron, 2014).

Literature Review

Background

It is clearly evident that there is a great lack of awareness and knowledge regarding contraception among rural women. Due to this, midwives face many challenges while providing contraceptive counseling. Therefore, regular and comprehensive counseling from every health center in rural areas is a must for all pregnant women. Midwives should provide adequate and authentic information concerning a variety of methods of contraception and rural women should be able to select a method of their own liking. It is clear that it is important to formulate initiatives that increase awareness of the use of contraception among rural women. It is also crucial to effectively develop and introduce post-partum family planning programs in rural areas by integrating them with health care services that are accepted by culture. Midwives can find themselves in complicated, ethical dilemmas when advising on contraception in the cultural and social context of rural areas.

Midwives worked to resolve inequalities in access to rural women's reproductive health care and increase the services of health care and contraceptive methods. For rural women who used condoms, midwives were linked with an increase in the use of contraceptive injectables and reduced chances of use of oral contraceptives and implants. The rural midwife system will guide women to use longer-lasting approaches, the "switching actions" of women, and encourage the use of contraception injectables (Weaver et al, 2013).

The responsibility of midwives is to give basic health care, in pregnancy and childbirth during and after. In general, they work on the basis of their knowledge and fieldwork experiences acquired through practices in society. They work in the country's rural settings. We can be properly integrated into the formal healthcare system to make our own. They work as a professional healthcare provider and play an important part in improving the health of mothers in rural settings. Women's health during pregnancy, infancy, and postpartum. Midwives are also known as trained professionals in health care services. Midwives transfer the information about food and care of newborn babies to the women. They emphasize the cleanliness of the baby, promote breastfeeding, and maintain the mother's special care at this time. When females are given good treatment over time for the complexity of pregnancy, it is definitely possible to save all mothers. CMWs are directly related to maternal health. Midwives typically have local residents, they are well known and have a trustworthy community character (Tabbassam and Menhas, 2014).




Family Planning Counselling Process

The midwives offer support through regular community visits on the use of contraception such as pills and condoms. Midwives have participated in organizing community outreach programs and in the ongoing distribution of oral contraceptives and condoms under the guidance of family planning programs. Village midwives were implemented mainly to resolve problems after and before pregnancy and also acted as an alternative contraceptive source. That policy relies on the availability of the midwives and their relations with customers pre- and post-pregnancy period.

Awareness of the health benefits of contraception may increase midwives' utilization of successful contraceptives among rural women, and improve the healthcare level of preconception. When females delay the birth of a child they are increasingly in need of preconception counseling for contraception. Counseling will be beneficial for long-term prevention and unintended pregnancy. Furthermore, health benefits attributed to pre-conception should be emphasized. The benefits include reducing the symptoms of excessive bleeding, anemia, and multiple cancers. The efficacy of common use and significant use of long-acting methods should be emphasized during contraceptive counseling (Kallner & Danielsson, 2016).

In addition to these basic tasks, a village midwife's responsibilities include:

1. Assisting maternal and child health and family planning, especially in family health care home visits.

2. Early diagnosis of mouth/teeth diseases and temporary treatment.

3. Assisting in infectious disease and immunization surveillance.

4. Documenting and monitoring activities.

5. Aiding in the assessment of the emotional development of the child and the follow-up of the sufferer.

6. Counselling.

7. Establishing a rural community health system and promoting a stable family / nutrition-conscious family program.

8. Contraceptive parole.

9. Referral.

Besides, record keeping and reporting should be performed by the midwife monthly in accordance with the existing regulations regarding record keeping and reporting, such as record keeping and reporting regarding the action or service the village midwives have been doing. The village midwives are also asked to keep records of basic epidemiological and other unusual occurrences. That adds to the village midwives' responsibility and obligations. The challenges include heavy workloads of village midwives, inadequate midwives' expertise, insufficient midwives' training, and skills upgrades, lack of supervision, disparity in incentives and workloads, and lack of engagement of village midwives in carrying out their duties and responsibilities. Besides, village midwives also encountered heterogeneous characteristics of communities (Indrayani and Mulyawati, 2015).

Methodology

Methodology's main objective is to illustrate different methods and techniques used to collect, evaluate, and interpret data related to the research problem under examination. Social research is the systematic process of discovering new facts or evaluating old facts, their patterns, interrelationships, causal theories, and the laws governing them. This qualitative research serves as a complement to gain a broader understanding of the findings of a parallel ongoing study to determine whether there are discrepancies between rural women in established issues faced by midwives during postpartum contraceptive counseling.




Research Design

Qualitative research focuses on understanding the experiences of human beings through careful analysis and examination of narrative. This approach enabled researchers to acquire from their own viewpoint a detailed understanding of midwives ' experiences in rural areas with regard to postpartum contraceptive counseling among rural women. A qualitative research methodology was used in which midwives used interviews observations and field notes to provide an overview of midwives' views on rural women's postpartum contraceptive counseling. The present study was conducted in a village, where midwives were easily accessible and available. The population for the study consisted of midwives who provide postpartum counseling to rural women in rural areas of the Lahore District.

Since the main objective of this research was to explain and interpret the perspectives of midwives, it was considered appropriate to have a qualitative design. This qualitative research serves as a complement to gain a broader understanding of the findings of a parallel ongoing study to determine the procedure of postpartum contraceptive counseling. I interviewed 20 midwives on postpartum contraception giving counseling to rural women in 2020 in-depth interviews have been used to study the design of qualitative methods. The study was conducted in Lahore's rural area. Midwives clients of selected health centers in rural Lahore were included in the study population for the qualitative process. On the other hand, an in-depth interview with key informants was given to midwives who provide rural women with postpartum contraceptive counseling.




Sampling

For this study, the research population comprised twenty (20) midwives offering postpartum contraceptive counseling among rural women. To understand the experiences of midwives in offering postpartum contraceptive counseling among rural women from their respective viewpoints, to select 20 participants a purposive sampling technique was used who gave rural women postpartum contraceptive counseling. A zone of rural area was selected for the study. Community Key Informants (CKIs) provided me with a list of potential participants (midwives) who provided postpartum contraceptive counseling among rural women in the selected area who gave their consent to participate in the study and met the inclusion criteria after describing the aim of the study. Taking into account age equality, status of education, employment, marital status, and method delivery experience, participants are purposely chosen to increase the sample variance and acquire diverse experiences. 

So, this study was based on in-depth qualitative interviews with rural midwives. Based on information saturation, the sample size was determined. After interviews with midwives, saturation was found; another interview was conducted to validate the saturation. In-depth interviews were conducted with the 20 midwives. Each interview lasted about an hour. The interview guide was then updated to include the pilot study concepts that were identified. The interviews were tape-recorded and transcribed with the midwives ' permission. To maintain confidentiality, they are encoded. A sample of 20 midwives was asked to participate in the study. Data collection stopped when saturation was reached and more interviews were not required in time. The interviews were conducted in January 2020.




Data Collection

Data was collected through an in-depth interview method that offered versatility for me. I collected data from a local midwife through a face-to-face interview. Before conducting an interview, I established contact with the midwife through key informants. The aim of the interview was explained to the participants before data collection began. They were guaranteed privacy, informed consent, and confidentiality. The consent form was read in Urdu, a language spoken in the study area to participants. Participants were told that they could, for whatever reason, refuse to answer any question or stop talking at any point during the interview process. I was also told at any time that they could ask to turn off the audio recorder. A detailed interview methodology was used to obtain a complete understanding of the perspectives of midwives in rural women's postpartum contraceptive counseling. I fluently conducted interviews in the Urdu language.

The interviews were conducted at a place convenient and accessible to the participants. A voice recorder was used during sessions to collect data. This took between 40 and 60 minutes for each interview. Within 24 hours of the interview, the audio-taped interviews were transcribed while the data was still fresh in my mind. The interviews were translated into the English language by me. 

After the interview, every in-depth interview was recorded tape, and notes were taken. Taking into account the local situation, the interview guide was produced in both English and Urdu language by reviewing various literature. The open-ended interview guide was used to examine midwives' experiences with postpartum counseling for contraceptives. Interviews were conducted respectively in the local language before saturation was reached where no further findings emerged during the research group debriefings. Interviews took place in environments that were audibly private. All the participants in the study were allowed to express their views freely. Personal information was not collected in the form of participants' names or any other identity.

Data Analysis

A thematic data analysis was used in six stages, as defined by Braun & Clarke (2006), This approach has been chosen as it offers an in-depth and systematic methodology and the ability to summarize key features of a large data set and a ' thick description ' of the data set. The transcripts were read and re-read multiple times to get an interpretation of the results. Subsequently, in themes and patterns, text excerpts were described and grouped according to content. Temporary categories were developed and cross-checked against themes, initial text collections, and transcripts in the next step. Finally, under a main theme, the sub-themes were grouped.

During the analysis process, my supervisor and I frequently discussed and updated classes, categories, and main themes. Background characteristics were put into a separate table. I translated quotes used to explain the results from Urdu to English. Analysis of data began with repetition of text readings and by listening to audio recordings repeatedly to recognize hidden patterns in the narratives of the informants. After a few interviews I finally reached a point with the general idea of recurring trends, the interviews continued to follow up and explore particular aspects of concern in detail. The theme of this study :

The themes were: Procedure of counseling sub-themes include Qualification, Timings of counseling, targeted group, Training, and Provision of contraceptives. 

Data gathered from the in-depth interviews were transcribed verbatim and analyzed to locate themes and sub-themes for the study. The methodology involves narrowing down narrative information into simpler units, coding and naming the units based on their content, and grouping coded material based on shared meanings and context. Interviews were transcribed, read, and re-read to identify controversial issues and categories, and compiled into sub-themes to recreate an overview of the issues faced by midwives in rural women's postpartum counseling. Many times, transcripts were read to establish a coding structure, which was decided by me and my supervisor. Transcripts were also made from audio-taped interviews. 

The data analysis occurred independently. So, all interviews were recorded and transcribed. All the interviews were translated into English and checked for accuracy after verification of the transcription in English. Primarily analyzed the data and included multiple iterative steps. The transcripts were analyzed several times using thematic analyses and a series of codes were created to identify groups of terms with similar meanings and used to create themes that arise from the content. 

In order to highlight key findings, direct quotes from key informants were identified in italics. Answers from the open-ended interview questions were written directly to the spaces on the interview guide. Many times I read through all the transcripts while making notes on the transcripts to the themes that merge.

The coding of the data and the analysis were done manually. The research unit was observations of midwives, respectively. I used the methodology of thematic analysis involving an in-depth description of the text's underlying meanings and condensing information without sacrificing their value to analyze the data. The codes were grouped into subcategories and themes were identified as highlighted by italics. Then a number of sub-themes were identified under the main themes. Finally, the categories were arranged under a main theme. During the process of analysis, groups, categories, and main themes were frequently discussed and revised. 




Ethical Considerations

The research participants received informed consent sent by me in the form of a letter to each participant illustrating in detail. Both English and Urdu transcription were used because most of the participants could not read in English, and the translation and interpretation of the knowledge about the aim and objectives into the Urdu language was undertaken. Participants who could read, and thumb printed by participants who were unable to read, signed the consent forms.

In addition, after explaining the purpose of the study, informed verbal consent was obtained from each research participant (midwives). The names of the midwives were not written in this study to ensure privacy. Participants ' privacy will be maintained. The study's goals were also conveyed to each participant Exposure to the information of the analysis was only open to the research team. The participants were told about the study's voluntary nature and confidentiality throughout the interviews was ensured. Anonymity was granted to all participants and the interviews were conducted in confidentiality.




Analysis 

The current research focuses on the experiences of midwives in giving postpartum contraceptive counseling. Data is influenced by the opinion of the selected members that information is used to control the Midwives 'Experiences and views of giving postpartum contraceptive counseling among rural women. All information was gathered through in-depth interviews with the selected 20 midwives from rural areas of Lahore, Punjab, Pakistan.




Main Theme and Categories 

The participating midwives were reluctant to make general assumptions regarding the difficulties that they faced while providing counseling on the use of postpartum contraceptives among women. Furthermore, the aversion towards generalization was apparently related to fears of being perceived as religious or as someone who is expressing traditional ideas in rural areas. However; even though participants were unwilling to generalize, the data analysis revealed the specific needs of the group of midwives as experienced by rural women, and a main theme appeared. Midwives face barriers while giving contraceptive advice to rural women. Many categories were identified sorting under this main theme: Procedure of counseling (Qualification, Timings of counseling, targeted group, Training, Provision of contraceptives). A summary of the data analysis is presented in Table 1.

 




Table 1

Main Theme	Experiences of Midwives in giving postpartum contraceptive counseling;
Categories	Procedure of counseling
Sub-categories	§  Qualification §  Timings of counselling §  Targeted group §  Training §  Provision of contraceptives

Procedure of CounsellingEducation of Midwives and Clients' Qualifications and Procedures about how to give Contraceptive Counselling (Formally or Informally).During the interview, the majority of participants looked calm. Most of my participants told me about their knowledge but some other participants also highlighted some other factors, such as one of my participants told me: ''I have trained to give formal counseling but also allow to give informally way of counseling to convince clients to use suitable methods''. Some of my participants told me: ''We mostly use formal way of counseling due to their sensitive position in the field but clients easily understand the informal way of counseling also in rural areas''. Mostly experienced participants told me:We go to the field formally pre-planned and give a description of every method but advise them informally but mostly it depends on our field experience, we give them counseling formally but answer all their fear about contraception use after postpartum informally also.The interpretation showed that the knowledge of midwives about contraception was good. Experienced midwives have great knowledge about counseling on contraception while some new midwives have old or little knowledge.
Planning and Procedure for CounsellingMy next research question was about the procedure for counseling, how midwives cover the different aspects of contraception discussion, Contraceptive planning, and the Duration of contraceptive discussion. This question addresses two aspects: Planning for contraceptive counseling and procedure for contraceptive counseling. Here some participants said that they had already planned their schedule before going to the field and also told us about the duration of counseling that it depends upon the number of clients that they deal with. One of my participants highlighted, ''I don't have a planned schedule because it depends upon the nature of the client issue how much the counseling takes time''. Some participants told me, "We don't need a proper plan before going to the field due to our field experience, we have much knowledge about the client issues that's why we manage it now without planning''. One of my participants highlighted the different aspects as compared to others; I already have a bag of medicine in which all the medicine is available at the time when I give counseling to the client. So, I gave medicine or advice according to the issue of the client, so I didn't need proper planning to go to the field with proper planning. The interpretation showed that most midwives go to the field for counseling with proper planning and procedure because it is a matter of the client's health midwives must have a health plan before going to the field, and after checking the health situation of the client give her advice and midwives don't recommend any method of contraception without knowing the client health condition.
Best Timing to Give Contraceptive Advice My next research question is about the best time to give contraceptive advice, how much midwives have knowledge on postpartum contraceptive advice, and from where midwives get knowledge about contraceptive counseling. Some of my participants told me, ''We get trained thorough course work or training centers, and the best time to give postpartum contraceptive counseling to clients is within 40 days after their baby's birth''. One of my participants told me, "I get knowledge about the contraceptive methods through doctors also and the best time to give postpartum contraceptive counseling to clients within 40 days after their baby's birth because in that time period, women have more  chances to conceive or get pregnant."The interpretation showed that most midwives who go for field work for counseling have proper knowledge about the best timings of contraception counseling because it is a matter of client health so midwives must have knowledge about the timings of contraceptive counseling.
The Educational Factor of the Targeted Clients for Contraception Counseling My next research question was on that targeted group of women that were advised on postpartum contraceptive methods, Experience of midwives that they think that the educational factor is important whenever midwives give contraceptive counseling to their clients. Some of my participants said, "We targeted only that woman who has given birth to a baby then we go to that client and gave them postpartum contraceptive counseling. They also talk about the education factor that is more important because it makes our work easy if the client is educated.The interpretation showed that the experience of midwives while providing contraceptive counseling to a particular group of women in rural areas is a very critical situation for providing counseling to these types of illiterate women. Educated clients understand easily but we face difficulties in dealing with uneducated clients due to their low level of understanding.
Level of Contraceptive Knowledge My next research question was about whether the Current contraception knowledge levels or methods are sufficient or not. Do all women understand midwives' counseling and advice easily or not? One of my participants said, ''The current contraception knowledge level or methods are sufficient because I know it and our client also knows about these methods, so I have no need to give basic detail on it''. Most of my participants highlighted the important aspects.The current contraception knowledge level or methods are sufficient because all clients now follow it regularly; they now have a proper follow-up schedule so there is no need to introduce any new method. The current contraception knowledge level or methods are sufficient because in rural areas most women are uneducated and they are not accepting new things easily so there is no need to introduce any new method.The interpretation showed that the current contraception knowledge level or methods are sufficient because clients feel comfortable when they use these current methods and consider these methods to be sufficient due to their acceptance of these methods in rural areas.
Availability of Contraceptive Distribution AlternativesMy next research question was about the availability of contraceptive distribution alternatives at the community level, in rural health centers, and there was a variety of methods often available or not. Some of my participants responded,They have the availability of contraceptives at both the community level and rural health centers by the government free of cost. The availability of a variety of contraceptives like condoms, injectables, and oral pills is provided by the government.Some participants highlighted, ''They have availability of contraceptives but they tell us that sometimes delivery of these methods stop due to any governmental issues''. Most of my participants highlighted, "They have availability of all methods at hospitals but some methods are not available at community health centers. They have availability of contraceptives but whenever they do not have a sufficient availability contraceptives then they report to upper-level health centers, UNICEF, and government."The interpretation showed that midwives face many barriers while giving counseling on the use of postpartum contraceptives like the availability of contraceptives. Midwives have availability of contraceptives at both the community level and rural health centers by the government free of cost but whenever they do have not sufficient availability contraceptives they report to upper-level health centers, UNICEF, and the government.

Discussion

This study highlighted two major sides of this debate, the positive side is that midwives are not confronted with any problem in providing counseling due to adequate knowledge and the negative side of this issue is that they actually think they have sufficient knowledge of contraception, but in the twenty-first century, where every second knowledge is updated, how it is possible to have enough knowledge. This study showed that midwives face administrative issues too, like the availability or unavailability of health services (condoms, pills, and injectables). Midwives are responsible for providing health services to their clients. So they have the free-of-cost provision of contraceptives at both community and rural health centers by the government, but when they do not have appropriate contraceptives available to them then they report to senior health centers, UNICEF, and the government. In case of unavailability of these methods at midwives' health centers due to any governmental issue then midwives refer to clients go to medical stores and buy these m

The main purpose of the present study was to explain midwives ' involvement in providing postpartum contraceptive therapy to rural women. This study revealed that midwives face many difficulties while providing postpartum contraceptive counseling among rural women due to many different factors such as; Qualification of participants, Timings of counseling, targeted group, Training, and Provision of contraceptives) and Personal value of clients, Involvement of client's family (husband, mother-in-law), Contradictory role of community, Misconceptions about the use of contraception(side effects), Accessibility of contraception, Religious unacceptability of contraception). Midwives may find themselves in difficult, ethical dilemmas while providing counseling on contraceptives in rural cultural and social contexts. So, the aim of this study was to obtain information about the counseling of rural women by midwives (dais) and to learn more about the characteristics and practices of that dais while providing counseling on the use of contraceptive counseling as compared to previous literature.  




Counselling Services 

In the present study, most participants tell us that we are getting knowledge by attending training sessions in health centers. The best time to give them counseling within 40 days after the baby's birth because when the women have 1st malnutrition time is very dangerous and has a high expectancy rate of pregnancy. So, we go to counseling in that time period when clients must take care of and use these contraceptive methods to save themselves from unwanted pregnancies. The present study showed that the knowledge of midwives about contraception was good. Experienced midwives have great knowledge about counselling on contraception while some new midwives have old or little knowledge.

The present study shows that midwives are trained to give formal counseling but they also allow, informal way of counseling to convince clients to use suitable methods. Midwives mostly use formal ways of counseling due to their sensitive position in the field but clients easily understand the informal way of counseling also in rural areas. Midwives go to the field formally pre-planned and give a description of every method but advise them informally but mostly it depends on our field experience, midwives give them counseling formally but answer their fears about contraception use after postpartum informally also.

This study showed that midwives' planning and duration depend upon the knowledge of clients and how much they have knowledge about the use of postpartum contraceptive methods. So, those clients who already have knowledge take less time and show their interest, and those who do not will take more time due to lack of information. This is a sensitive issue so needs proper planning due to societal issues midwives must make plans before going to the field and then ask questions about the issues of clients (rural women).

The present study showed that most midwives in rural areas face many difficulties while providing counseling on the use of contraceptives so they must have knowledge about contraceptives and their use and also have some knowledge about the rural women's level of understanding while making procedures and planning how to give counseling. Most midwives highlighted that it is a matter of the client's health so we must have a health plan before going to the field, after checking the health situation of the client give them advice on the use of contraception methods for how to protect against unintended pregnancies.

The present study showed that the knowledge of midwives about contraception was good. Experienced midwives have great knowledge about counseling on contraception while some new midwives have old or little knowledge. Midwives go to the field formally pre-planned and give a description of every method but advise them informally but mostly it depends on the midwives' field experience, Midwives give them counseling formally but answer all their fears about the contraception use after postpartum informally also.

The present study showed that Midwives have knowledge about the best timing of contraceptives because it's a matter of the client's health so they mostly get training on it. Midwives get knowledge about it while taking classes/coursework. Midwives gave counseling to the client within 1st week after the baby's birth. Because if some clients have no malnutrition after the baby's birth they conceive too sometimes. So midwives advise them on how they save from unexpected pregnancy. Midwives also give advice on what types of methods they use in that time period we never recommend the injectables method at that time because due to this method, clients may never conceive again.

The present study showed that the experience of midwives while providing contraceptive counseling to a particular group of women in rural areas it is difficult to give contraceptive information due to lack of knowledge. Educated clients understand easily but we face difficulties in dealing with uneducated clients due to their low level of understanding. The present study also showed that current contraception knowledge levels or methods are sufficient because clients feel comfortable when they use these current methods and consider these methods to be sufficient due to their acceptance of these methods in rural areas.

Language barriers, health care providers'(midwives) own misconceptions about other cultures, and misunderstandings of patients' needs have been suggested by Newbold and Willinsky (2009) to add to the complexity of health care provision in rural areas. Norms that are bounded by culture and values have a profound impact on midwives while providing counseling on the use of postpartum contraceptives in rural areas, including contraceptive counseling and abortion care. The hesitation among the responding midwives to acknowledge that rural areas patients often have specific needs might sometimes be counterproductive and might pose many barriers. All of our midwives agreed that rural women more often have a low level of knowledge of contraceptives, body functions, and anatomy. Insufficient knowledge could be due to both educational and cultural matters. This involves both a lack of schooling and a lack of a cultural background where women discuss these issues due to this they face many difficulties while providing counselling on the use of contraceptives. The present study showed that the experience of midwives while providing contraceptive counseling to a particular group of women in rural areas that it was difficult to give advice on contraceptives due to their level of literacy. Educated clients understand easily but we face difficulties in dealing with the uneducated client due to their low level of understanding. In rural areas, there are very few educated women which is why midwives use very easy language while giving counseling on postpartum contraceptive counseling that clients can easily understand, in that way, we save time due to the language barrier in rural areas.

Midwives need all the knowledge about factors that affect their counseling process. It is important for midwives to be aware that women have different values regarding sexual and reproductive health. The challenge for midwives in rural areas is to understand and be curious about every woman's life world perspective, culture, and religion. Knowledge makes a midwife confident in her role as the contraception counseling provider to rural women. Cultural and religious factors affect contraception counseling in rural areas. According to the midwives, knowledge, and awareness of these factors are crucial and lead to improved understanding of rural women's providing contraception counseling, better compliance, fewer unwanted pregnancies, and improved sexual and reproductive health among rural women. The present study showed that the knowledge of midwives about contraception is good. Experienced midwives have great knowledge about counseling on contraception while some new midwives have old or little knowledge. The present study also showed that most midwives go to the field for counseling with proper planning and procedure because it is a matter of the client's health midwives must have a health plan before going to the field, and after checking the health situation of the client give her advice and midwives don't recommend any method of contraception without knowing the client health condition.

In the present study, Most of the participants highlighted that educated women feel shy when they share their personal feelings. But uneducated women share all their feelings and problems openly, they tell them details openly.

Results

Midwives within a rural setting are a long way from tertiary facilities by their very nature. Families may not fully appreciate how much stress this imposes on the part of the midwife who takes care of them. It is the midwife who has to watch for signs of issues and has to make sure that the family knows what to do if any problem occurs. Also, she has to get to work within the proper time and is always ready to prepare in a time of emergencies.3

The shortage of staff and lack of knowledge about counseling in maternity units has become a cause of crises like; having a large number of children due to the unavailability of health workers, inadequate facilities, lack of information, concerns about the use of contraceptives, and opposition from husbands and their family or relatives. These are the most frequent causes of having a large family, especially in rural areas.5

The present study shows that midwives are trained to give formal counseling but they also allow, informal ways of counseling to convince clients to use suitable methods. Midwives mostly use formal ways of counseling due to their sensitive position in the field but clients easily understand the informal way of counseling also in rural areas. Midwives go to the field formally pre-planned and give a description of every method but advise them informally but mostly it depends on our field experience, midwives give them counseling formally but answer all their fears about contraception use after postpartum informally also.

This study showed that midwives' planning and duration depend upon the knowledge of clients and how much they have knowledge about the use of postpartum contraceptive methods. So, those clients who already have knowledge take less time and show their interest, and those who do not will take more time due to lack of information. This is a sensitive issue so it needs proper planning due to societal issues midwives must make plans before going to the field and then ask questions about the issues of clients (rural women).

The present study showed that Most midwives in rural areas face many difficulties while providing counseling on the use of contraceptives so they must have knowledge about contraceptives and their use and also have some knowledge about the rural women's level of understanding while making procedures and planning how to give counseling. Most midwives highlighted that it is a matter of the client's health so we must have a health plan before going to the field, then after checking the health situation of the client give them advice on the use of contraception methods for how to protect against unintended pregnancies.

So, Midwives build rapport with these women, take them into confidence, and ensure their confidentiality and anonymity when they share their feelings with us. Midwives gave them counseling separately by creating comfort zones then women gave them their details openly without shying because, in their comfort zones, they don't hesitate to share their personal feelings. Often midwives face very bad experiences with the upper class of rural areas; the midwives ' hands do not allow anything because of cleanliness. Therefore, instead of midwives, these types of ladies belonging to upper-class families go to the hospital and work for private doctors.

Conclusion

Midwives need all the knowledge about factors that affect their counseling process. It is important for midwives to be aware that women have different values regarding sexual and reproductive health. Clearly, due to many issues, there is a considerable low level of awareness and knowledge of contraception in rural areas. Therefore regular and comprehensive counselling procedure from midwives in a village is a must for all rural women. Proper and accurate information should be provided on various methods of contraception which should allow rural women to choose a method of their choice. There is, therefore, a great need for policymakers and field workers to better encourage spacing methods and couple incentives to embrace them.

References

• Adatara, P., Strumpher, J., & Ricks, E. (2019). A qualitative study on rural women’s experiences relating to the utilisation of birth care provided by skilled birth attendants in the rural areas of Bongo District in the Upper East Region of Ghana. BMC Pregnancy and Childbirth, 19(1). https://doi.org/10.1186/s12884-019-2337-0

• World Health Organization. (2007). Facts on induced abortion worldwide. World Health Organization.
• Indrayani, I., & Mulyawati, G. (2015). Village midwives’ experiences in rural area. Jurnal Ilmiah Permata Medica, 4(1), 1-24.
• Kallner, H. K., & Danielsson, K. G. (2016). Prevention of unintended pregnancy and use of contraception—important factors for preconception care. Upsala Journal of Medical Sciences, 121(4), 252–255. https://doi.org/10.1080/03009734.2016.1208310
•  Kamran, I., Tasneem, Z., Parveen, T., & Zaidi, Y. (2015). Investigating the low patterns of modern contraceptive use in Pakistan. https://doi.org/10.31899/rh9.1077
• Kolak, M., Jensen, C., & Johansson, M. (2017). Midwives’ experiences of providing contraception counselling to immigrant women. Sexual & Reproductive Healthcare, 12, 100–106. https://doi.org/10.1016/j.srhc.2017.04.002
• McCance, K., & Cameron, S. (2014). Midwives’ experiences and views of giving postpartum contraceptive advice and providing long-acting reversible contraception: a qualitative study: Table 1. Journal of Family Planning and Reproductive Health Care, 40(3), 177–183. https://doi.org/10.1136/jfprhc-2013-100770
•  Nath, J., & Islam, F. (2015). A Study on the Knowledge, Attitude and Practice about Contraception in Postpartum Women of North India. International Journal of Science and Research, 4(12), 465–468. https://doi.org/10.21275/v4i12.nov151971
• Sarfraz, M., & Hamid, S. (2014). Challenges in delivery of skilled maternal care – experiences of community midwives in Pakistan. BMC Pregnancy and Childbirth, 14(1). https://doi.org/10.1186/1471-2393-14-59
• Tabbassam, H. F., & Menhas, R. (2014). Role of community midwife in maternal health care system in rural areas of Pakistan.
• Weaver, E. H., Frankenberg, E., Fried, B. J., Thomas, D., Wheeler, S. B., & Paul, J. E. (2013). Effect of village midwife program on contraceptive prevalence and method choice in Indonesia. Studies in Family Planning, 44(4), 389–409. https://doi.org/10.1111/j.1728-4465.2013.00366.x