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Contraceptive use among postpartumwomen in IndiaK. K. Singh, Shruti Verma & Shilpi TantiPublished online: 09 Sep 2013.

To cite this article: K. K. Singh, Shruti Verma & Shilpi Tanti (2014) Contraceptiveuse among postpartum women in India, Asian Population Studies, 10:1, 23-39, DOI:10.1080/17441730.2013.827368

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CONTRACEPTIVE USE AMONG

POSTPARTUM WOMEN IN INDIA

K. K. Singh, Shruti Verma and Shilpi Tanti

Various family planning programmes have recognised the importance of family planning in the

first year postpartum. Contraception plays a critical role for women in the postpartum period in

preventing unwanted pregnancy and reducing the risk of infant and maternal mortality by

lengthening the subsequent birth intervals. In the present study, an attempt has been made to

explore the level and patterns of contraceptive use and associated factors affecting the use of

contraception during the first 12-month-postpartum period among Indian women. A comparison

regarding postpartum contraceptive use between rural and urban women of India clearly shows

that rural women are still lagging behind urban women with regard to awareness about

postpartum contraceptive use within one year of childbirth. Education as well as economic status,

amenorrheic and abstinence status, postpartum duration and media exposure were found to be

the important factors affecting postpartum contraceptive use among Indian women.

KEYWORDS: contraception; family planning; postpartum amenorrhea; postpartum period;

postpartum women; unwanted pregnancy

Introduction

Complications associated with pregnancy and childbirth is the leading cause of

morbidity and mortality among women of reproductive age, particularly in less developed

countries and that is why maternal health is one of the most urgent global concerns.

The fifth millennium development goal that aims to reduce infant deaths and improve

maternal health by 2015 also recognises this major concern (Ndugwa, Cleland, Madise,

Fotso, & Zulu, 2011). The dynamics of contraceptive use among women in the postpartum

period, i.e. the period of a year after the birth of a child, is of interest at the family planning

programme level, since the delay of contraceptive use until the return of menstruation

might increase the risk of unwanted pregnancy. An increase in contraceptive use during

the postpartum period substantially reduces the rates of maternal and infant mortality by

preventing unplanned and unwanted pregnancies, and spacing births such that there is at

least a two-year interval between a woman’s previous birth and her new pregnancy

(Vernon, 2009).

A research study by Ross and Winfrey (2001) on unmet need for contraception

across 27 countries found that among women who were in their first year after the last

birth, more than 50% had an unmet need for contraception. Thus family planning

Asian Population Studies, 2014Vol. 10, No. 1, 23�39, http://dx.doi.org/10.1080/17441730.2013.827368

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programmes need to target these women, in their first year postpartum, to reduce the

unmet need for contraception.

The report from the Third National Family Health Survey (NFHS-3) (International

Institute for Population Sciences [IIPS], 2007) India states that 21% of all pregnancies that

resulted in live births in the five years preceding the survey (including current pregnancies)

were unplanned, 10% were wanted later and 11% were not wanted at all. An analysis of

data from 25 countries collected as part of the Demographic and Health Surveys (DHS)

project found that mortality risks are elevated for both the previous child and for

the newborn infant if intervals between successive births are shorter than 24 months

(Hobcraft, 1991). A research study conducted for 17 countries in three developing regions

and four Indian regions shows that in all of these countries, observed birth intervals are

considerably small, which is a matter of concern regarding the health of mother and child

(Rutstein, 2000).

According to the NFHS-3 report, in India, 11% of births occur within 18 months of a

previous birth and 28% occur within 24 months. More than 60% occur within three years

of the previous birth and only 28% have an optimal birth interval of 36�59 months (IIPS,

2007). Thus in India, the higher proportion of unplanned pregnancies might be due to

short birth intervals. In this context, the postpartum period is particularly important for

initiating contraception to space births in a healthy manner.

In order to reduce the possible risk of adverse maternal, perinatal and infant

outcomes, the World Health Organization (WHO, 2006) recommended that the interval

between a live birth and an attempt to the next pregnancy should be at least 24 months.

Also, an analysis of Demographic and Health Survey (DHS) data from 17 developing

countries found that the risk of the infant and newborn mortality decreases as the length

of birth interval increases up to 36 months (Rutstein, 2005). Moreover, short birth intervals,

namely, intervals less than 24 months, also have a potential effect on the increased risk of

pregnancy complications and maternal mortality (Conde-Agudelo & Belizan, 2000). Various

research studies have demonstrated that short birth intervals are associated with infant

and child mortality. The use of contraceptives in the postpartum period is the most

effective way to lengthen the interval between subsequent births and, consequently, to

reduce maternal and child morbidity and mortality. Also, the use of contraception in this

period plays a very important role in cutting down the unwanted fertility rate.

Pregnancies that occur in the first-year postpartum are very much likely to have

adverse outcomes on both the baby and mother. A large number of women are not aware

of the risk of return of fecundability and pregnancy in this period and they have to

experience an unwanted pregnancy. Few months after delivery, exclusive breastfeeding

reduces and women resume sexual intercourse that makes them prone to conceiving if

they do not use contraception. Even if a woman is amenorrheic, she is at the risk of

becoming pregnant as ovulation starts before the resumption of menstruation. Thus, by

waiting for menstruation to resume before initiating contraception, many women are

unnecessarily at risk of becoming pregnant in the postpartum period. In India, postpartum

family planning programmes were implemented long before but these programmes

lack further promotion in an effective manner (Castadot, 1975; Thapa, Kumar, Cushing, &

Kennedy, 1992; Winikoff & Mensch, 1991). The interest towards postpartum family plann-

ing programmes regenerated among international policy makers and family planners after it

was realised that the postpartum period is the most effective time for motivating women

to initiate contraceptives as unmet need in this period is very high (Thapa et al., 1992).

24 K. K. SINGH, SHRUTI VERMA AND SHILPI TANTI

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The interest towards research on women’s use of contraception in the extended

postpartum period, ranging from childbirth to the twelfth month thereafter, has been

growing since.

Today, the world population is around 7 billion and India has a population of

1.2 billion. One of the reasons for the uncontrolled population growth is unregulated

fertility. Unregulated fertility often leads to unintended pregnancies, and consequently,

many unwanted or mistimed births. Contraceptive use is an effective way to regulate the

unregulated fertility. Thus it is essential to search for the crucial determinants of

contraceptive use among married women. The factors that determine use or non-use

of contraceptives depend upon a range of socio-demographic factors, which vary from

place to place.

Keeping in view the importance of contraceptive use in the postpartum period, this

research study is mainly inclined towards investigating the levels and patterns of

contraceptive use among Indian women in the first year postpartum and examining the

important socio-economic and demographic determinants of contraceptive use in this

period. Patterns of postpartum contraceptive use are observed through whether a woman

is amenorrheic and also whether she is abstinent since non-amenorrheic and non-

abstinent women are more likely to get pregnant if they do not use contraception in this

period. In addition, survival analysis techniques are used to assess the time to event, such

as resumption of menstruation and resumption of sexual intercourse and time to first

contraceptive use, by postpartum duration. Logistic regression analysis is performed to

observe the impact of different covariates on postpartum contraceptive use while

controlling for other covariates. A woman’s educational status, exposure to media, and

her economic status also affect her choice of whether to use contraceptives, thus these

covariates are also considered in the regression analysis. The analysis is also done

separately for rural and urban women and some comparative results are presented.

Data and Methodology

The data for present study has been taken from the Third National Family Health

Survey (NFHS-3), that took place between November 2005 and August 2006. It is a

nationally representative source of data on population, health and nutrition for India and

its states. NFHS-3 covered all 29 states in India, which comprise more than 99% of India’s

population. It is designed to provide estimates of key indicators for India as a whole and

for each of the 29 states by urban-rural residence and provides information on fertility,

mortality, family planning, HIV-related knowledge and important aspects of nutrition,

health and health care. NFHS-3 collected information from a nationally representative

sample of 124,385 women aged 15�49 years. Present analysis is based on 9433 currently

married women who were in the reproductive age group (15�49) and had children less

than or of 12 months of age at the time of interview (women who had a live birth during

the one-year period preceding the survey but the child died in this period are not

included). Women who were pregnant at the time of interview are excluded from this

study as both menstrual status and contraceptive use are affected by pregnancy.

The present study focuses on one dependent variable i.e. contraceptive use in the

postpartum period and employs both bivariate and multivariate techniques for analysing

the said dependent variable. In this paper, focus is solely on the current use of modern

CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN IN INDIA 25

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contraceptives. Here, the switching between contraceptive methods prior to the current

method employed is not analysed due to the non-availability of data on switching

behaviour. Traditional methods are very popular in India but this paper is directed at

observing the use or non-use of only modern contraceptives among postpartum women

to see the effectiveness of postpartum family planning programmes in generating moti-

vation among postpartum women to use modern contraceptives. To study the levels and

patterns of contraceptive use among women in the postpartum period in rural and urban

areas of India, a bivariate technique is used, while for investigating the important socio-

economic and demographic determinants of contraceptive use in the postpartum period,

univariate and multivariate logistic regression techniques are employed. The logistic

model for multiple predictors is defined by the following equation:

Logit pðxÞ ¼ lne

pðxÞ1� pðxÞ

!¼ aþ

XbiXi ¼ log odds for individual X

where p(x) is the probability that the response variable, Y �1, a is the constant, and bi is

the coefficient of predictor variable Xi (i �1, 2,. . ., k).

Events such as time to resumption of menstruation and resumption of sexual

intercourse and time to first contraceptive use after the birth of child are analysed through

a life table technique which utilises both complete and incomplete observations at the

time of survey. The complete observations are those in which women had experienced the

event of interest and exact durations are known. Incomplete or censored observations are

those in which women are yet to experience the event of interest.

In logistic regression analysis, the dependent variable, contraceptive use in the

postpartum period, is categorised into two parts i.e. using or not using postpartum

contraception. The predictor variables included in the logistic model are: number of living

children (1, 2, 3, more than 3), amenorrheic status (amenorrheic, menstruating), abstinence

status (currently abstinent, not abstinent), media exposure (to at least one form of media,

no exposure), duration postpartum (less than 7 months, 7, or more months), residence

(rural, urban), level of education (not or less educated, more educated), and economic

status (low, middle, high). These variables are assumed to have an effect on the use or

non-use of contraception in the postpartum period and their possible effects on the

dependent variable are seen through unadjusted and adjusted logistic regression analysis.

Here, amenorrheic women are defined as those whose periods have yet to resume after

childbirth while menstruating women are those who have resumed their menstruation

after childbirth. Also, currently abstinent women are defined as women who have not

resumed sexual intercourse after childbirth. Postpartum duration is the time between the

date of childbirth and the interview date, as recorded in months. As far as the classification

of the variable ‘education level’ is concerned, women coming under the subgroups ‘not

educated’ and ‘educated up to primary level’ are classified under the ‘not or less educated’

category. On the other hand, women who have received education up to secondary level

or higher are put into the ‘more educated’ category. Economic status is measured by the

wealth index of women, which is constructed using household asset data and housing

characteristics. Women who fall under the ‘poorest’ and ‘poorer’ wealth index groups are

put into the category of ‘low’ economic status while women who are observed to be in the

‘richer’ and ‘richest’ wealth index groups are considered to be of ‘high’ economic status.

26 K. K. SINGH, SHRUTI VERMA AND SHILPI TANTI

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Results

Table 1 represents the percentage distribution of women under study by different

socio-demographic and economic characteristics. It is observed that overall, only about

one-fourth of the total number of women were using any form of contraception in the

postpartum period and the rest (75%) were not using any contraceptive method. In urban

parts of India, about one-third of postpartum women were using contraceptives while less

than one-fifth of rural women were using some form of postpartum contraception. About

55% of postpartum women were amenorrheic at the time of the survey. Among the

women living in rural areas and those living in urban areas, 60.4% and 46.2% were

amenorrheic at the survey date respectively. About 94% of the entire sample of women

were breastfeeding their children in the postpartum period. Also, only about one-fourth of

the women were abstaining from sex in this period while the remaining had resumed

sexual intercourse after childbirth. About 13% of urban women had four or more living

children at the time of survey, and among rural women, this percentage was about 22%. In

comparison to rural areas, the percentage of educated women was about 28% in urban

areas.

TABLE 1

Percentage distribution (and number) of women according to different characteristics.

Characteristics Rural Urban All women

Contraceptive useUsing 20.0 (1163) 34.8 (1182) 25.4 (2345)Not using 80.0 (4659) 65.2 (2211) 74.6 (6870)Amenorrheic statusAmenorrheic 60.4 (3517) 46.2 (1569) 55.2 (5086)Menstruating 39.6 (2305) 53.8 (1824) 44.8 (4129)Breastfeeding statusBreastfeeding 95.5 (5558) 91.8 (3115) 94.1 (8673)Not breastfeeding 4.5 (264) 8.2 (278) 5.9 (542)Abstinence statusAbstinent 26.8 (1560) 23.8 (809) 25.7 (2369)Not abstinent 73.2 (4262) 76.2 (2584) 74.3 (6846)No. of living children1 33.0 (1924) 39.0 (1323) 35.2 (3247)2 27.9 (1623) 33.2 (1128) 29.9 (2751)3 17.1 (995) 14.4 (490) 16.1 (1485)]4 22.0 (1280) 13.3 (452) 18.8 (1732)Exposure to mediaTo at least one form of media 66.7 (3882) 91.5 (3106) 75.8 (6988)No exposure 33.3 (1940) 8.5 (287) 24.2 (2227)Women’s educationNot or less educated 63.2 (3679) 34.8 (1180) 52.7 (4859)More educated 36.8 (2143) 65.2 (2213) 47.3 (4356)Economic statusLow 51.2 (2979) 10.0 (338) 36.0 (3317)Medium 22.8 (1329) 16.3 (554) 27.1 (1883)High 26.0 (1514) 73.7 (2501) 43.6 (4015)Total 100 (5822) 100 (3393) 100 (9215)

CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN IN INDIA 27

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Contraceptive Use and Amenorrhea

The extent of overlap between contraceptive use and amenorrhea is also of

demographic interest since it has implications for the assessment of the fertility-inhibiting

impact of contraceptive use within a population (Ross & Winfrey, 2001). From Table 2

it is clear that overall, about 15% of amenorrheic women were using some form of

contraception; this may be because of awareness about the risk of conception prior to the

first menstruation after childbirth among these women. The percentage of women using

contraception during postpartum amenorrhea was higher in urban areas (19.2%) as

compared to rural ones (12.3%). It is observed that contraceptive use was substantially

lower for amenorrheic women than for menstruating women in both rural and urban

areas. Although there were differences between breastfeeding and non-breastfeeding

women with regard to use of contraceptives, this difference seemed to be much larger for

amenorrheic and menstruating women. The percentage of contraceptive users was the

lowest (12.3%) for rural amenorrheic women. Among all women, postpartum contra-

ceptive prevalence for menstruating women was more than twice of that for amenorrheic

women.

From Figures 1 and 2, it is clear that contraceptive use increases with time after birth

in rural as well as urban parts of India. It is observed that for all postpartum durations,

contraceptive use was more among urban women as compared to rural women. Figure 1

clearly shows that contraceptive use increased about two-fold from the first to the fourth

month postpartum but after this period, the contraceptive prevalence did not increase as

rapidly as the previous two-fold increment. Contraceptive use was about two times higher

for urban women as compared to rural women who have reached the four-month

postpartum period but this ratio started decreasing after the four-month postpartum

period (Figure 2). The reason behind this may be that after four months from childbirth

many women do not remain in an amenorrheic state and many resume sexual intercourse

with their partners and start using contraception to avoid pregnancy.

Table 3 represents contraceptive prevalence by months postpartum and contra-

ceptive methods separately for amenorrheic and menstruating women. This table shows

that among urban menstruating women, contraceptive use reached 45% at five to six

months postpartum while it was only about 28% among rural menstruating women at the

same point in time postpartum. For women who gave birth only few months prior to the

TABLE 2

Prevalence of contraceptive use by amenorrheic and breastfeeding status.

Amenorrheic status Breastfeeding status

Amenorrheic MenstruatingChi squarea

(p value) BreastfeedingNot

breastfeedingChi squareb

(p value)

Rural 12.3 31.7 173.96 (0.00*) 19.4 31.1 51.84 (0.00*)Urban 19.2 48.2 33.6 48.6All women 14.5 39.0 24.5 40.0

aChi square for testing significance of difference between residence (rural, urban) and amenorrheic status.bChi square for testing significance of difference between residence (rural, urban) and breastfeedingstatus.*pB0.05.

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survey, contraceptive practice was more common among menstruating women as

compared to amenorrheic women. This suggests that the resumption of menstruation

after childbirth is an important stimulating factor for the use of contraception among

postpartum women. Among all women (rural and urban combined) about 19%

amenorrheic women and 45% menstruating women were using some form of contra-

ception one year after childbirth. Also about 8% of amenorrheic women and 19% of

menstruating women initiated contraceptive use within two months of childbirth.

Pill use was very low among postpartum women, especially those who were

amenorrheic. About 3% of amenorrheic women in rural areas and 9% of amenorrheic

women in urban areas went for sterilisation in the initial months (1�2 months)

postpartum. At all points in time postpartum, condoms were the most preferred method

of contraception among menstruating women who were residing in urban areas.

As far as the use of intrauterine devices and injections is concerned, it was low

among amenorrheic as well as menstruating women but was somewhat more common

amongst menstruating women as compared to amenorrheic women. It is observed that

among menstruating women, use of these internal devices was about five times greater at

11�12 months postpartum as compared to the initial months after childbirth. Also, it can

be seen that among menstruating women, the use of sterilisation as a method of birth

control almost doubled (7.7% to 14.9%) from the initial months to the twelfth month

FIGURE 2

Percentage of contraceptive users (rural and urban women).

FIGURE 1

Percentage of contraceptive users in different postpartum durations (all women).

CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN IN INDIA 29

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postpartum. It is worthwhile to mention that about 55% of menstruating women had not

started using contraceptives even after their child was 11�12 months old.

Abstinence, Amenorrhea and Postpartum Contraception

It is well known that women who have resumed menstruation after childbirth and

do not practice abstinence are at higher risk of pregnancy than amenorrheic women if

they do not use any form of contraception, regardless of whether they are breastfeeding

or not. The proportion of such women was high in rural areas as compared to urban areas.

This can be clearly observed from Table 4 which shows that in rural areas, 34% of

menstruating and non-abstinent women were using contraceptives while the rest (66%)

were not using any, whereas in urban areas, 53% were using some form of contraception

and 47% were not using any. This shows that in comparison to urban women, rural

women had a higher risk of unwanted pregnancy in the postpartum period. Among

amenorrheic women who were not abstinent, contraceptive use was about 1.6 times more

among urban women as compared to rural women (22% among urban vs. 14% among

rural women). Again this may be due to greater awareness among urban women about

TABLE 3

Contraceptive prevalence by amenorrheic status and postpartum duration.

Months since last birth and amenorrheic status

1�2 3�4 5�6 7�8 9�10 11�12

Contraceptive methods A* M** A* M** A* M** A* M** A* M** A* M**

RuralNone 94.7 83.3 89.3 75.7 84.7 72.0 83.5 68.1 82.2 64.5 83.5 61.2Pill 0.1 3.8 0.4 2.7 0.3 6.2 0.2 7.3 0.3 7.3 0.8 11.0IUD/injection 0.1 0.8 0.3 2.0 0.3 1.6 0.7 1.8 0.8 2.1 0.4 3.5Condom 2.1 3.8 3.0 10.1 4.3 10.6 2.3 10.1 3.3 11.9 2.0 9.9Sterilisation 2.9 8.3 7.1 9.5 10.4 9.6 13.3 12.7 13.6 14.2 13.3 14.3Total (user) 5.3 16.7 10.7 24.3 15.3 28.0 16.5 31.9 17.8 35.5 16.5 38.8UrbanNone 86.4 78.1 80.0 61.2 80.8 54.7 73.8 50.7 77 42.2 75.9 45.9Pill 0.2 3.5 0.6 4.1 0.0 7.7 0.5 5.3 1.4 9.9 0.0 10.4IUD/injection 0.6 1.8 0.8 3.3 0.7 5.0 1.0 5.9 0.0 8.2 0.0 7.1Condom 3.8 9.6 7.8 22.7 6.2 24.0 8.9 24.3 10.1 24.8 9.3 21.0Sterilisation 8.9 7.0 10.8 8.7 12.4 8.6 15.7 13.6 11.5 14.9 14.8 15.6Total (user) 13.6 21.9 20.0 38.8 19.2 45.3 26.2 49.3 23.0 57.8 24.1 54.1All womenNone 91.9 80.9 86.4 69.1 83.5 63.6 81.0 61.1 80.8 54.3 81.2 54.9Pill 0.1 3.7 0.4 3.3 0.2 7.0 0.3 6.5 0.5 8.5 0.6 10.8IUD/injection 0.3 1.2 0.4 2.6 0.4 3.2 0.8 3.5 0.5 4.9 0.3 5.0Condom 2.7 6.5 4.5 15.8 4.9 17.1 4.0 15.8 5.1 17.8 4.2 14.5Sterilisation 5.0 7.7 8.3 9.1 11.0 9.1 13.9 13.1 13.0 14.5 13.8 14.9Total (user) 8.1 19.1 13.6 30.9 16.5 36.4 19.0 38.9 19.2 45.7 18.8 45.1

Note: Chi-square test showed the significant differences among rural and urban women with respect tocontraceptive prevalence at 5% level of significance.*Amenorrheic.**Menstruating.

30 K. K. SINGH, SHRUTI VERMA AND SHILPI TANTI

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possible pregnancy risk in the postpartum amenorrhea period as compared to rural

women. Among all amenorrheic women who were not abstaining sexually, more than

16% were using some form of contraception, thus these women could be seen as those

who were aware of pregnancy risks during postpartum amenorrhea. Among all

menstruating women who were not abstinent, about 43% were using contraception

and the rest (57%) were not using any form of contraception and thus the latter group

might be at a higher risk of becoming pregnant in this sensitive period, sensitive in the

sense that the risk of maternal and infant mortality becomes very high should the woman

conceive again within the first year after the birth of child.

Time to Menstrual, Sexual, and Contraceptive Use Resumption

Survival probabilities for time to resumption of menstruation and sexual intercourse

and time to start of contraceptive use after birth are calculated through the life table

method and these probabilities are plotted against the postpartum duration separately

for rural, urban and all women combined (Figure 3). From this figure, it can be clearly

observed that among all women, 50% resumed menstruation within six months of

childbirth. Urban women resumed menstruation about three months before their rural

counterparts. Probability curves representing the resumption of sexual intercourse show

that more than 60% of postpartum women resumed sexual relations within three months

and about 80% resumed it within five months after birth. Only about 15% of women

TABLE 4

Contraceptive prevalence by amenorrheic and abstinence status.

Contraceptive prevalence %(total)

Characteristics Using Not using Chi square (p-value)

Urban AmenorrheicCurrently abstinent 14.7 (86) 85.3 (499) 12.4 (0.00*)Not abstinent 22.0 (216) 78.0 (768)MenstruatingCurrently abstinent 11.6 (26) 88.4 (198) 137.3 (0.00*)Not abstinent 53.4 (854) 46.6 (746)

Rural AmenorrheicCurrently abstinent 9.1 (110) 90.9 (1100) 17.7 (0.00*)Not abstinent 14.0 (323) 86.0 (1984)MenstruatingCurrently abstinent 16.6 (58) 83.4 (292) 43.5 (0.00*)Not abstinent 34.4 (672) 65.6 (1283)

All women AmenorrheicCurrently abstinent 10.9 (196) 89.1 (1599) 28.0 (0.00*)Not abstinent 16.4 (539) 83.6 (2752)MenstruatingCurrently abstinent 14.6 (84) 85.4 (490) 166.3 (0.00*)Not abstinent 42.9 (1526) 57.1 (2029)

Note: Numbers in parentheses ().*pB0.05.

CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN IN INDIA 31

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remained abstinent at six months postpartum. Thus, a comparison of probability curves

representing the resumption of menstruation and of sexual intercourse clearly show that

most of the women resumed sexual intercourse before the resumption of menstruation

after childbirth. While considerable differences in timings of resumption of menstruation

after childbirth were found between urban and rural women, the timings of resumption of

sexual intercourse during the postpartum period were almost similar for both rural and

urban women. Comparison of all three types of survival curves indicate that a large

proportion of women were at risk of unwanted pregnancy as most of the women who had

resumed menstruation as well as sexual intercourse started using contraceptives much

later. While the use of modern contraceptives in the postpartum period was initiated

earlier among urban women as compared to rural women, it was still not as early as was

required for preventing unwanted pregnancy.

Logistic Regression Analysis

For investigating the important socio-economic and demographic determinants

of contraceptive use among women in the postpartum period, multivariate logistic

regression technique is employed separately for rural, urban, and all Indian postpartum

women in the study. Table 5 presents the unadjusted and adjusted odds ratios (with their

confidence intervals) of contraceptive use among postpartum women for different socio-

economic and demographic characteristics, obtained from the logistic regression model.

All predictors taken in the model were found to have significant impact on postpartum

contraceptive use in both univariate and multivariate analysis, which can be observed

from the confidence intervals calculated for each and every characteristic. The adjusted

FIGURE 3

Survival probabilities for menstrual resumption, sexual resumption and use of modern

contraceptives during a one-year postpartum period.

(A: All women, U: Urban women, R: Rural women).

32 K. K. SINGH, SHRUTI VERMA AND SHILPI TANTI

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TABLE 5

Logistic regression analysis of use of contraception postpartum by different background characteristics.

Rural Urban All women

Characteristics C.O.R. A.O.R. C.O.R. A.O.R. C.O.R. A.O.R.

Number of living children1*2 2.416 3.146 1.957 2.559 2.117 2.805

(2.032, 2.874) (2.606, 3.798) (1.654, 2.315) (2.118, 3.091) (1.881, 2.382) (2.458, 3.200)3 2.465 4.356 1.639 2.520 1.885 3.413

(2.030, 2.992) (3.505, 5.415) (1.319, 2.038) (1.967, 3.230) (1.638, 2.170) (2.903, 4.012)]4 1.448 3.298 1.058 2.191 1.105 2.733

(1.190, 1.762) (2.626, 4.141) (0.836, 1.340) (1.656, 2.901) (0.955, 1.278) (2.297, 3.252)Amenorrheic statusAmenorrheic 0.303 0.354 0.256 0.343 0.264 0.350

(0.265, 0.346) (0.305, 0.412) (0.219, 0.299) (0.288, 0.408) (0.239, 0.292) (0.312, 0.392)Menstruating*Abstinence statusCurrently abstinent 0.396 0.553 0.227 0.340 0.310 0.449

(0.333, 0.472) (0.456, 0.671) (0.184, 0.282) (0.268, 0.430) (0.271, 0.355) (0.387, 0.522)Not abstinent*Exposure to mediaTo at least one form of media 2.156 1.555 2.521 1.434 2.694 1.492

(1.850, 2.513) (1.297, 1.865) (1.855, 3.427) (1.009, 2.039) (2.360, 3.076) (1.271, 1.752)No exposure*Duration postpartumB7 months 0.428 0.639 0.416 0.697 0.435 0.664

(0.375, 0.489) (0.550, 0.742) (0.360, 0.481) (0.590, 0.823) (0.395, 0.479) (0.594, 0.742)7 or more months*ResidenceRural � � � � 0.467 0.798

(0.424, 0.514) (0.709, 0.897)

CO

NTR

AC

EPTIV

EU

SEA

MO

NG

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STPA

RTU

MW

OM

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IND

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TABLE 5 (Continued )

Rural Urban All women

Characteristics C.O.R. A.O.R. C.O.R. A.O.R. C.O.R. A.O.R.

Urban*Women’s educationNot or less educated*More educated 2.239 1.774 2.169 1.731 2.544 1.777

(1.966, 2.551) (1.495, 2.104) (1.851, 2.540) (1.417, 2.115) (2.309, 2.804) (1.562, 2.023)Economic statusLow 0.351 0.550 0.268 0.415 0.277 0.508

(0.302, 0.408) (0.454, 0.667) (0.198, 0.365) (0.293, 0.587) (0.247, 0.312) (0.432, 0.596)Middle 0.566 0.716 0.408 0.500 0.450 0.613

(0.477, 0.672) (0.590, 0.867) (0.328, 0.507) (0.390, 0.641) (0.396, 0.512) (0.528, 0.712)High*

Note: 95% CI within parentheses.*Represents reference category.C.O.R.: Crude Odds Ratio; A.O.R.: Adjusted Odds Ratio.

34

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odds ratios show that in both urban and rural parts of India, women with two, three or

more children were more likely to use contraception in the postpartum period as

compared to the women with only one living child. Women having two living children

were approximately three times more likely to use postpartum contraception as compared

to the women who had only one living child.

Amenorrheic women were about 65% less inclined towards using postpartum

contraception as compared to the menstruating women in both rural and urban areas of

India. The abstinence status of women in the postpartum period is also found to be a

significant factor affecting use of contraceptives in the postpartum period. Rural women

who were abstaining in this period were 45% less likely to be using contraceptives during

this period while urban abstinent women were 66% less likely to be using postpartum

contraception as compared to the women who had resumed sexual intercourse with their

partner in the postpartum period. Also among all women, the abstinent women were

about 55% less likely to be using postpartum contraception as compared to the women

who were abstinent after childbirth.

Media exposure also played a significant role in spreading awareness among the

women for using postpartum contraception. Women who were exposed to at least one

form of media were about 1.5 times more likely to be using postpartum contraception as

compared to the women who had no exposure to any type of media.

Also, the duration after birth of child (in months), i.e. duration postpartum, and

women’s educational status are found to be significant factors affecting use of contra-

ceptives in the postpartum period. As expected, it is found that the women with a

postpartum duration of six or less months were less likely to use postpartum contra-

ception as compared to their counterparts (the women for whom postpartum duration is

more than six months) in both urban and rural parts. As was also expected, education is

also found to be an important covariate affecting the use of contraceptives in the

postpartum period. The highly educated women were 1.8 times more likely to be using

contraceptives in the postpartum period as compared to uneducated or less educated

women.

It is also observed that the urban women in the low economic status category

were 58% less likely to be using postpartum contraception while the rural women in the

same category were about 45% less likely to be using contraceptives in the postpartum

period as compared to the women of high economic status. This shows that as far as

contraceptive use in the postpartum period is concerned, the difference between the

urban women of low economic status and high economic status was much bigger as

compared to the difference between rural women of low and high economic status. Both

in rural as well as urban areas, it is clear that with the decline in the economic status of

households to which women belong, postpartum contraceptive use also declined after

controlling for the other covariates.

In the logistic regression model, of all postpartum women under study, one

more covariate viz. residence is also included and it is found that contraceptive use in

the postpartum period also varied significantly according to the place of residence.

Rural women were 20% less likely to be using postpartum contraception than

urban women; this may be because of less awareness and motivation among the

rural women to use contraceptives in the first year after childbirth as compared to the

urban women.

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Discussion

In the present study, postpartum contraceptive use was found to be consistently

increasing with the duration postpartum. This finding is partly supported by the finding of

a report of Urban Health Initiative (UHI) in Uttar Pradesh which states that the percentage

of married women who use a modern contraceptive method increases with the age of a

woman’s youngest child (UHI, n.d.).

It is clear from the analysis that there was very low use of oral contraception in the

postpartum period. This may be due to the fact that during this period, most of the

women were breastfeeding their children and they preferred not to use pills possibly

because of the possible adverse effects of hormones on baby and milk production in

mothers. Oral contraceptives contain oestrogen and progestin and oestrogen-containing

birth control pills are not considered to be compatible with breastfeeding since oestrogen

reduces milk production (Court, n.d.). Condoms were the most preferred temporary

method of contraception among postpartum women.

The number of living children that a woman currently has was positively associated

with postpartum contraceptive use. This result is well established in existing literature on

the subject and is consistent with the findings of various studies. As an illustration, a study

on the determinants of contraceptive use among married women residing in rural areas of

Belgaum (a district in Karnataka) states that ‘it is mainly the number of children that

decides the use of family planning methods’ (Walvekar, 2012). Another study in the state

of Orissa also reveals that contraceptive use goes up with the number of children a

woman currently has (Sahoo, 2007).

The level of women’s education had a significant impact on use or non-use of

postpartum contraception. Highly educated women were more willing to use contra-

ceptives in this period as compared to uneducated women. This may be due to the fact

that highly educated women are more likely to appreciate the advantages of having fewer,

better educated children (Okezie, Ogbe, & Okezie, 2010). Mass media exposure also played

a very important role in shaping the women’s decision about whether to adopt the use of

postpartum contraception. This result is supported by many research findings in different

regions of India that report a positive association between contraceptive use and women’s

exposure to mass media (Kulkarni, 2003; Retherford & Mishra, 1997; Sahoo, 2007). Instead

of these covariates, women’s economic status and place of residence were also important

covariates influencing the use of postpartum contraception. All these results are consistent

with previous analyses in four developing countries which concluded that better

educated, wealthier women who lived in urban areas as well as those women who

were regularly exposed to media were more likely to use contraception (Gabreselassie,

Rustein, & Mishra, 2008).

The return of menstruation was a strong covariate affecting postpartum contra-

ceptive use and amenorrheic women were less willing to use postpartum contraception as

compared to their menstruating counterparts. This may be due to the reason that

amenorrheic women assume that they are safe from pregnancy risk and do not opt for

postpartum contraception. Thus the return of menstruation was a strong stimulating

factor for determining the initiation of postpartum contraceptive use among women. The

proportion of women who started using contraceptives in the postpartum period was very

low and the timing of initiation was much later than the timing of both the resumption of

menstruation and the timing of the return to sexual intercourse. Therefore, there is a need

36 K. K. SINGH, SHRUTI VERMA AND SHILPI TANTI

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to educate women about the right time to initiate postpartum contraceptive use to

prevent unwanted pregnancy and maintain an optimal birth interval. Thus, it calls for

further investigation of factors influencing the timing of postpartum contraceptive use

initiation.

Here a very important point is that only about one-fourth of a total number of

postpartum women were using modern contraceptives regardless of their breastfeeding

and menstrual status. The remaining were either not aware of the risk of pregnancy in this

period or were not getting enough support and motivation for the adoption of

postpartum contraception. Thus in India, postpartum family planning programmes still

need to be strengthened and implemented more effectively. It is to be noted here that in

the present study, the focus is only on the use or non-use of modern contraceptives in the

postpartum period but this study can be further extended to incorporate the traditional

methods of contraception in the analysis.

After investigating the contraceptive prevalence in all the postpartum durations it is

apparent that the urban women were more aware regarding postpartum contraceptive

use than the rural women. One of the reasons for this may be that women in urban areas

are more educated and it is more likely that they have been exposed to at least one form

of media as compared to their rural counterparts. Thus it seems that in comparison to the

urban women, rural women are more at risk of unwanted pregnancy in the postpartum

period.

The findings of the present study suggest that although there is a need to pay more

attention towards family planning programmes for postpartum women in both rural and

urban parts of India, rural parts are still lagging behind urban parts with regard to

postpartum contraceptive use. Also, there is an undeniable need to target poor and less

educated women for the success of postpartum family planning programmes in India.

Although the resumption of menstruation and sexual intercourse were found to be

important determinants of the use of contraceptives in the postpartum period, the

remarkably low proportion of women (amenorrheic or menstruating) using contraceptives

in the postpartum period is a matter of concern and is an issue that must be taken

seriously by policy makers. Women who have recently given birth need greater attention

from family planning and reproductive health programmes if they are to reduce their

numbers of unwanted births and abortions and to lengthen subsequent birth intervals.

According to Ross and Winfrey (2001), ‘Prenatal visits, delivery services and subsequent

health system contacts are promising avenues for reaching postpartum women with an

unmet need for and a desire to use family planning services’.

While it is essential to devise programmes to spread awareness among women to

use contraception to limit births, it is also very essential to effectively devise and

implement postpartum family planning programmes in India by integrating them with

maternal and child health services. There are a number of potential benefits of integrating

postpartum family planning with maternal and child health care services. When

postpartum family planning is presented as a part of maternal and child health services,

it will have a broader cultural acceptance. In addition, women who receive counselling

during their hospital stay for delivery are more likely to use contraceptives in the

postpartum period. Thus, there is a need to observe more closely the role of family

planning policies and health care providers in effectively motivating and spreading

knowledge among Indian women to use contraceptives in the postpartum period. In

CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN IN INDIA 37

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addition, more and more studies focusing on the knowledge and motivation for using

contraceptives in this particular period are needed in India.

ACKNOWLEDGEMENTS

The authors are grateful to the anonymous reviewers of this paper for their valuable

suggestions to improve the earlier version of the paper.

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Shruti Verma (author to whom correspondence should be addressed), Research Fellow,

Department of Statistics, Faculty of Science, Banaras Hindu University, Varanasi

221005, India. Email: shrutiverma.bhu@gmail.com.

Shilpi Tanti, Senior Research Fellow, DST-CIMS, Department of Statistics, Faculty of Science,

Banaras Hindu University, Varanasi 221005, India.

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