title: Postpartum uptake of contraception in rural northern Malawi: A prospective study.
abstract: Cross-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.
  
  
  
  A 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).
  
  
  
  Of 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.
  
  
  
  The 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.
  
  
  
  There 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.
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. Electronic address: aisha.dasgupta@lshtm.ac.uk.
authors.forename: Aisha N Z
authors.initials: ANZ
authors.lastname: Dasgupta
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
authors.affiliation: London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; Karonga Prevention Study, Chilumba, Karonga District, Malawi.
authors.forename: Amelia C
authors.initials: AC
authors.lastname: Crampin
mesh_terms: D000293:Adolescent; D000328:Adult; D000568:Amenorrhea; D003267:Contraception / Q000379:methods*; D003268:Contraception Behavior / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005193:Family Planning Services / Q000592:standards; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008295:Malawi; D008875:Middle Aged; D049590:Postpartum Period; D011247:Pregnancy; D049168:Pregnancy, Unplanned; D011446:Prospective Studies; D012746:Sexual Abstinence; D013997:Time Factors; D055815:Young Adult
keywords: Amenorrhea; Contraception; Malawi; Postpartum; Postpartum abstinence