This study examines the associations between the use of maternal health care (specifically ANC and PNC services) and post-partum modern FP practice in Kenya and Zambia. Results indicate a positive association between the intensity of ANC and PNC services and post-partum use of modern contraception in both countries. The more intensively women use ANC and PNC services, the more likely they go on to adopt a modern method of contraception after the index childbirth. The evidence also suggests that the use of maternal health services can be a mediator for individual’s socio-demographic characteristics to influence post-partum modern contraceptive use. Tests of exogeneity indicate no evidence that maternal health care use and post-partum FP practice were influenced by common unobserved factors. In addition, we found that when maternal health care was disaggregated into ANC and PNC services, only the use of ANC services was found to be significantly related to post-partum modern contraceptive use.
An important program implication of the findings is that the promotion of ANC services should be considered as a mechanism to promote post-partum FP use. Since the use of contraception after a childbirth is related to ANC service factors that are relating to health providers and the health system, a health system approach to improving ANC services should be a priority in low-resource settings. Policy makers in countries like Kenya and Zambia, where most women already receive at least one ANC visit, who want to promote post-partum FP use should emphasize the comprehensiveness and quality of ANC services. For example, women should be made sure to receive tetanus vaccine and a range of standard ANC procedures. Such services may contribute to women’s trust of the health system and their overall satisfaction with health care services, which make them more likely to return for other services. As most women who attend ANC clinics do not regularly receive any health education , the provision of FP counseling during ANC visits may also serve to improve the quality of these visits and client satisfaction. In fact, previous research suggests that a pilot introduction of a focused ANC package that included FP counseling in two districts in Kenya was welcomed by providers as well as clients and significantly increased the overall quality of care .
The null finding related to PNC service intensity warrants some discussion. Theoretically, the use of PNC should be related to post-partum FP practice for the same reasons that ANC is related to this contraceptive behavior outcome. Previous research in the sub-Saharan African region has shown that PNC is among the weakest aspects of reproductive health programs [20, 21, 31]. Health facilities do not routinely record PNC visits; the vast majority of women who deliver their babies at home do not receive PNC . In addition, although FP counseling is theoretically part of the routine PNC package, in practice it is often overlooked when priority is given to a child’s health during postnatal checkups . Even when PNC services are used by women, they still seem to be a missed opportunity for FP promotion; for example, 68% of post-partum women in Kenya had unmet need for FP in during the first year . Moreover, access to PNC services remains limited, at least in the two countries under this study .
However, because we cannot test these hypotheses with the available DHS data, it is likely that the null finding related to PNC service in this study is due to limitations in the measure of PNC services available in the DHS. There are no questions about the content or quality of PNC services. Our measure of PNC service intensity is only based on three binary indicators of whether a woman received any check-up by a trained provider before, after discharge and two months after the childbirth; the first one is likely outside of women’s control. Therefore, it is possible that the quality of PNC services, for which we do not have a measure, may be related to post-partum FP use. Had we had more information on the content and quality of PNC services, the results might have been different.
In addition to ANC and PNC service use intensity, several other individual characteristics that are important for FP practice are highlighted in this study. As mentioned earlier, prior use of modern contraception has a direct association with post-partum FP use, as well as an indirect one through ANC service intensity in Kenya. It is important to note that in both countries, women who visited and talked about FP at a health facility within the last 12 months were significantly more likely than others to adopt a modern contraceptive after a childbirth. The finding further underlines the role of the health care system in promoting FP practice. Socio-economic characteristics, including education, household wealth, and women’s employment, were also consistently associated with an increased likelihood of post-partum modern contraceptive use, suggesting that efforts to increase FP use should continue to address women of lower education level, from poorer households, and those who do not work outside of the home.
One limitation of this study is that the results are not necessarily generalizable to all women of childbearing age in Kenya and Zambia. The group of women included in this study, married and cohabiting women who gave birth within five years before the survey, are significantly different from women who were not included in terms of a number of socio-demographic factors. Study women were older, less educated, poorer, and more likely to live in rural areas than those who were not in the study (results not shown).
Another potential limitation of the study is the possible endogeneity between the FP use outcome and the variables relating to exposure to FP messages on the media and visits by a FP field worker. Some women may have been motivated to adopt a modern method of contraception because of their exposure to FP messages in the media or because they were visited by a FP field worker. On the other hand, it is plausible that women who are already using contraceptives may be more likely than others to pay attention to FP messages in the media and recall them better. Contraceptive users may also be more likely than non-users to be visited by a FP fieldworker for follow up or resupply. Testing for these potential endogenous associations is beyond the scope of this study. Nevertheless, the study results did not change when these variables were excluded from the model. Therefore, any bias potentially introduced by this type of endogeneity would not significantly change our main findings.
Finally, only individual-level factors were examined in this study. It is possible that post-partum modern FP practice is influenced by community-level factors that were not measured. For example, the availability of and access to modern contraceptives in the community may influence a woman’s use of contraception. Community norms about contraceptive use may also positively influence an individual’s contraceptive behaviors. Similarly, facility-level data on the degree of integration of FP and reproductive health services would have been useful for this type of analyses. Many of these factors, however, are not readily measurable with existing DHS data.
Despite the limitations, this study adds to the currently limited body of evidence of the associations between maternal health care (and ANC service use in particular) and post-partum modern FP use, using recent nationally representative survey data in Kenya and Zambia. ANC services could provide an important opportunity to promote the use of modern contraceptives after childbirth. The findings underline the importance of working with the health system to improve ANC service delivery in order to promote post-partum modern contraceptive use, at least in the context of these two countries.