The effect of contraceptive empowerment during pregnancy on postpartum family planning use in Ethiopia: evidence from a longitudinal panel study

Abstract

Background:

Women’s empowerment significantly influences maternal and child health by enhancing access to healthcare and enabling autonomous reproductive decisions, including timely family planning during postpartum. However, in Ethiopia, the specific role of contraceptive empowerment in postpartum family planning (PPFP) use remains insufficiently studied despite the low level of women’s empowerment.

Objective:

To assess the effect of contraceptive empowerment on PPFP use in Ethiopia.

Design:

A community-based panel study design.

Methods:

We used the panel data from Performance Monitoring for Action Ethiopia (2021–2023), which followed 1759 pregnant women aged 15–49 years from four regions of Ethiopia. The analytic sample is restricted to non-pregnant women who completed the interview at 1 year postpartum. Contraceptive empowerment was assessed using five items on a 5‑point Likert scale, whereas PPFP use was measured through yes/no question regarding modern contraceptive use at 1 year postpartum. A mixed-effect multilevel multivariable logistic regression model was employed, and p-value of 0.05 was used to determine the statistical significance.

Result:

PPFP use at 12 months of postpartum is significantly higher among women reporting high and medium contraceptive empowerment during pregnancy, compared to low contraceptive empowerment (AOR: 1.8, 95% CI: 1.3–2.6) and (AOR: 1.7, 95% CI: 1.2–2.3) respectively. In addition, women whose birth was attended by a skilled birth attendant (AOR: 1.7, 95% CI: 1.3–2.4), lower parity (1: AOR: 4.5, 95% CI: 2.5–8.1, 2–4: AOR: 2.1, 95% CI: 1.3–3.3 compared to ⩾5), and those who previously used contraception (AOR: 3.8, 95% CI: 2.8–5.4) were more likely to use PPFP; women residing in Amhara (AOR: 0.4, 95% CI: 0.1–0.8) and Oromia regions (AOR: 0.4, 95% CI: 0.1–0.8) had significantly lower use of PPFP.

Conclusion:

Contraceptive empowerment during pregnancy predicted PPFP use at 12 months of postpartum. Higher contraceptive empowerment at pregnancy significantly increases the use of PPFP at 1 year postpartum in Ethiopia. The findings highlight the need for targeted interventions to enhance contraceptive empowerment prior to, during, and after pregnancy; strengthen skilled birth attendance and address regional disparities for equitable and sustained PPFP use.

Plain language summary

Contraceptive empowerment and post-partum family planning in Ethiopia

This study explored how women’s empowerment in making contraceptive decisions influences the use of family planning after childbirth in Ethiopia. Family planning during the postpartum period is critical for maternal and child health, yet uptake remains uneven across the country. Using data from the Performance Monitoring for Action Ethiopia project (2021–2023), researchers followed 1,759 pregnant women across four regions and analyzed their contraceptive use one year after delivery. The findings show that women who reported medium or high levels of contraceptive empowerment during pregnancy were significantly more likely to adopt family planning methods postpartum compared to those with low empowerment. Empowerment here refers to women’s confidence, autonomy, and ability to make informed choices about contraception. Other factors also played a role: women attended by skilled birth attendants, those with fewer children, and those with prior contraceptive experience were more likely to use postpartum family planning. In contrast, women living in Amhara and Oromia regions had lower rates of use, highlighting regional disparities. Overall, the study demonstrates that strengthening contraceptive empowerment during pregnancy can have lasting effects on family planning uptake after childbirth. It suggests that interventions should focus not only on expanding access to services but also on building women’s decision-making power, supporting skilled birth attendance, and addressing regional inequalities. These efforts could contribute to more equitable and sustained improvements in maternal and child health outcomes in Ethiopia.

Keywords

contraceptive empowerment Ethiopia postpartum family planning service utilization

Introduction

Gender equality and maternal health are integral to the sustainable development goals (SDGs), which advocate for universal access to sexual and reproductive health services and the implementation of gender-responsive policies.¹ Despite a 40% reduction in maternal mortality since 2000, Sub-Saharan Africa continues to bear a disproportionate burden, accounting for nearly 70% of global maternal deaths.^2,3 In 2023, the region’s maternal mortality ratio was estimated at 448 deaths per 100,000 live births, more than double the global average and far from the SDG target of fewer than 70 deaths by 2030.⁴ The lifetime risk of maternal death in Sub-Saharan Africa remains alarmingly high at 1 in 40 women, compared to 1 in 190 globally.^4,5 These disparities are driven not only by health system challenges but also by entrenched gender inequalities and harmful norms that restrict women’s access to timely and quality care.⁶ Addressing these structural barriers alongside targeted health interventions is essential to accelerating progress and achieving equitable maternal health outcomes.^5,7 This requires expanding women’s access to education and employment, enforcing gender-equitable policies, and fostering empowerment across all spheres of life.^6,8,9

Women’s empowerment plays a crucial role in reducing unintended pregnancies and unmet need for contraception, which are significant contributors to maternal mortality, especially in Sub-Saharan Africa. Between 2015 and 2019, an estimated 112 million unintended pregnancies occurred globally, with Sub-Saharan Africa experiencing the highest rate of 91 per 1000 women aged 15–49.¹⁰ These unintended pregnancies are largely driven by low access to and utilization of sexual and reproductive health services, including family planning.^11,12 Gender inequality remains a major obstacle, limiting women’s autonomy, decision-making power, and ability to access maternal, neonatal, and child health services.^13,14 Evidence shows that when women have greater decision-making power, the uptake of these health services improves, positively impacting health outcomes.^15,16 Empowering women and girls by promoting gender-integrated interventions is therefore an effective strategy to decrease maternal mortality, reduce unmet family planning needs, lower unintended pregnancies, and increase access to essential health services.^17
–19 Women who lack access to modern contraceptive methods are at increased risk of high-parity births, unsafe abortions, and pregnancy-related complications.²⁰ Contraceptive use significantly lowers mortality and facilitates better maternal health outcomes by enabling women to delay, space, or limit pregnancies.²¹ In low-resource settings, access to quality contraceptive services particularly during the postpartum period can substantially reduce maternal deaths and improve the reproductive health outcomes.²²

Postpartum family planning (PPFP), which involves the use of contraception within the first year after childbirth, is vital for reducing maternal morbidity and mortality by preventing unintended and closely spaced pregnancies.²³ The World Health Organization recommends a minimum waiting time of at least 24 months before conceiving again. This interval is advised to lower various complications, including preterm birth, low birth weight, and infant mortality.^23,24 PPFP improves birth spacing, reducing complications like miscarriage, postpartum hemorrhage, and maternal anemia.^24,25 Despite its benefits, postpartum contraceptive use remains low in many low-resource settings due to sociocultural barriers and unmet needs.^26,27 Empowering women through integrated PPFP services is therefore essential to avert maternal deaths and improve health outcomes for mothers and children, making PPFP a key component of global maternal and child health strategies.^27,28

Research on the effect of women’s empowerment on family planning utilization reveals important positive associations, but several research gaps remain. While studies consistently show that greater women’s empowerment, especially household decision-making power, access to information, and attitudes towards gender norms linked with contraceptive use, they often rely on distal indicators and cross-sectional data that obscure direct pathways to reproductive outcomes.^29
–32 Contraceptive-specific empowerment, by contrast, captures women’s agency in domains uniquely tied to reproductive decision-making, including the ability to exercise autonomy over contraceptive choice and resist coercion. These proximal, context-specific indicators provide a more precise lens for understanding of how empowerment shapes family planning uptake. Unlike broader empowerment measures, contraceptive-specific empowerment indicators directly reflect women’s lived capacity to act on reproductive decision-making, making it a critical determinant of family planning. Evidence from studies that examined sexual autonomy as a domain of women’s empowerment found a positive association contraceptive use^29,31 but limited geographic scope cautions against generalizations and underscores the need for deeper investigation in varied settings.

The current study adopts the sexual and reproductive empowerment framework developed by Wood et al.,³³ that builds on the prior of women empowerment frameworks,^8,34,35 This framework aligns with the earlier conceptualizations by recognizing empowerment as multidimensional, relational, and dynamic, while also highlighting how choices are limited by the realities of partnerships, family, and cultural norms.^33,36 Importantly, it captures women’s lived concerns around family planning through contextual indicators addressing partner pressure, marital conflict, fears of contraceptive side effects, and child health perceptions that might affect contraceptive decision-making.³⁷ Despite these concerns, women could exercise their choice through negotiation with partners, involving family in reproductive discussion and covert contraceptive use.³⁶ Contraceptive empowerment during pregnancy could influence postpartum contraceptive behavior through strengthening women’s ability to act confidently on the fertility preference after childbirth and increasing women’s knowledge, as antenatal contraceptive counseling is more likely to be recalled and applied during postpartum.^38,39 Frequent health facility contact during pregnancy further enables empowerment to translate counseling into decision making, ensuring timely postpartum contraceptive adoption. Moreover, it challenges sociocultural norms and enhances the power and autonomy to resist community and partner opposition, which could facilitate the use of contraception even in restrictive contexts.⁴⁰

Although the association between women’s empowerment and contraceptive use has been studied, little research has examined how contraceptive empowerment during pregnancy influences postpartum contraceptive behavior. As pregnancy is a unique window for frequent health facility contact and supports reproductive decision-making, the mechanism through which empowerment in this period translates into sustained postpartum contraceptive uptake remains underexplored. Addressing these gaps will help tailor policies that not only increase contraceptive uptake but also sustainably enhance women’s agency and reproductive health outcomes. To fill these gaps, the current study aimed to examine the effect of contraceptive empowerment on the utilization of PPFP using a comprehensive tool of women’s and girls’ empowerment on sexual and reproductive health developed and validated in four Sub-Saharan African countries, including Ethiopia.³³

Methods

Study design and setting

This study was based on community-based panel data collected by Performance Monitoring for Action (PMA) Ethiopia (https://www.pmadata.org/countries/ethiopia). With a projected population of over 130 million in 2024, Ethiopia is the second most populated nation in Africa and the 10th most populous nation globally.⁴¹ The country is characterized by rapid population growth (2.6%), young age structure, and a high dependency ratio, with a high rural-urban differential.⁴² Ethiopia has a high total fertility rate of 4.6 births per woman (2.3 in urban areas and 5.2 in rural areas).⁴³ The current study used the PMA panel survey (cohort two) which was a panel study following women from pregnancy to 1 year postpartum and collected from three regions, Oromia, Amhara, and Southern Nations, Nationalities, and Peoples’ regions (SNNPR; “SNNPR” at the time refers to the four newly formed regions, namely, Central Ethiopia region, Sidama, South Ethiopia region, and Southwest Ethiopia region), and one city, Addis Ababa, between October 2021 to September 2023. The reporting of this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies (see Supplemental File 1).⁴⁴

Sampling and procedures

PMA followed pregnant women and conducted four interviews at baseline, 6-week, 6-month, and 1 year postpartum. We analyzed the 2021 PMA baseline, 6 weeks, 6 months, and 1-year datasets. Participants were selected using a two-stage stratified cluster sampling design for the regions of Amhara, Oromia, and SNNPR. For Addis Ababa, participants were drawn without additional urban–rural stratification. Sampling was based on the 162 enumeration areas (EAs), using a probability sample of households and women of reproductive age. A census of all households was conducted. From the census, resident enumerators (REs) identified all women who were aged 15–49 and regular members of the household. Women were screened, and those who reported being pregnant or having given birth in the past 6 weeks were eligible for the survey. Those who were able and willing to give oral consent were enrolled into the study. After obtaining informed consent, the household questionnaire was given to the head of household, followed by the baseline questionnaire was given to all eligible women. REs contacted the respondent at frequent intervals to monitor whether the delivery has occurred based on the expected date of delivery and conducted the first follow-up interview at approximately 6 weeks postpartum. Once the 6-week interview was complete, the 6-month and 1-year interviews were scheduled. Smartphones were used to collect data throughout every survey round. The details of the panel survey data were described by other PMA publications.⁴⁵ A total of 1759 non-pregnant women who completed baseline and all follow-up surveys were the analytic sample of this analysis (Figure 1).

Figure 1.

Schematic presentation of analytic sample for the effect of contraceptive empowerment on PPFP use, PMA 2023.

Sample size requirements were estimated using Stata version 17’s power two proportions command. Assuming PPFP uptake of 32% among women with low empowerment and 54% among those with high empowerment (Δ = 0.22), with a two-sided α of 0.05 and 80% power, the minimum sample size required was 158 women (79 per group). Our analytic sample included 1759 women, far exceeding the minimum requirement. This larger sample size provided substantially greater statistical power, ensuring robust detection of differences in PPFP uptake across empowerment categories. Baseline measures of contraceptive empowerment were collected during pregnancy, and women were subsequently followed for 1 year after birth, with PPFP use assessed during the 1‑year postpartum interview. Categorization into low, medium, and high empowerment groups was conducted analytically during data analysis, based on baseline empowerment scores. The design allowed prospective examination of the relationship between empowerment measured during pregnancy and PPFP uptake assessed 1 year postpartum.

Variables and measurement

The dependent variable was PPFP use assessed by yes/no question about the current use of any of modern contraceptive methods to avoid pregnancy at 1 year of postpartum.

Our main exposure variable was contraceptive empowerment measured at pregnancy (baseline) using five Likert scale-type questions ranging from “1” strongly disagree to “5” strongly agree. These are; (1) if I use family planning, my husband/partner may seek another sexual partner (2) if I use family planning, I may have trouble getting pregnant the next time I want to; (3) there could be/will be conflict in my relationship/marriage if I use family planning; (4) if I use family planning, my children may not be born normal; (5) if I use family planning, my body may experience side effects that will disrupt my relations with my husband/partner. These items primary capture concerns and perceived barriers to contraceptive use, specifically contraceptive choice, negotiation capacity, and freedom from coercion. As Wood et al. highlight in the development of the contraceptive empowerment scale, these items capture women’s agency and relational concerns about family planning, such as confidence in contraceptive choice, negotiation capacity, and freedom from coercion.³³ So, our operationalization reflects perceived threats to empowerment, and the internal consistency of these constructs was acceptable, with a Cronbach’s alpha of 0.77. We reversed the response categories and assigned “5” strongly disagree to “1” strongly agree, so that the highest point on the scale designates more empowerment. Then we computed a composite variable and created tertile ordinal variables (low, medium, and high) by equal distribution. Alternative approaches, including quartile categorization and treating empowerment as a continuous variable, were tested; however, results did not differ meaningfully. We therefore adopted the tertile categorization, as it provides easier interpretation and clearer communication of findings.

The other independent (control) variables were categorized into individual, household, and community level variables. Individual-level variables include: Age (<15–24, 25–34, 35–49); education (no formal education, primary education and secondary education and above); Parity (1, 2–4, ⩾5); intimate partner violence (IPV) a composite variable measured at 6 weeks by 10 yes/no question a women responded “yes” to at least one question was considered as experienced IPV and coded “1” and otherwise “0”; pregnancy desire at baseline (pregnancy) (then, later, not at all); ever use of family planning (yes/no), utilization of antenatal care (ANC) (yes/no); skilled birth attendance (SBA) (yes/no); utilization of postnatal care (PNC) (yes/no). Community and household factors include residence (Urban/Rural); region (Amhara, Oromia, Southern Nations, Nationalities and People, and Addis Ababa); and wealth index (Lowest, Lower, Middle, Higher, Highest).

Statistical analysis

The data analysis and management were performed by STATA^TM version 17 software. Descriptive statistics was used to determine the weighted and unweighted frequencies of individual-level, household, and community factors and the outcome variable use of PPFP in frequencies, proportions, and tables. We tested whether attrition was differential across contraceptive empowerment categories (low, medium, high) based on baseline scores. Attrition status (1 = lost to follow-up, 0 = retained) was compared across these categories using chi-square tests. We found no statistically significant differences, indicating that attrition was not differential across contraceptive empowerment categories.

Respondents were clustered within EAs, potentially violating the assumption of independence required for individual-level analysis. The explanatory factors are at the cluster and individual levels, while the outcome variables are at the individual level. The effects of both group-level and individual-level predictors on individual-level outcomes must be simultaneously investigated by the model. In order to identify the factors that influence the use of PPFP, we used multilevel mixed-effect logistic regression, which is a suitable method for multilevel analysis.

Potential confounders were identified using a combination of statistical and theoretical criteria. Variables with a p value ⩽0.25 in bivariable analyses were considered candidates for inclusion in the multivariable model. In addition, sociodemographic, reproductive, and health service factors identified as conceptually important or supported by prior evidence were retained regardless of statistical significance. No missing data were observed in the selected variables; therefore, all models were estimated using the complete analytic sample of 1759 women.

We fitted four models. Model 0 was an empty or unconditional model that had no explanatory variables; Model I only had variables at the individual level; Model II only had variables at the community level; and the fourth model (full model) simultaneously for factors at the individual and community/cluster levels. To select the best fit, we compared the models using the Akaike Information Criteria (AIC) and Schwarz’s Bayesian Information Criteria (BIC). The final (full) model was the best-fit model with the lowest AIC and BIC. The fixed effect size of individual and community-level factors using adjusted odds ratio (AOR) at 95% CI was used to measure the association between outcome and predictor variables. Finally, a p-value <0.05 in the multivariable analysis was considered statistical significance.

Result

Sociodemographic and reproductive characteristics of the participants

Out of 1759 women who completed one follow-up and were eligible for this study, around half, 842 (47.9%) of the women’s age fall in the age range of 25–34 years. Almost one-third of women, 555 (31.5%) didn’t attend formal education, while only one-fifth of women, 400 (22.7%) attended secondary education and above. Nearly two-thirds of the women 1095 (62.2%) had a parity of 2–4 and had a history of prior use of contraception 1131 (64.3%) (Table 1).

Table 1.

Sociodemographic and reproductive characteristics of the women of reproductive age, PMA Ethiopia 2023.

Variables	Category	Unweighted frequency (%)	Weighted frequency (%)
Women age	15–24	574 (32.6)	636 (36.1)
	25–34	907 (51.6)	842 (47.9)
	35–49	278 (15.8)	281 (16.0)
Women education	No formal education	476 (27.1)	555 (31.5)
	Primary education	750 (42.6)	804 (45.8)
	Secondary and above	533 (30.3)	400 (22.7)
Religion	Christian	1237 (70.3)	1097 (62.4)
	Muslim	503 (28.6)	634 (36.0)
	Others	19 (1.1)	28 (1.6)
Residence	Rural	1012 (57.5)	1322 (75.2)
	Urban	747 (42.5)	437 (24.8)
Region	Amhara	381 (21.7)	360 (20.5)
	Oromia	628 (35.7)	920 (52.3)
	SNNPR	505 (28.7)	398 (22.6)
	Addis Ababa	245 (13.9)	81 (4.6)
Wealth quantile	Lowest	275 (15.6)	349 (19.8)
	Lower	268 (15.2)	345 (19.6)
	Middle	283 (16.1)	352 (20.0)
	Higher	333 (18.9)	355 (20.2)
	Highest	600 (34.1)	358 (20.4)
Parity	1	350 (19.9)	326 (18.6)
	2–4	1122 (63.8)	1095 (62.2)
	⩾5	287 (16.3)	338 (19.2)
IPV	Yes	183 (10.4)	189 (10.7)
	No	1576 (89.6)	1570 (89.3)
Contraceptive empowerment	Low	591 (33.6)	617 (35.1)
	Medium	704 (40.0)	662 (37.6)
	High	464 (26.4)	480 (27.3)
Prior use of FP	Yes	1200 (68.2)	1131 (64.3)
	No	559 (31.8)	628 (35.7)

FP, family planning; IPV, intimate partner violence; PMA, Performance Monitoring for Action.

Distribution of modern family planning use at 1 year postpartum

The level of PPFP use at 1 year postpartum was 44.2% (±2.8%) with the highest level, 81.6% (±5.7) in Addis Ababa and the lowest in Oromia, 39% (±4.1). The use of PPFP increases from 32.2% to 54.2% as contraceptive empowerment increases from the low to high category. In addition, PPFP use was decreasing from 63% to 21.3% as the parity increased from 1 to ⩾5. The use of PPFP is higher among women who received SBA (55.9%) and among those with a history of prior contraceptive use (57.5%) (Table 2).

Table 2.

Distribution of PPFP use by individual, household, and community level variables among women of reproductive age, PMA Ethiopia 2023.

Variable	Category	PPFP use		p-Value
Variable	Category	Yes	No	p-Value
Contraceptive empowerment	Low	199 (32.2)	418 (67.8)	0.0001
	Medium	338 (51.0)	324 (49.0)
	High	260 (54.2)	220 (45.8)
Age	15–24	327 (51.4)	309 (48.6)	0.0001
	25–34	379 (45.0)	464 (55.0)
	35–49	91 (32.5)	189 (65.5)
Education	No formal	162 (29.2)	393 (70.8)	0.0001
	Primary	374 (46.5)	430 (53.5)
	Secondary and above	261 (65.3)	139 (34.7)
Parity	1	206 (63.0)	121 (37.0)	0.0001
	2–4	520 (47.5)	574 (52.5)
	⩾5	72 (21.3)	266 (78.7)
Pregnancy desire	Then	530 (46.9)	600 (53.1)	0.014
	Later	235 (43.1)	310 (56.9)
	Not at all	32 (38.0)	52 (62.0)
IPV	Yes	51 (34.7)	96 (65.3)	0.001
	No	747 (46.3)	865 (53.7)
ANC 4+	Yes	308 (55.2)	248 (44.8)	0.0001
	No	489 (40.6)	714 (59.4)
PNC	Yes	304 (49.9)	305 (50.1)	0.003
	No	494 (42.9)	656 (57.1)
SBA	Yes	576 (55.9)	454 (44.1)	0.0001
	No	222 (30.5)	507 (69.5)
Ever use of FP	Yes	650 (57.5)	481 (42.5)	0.0001
	No	148 (23.5)	480 (76.5)
Wealth quantile	Lowest	94 (26.9)	256 (73.1)	0.0001
	Lower	139 (40.3)	206 (59.7)
	Medium	139 (39.5)	213 (60.5)
	Higher	188 (53.1)	166 (46.9)
	Highest	237 (66.2)	121 (33.8)
Residence	Urban	272 (62.2)	165 (37.8)	0.0001
	Rural	525 (39.7)	797 (60.3)
Region	Amhara	174 (48.3)	186 (51.7)	0.0001
	Oromia	383 (41.6)	538 (58.4)
	SNNP	175 (44.1)	222 (55.9)
	Addis Ababa	66 (81.5)	15 (18.5)

ANC, antenatal care; FP, family planning; IPV, intimate partner violence; PMA, Performance Monitoring for Action; PNC, postnatal care; PPFP, postpartum family planning; SBA, skilled birth attendance; SNNP, Southern Nations, Nationalities and People.

The effect of contraceptive empowerment on PPFP service utilization

The empty model (Model 0) indicated substantial clustering, with an intra-cluster correlation (ICC) of 41%, indicating that 41% the variation in the PPFP use is due to differences between the clusters. In the final multilevel mixed-effect logistic regression model, the ICC was reduced to 8%, showing that much of the variability was explained by the included covariates. After adjusting for parity, ever use of contraception, use of skilled birth services, and region, contraceptive empowerment remained statistically significantly associated with PPFP use.

Accordingly, women who had high contraceptive empowerment had nearly two times higher odds of utilizing PPFP as compared to those with low contraceptive empowerment (AOR: 1.8, 95% CI: 1.3–2.6). PPFP use increased from 32.2% among women with low contraceptive empowerment to 54.2% among women with high contraceptive empowerment, an absolute difference of 22 percentage points. Similarly, women with medium contraceptive empowerment had twice the odds of PPFP use (AOR: 1.7, 95% CI: 1.2–2.3), a corresponding probability of 51%, with an absolute increase of 18.8 percentile points compared to low contraceptive empowerment. On the other hand, women who had a parity of 1 (AOR: 4.5, 95% CI: 2.5–8.5) and 2–4 (AOR: 2.2, 95% CI: 1.3–3.5) were five and two times more likely to utilize PPFP service as compared to women who had a parity of ⩾5, respectively. Similarly, women who attended skilled birth service were two times more likely to utilize PPFP as compared to their counterparts (AOR: 1.7, 95% CI: 1.3–2.4). Furthermore, women who ever used family planning were four times more likely to utilize PPFP as compared to their counterparts (AOR: 3.8, 95% CI: 2.8–5.4). Regional variety reduces the uptake of PPFP. Women residing in Amhara and Oromia had 60% lower odds of utilizing PPFP as compared to those residing in Addis Ababa (AOR: 0.4, 95% CI: 0.2–0.8) (Table 3).

Table 3.

Individual, household, and community level determinants of PPFP service utilization among women of reproductive age, PMA Ethiopia 2023.

Variable	Category	Crude Odds Ration 95% CI	Model I (AOR 95% CI)	Model II (AOR 95% CI)	Model III (AOR 95% CI)
Contraceptive empowerment	Low empowerment	1	1		1
	Medium empowerment	1.8 (1.3–2.4)**	1.7 (1.2–2.3)*		1.7 (1.2–2.3)*
	High empowerment	1.9 (1.4–2.7)**	1.8 (1.3–2.6)*		1.8 (1.3–2.6)*
Age	15–24	2.8 (1.9–4.2)**	1.3 (0.0.8–2.1)		1.4 (0.8–2.2)
	25–34	1.7 (1.2–2.5)*	1.1 (0.7–1.6)		1.1 (0.7–1.5)
	35–49	1	1		1
Education level	No formal education	0.3 (0.2–0.4)**	0.7 (0.5–1.1)		0.7 (0.5–1.1)
	Primary	0.6 (0.5–0.9)*	0.8 (0.6–1.2)		0.9 (0.6–1.7)
	Secondary and above	1	1		1
Parity	1	4.8 (3.1–7.4)	4.5 (2.6–8.1)		4.5 (2.5–8.1)**
	2–4	2.6 (1.8–3.7)	2.1 (1.13–3.3)		2.1 (1.3–3.3)**
	⩾5	1	1		1
Pregnancy desire	Then	1.2 (0.7–2.2)	0.6 (0.3–1.2)		0.6 (0.3–1.2)
	Later	1.2 (0.7–2.3)	0.7 (0.4–1.3)		0.6 (0.4–1.3)
	Not at all	1	1		1
Wealth index	Lowest	0.4 (0.2–0.6)**	0.5 (0.3–0.9)*		0.8 (0.4–1.6)
	Lower	0.4 (0.2–0.6)**	0.5 (0.3–0.9)*		0.8 (0.4–1.5)
	Middle	0.4 (0.2–0.7)**	0.6 (0.3–1.0.9)		0.8 (0.4–1.5)
	Higher	0.7 (0.5–1)**	0.8 (0.5–1.2)		1.1 (0.6–1.6)
	Highest	1	1		1
IPV	Yes	0.9 (0.6–1.4)	0.9 (0.5–1.4)		0.9 (0.5–1.4)
	No	1	1		1
ANC 4+	Yes	1.3 (0.9–1.7)	0.9 (0.7–1.3)		0.9 (0.7–1.2)
	No	1	1		1
SBA	Yes	2.3 (1.7–3.1)**	1.8 (1.3–2.4)**		1.7 (1.3–2.4)**
	No	1	1		1
PNC	Yes	1.2 (0.9–1.6)	1.1 (0.7–1.3)		1.1 (0.8–1.4)
	No	1	1		1
Ever use of FP	Yes	2.8 (2.1–3.7)**	3.8 (2.8–5.2)**		3.9 (2.8–5.4)**
	No	1	1		1
Residence	Urban	1		1	1
	Rural	0.3 (0.2–0.5)**		0.4 (0.2–0.6)**	0.7 (0.4–1.4)
Region	Addis Ababa	1		1	1
	Amhara	0.2 (0.1–0.5)**		0.4 (0.2–0.9)*	0.4 (0.1–0.8)*
	Oromia	0.2 (0.1–0.4)**		0.3 (0.1–0.7)*	0.4 (0.1–0.8)*
	SNNP	0.1 (0.05–0.4)**		0.3 (0.1–1.7)*	0.5 (0.2–1.2)

Significant at p-value <0.05.

Significant at p-value <0.001.

ANC, antenatal care; AOR, adjusted odds ratio; FP, family planning; IPV, intimate partner violence; PMA, Performance Monitoring for Action; PNC, postnatal care; PPFP, postpartum family planning; SBA, skilled birth attendance; SNNP, Southern Nations, Nationalities and People.

Discussion

This study found that contraceptive empowerment measured at pregnancy significantly influences the use of modern PPFP within 1 year postpartum. The findings reveal that strengthening contraceptive empowerment can be significantly associated with higher postpartum contraceptive uptake. Moving from low to medium empowerment is associated with nearly a 19-percentage point increase in PPFP use, while moving from low to high empowerment yields a 22-percentage point increase. This suggests that women with higher autonomy, confidence, or access to information regarding contraceptive choices are more likely to initiate family planning during the postpartum period, even when adjusted for their prior contraceptive use. Contraceptive empowerment encompasses not only knowledge and access but also the ability to make informed decisions free from coercion or external pressure.⁴⁶ Consistent with the current finding, previous studies have emphasized the role of empowerment in shaping reproductive health behaviors, noting that women with higher decision-making power are more likely to adopt modern contraceptive methods.^32,47
–49 While earlier studies examined the association between empowerment and contraceptive use, they relied on general empowerment indicators and cross-sectional data.^32,48
–50 The current study advances literature by applying context-specific and proximal indicators of empowerment to reproductive outcomes and uses longitudinal data that allow us to establish temporal ordering between contraceptive empowerment and PPFP use.

The relationship between contraceptive empowerment and postpartum contraceptive use is pivotal in shaping reproductive outcomes during the critical postnatal period. Women who possess greater autonomy, confidence, and access to contraceptive information during pregnancy are more likely to initiate and maintain PPFP practices.⁵¹ This enables women to overcome common barriers such as misinformation, partner opposition, and limited access to services, which could hinder contraceptive uptake after childbirth.⁴⁷ Empowered women are more likely to adopt modern contraceptive methods during the postpartum period, thereby reducing the risk of unintended pregnancies and improving maternal and child health outcomes.^16,48,50 Strengthening contraceptive empowerment during pregnancy may thus serve as a strategic entry point for enhancing PPFP coverage and continuity, achieved through the integration of routine ANC counseling, engaging couples to address misconceptions, and promotion of women’s autonomy and informed choice.

Additionally, parity, prior use of contraception, utilization of skilled birth services, and region were independently associated with PPFP use. Higher parity has been found to significantly reduce the uptake of PPFP services. This trend might be driven by fears of contraceptive-induced fertility impairment, which have been shown to negatively influence contraceptive use. Evidence from a PMA 2020 cross-sectional survey indicates that concerns about potential fertility impairment significantly reduce use of hormonal contraception, with such fears more pronounced among high-parity women.⁵² This implies that it is important to recognize that there is a need to tailor PPFP interventions to address the unique needs of both primiparous and multiparous women to enhance service uptake and reproductive outcomes.

The utilization of skilled birth services significantly increases the odds of PPFP use. Skilled birth attendance serves as a critical touchpoint for delivering comprehensive maternal health services, including counseling on birth spacing and contraceptive options. Women who give birth in health institutions are more likely to receive timely information, immediate postpartum contraceptive services, and follow-up, which enhance PPFP use. The finding is consistent with evidence from Sub-Saharan Africa, where health facility delivery has been positively associated with PPFP use.^53,54

Prior use of family planning services increased the odds of PPFP use. This highlights the importance of continuity in reproductive health care and suggests that women who engage with family planning services before are more likely to accept contraceptive methods during the postpartum period. Prior exposure may enhance women’s knowledge, confidence, and trust in health systems, thereby facilitating informed decision-making and timely uptake of PPFP. These results are consistent with previous studies conducted, which found that antenatal family planning counseling and prior contraceptive use were positively associated with postpartum contraceptive adoption.^53,55,56

Regional variation significantly influenced the use of PPFP, with women from the Oromia and Amhara regions exhibiting notably lower utilization levels compared to those in Addis Ababa. Such disparities may reflect differences in educational status, health system capacity, sociocultural norms, and access to quality reproductive health services across regions. Similarly, it was reported from Sub-Saharan Africa that regional disparities are the key determinant for the uptake of the PPFP.^57,58 Addressing these inequities requires region-specific strategies that strengthen service delivery, community engagement, and provider capacity to ensure equitable access to PPFP across all settings.

Limitations

The analysis was limited by the absence of key explanatory variables such as women’s knowledge, attitudes, occupational status, and sociocultural beliefs, which are critical for capturing the nuanced determinants of contraceptive uptake. In addition, the contraceptive empowerment items primarily reflect perceived threats and barriers rather than positive indicators of empowerment, potentially conflating empowerment with fear or stigma. Thus, while reliable and context-specific, the measure emphasizes constraints more than capacities. Nevertheless, the major strength of this study lies in its use of community-based longitudinal panel data drawn from four diverse regions of Ethiopia, which enabled a robust examination of temporal relationships and external validity. The measurement of contraceptive empowerment also demonstrated contextual relevance, acceptable internal consistency, and prospective timing during pregnancy, allowing meaningful analysis of its influence on PPFP.

Conclusion

This study underscores the pivotal role of contraceptive empowerment in enhancing PPFP service utilization regardless of age, education status, parity, pregnancy desire, prior use of contraception, ANC utilization, SBA, PNC utilization, IPV, wealth status, residence, and region. Women with greater autonomy and decision-making capacity regarding contraceptive choices were more likely to adopt PPFP methods. These suggest that strengthening contraceptive empowerment during pregnancy can substantially increase PPFP uptake. To translate this evidence into practice, family planning counseling during ANC should be strengthened, ensuring that the women build confidence and autonomy in contraceptive decision-making before delivery. Couple-based interventions during pregnancy can further enhance joint decision-making and partner support, which are critical for sustained PPFP use. Interventions must be tailored to the unique needs and motivations of multiparous women, recognizing their differing reproductive experiences. Contraceptive counseling during pregnancy should emphasize informed choice, autonomy, and addressing fears around fertility impairment, especially among high-parity women. Training skilled birth attendants and postnatal care providers to reinforce empowerment messages across the maternal health continuum will create continuity of care and maximize impact. Equally, it is important to identify and engage women with no history of contraceptive use, as targeted counseling and support during these critical contact points may facilitate informed decision-making and address underlying barriers to initial adoption. Finally, addressing regional disparities through context-specific strategies that reflect local sociocultural norms and health system capacities is critical, especially in underserved areas. By embedding empowerment interventions across the maternal health continuum, programs can achieve measurable increases in postpartum contraceptive uptake and contribute to improved maternal and child health outcomes.

Supplemental Material

sj-doc-1-reh-10.1177_26334941261451339 – Supplemental material for The effect of contraceptive empowerment during pregnancy on postpartum family planning use in Ethiopia: evidence from a longitudinal panel study

Supplemental material, sj-doc-1-reh-10.1177_26334941261451339 for The effect of contraceptive empowerment during pregnancy on postpartum family planning use in Ethiopia: evidence from a longitudinal panel study by Tsegaye Lolaso Lenjebo, Mitike Molla, Solomon Shiferaw and Shannon N. Wood in Therapeutic Advances in Reproductive Health

Footnotes

Acknowledgements

We thank PMA Ethiopia for granting on-request open access to its dataset.

Declarations

ORCID iD

Tsegaye Lolaso Lenjebo

Supplemental material

Supplemental material for this article is available online.

References

UN. Transforming our world: the 2030 agenda for sustainable development A/RES/70/1. Newyork, USA: United Nations, 2015.

WHO, UNICEF, UNFPA, et al. Trends in maternal mortality: 1990 to 2015. 2015. Geneva: World Health Organization, 2015.

Kramer

MS.

The epidemiology of adverse pregnancy outcomes: an overview. J Nutr 2003; 133(5): 1592S–1596S.

Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division . Geneva: World Health Organization, 2025.

Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division . Geneva: World Health Organization, 2023.

Jayachandran

Social norms as a barrier to women’s employment in developing countries. IMF Econ Rev 2021; 69(3): 576–595.

WHO and UNFPA Ending Preventable Maternal Mortality (EPMM): a renewed focus for improving maternal and newborn health and well-being, https://www.who.int/publications/i/item/9789240040519 (2021, accessed 25 August 2025).

Edmeades

Mejia

Parsons

, et al. A conceptual framework for reproductive empowerment: empowering individuals and couples to improve their health (Background Paper). Washington, DC: International Center for Research on Women, 2018.

Klasen

The impact of gender inequality on economic performance in developing countries. Annu Rev Resour Econ 2018; 10(1): 279–298.

10.

Bearak

Popinchalk

Ganatra

, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Glob Health 2020; 8(9): e1152–e1161.

11.

World Family Planning 2022: Meeting the changing needs for family planning: Contraceptive use by age and method . New York: United Nations Department of Economic and Social Affairs, Population Division, 2022.

12.

Sully

Biddlecom

Darroch

, et al. Adding it up: investing in sexual and reproductive health 2019. New York: Guttmacher Institute. https://www.guttmacher.org/report/adding-it-up-investing-in-sexual-reproductive-health-2019 (2020, accessed 22 July 2025).

13.

Blackstone

SR.

Women’s empowerment, household status and contraception use in Ghana. J Biosoc Sci 2017; 49(4): 423–434.

14.

Thorpe

VanderEnde

Peters

, et al. The influence of women’s empowerment on child immunization coverage in low, lower-middle, and upper-middle income countries: a systematic review of the literature. Matern Child Health J 2016; 20(1): 172–186.

15.

Wado

Gurmu

Tilahun

, et al. Contextual influences on the choice of long-acting reversible and permanent contraception in Ethiopia: a multilevel analysis. PLoS One 2019; 14(1): e0209602.

16.

Hameed

Azmat

Ali

, et al. Women’s empowerment and contraceptive use: the role of independent versus couples’ decision-making, from a lower middle income country perspective. PLoS One 2014; 9(8): e104633.

17.

Moller

Patten

Hanson

, et al. Monitoring maternal and newborn health outcomes globally: a brief history of key events and initiatives. Trop Med Int Health 2019; 24(12): 1342–1368.

18.

Muralidharan

Fehringer

Pappa

, et al. Transforming gender norms, roles, and power dynamics for better health: evidence from a systematic review of gender-integrated health program s in low- and middle-income countries. Washington, DC: Futures Group, Health Policy Project, 2015.

19.

James-Hawkins

Peters

VanderEnde

, et al. Women’s agency and its relationship to current contraceptive use in lower- and middle-income countries: a systematic review of the literature. Glob Public Health 2018; 13(7): 843–858.

20.

Kasahun

Abebe Adane

Girum

, et al. Effects of scaling up family planning on maternal survival in ethiopia: spectrum modeling. Int J Womens Health 2021; 13: 711–716.

21.

Ahmed

Liu

, et al. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012; 380(9837): 111–125.

22.

Dev

Kohler

Feder

, et al. A systematic review and meta-analysis of postpartum contraceptive use among women in low- and middle-income countries. Reprod Health 2019; 16(1): 154.

23.

Gaffield

Egan

Temmerman

It’s about time: WHO and partners release programming strategies for postpartum family planning. Glob Health Sci Pract 2014; 2(1): 4–9.

24.

WHO. Programming strategies for postpartum family planning. Geneva: World Health Organization, 2013.

25.

Cleland

Conde-Agudelo

Peterson

, et al. Contraception and health. Lancet 2012; 380(9837): 149–156.

26.

Geltore

Alemu

Angelo

, et al. Magnitude and associated factors of postpartum family planning uptake among postpartum women in Ethiopia: an umbrella review. Front Glob Womens Health 2024; 5: 1481601.

27.

Yemane

Bogale

Egata

, et al. Postpartum family planning use and its determinants among women of the reproductive age group in low-income countries of sub-Saharan Africa: a systematic review and meta-analysis. Int J Reprod Med 2021; 2021: 5580490.

28.

Sirage

Desalegn

Wako

, et al. Family planning utilization among postpartum women in the Bule Hora District, southern Ethiopia. Front Glob Womens Health 2024; 5: 1323024.

29.

Crissman

Adanu

Harlow

SD.

Women’s sexual empowerment and contraceptive use in Ghana. Stud Fam Plann 2012; 43(3): 201–212.

30.

Sougou

Bassoum

Faye

, et al. Women’s autonomy in health decision-making and its effect on access to family planning services in Senegal in 2017: a propensity score analysis. BMC Public Health 2020; 20(1): 872.

31.

Viswan

Ravindran

TKS

Kandala

, et al. Sexual autonomy and contraceptive use among women in Nigeria: findings from the Demographic and Health Survey data. Int J Womens Health 2017; 9: 581–590.

32.

Efendi

Sebayang

Astutik

, et al. Women’s empowerment and contraceptive use: recent evidence from ASEAN countries. PLOS ONE 2023; 18(6): e0287442.

33.

Wood

Karp

Tsui

, et al. A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa. Cult Health Sex 2021; 23(6): 804–821.

34.

Eerdewijk

Wong

Vaast

, et al. White Paper: a conceptual model of women and girls’ empowerment. Amsterdam: Royal Tropical Institute (KIT), 2017.

35.

Alsop

Bertelsen

Holland

Empowerment in practice: from analysis to implementation. Directions in Development. https://hdl.handle.net/10986/6980 (2006, accessed 13 April 2025).

36.

Karp

Wood

Galadanci

, et al. “I am the master key that opens and locks”: presentation and application of a conceptual framework for women’s and girls’ empowerment in reproductive health. Soc Sci Med 2020; 258: 113086.

37.

Moreau

Karp

Wood

, et al. Reconceptualizing women’s and girls’ empowerment: a cross-cultural index for measuring progress toward improved sexual and reproductive health. Int Perspect Sex Reprod Health 2020; 46: 187–198.

38.

Cherie

Wordofa

Debelew

GT.

Empowering maternal choice: exploring factors influencing early postpartum contraceptive adoption intention among pregnant women in northeast Ethiopia. Int J Environ Res Public Health 2024; 21(11): 1418.

39.

McCarthy

Fardousi

Tripathi

, et al. Antenatal care interventions to increase contraceptive use following birth in low- and middle-income countries: systematic review and narrative synthesis. Glob Health Sci Pract 2024; 12(5): e2400059.

40.

Eustis-Guthrie

Williamson

Alhassan

, et al. Evaluating two models of postpartum family planning counseling on contraceptive uptake, knowledge, and intended use: evidence from a repeated cross-sectional study in Ghana. Reprod Health 2026; 23(1): 36.

41.

United Nations. World Population Prospects 2024: summary of results. New York: United Nations, 2024.

42.

CSA. Population Projections for Ethiopia 2007-2037. Addis Ababa: Federal Democratic Republic of Ethiopia, Population Census Commission, 2013.

43.

EDHS. Central Statistical Agency [Ethiopia] and ORC Macro. Ethiopia Demographic and Health Survey (EDHS). Addis Ababa, Rockville, MD: CSA and ICF, 2016.

44.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007; 370(9596): 1453–1457.

45.

Zimmerman

Desta

Yihdego

, et al. Protocol for PMA-Ethiopia: a new data source for cross-sectional and longitudinal data of reproductive, maternal, and newborn health. Gates Open Res 2020; 4: 126.

46.

Senderowicz

Contraceptive autonomy: conceptions and measurement of a novel family planning indicator. Stud Fam Plann 2020; 51(2): 161–176.

47.

Prata

Fraser

Huchko

, et al. Women’s empowerment and family planning: a review of the literature. J Biosoc Sci 2017; 49(6): 713–743.

48.

Yaya

Uthman

Ekholuenetale

, et al. Women empowerment as an enabling factor of contraceptive use in sub-Saharan Africa: a multilevel analysis of cross-sectional surveys of 32 countries. Reprod Health 2018; 15(1): 214.

49.

Alam

Khanam

Kabir

, et al. Association between women’s empowerment and use of modern contraception methods in Bangladesh: evidence from Bangladesh demographic and health survey 2022. Contracept Reprod Med 2025; 10(1): 41.

50.

Some

Huang

S-L.

Empowerment and use of modern contraceptive methods among married women in Burkina Faso: a multilevel analysis. BMC Public Health 2021; 21(1): 1–13.

51.

Moloro

Beza

Kumsa

MA.

Modern contraceptive utilization and associated factors among postpartum women in Kena Woreda, Konso Zone, South Ethiopian Regional State, Ethiopia, 2023: mixed type community based cross-sectional study design. Contracept Reprod Med 2024; 9(1): 31.

52.

Zimmerman

Karp

Shiferaw

, et al. Assessing the effect of concerns about contraceptive-induced fertility impairment on hormonal contraceptive use by parity and residence: evidence from PMA Ethiopia 2020 cross-sectional survey. BMJ Open 2024; 14(8): e077192.

53.

Oljira

Tilahun

Tiruneh

, et al. Postpartum family planning uptake and its associated factors among postpartum women in Asosa zone, Benishangul Gumuz regional state, Ethiopia: a facility-based cross-sectional study. Contracept Reprod Med 2023; 8(1): 53.

54.

Nugussa

Solomon

Tadelu

Modern postpartum family planning and associated factors among postpartum women in a rural district of Ethiopia, 2021: a cross-sectional study. Inquiry 2023; 60: 00469580231153268.

55.

Agula

Henry

Asuming

, et al. Postpartum contraceptive initiation and use: evidence from Accra, Ghana. Womens Health (Lond) 2022; 18: 17455057221141290.

56.

Wassihun

Wosen

Getie

, et al. Prevalence of postpartum family planning utilization and associated factors among postpartum mothers in Arba Minch town, South Ethiopia. Contracept Reprod Med 2021; 6(1): 6.

57.

Sani

Oluyomi

Wali

, et al. Regional disparities on contraceptive intention and its sociodemographic determinants among reproductive women in Nigeria. Contracept Reprod Med 2025; 10(1): 13.

58.

Negash

Gelaw

Getnet

, et al. Geographic variation in modern contraceptive utilization among women of reproductive age in Mozambique: a multilevel analysis. Contracept Reprod Med 2024; 9(1): 68.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.09 MB