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Citation: Khan MN, Khan MMA, Billah MA,
Khanam SJ, Haider MM, Sarker BK, et al.
(2025) Effects of maternal healthcare service
utilization on modern postpartum family
planning access in Bangladesh: insights from
a National representative survey. PLoS ONE
20(2): e0318363. https://doi.org/10.1371/
journal.pone.0318363
Editor: Akaninyene Eseme Bernard Ubom,
OAUTHC: Obafemi Awolowo University
Teaching Hospital Complex, NIGERIA
Received: June 27, 2023
Accepted: January 4, 2025
Published: February 4, 2025
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RESEARCH ARTICLE
Effects of maternal healthcare service
utilization on modern postpartum family
planning access in Bangladesh: insights from
a National representative survey
Md. Nuruzzaman Khan 1,2*☯, Md. Mostaured Ali Khan3☯, Md Arif Billah4☯,
Shimlin Jahan Khanam 1, Md. Moinuddin Haider4, Bidhan Krishna Sarker3‡,
Melissa L. Harris2‡
1 Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Bangladesh,
2 Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University
of Melbourne, Australia, 3 Maternal and Child Health Division, International Centre for Diarrhoeal Diease
Research, Dhaka, Bangladesh, 4 Health System and Population Studies Division, International Centre for
Diarrhoeal Diease Research, Dhaka, Bangladesh
☯ Joint 1st author as they contributed equally to this paper.
‡ Joint Senior authorship.
* sumonrupop@gmail.com
Abstract
Background
Access to modern family planning is critical for improving maternal and child health
outcomes, yet it remains severely lacking in low- and middle-income countries, including
Bangladesh. Maternal healthcare utilization during and after pregnancy is vital for promot-
ing postpartum family planning. This study examined the effects of maternal healthcare
service utilization on postpartum family planning uptake in Bangladesh.
Methods
Reproductive calendar data from 4,081 women with recent live births were extracted from
the cross-sectional 2017/18 Bangladesh Demographic and Health Survey and analyzed.
The outcome variable was uptake of modern postpartum family planning methods and
the exposure variables were different types of maternal healthcare services. Kaplan-Meier
methods were used to calculate cumulative probabilities of modern postpartum family
planning method uptake within 12 months post-delivery, and modied Poisson regression
models were used to estimate the effects of utilizing maternal healthcare services on mod-
ern postpartum family planning method uptake.
Results
Modern family planning methods in the 12 month postpartum period were used by 72%
of women, with over 60% starting after day 40. Less than 4% used long-acting family
planning methods, while almost 40% relied on the oral contraceptive pill. Utilizing maternal
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
healthcare services was associated with up to a 7% higher uptake of modern postpartum
family planning methods compared to non-users.
Conclusion
Three-quarters of Bangladeshi women use modern family planning within the 12 months
postpartum, but often rely on less effective methods. Additionally, 25% of these women
resort to traditional or no use of contraceptive methods, increasing the risks of unintended
pregnancy, short birth intervals, and adverse maternal and infant health outcomes. Mater-
nal healthcare services, including private facilities, should prioritize modern postpartum
family planning provision, along with education and counseling on the benets of long-
acting contraception.
Background
Sustainable Development Goal (SDG) 3 aims to significantly reduce preventable maternal
and child mortality which is widespread in low- and middle-income countries (LMICs) [1].
Consistent and correct use of family planning (FP) methods can reduce the occurrence of
maternal and child mortality in LMICs [2] through reductions in short-interval births and
unintended pregnancies. However, these issues remain persistent public health challenges
in LMICs accounting for 25% and 49% of total pregnancies, respectively [3]. Notably, in the
extended postpartum period (i.e., 0–12 months following delivery), the non-use of FP meth-
ods has been associated with all short interval births and the majority of the unintended preg-
nancies in LMICs [3]. Therefore, increasing the use of modern postpartum family planning
(PPFP) methods, such as progestin-only pills, injectables, implants, and intrauterine devices
(IUDs), condoms, is crucial to preventing these adverse outcomes.
Despite the urgent need for modern PPFP, only 41% of women in LMICs use such methods
during the postpartum period [4]. This burden is additional to the ongoing lower coverage of
modern contraception use (58%) seen in LMICs [4]. Importantly, women have been found
to have a higher unmet need for FP methods during the postpartum period (49%) compared
to the preconception period (24%). This unmet need is even higher in South Asian countries
(59%) [4]. This is despite 95% of women intending to either not have another child or delay
their next pregnancy [5]. These figures indicate potential barriers during the postpartum
period that hinder women’s access to modern PPFP methods. Consequently, the World Health
Organization (WHO) has advocated for the use of modern FP methods in the postpartum
period, and this issue has been prioritized as a key indicator of national FP programmes in
LMICs including Bangladesh [2].
Bangladesh has one of the highest rates of maternal (173 per 100,000 livebirths) and under-
five mortality (45 per 1,000 livebirths) among LMICs [6,7] which is exacerbated by high rates of
unintended pregnancy (47%) [8] and short-interval births (26%) [9]. Higher occurrences of unin-
tended pregnancy and short birth interval have been found to occur mostly due to a very high rate
of non-use (46%) and unmet need for FP methods (12%) [10,11]. Unmet need for FP methods is
considered to be higher in the postpartum period; however, an accurate estimate is lacking.
Unfortunately, these situations have remained unchanged in Bangladesh since the early
2000s, despite the government’s efforts to improve maternal and infant outcomes in line with
the Millennium Development Goals [7]. These included strength in FP services at the field
level and increased education and awareness regarding FP. However, the lack of progress in
Bangladesh instigated the development of the National Action Plan for PPFP [10]. As part
and reproduction in any medium, provided the
original author and source are credited.
Data availability statement: The datasets used
and analyzed in this study are available from
the Measure DHS website: https://dhsprogram.
com/data/available-datasets.cfm.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have
declared that no competing interests exist.
Abbreviations: LMICs, Low- and Middle-
Income Countries; DHS, Demographic Health
Survey; BDHS, Bangladesh Demographic
Health Survey; PPFP, Postpartum family
planning; ANC, Antenatal care; PNC, Postnatal
care; CI, Confidence Interval; SDG, Sustainable
Development Goal; NIPORT, National Institute
of Population Research and Training; PSU,
Primary Sampling Unit.
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
of this plan, coordination between healthcare and FP service providers was established to
increase the uptake of FP methods during the postpartum period through counselling and
provision of modern FP methods during maternal healthcare service attendance [10]. These
services provide numerous opporunties to have discussions about modern PPFP methods
during antental care, delivery and postpartum care. Such programs have been provided in
addition to previous home-based contraceptive approaches. A similar approach (i.e coun-
selling abour the importance of PPFP during maternal healthcare services uptake) is also
recommended by the WHO to improve PPFP uptake at a global level [12] and has been found
to be effective in LMICs [13–15]. However, regardless of this focus for PPFP, related research
are scare in Bangladesh and LMICs mostly because of lack of data. Current research primarily
focuses on low use of modern contraception (54%) and overall unmet need for contraception
(12%) and their associated socio-demographic factors [16–19], as is the case in other LMICs
[20,21]. We therefore aimed to determine the effects of maternal healthcare services use,
including antenatal care (ANC), delivery with skilled birth attendants (SBA), delivery care in
healthcare facilities (DHC), caesarean section delivery and postnatal care (PNC), on modern
PPFP methods uptake in Bangladesh.
Methods
Data source
This study analysed national representative cross-sectional survey data from the 2017–18 Ban-
gladesh Demographic Health Survey (BDHS), conducted as part of the Demographic and Health
Survey (DHS) program. Data collection took place between September and December 2017.
The National Institute of Population Research and Training (NIPORT) conducted this survey
in Bangladesh as a local partner and as a representative of the Ministry of Health and Family
Welfare of Bangladesh (MoHFW). A two-stage stratified random sampling procedure was used.
The first stage involved randomly selecting 675 primary sampling units (PSUs). This included
the 293,579 PSUs listed by the Bangladesh Bureau of Statistics (BBS) as part of the 2011 National
Population Census. Of these primary selected PSUs, data collection was undertaken in 672 PSUs
with the remainder excluded due to flood. In the second stage of sampling, 30 households were
randomly selected from each PSU, generating a list of 20,160 households covering 20,376 eligible
respondents. Interviews were conducted in 19,457 households (96% of coverage). There were
20,376 eligible women in the chosen households, and data were gathered from 20,127 women
with a response rate of > 99%. The inclusion criteria for completion of this survey were: (i)
ever-married women aged 15–49 years and (ii) staying in the selected households on the night
preceding the survey. Eligible women were asked about their socio-demographic and reproduc-
tive health-related characteristics, such as the use of ANC, DHC, and PNC for their most recent
pregnancy that occurred within three years of the survey date. BDHS also collected information
on FP method use, pregnancy, live births, and termination history for up to five years preceding
the survey. Further details regarding the sampling strategy have been published elsewhere [22].
Study participants
This study focused on ever married women aged 15–49 years who met three specific criteria:
i) had given birth within three years prior to the survey, ii) had data available on their use or
non-use of family planning methods during the postpartum period and maternal healthcare
services, and (iii) had completed the postpartum period (up to 12 months from delivery as per
the WHO recommendation). In the 2017–18 BDHS, a total of 7,562 women were interviewed
who had given birth within five years. Of these 5,012 women had given birth within the previ-
ous three years of the survey and had data on family planning method use, as well as maternal
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
healthcare service utilization. From these, data from 931 women were further excluded because
they were either pregnant (n = 179) or were currently in the postpartum period (n = 752). A
total of 4,081 women met the participant selection criteria for inclusion in this analysis (Fig 1).
Outcome variable
The primary outcome variable for this study was modern PPFP method use during the postpar-
tum period (i.e., 0–12 months post-delivery, as recommended by the WHO) [1]. To generate
this variable, we used women’s reproductive calendar data, taking into account the month they
started using FP methods following a live birth and the types of FP methods used. In this par-
ticular form of data collection technique, women were asked to document their monthly his-
tory of contraception use or non-use by asking respondents monthly history of contraception
during the last few years (asked about the form of contraception use and duration of use and
consolidated information was reported) and provide reasons for non-use or discontinuation.
Fig 1. Selection of the study participationts following the STROBE guideline.
https://doi.org/10.1371/journal.pone.0318363.g001
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
A list of contraceptive methods available in Bangladesh at the time of the survey, as outlined in
Table 2, were provided to assist reporting. Respondents were also given the option to indicate if
the contraceptive methods they used were not listed. We reclassified these responses according
to WHO’s categorization guidelines into the utilization of modern FP methods (which included
the pill, intra-uterine devices (IUDs), injectables, condoms, female sterilization, male steriliza-
tion, and implant, coded as 1) and other methods (coded as 0). We also extracted data on the
duration (in months) of initiating modern FP use. This was measured from the date of the most
recent childbirth within the first 12 months postpartum period and censored at the time of FP
discontinuation or at 12 months whichever occurred first. Duration of PPFP was defined as the
month in which modern contraception was first initiated after the live birth.
Exposure variables
Utilization of maternal healthcare services was our primary exposure of interest. Based on the
WHO guidelines these included ANC (0 = no, 1 = yes), SBA (0 = no, 1 = yes), DHC (0 = no,
1 = yes), caesarean delivery (0 = no, 1 = yes), and PNC (0 = no, 1 = yes). The WHO’s 2014
guideline stated that during the course of a pregnancy, each woman should: i) receive at least
four skilled ANC visits (while this was revised to eight ANC visits in 2016, Bangladesh’s govern-
ment still follow the recommendation of four visits); ii) be assisted by a SBA during delivery; and
iii) receive at least one PNC visit within 2 days of delivery from skilled healthcare personnel [23].
Two survey questions regarding ANC services were used to determine if women had received
ANC, and if so, the number of times. Delivery care-related questions collected information on
who had provided care during delivery and where delivery had occurred. Four additional ques-
tions collected information on the timing of the first PNC, as well as providers of PNC. Finally,
we combined these ANC, SBA, and PNC variables and created a Continuity of Care (CoC)
variable based on previous research in Bangladesh [24]. This variable was categorised as: no CoC
(received none of the services), low/moderate level of CoC (received at least one or two of the
three services), and high level of CoC (received all three recommended services) [24].
Adjusted variables
We conducted a three-stage process to identify the variables for adjustment. First, we
conducted an extensive literature search for relevant studies in LMICs and Bangladesh [5,13–
21,25,26]. Based on this literature review, we generated a list of potential adjustment vari-
ables, which were subsequently verified for their presence in the survey dataset. The variables
that were found to be available in the survey were then assessed for their statistical signifi-
cance in relation to the outcome variables. Finally, only the variables that exhibited statistical
significance in a forward regression model were considered for inclusion in the analysis.
Women’s factors included women’s current age (15–24 years, 25–34 years, 35–49 years), age
at birth of most recent child (≤19 years, 20–34 years, ≥ 35 years), education (no education,
primary, secondary, higher), working status (no, yes), decision-making autonomy (contin-
uous variable), month of menstruation resumption (continuous variable), and history of
pregnancy termination (yes, no). Husband’s age at the time of survey (<24 years, 25–34 years,
35–44 years, ≥ 45 years), husband’s education (no education, primary, secondary, higher),
parity (≤2, > 2), media exposure (not exposed (i.e., reported no access to radio/television/
newspapers within a week of the survey), moderately exposed (i.e., reported at least one
day but less than 3 days access to radio/television/newspapers within a week of the survey),
and highly exposed (if respondents reported regular access to radio/television/newspapers
within a week of the survey)) and pregnancy intention (wanted, unwanted) were household
level characteristics included in the model. Other factors considered were place of residence
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
(urban, rural), wealth quintile (poorest, poor, middle, rich and richest) and administrative
divisions (Barishal, Chattogram, Dhaka, Khulna, Mymensingh, Rajshahi, Rangpur, Sylhet).
Statistical analysis
The characteristics of the study population were described using descriptive statistical anal-
ysis. The prevalence of modern FP methods per months of the postpartum period were also
determined. A time-to-event approach was used to handle postpartum women, irrespective of
whether or not they had adopted modern FP methods by the time of the survey. As such, the
‘event’ (failure) was postpartum modern contraceptive uptake, and the ‘duration’ (time) was
measured up to the first 12 months (follow-up period) following the most recent live birth.
Cumulative probabilities of uptake of any modern FP methods during the postpartum period
(0–11 months) was also reported. Kaplan-Meier survival curves were created to illustrate
the distribution of any modern FP method use during the postpartum period according to
women’s socio-demographic characteristics. Finally, a modified poison regression approach
was used to determine the effect of maternal healthcare services use on modern FP method
use in the postpartum period. A separate model was run for every form of healthcare ser-
vice used. We used the Poisson modified generalised linear regression model with clustered
error variance. Given the survey we analysed had a hierarchical structure and the prevalence
of maternal healthcare services use was over 10%, this statistical approach was chosen as it
produces a more precise result compared to logistic regression analysis [27]. We ran both
unadjusted and adjusted models. In the unadjusted model, each form of maternal healthcare
services use was considered with the outcome variable without any confounding variables. In
the adjusted model, confounding variables were considered. Before executing the models, we
conducted a multicollinearity check utilizing Variance Inflation Factors (VIF) (Supplementary
Table 1 in S1 File). If we detected evidence of multicollinearity, specifically if the VIF exceeded
10, we proceeded to remove the pertinent variables and then re-ran the models. All analyses
accounted for the complex survey design and sampling weights. We used STATA windows
version 15.1 MP (StataCorp, LP, College Station, TX, USA) for data analysis.
Results
Background characteristics
Table 1 shows the background characteristics of the study participants. Among the 4,081
women included in the study, the majority (70.7%) were aged between 15–24 years at the
birth of their most recent child, and 41.0% were aged between 25–34 years. Around half of the
women reported having secondary education, 62.7% were classified as unemployed, and 71%
had parity ≤ 2. Nearly one-third of the women’s partners had completed primary or secondary
education. Approximately 73% of the women lived in rural areas, and nearly 26% reported
Dhaka as their current residing division.
Maternal healthcare services utilization
Approximately 44% of the women received at least four ANC from medically trained pro-
viders during their most recent pregnancy, 52.9% delivered via a SBA, 49.9% had a facility
delivery, and 52% received PNC services (Table 1). The prevalence of CoC was 30.9%.
Uptake of family planning methods during the postpartum period
Table 2 presents the use of any modern PPFP methods. A total of 71.8% of the analysed sample
used modern FP methods within 12 months postpartum. More than one-third (40.2%) initiated
these methods from the second month of delivery (Fig 2). The majority of women (39.5%) who
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
Table 1. Background characteristics of the ever-married women who have given birth in last three years preced-
ing the survey, BDHS 2017–18 (n = 5012).
Characteristics % (95% CI)
Women’s age
15–24 years 53.1 (51.5–54.7)
25–34 years 41.0 (39.5–42.6)
35–49 years 5.9 (5.2–6.6)
Age at last childbirth
≤19 years 25.1 (23.7–26.5)
20–34 years 70.7 (69.3–72.2)
≥35 years 4.2 (3.7–4.8)
Women’s educations
No education 6.3 (5.5–7.2)
Primary 27.6 (25.8–29.5)
Secondary 49.0 (47.2–50.8)
Higher 17.1 (15.6–18.7)
Women’s working status
No 62.7 (60.5–64.8)
Yes 37.3 (35.2–39.5)
Parity
≤2 71.0 (69.4–72.6)
>2 29.0 (27.4–30.6)
Husband’s agea
<24 years 7.8 (7.0–8.7)
25–34 years 50.2 (48.6–51.8)
35–44 years 34.4 (32.9–35.9)
≥45 years 7.6 (6.7–8.3)
Husband’s educationb
No education 13.6 (12.3–15.2)
Primary 33.6 (31.9–35.4)
Secondary 34.0 (32.4–35.7)
Higher 18.5 (17–20)
Wealth quintile
Poorest 20.6 (18.6–22.8)
Poorer 20.5 (19.0–22.1)
Middle 19.2 (17.7–20.8)
Richer 20.2 (18.4–22.0)
Richest 19.5 (17.6–21.6)
Religion
Non-Muslim 8.1 (6.6–10.1)
Muslim 91.9 (88.9–93.4)
Media exposure
Low exposed 34.3 (31.8–36.7)
Moderately exposed 55.2 (52.9–57.4)
Highly exposed 10.6 (9.5–11.7)
Place of residence
Urban 26.9 (25.2–28.6)
Rural 73.2 (71.4–74.8)
(Continued)
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
Characteristics % (95% CI)
Division
Barishal 5.7 (5.1–6.3)
Chattogram 21.2 (19.5–23)
Dhaka 25.6 (23.9–27.4)
Khulna 9.2 (8.3–10.1)
Mymensingh 8.5 (7.7–9.5)
Rajshahi 11.6 (10.4–13)
Rangpur 10.6 (9.5–11.7)
Sylhet 7.6 (6.7–8.5)
Ever had terminated pregnancy
No 83.6 (82.4–84.7)
Yes 16.4 (15.3–17.6)
Menstrual resumption
No 18.1 (17.0–19.2)
Yes 81.9 (80.8–83.0)
Wanted last child
Later or no more 20.9 (19.7–22.1)
Wanted then 79.1 (77.8–80.3)
Maternal healthcare service utilizationc
4 ANC at least one with medically trained providers
No 56.3 (54.1–58.5)
Yes 43.7 (41.5–45.9)
Delivery by a skilled birth attendance
No 47.1 (44.7–49.5)
Yes 52.9 (50.5–55.3)
Delivery in healthcare facility
No 50.1 (47.8–52.4)
Yes 49.9 (47.6–52.2)
Caesarean delivery
No 66.8 (64.8–68.7)
Yes 33.2 (31.3–35.2)
Post-natal healthcare services
No 47.9 (45.6–50.2)
Yes 52.1 (49.8–54.5)
Level of continuum of care (CoC)
No CoC 34.4 (32.2–36.7)
Low/moderate level of CoC 34.7 (33.1–36.4)
High level of CoC (WHO recommended level) 30.9 (28.8–33.1)
Note: Calculated for column percentages.
amissing, n = 146;
bmissing, n = 141;
cwas classified according to WHO definition and was measured for last 3 years prior to the survey, sample n = 5012.
dIncludes the sample who didn’t seek ANC or PNC.
https://doi.org/10.1371/journal.pone.0318363.t002
Table 1. (Continued)
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
reported the use of modern FP methods in the postpartum period used birth control pills, and
this usage increased significantly over the observation period. Additionally, 13.1% of women
used injectables (Depo-Provera) and 13.2% reported condom use. Female sterilization was
reported by 2.8% of women and over 91% was performed in the first month postpartum.
Cumulative survival probability of using modern family planning methods
in the postpartum period
Table 3 and Supplementary Figure 1 in S1 File show the cumulative survival probability of
using modern FP methods (for the women who indicated the use of FP methods) in the post-
partum period. The probability of using any modern FP methods in the first month postpar-
tum was 6.1%. This significantly increased to 36.9% after the second month. A similar trend
was observed in the sixth month, where the percentage of any modern FP method use increased
to 80.6%. By the end of the designated postpartum period, the probability of using any modern
FP method had risen to nearly 100%. There was no significant variation in modern FP meth-
ods used in the postpartum period across women’s place of residence (Fig 3) and wealth index
(Fig 4). However, we found a variation in modern FP methods used in the postpartum period
according to women’s level of education, with women with higher education levels more likely
to use modern FP methods in the postpartum period than those with no education (Fig 5).
Association between the maternal healthcare services utilization and
uptake of any modern postpartum period family planning methods
Table 4 presents both unadjusted and adjusted associations between maternal healthcare ser-
vices use and women’s use of any modern FP methods in the postpartum period. Full model
Table 2. Prevalence of postpartum family planning use by months after childbirth among the ever-married women who have given birth in last three years pre-
ceding the survey, BDHS 2017–18 (n = 4081).
Family planning methods Months after childbirth, % Total, %b
0th 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th
Use of FP methodsa
No methods 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 20.4
Traditional methods 0.0 1.9 34.9 22.6 14.0 3.32 4.32 8.0 2.5 3.8 3.9 0.7 7.7
Modern methods 0.0 5.9 34.4 20.0 13.7 5.5 4.8 6.2 2.8 2.7 2.3 1.7 71.8
Type of traditional methodsb
Safe period 0.0 1.3 33.9 19.3 13.6 2.6 5.8 10.0 2.6 4.7 5.5 0.6 4.4
Withdrawal 0.0 2.7 36.3 27.1 14.5 4.3 2.4 5.2 2.4 2.7 1.7 0.8 3.3
Type of modern methodsb
Pill 0.0 30.0 1.6 36.3 22.0 13.1 4.7 5.9 3.1 3.2 2.8 2.2 39.5
IUD 0.0 48.1 24.2 9.6 5.2 0.0 6.3 3.9 2.8 0.0 0.0 0.0 0.5
Injectables 0.0 2.0 38.6 15.4 13.2 7.1 5.4 8.0 3.2 3.0 3.0 1.1 13.1
Condom 0.0 0.7 32.4 23.0 19.7 7.3 4.5 5.8 2.1 2.3 1.2 1.0 13.2
Female sterilization 0.0 91.2 7.3 0.0 1.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 2.8
Male sterilization 0.0 43.8 6.8 15.5 15.5 18.3 0.0 0.0 0.0 0.0 0.0 0.0 0.2
Implant 0.0 11.2 31.2 22.3 9.1 4.4 7.3 10.8 2.3 0.0 0.0 1.3 2.4
Other 0.0 33.3 0.0 33.3 0.0 33.4 0.0 0.0 0.0 0.0 0.0 0.0 0.1
Note:
aCalculated for cumulative row percentages;
bis calculated for column percentage. Other includes all other reported modern contraception (ECP, and others).
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
results are presented in Supplementary Tables 2–7 in S1 File. Women who received at least
four ANC visits from skilled providers were found to be 1.04 times more likely (95% CI: 1.00–
1.07) to use any modern FP methods in the postpartum period compared to those who did
Table 3. Cumulative survivor function to estimate the probability of postpartum modern family planning uptake
among women who had given birth in three years preceding the survey, BDHS, 2017–18 (n = 4081).
Months Total n Failure Lost Not using, S(t) Using, 1-S(t) Error 95% CI
0st 4081 46 748 0.9887 0.0113 0.0017 0.985– 0.9915
1st 3287 167 6 0.9385 0.0615 0.0041 0.9299– 0.946
2nd 3114 1022 108 0.6305 0.3695 0.0084 0.6138– 0.6466
3th 1984 620 77 0.4335 0.5665 0.0087 0.4163– 0.4505
4th 1287 418 49 0.2927 0.7073 0.0082 0.2768– 0.3088
5th 820 148 15 0.2399 0.7601 0.0078 0.2248– 0.2552
6th 657 125 17 0.1942 0.8058 0.0073 0.1802– 0.2087
7th 515 181 25 0.126 0.874 0.0062 0.114– 0.1385
8th 309 79 9 0.0938 0.9062 0.0056 0.0832– 0.1051
9th 221 81 12 0.0594 0.9406 0.0047 0.0507– 0.069
10th 128 62 10 0.0306 0.9694 0.0036 0.0242– 0.0382
11th 56 54 2 0.0011 0.9989 0.0008 0.0002– 0.0038
Note: S(t): survivor probability of not using contraceptives; 1-S(t): probability of using contraceptives.
https://doi.org/10.1371/journal.pone.0318363.t003
Fig 2. Cumulative percentage distribution of women who started to use modern postpartum family planning methods, distributed over the
months after childbirth (0–11 months).
https://doi.org/10.1371/journal.pone.0318363.g002
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
not receive at least four ANC visits. Similarly, the likelihood of using any modern FP meth-
ods in the postpartum period was found to be significantly higher for women who delivered
with a SBA (aPR: 1.07, 95% CI: 1.03–1.11) and/or at a DHC (aPR: 1.06, 95% CI: 1.02–1.10).
Caesarean delivery was also found to be associated with 1.08 times (95% CI: 1.03–1.12) higher
likelihood of using any modern FP method in the postpartum period. A significantly higher
likelihood of using any modern FP method was found among women who reported the use
of PNC (aPR: 1.06, 95% CI: 1.03–1.10) compared to their counterparts who did not report the
use of this service. We also found a 1.09 times (95% CI: 1.05–1.13) higher likelihood of using
any FP method in the postpartum period among women who reported a higher level of CoC
compared to the women who reported lower level of care.
Discussion
The aim of this study was to explore the association between maternal healthcare service
utilization and the adoption of modern FP methods during the postpartum period. Our
results indicate that the prevalence of PPFP uptake was 73%. Pill and condom were reported
as dominant methods in the postpartum period. The use of maternal healthcare services as
well as continuity of using maternal healthcare services, were found to be associated with only
a 3%–7% increase in uptake of any modern FP method in the postpartum period. These find-
ings suggest that Bangladesh’s national target of counselling on modern FP methods during
maternal healthcare services is largely inactive at the field level, and that maternal healthcare
service utilization only modestly affects modern FP method adoption during the postpartum
Fig 3. Probability of not using postpatum modern family planning methods over the months after childbirth (1–12 months) by wom-
en’s place of residence using Kaplan Meier survival estimates.
https://doi.org/10.1371/journal.pone.0318363.g003
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
period. As a result, the government’s objectives of reducing unintended pregnancies and short
birth intervals by ensuring PPFP through counselling women regarding PPFP during mater-
nal healthcare service usage may not be achieved.
Our findings suggest that over one-quarter of women in Bangladesh do not start using
modern FP methods within 12 months after childbirth. Moreover, among women who
do use modern FP methods during the postpartum period, the majority do so within the
5th–6th week post-birth, although the prevalence was only 33%, after becoming fertile again
[7,28]. This indicates that over 1 million postpartum women in Bangladesh are at risk of a
short interval pregnancy, with a significant portion of these pregnancies unintended [9]. In
addition, the pattern of modern FP method use during the postpartum period in Bangla-
desh is problematic. While the postpartum FP program in Bangladesh primarily focuses on
providing postpartum IUDs, implants, and female sterilization, these methods account for
less than 5% of the total postpartum modern FP methods used in Bangladesh. On the other
hand, pills, injections, and condoms are the dominant methods, covering around 92% of the
total modern FP method users in Bangladesh in the postpartum period [6,7]. This reflects the
general pattern of modern FP method use in Bangaldesh [29]. However, failure rates of these
modern methods under typical use conditions are very high, ranging from 4% for injections,
to 13–21% for condoms [30]. This places these women at high risk of unintended pregnan-
cies and short birth intervals. Further, progestogen-only pills are primarily recommended for
non-breastfeeding women or after six weeks of delivery for breastfeeding women, while con-
doms are recommended for all women [31]. This pattern of pill use indicates that 35% women
are at further risk of adverse child health outcomes given that 65% exclusively breastfeed in
Fig 4. Probability of not using postpatum modern family planning methods over the months after childbirth (1–12 months) by house-
hold wealth using Kaplan Meier survival estimates.
https://doi.org/10.1371/journal.pone.0318363.g004
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
Bangladesh [7]. Low use of contraception in general and lower use of long-acting modern
contraception in particular in Bangladesh may be attributed to insufficient awareness of the
effectiveness of these methods to prevent pregnancy during the postpartum period. This may
be a result of challenges at both the system and individual level.
Like the WHO’s global recommended guidelines, the Government of Bangladesh prioritize
women and healthcare personnel contacts during the intrapartum and postpartum periods to
provide vital FP counselling [10]. Unfortunately, however, this is not largely reflected at the
field level with a lack of proper counselling and poor quality of services identified [32]. Here,
we found the use of maternal healthcare service and continuity of care only increased the
probability of using modern FP method use in the postpartum period by 3%-7%. While this
process has been found effective in several LMICs [13–15,13,33], in Bangladesh, at least three
limitations may have attributed to it being less effective. First, the recommendation primarily
focuses on postpartum women who have accessed healthcare services; however, over 30%
of Bangladeshi postpartum women do not receive any maternal healthcare services during
pregnancy [7], similar to women in other LMICs [34,35]. Second, more than 70% of pregnant
women in Bangladesh do not access all maternal healthcare services, mainly dropping out
after transferring from at least one ANC visit to four or more ANC visits, and from DHC to
PNC [24]. A similar trend has been reported in other LMICs [36,37]. In both cases, maternal
healthcare services are perceived unnecessary in Bangladesh unless complications arise [24].
Third, while private sectors are becoming increasingly popular in Bangladesh for providing
maternal healthcare services, with around 75% of total DHC provided by private facilities,
Fig 5. Probability of not using postpartum modern family planning methods over the months after childbirth (1–12 months) by wom-
en’s education level using Kaplan Meier survival estimates.
https://doi.org/10.1371/journal.pone.0318363.g005
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
the government’s policy does not address how they will ensure modern FP method use in the
postpartum period among mothers accessing services from any private facilities [10]. Conse-
quently, although maternal healthcare service use is increasing, this does not largely influence
modern FP method use in the postpartum period.
These challenges are exacerbated by coordination issues between the two wings of the
Ministry of Health and Family Welfare in Bangladesh: the Director General of Family Plan-
ning (DGFP) and the Director General of Health Services (DGHS) [10]. Although these
two wings have strong parallel infrastructure within Bangladesh and have recently started
providing integrated services for FP only, their focuses are different [11]. The DGHS mainly
operates maternal healthcare services and immunization, while FP services mainly operated
by DGFP. Therefore, DGHS service providers often overlook FP issues because they may not
see it as their responsibility [25]. Even if DGHS service providers wish to counsel mothers
about modern FP methods, they may not do so because FP is usually considered a culturally
sensitive issue in Bangladesh that requires a private room to discuss [25]. However, this is
not available in almost all maternal healthcare facilities. These challenges are additional to
the DGHS’s healthcare providers’ higher pressure to treat complicated cases because of very
low doctor-population ratio and the lack of monitoring from the governmental level. On the
Table 4. Association of maternal healthcare service utilization with postpartum modern family planning uptake
among women who had given birth in three years preceding the survey using poison modified generalised linear
model estimates: BDHS, 2017–18 (n = 4081).
Maternal healthcare service utilization Unadjusted Adjusteda
PR (95% CI) PR (95% CI)
4 ANC at least one with medically trained providers
No (ref) 1.00 1.00
Yes 1.04 (0.99–1.08) 1.04 (1.00–1.07)*
Delivery by a skilled birth attendance
No (ref) 1.00 1.00
Yes 1.05 (1.01–1.08)*1.07 (1.03–1.11)**
Delivery in healthcare facility
No (ref) 1.00 1.00
Yes 1.04 (1.01–1.08)*1.06 (1.02–1.10)**
Caesarean delivery
No (ref) 1.00 1.00
Yes 1.06 (1.02–1.09)** 1.08 (1.03–1.12)***
Post-natal healthcare services
No (ref) 1.00 1.00
Yes 1.04 (1.01–1.07)*1.06 (1.03–1.10)***
Continuity of care
Low (ref) 1.00 1.00
Moderate 1.01 (0.96–1.06) 1.02 (0.96–1.07)
High 1.06 (1.01–1.11)*1.09 (1.05–1.13)***
Note:
aAll the models were run separately for each types of maternal healthcare service utilization and was adjusted for
women’s menstruation resumption time after childbirth, wanted pregnancy, ever had terminated pregnancy, age at
birth, women’s education, women’s working status, parity (children ever born), husband’s age, husband’s education,
media exposure, wealth quintile and place of residence. Values with superscript asterisks * , **, and ***indicate p < 0.05,
p < 0.01, and p < 0.001, respectively. (ref): Reference category, PR: prevalence ratio, CI: confidence interval. Full model
results are presented in Supplementary Tables 1–6 in S1 File.
https://doi.org/10.1371/journal.pone.0318363.t004
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
other hand, DGFP service providers mainly focus on providing FP counselling and distrib-
uting contraceptive methods to sexually active, non-pregnant married women [7,25]. They
usually do not consider pregnant women and women who have just given birth as their target
groups because they do not require contraceptive methods at that specific time [10]. Together,
these challenges contribute to the failure of providing appropriate FP counselling to pregnant
and postpartum women, despite this being a key target in the national strategy in Bangladesh
[26]. However, the few instances of counselling that are provided during maternal healthcare
service use have shown modest effects on the uptake of FP methods in the postpartum period,
as reported in this study as well as other studies conducted in LMICs [13,31,33].
At an individual level, limited knowledge of FP methods, as well as the stigma and cultural
norms surrounding it play important roles in influencing the uptake of FP methods among
postpartum women [26]. For instance, a significant proportion of postpartum women in Ban-
gladesh lack knowledge regarding the importance of using FP methods during the postpartum
period, and there is a belief in the community that women do not need FP methods follow-
ing delivery, particularly while breastfeeding [7,26]. These difficulties are compounded by
limited access to information and services related to family FP methods, which is increasing
rather than declining. For instance, exposure to FP messages through home visits by family
planning workers decreased from 40% in 1994 to 13% in 2017/18, and exposure through mass
media decreased from 50% in 1994 to 24% in 2017/18 [7,10]. The reasons for this could be
the ongoing lack of FP workers at the community level, inadequate monitoring, and extra
burden to provide services to more people, as the current number of posts for family planning
workers was developed in early 1978 when the total population of Bangladesh was less than
half of what it is now [11]. Moreover, a significant number of the currently approved posts are
also vacant [25]. Additionally, women are increasingly outside the home for work may reduce
their availability at home when visited by family planning workers [26]. Together, these factors
may contribute to the lower uptake of postpartum FP methods.
The findings of this study suggest important policy implications for increasing the uptake
of PPFP. It is evident that the current approach to increasing PPFP through access to maternal
healthcare services is not as effective as desired; their role is relatively minor but still signifi-
cant. Therefore, there is an urgent need to address the challenges within maternal healthcare
sector to enhance counselling on PPFP. This includes increasing the coverage of maternal
healthcare services and the number of healthcare personnel dedicated to provide maternal
healthcare. Furthermore, PPFP counselling should be integrated as a vital component of the
services provided by private healthcare facilities in Bangladesh. Challenges associated with
providing and ensuring maternal healthcare services and FP in government healthcare facili-
ties also need to be addressed. This involves ensuring proper integration between the DGHS
and the DGFP and addressing structural issues, such as designating specific areas for PPFP
services.
This study has several strengths and a few limitations. First, we analysed a large sample
extracted from a nationally representative survey. The results are adjusted with a wide range
of confounding variables at the individual, household, and community level through advanced
statistical modelling. The WHO recommendations were followed to generate modern FP
methods variables, and maternal healthcare service use variables. Together, these allowed us
to generate more precise findings. However, analysis of cross-sectional data is the primary
limitation of this study; therefore, the findings reported in this study are cross-sectional only,
not causal. Additionally, both maternal healthcare services and contraception uptake data,
as reported in the calendar methods, were collected retrospectively. Consequently, there is a
potential for recall bias, although any such errors are likely to be random in nature. Moreover,
rather than the factors we considered in the model, community-level norms and traditions
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
and availability and readiness of healthcare facilities play an important role in ensuring FP
methods uptake during the postpartum period. However, we could not do it because of the
lack of relevant data. Furthermore, the global literature has demonstrated the effectiveness of
four postnatal care visits in increasing the adoption of modern FP methods. Unfortunately,
we were unable to consider this factor due to a lack of available data. Another limitation is
our inability to consider unmarried women in the analysis as the survey data we analysed did
not collect this information considering Bangaldeshi culture is prohibitive of sex outside of
marriage and evidence of this is mostly unreported. Despite these limitations which needs
further exploration, as far as we know, this is the first study of its kind, which should be used
for making country-level policies and programs to ensure FP methods uptake at the postpar-
tum period. Future research should be conducted by implementing a prospective study design
along with a broad range of contributing factors.
Conclusion
Modern FP methods in the postpartum period were reported by 73% of women. However,
over 60% started using modern FP methods six months post-birth. Along with these chal-
lenges, the pattern of modern FP methods reported in this study was found to be problem-
atic, with very few (<5%) using modern FP methods that are recommended for postpartum
women. Added to this, maternal healthcare service use had only modest effects on up taking
modern FP methods. These findings indicate that the 2015 National Action Plan for PPFP
in Bangladesh is not active enough at the field level in Bangladesh. This might contribute to
a higher occurrence of short interval births and unintended pregnancies and related adverse
outcomes, including maternal and child mortality. This would challange Bangladesh’s ability
to achieve the SDGs targets related to improving maternal and child health. Enhancing mater-
nal healthcare services, integrating PPFP as a component of services offered by private health-
care facilities, and addressing structural challenges are recommended to improve the uptake
PPFP. This however requires a greater focus on the healthcare service delivery system.
Supporting information
S1 File. Supplementary file.
(DOCX)
Acknowledgments
We are thankful to MEASURE DHS for the data support. Also we are grateful to icddr,b which
is grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing
core/unrestricted support for its operations and research, where the data for this study was
analysed. The authors also acknowledge the support of Maternal and Child Health Division of
icddr,b, Health System and Population Studies Division of icddr,b and Department of Popu-
lation Science of Jatiya Kabi Kazi Nazrul Islam University, where this study was designed and
conducted.
Author contributions
Conceptualization: Md. Nuruzzaman Khan, Md. Moinuddin Haider.
Data curation: Md. Nuruzzaman Khan, Md. Mostaured Ali Khan, Md Arif Billah, Md.
Moinuddin Haider.
Formal analysis: Md. Nuruzzaman Khan, Md. Mostaured Ali Khan, Md Arif Billah.
Funding acquisition: Md Arif Billah.
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PLOS ONE Maternal healthcare service utilization and modern postpartum family planning
Investigation: Md. Mostaured Ali Khan, Md. Moinuddin Haider, Bidhan Krishna Sarker.
Methodology: Md. Nuruzzaman Khan, Shimlin Jahan Khanam.
Supervision: Bidhan Krishna Sarker, Melissa L. Harris.
Writing – original draft: Md. Nuruzzaman Khan.
Writing – review & editing: Md. Nuruzzaman Khan, Md. Mostaured Ali Khan, Md Arif
Billah, Shimlin Jahan Khanam, Melissa L. Harris.
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