A total of 570 healthcare providers were trained in PPIUD provision during the entire FIGO PPIUD project period from 2015 to 2019 [32]. Trained enumerators posted in the hospitals interviewed healthcare providers working in the Obstetrics and Gynecology departments in the study hospitals using structured questionnaires recording responses on hand-held tablets. Providers were interviewed at baseline before the FIGO intervention was implemented and were interviewed in two follow-up rounds – at 6 months, and 24 months after the start of the intervention. In total, 146 providers working in the study hospitals were recruited into the baseline survey. Of which, 135 were interviewed at 6 months and 119 providers were interviewed at 24 months. This study only includes those providers who completed all three rounds of interviews, a total of 113 providers. To better asses the KAP of providers involved in the PPIUD intervention and analyze any changes throughout the intervention we focused the main analysis on those providers who were trained at baseline or anytime in 24 months. This resulted in a final study sample of 96 trained providers, as shown in Fig. 1. The same analysis was also conducted on the 17 providers that were not trained for comparative purposes.

Sample of healthcare providers

Though KAP survey questions were based on the Nepal National Health Facility Survey [13] and adapted for this study, many questions were purposively designed for the parent study. The parent study collected providers’ background characteristics, perspectives on contraceptive method choice, timing of initiating contraceptive use, factors considered important in making postpartum contraceptive decisions and barriers to greater use of postpartum contraceptive methods, especially PPIUD. It also covered factors that are important for expanding PPIUD services, including PPIUD knowledge, attitudes, behaviors, and practice, as well as factors important for sustainable delivery of PPIUD, such as intention to continue to provide PPIUD when moving to a new hospital.

To determine the PPIUD knowledge of providers the following four questions were used: What chance do you think that a woman using a copper IUD can get pregnant (the correct answer is ‘less than 1%’)? How long can a woman continually use the same copper IUD without removing (the correct answer is ‘12 years’)? How soon after can a woman get pregnant once her copper IUD is removed (the correct answer is ‘immediately’)? Do you think an IUD can protect against sexually transmitted infections (STIs) (the correct answer is ‘no’)?

To assess a provider’s attitude towards PPIUD we used seven questions asking if they would recommend a PPIUD to different patient populations: Would you recommend patients receive PPIUD if they were: (1) 20 years old or younger, (2) 20–29 years old, (3) 30–39 years old, and (4) 40 years old or older (positive answer is ‘yes’ for each category)? Do you recommend PPIUD to women who are not married (positive answer is ‘recommend routinely’)? How frequently do you recommend PPIUD to women who have ever had an abortion (positive answer is ‘recommend routinely’)? How frequently do you recommend PPIUD to women who have ever had an ectopic pregnancy (positive answer is ‘recommend routinely’)?

To measure a provider’s PPIUD practice three questions were used. Do you provide: (1) general counseling for family planning, (2) counseling on PPIUD, and (3) PPIUD insertion/removal (removal was included in the baseline questionnaire). The positive response for these questions is ‘yes’ for each category.

These questions were the same for interviews at the baseline, 6, and 24 months. The same questions were also used to compose three composite score indexes, one each for knowledge, attitude, and practice. Each provider was scored ‘1′ if they answered a question correctly or positively and ‘0′ if they answered incorrectly or negatively. The providers’ knowledge score ranges from 0 to 4, attitude score ranges from 0 to 7, and practice score ranges from 0 to 3, with a higher score indicating a better knowledge of, attitude towards, and practice of PPIUD.

Other questions were used to assess the changes in providers’ views on PPFP and PPIUD before and after the intervention, these include: Overall, how do you rate the IUD as compared to other methods of family planning for women in our country? How do you rate the postpartum IUD compared to other methods of family planning for immediate postpartum protection against pregnancy? (Response options were ‘worst method’, ‘worse than some’, ‘about the same’, ‘better than most’, ‘best method’ or ‘don’t know’). How important is it for women to be protected against another pregnancy during the 1 year postpartum period? (Response options were ‘not important’, ‘neutral’, ‘important’ or ‘don’t know’).

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