title: Patterns and trends of postpartum family planning in Ethiopia, Malawi, and Nigeria: evidence of missed opportunities for integration.
abstract: BACKGROUND
  The first 12 months following childbirth are a period when a subsequent pregnancy holds the greatest risk for mother and baby, but also when there are numerous contacts with the healthcare system for postnatal care for mother and baby (immunisation, nutrition, etc.). The benefits and importance of postpartum family planning are well documented. They include a reduction in risk of miscarriage, as well as mitigation of (or protection against) low birth weight, neonatal and maternal death, preterm birth, and anaemia.
  
  
  OBJECTIVE
  The objectives of this paper are to assess patterns and trends in the use of postpartum family planning at the country level, to determine whether postpartum family planning is associated with birth interval and parity, and to identify the health services most closely associated with postpartum family planning after adjusting for socio-economic characteristics.
  
  
  METHODS
  Data were used from Demographic and Health Surveys that contain a reproductive calendar, carried out within the last 10 years, from Ethiopia, Malawi, and Nigeria. All women for whom the calendar was completed and who gave birth between 57 and 60 months prior to data collection were included in the analysis. For each of the births, we merged the reproductive calendar with the birth record into a survey for each country reflecting the previous 60 months. The definition of the postpartum period in this paper is based on a period of 3 months postpartum. We used this definition to assess early adoption of postpartum family planning. We assessed variations in postpartum family planning according to demographic and socio-economic variables, as well as its association with various contact opportunities with the health system [antenatal care (ANC), childbirth in facilities, immunisation, etc.]. We did simple descriptive analysis with tabular, graphic, and 'equiplot' displays and a logistic regression controlling for important background characteristics.
  
  
  RESULTS
  Overall, variation in postpartum use of modern contraception was not affected over the years by age or marital status. One contrast to this is in Ethiopia, where the data show a significant increase in uptake of postpartum contraception among adolescents from 2005 to 2011. There are systematic and pervasive equity issues in the use of modern postpartum family planning by education level, place of residence, and wealth quintile, especially in Ethiopia where the gaps are very large. Disaggregation of data also point to significant sub-national variations. After adjusting for socio-economic variables, the most consistent health sector services associated with modern postpartum contraception are institutional childbirth and child immunisation. ANC is less likely to be associated with the use of modern postpartum family planning.
  
  
  CONCLUSIONS
  Postpartum use of modern family planning has remained very low over the years, including for childbearing adolescents. Our results indicate that improving postpartum family planning requires policies and strategies to address the inequalities caused by socio-economic factors and the integration of family planning with maternal and newborn health services, particularly with childbirth in facilities and child immunisation. Scaling up systematic screening, training of providers, and generation of demand are some possible ways forward.
authors.affiliation: United Nations Population Fund, New York, NY, USA; hounton@unfpa.org.
authors.forename: Sennen
authors.initials: S
authors.lastname: Hounton
authors.affiliation: Avenir Health, Glastonbury, CT, USA.
authors.forename: William
authors.initials: W
authors.lastname: Winfrey
authors.affiliation: International Center for Equity in Health, Federal University of Pelotas, Capão do Leão, Brazil.
authors.forename: Aluisio J D
authors.initials: AJ
authors.lastname: Barros
authors.affiliation: Population Council, Nairobi, Kenya.
authors.forename: Ian
authors.initials: I
authors.lastname: Askew
mesh_terms: D000293:Adolescent; D000328:Adult; D003267:Contraception; D003695:Delivery of Health Care; D005002:Ethiopia; D005193:Family Planning Services / Q000706:statistics & numerical data*; D005260:Female; D005298:Fertility; D006801:Humans; D008295:Malawi; D008427:Maternal Health Services; D008428:Maternal Mortality; D009549:Nigeria; D010298:Parity; D011181:Postnatal Care / Q000706:statistics & numerical data*; D049590:Postpartum Period; D011247:Pregnancy; D012959:Socioeconomic Factors
keywords: integration; maternal and newborn health services; postpartum contraception; sub-Saharan Africa