Postpartum uptake of contraception in rural northern Malawi: A prospective study

Abstract

ObjectivesCross-sectional estimates of contraceptive use do not provide understanding of time to postpartum uptake. This paper uses a range of Malawian data sources: a prospective study to explore time to uptake of contraception and a cross-sectional survey to assess whether sexually active postpartum women whose fecundity has returned use contraception, and whether abstaining/amenorrheic women report using contraception.Study designA demographic surveillance site (DSS) in Malawi was used to identify 7393 women aged 15–49 years eligible for a 1-year prospective study of contraception using provider-recorded data on patient-held records (2012–2013). This provided a reliable record of time to uptake of postpartum contraception. The average timing of resumption of sexual activities after postpartum abstinence and return of menses was estimated from a population-based sexual behaviour survey in the DSS (2010–2011).ResultsOf 4678 women recruited to the prospective contraception study, 442 delivered an infant during the observation period. Of these, 28.4% used modern contraception within 6 months of delivery. However, at 6–9 months after delivery, only 28.0% women had started menstruation and resumed sexual activities; of these, 77.6% used contraception. Amongst abstaining/amenorrheic women, a quarter reported contraceptive use.ConclusionsThe low uptake of postpartum contraception is likely due to many women abstaining and/or experiencing amenorrhea. Self-reports of contraceptive use amongst abstaining/amenorrheic women bring into question the quality of cross-sectional surveys and demonstrate that contraceptive use by women at low risk of pregnancy could contribute to the Malawi paradox of high contraceptive use and high fertility. Given relatively low risk of pregnancy in the postpartum period in this context, a focus on long-acting/permanent methods may be more effective to avert unintended pregnancies.ImplicationsThere has been increasing interest in the utility of postpartum contraceptive programmes to assist women to space births. Our findings suggest that, although uptake of contraception is low, this is partly due to postpartum abstinence and amenorrhea. Provision of long-acting/permanent methods will be more effective for women after delivery.

Patterns of Contraceptive Adoption, Continuation, and Switching after Delivery among Malawian Women

“…The women included in this analysis had high levels of education and were mostly from urban areas in Lilongwe district, which has been shown to have higher postpartum family planning use than most districts in Malawi[8]. The recently published study by Dasgupta used a rural population in northern Malawi and reported that 28.4% of women using modern methods by 6 months and 45.8% using modern methods by 12 months after delivery[9]. However, these proportions included women who reported abstinence and also using a contraceptive method.…”

“…In a study that used a minimum of data from three visits in the first 12 months after delivery in a cohort of urban women in Nairobi, 32% of women discontinued their initial contraceptive method by 6 months and 49% by 12 months after initiation[10], similar to our results. Another recent study of rural postpartum women in Malawi found that only 5 of 169 modern contraceptive users reported use of more than one modern method in the year after delivery[9], though the number of encounters per woman (where an opportunity to record method discontinuation would arise) in this study was not specified. Contraceptive switching at other time points (outside of the postpartum period) has been studied, and a review of DHS data from 25 countries (including Malawi) demonstrated an overall method discontinuation (and switching) rate of 38% by 12 months after initiation[15].…”

Barriers to Uptake of Postpartum Long‐Acting Reversible Contraception: Qualitative Study of the Perspectives of Ugandan Health Workers and Potential Clients

“…Although most women in low‐income countries want to delay or prevent future pregnancies after giving birth (Pasha et al. ; Dasgupta, Zaba, and Crampin ), only 25–34 percent report using any contraception in the 3–12 months postpartum (Keogh et al. ; Rutaremwa et al.…”

“…They most commonly use relatively short‐acting methods such as injections, which have high discontinuation rates (Keogh et al. ; Dasgupta, Zaba, and Crampin ).…”

Modern contraceptive use among postpartum women living with HIV attending mother baby care points in Kabarole District, Uganda

“…For the postpartum women, contraceptive use supports them to limit or delay childbearing depending on their reproductive intentions [14]. However, few postpartum women in sub-Saharan Africa embrace contraception and those using contraceptives often depend on short acting or traditional methods [15,16]. Studies in the region show that some postpartum women misinterpret breastfeeding as a method of contraception even when the criteria for lactation amenorrhea method (LAM) are not met [17,18].…”