Study design and setting

We conducted qualitative interviews as part of a study to understand the feasibility of delivering PPFP services through infant vaccination camps offered by the public health system in India. Vaccination camps, delivering routine immunization, comprised public delivery points for child health services and could be utilized for greater outreach for family planning, particularly postpartum family planning counseling and service delivery. These immunization camps could serve as a platform for delivering family planning services, overcoming barriers related to outreach and health service access towards young mothers.

These interviews were conducted between March and May 2022 in Maharashtra, India. Maharashtra is a rapidly urbanizing state that has also seen an expansion of health services. The proportion of women using contraception in 2019−21 was similar to the national average; the unmet need for family planning was higher than the national average [34]. The state has higher rates of female permanent contraception (44%) than the national average, while the rates of PPIUD are lower than the national average [34]. These use patterns provide a unique setting for understanding the low use of reversible postpartum contraception.

Sample and recruitment

We conducted one-on-one interviews with a sample of 62 participants including: women 12 weeks postpartum or less (n = 22), husbands of postpartum women (n = 10), mothers-in-law (MIL) of postpartum women (n = 10), frontline health providers (n = 10), and village leaders (n = 10). Eligible postpartum women, husbands and MILs were recruited by a gender-matched research assistant near antenatal clinics, primary health centers, community centers and immunization camps. We did not seek to recruit eligible participants from the same family, nor did we attempt to link data between family members. More postpartum women were interviewed given the need to center the lived experience of these women in this work. However, the study team also explored the perspectives of other important stakeholders including 10 interviews each among frontline healthcare workers and community leaders (including NGO leadership and primary health center medical officers). Health providers were recruited at their place of work. Community leader participants were asked for referrals to other potential participants, as needed, to reach the desired sample size. Interviews were conducted in households and at health centers per the convenience of participants and lasted for 40 minutes.

Data were collected via semi-structured interviews that were developed based on the study objectives and research literature identified by investigators. All interviews were conducted in the local language (Marathi). Data were collected by four Master’s degree-level field investigators who were trained in qualitative data collection, had local language expertise and understood the nuances of local cultural practices. Our research followed ethical norms and standards as per the norms for research. All mandated protocols were followed for data collection and management. Written informed consent was obtained from the study participants. None of the postpartum women who participated in the study were minors or non-literate. Three mothers-in-law, ages 50–60 years who participated in the study were non-literate. Interviews were audio-recorded with the consent of the participant and subsequently transcribed and translated into English. For participants with limited or no literacy, informed consent was obtained in front of a literate witness, who also had the opportunity to ask questions.

Interviews were audio-recorded with the consent of the participant and subsequently transcribed and translated into English. The study received ethical approval from the Human Research Protections Program at University of California San Diego in the United States, and the Sigma Institutional Review Board (A Division of Sigma Research and Consulting Pvt Ltd) in India.

Interviews probes

Our study utilized Urie Bronfenbrenner’s Ecological Systems Theory to identify stakeholders as well as their spheres of influence [35]. Bronfenbrenner’s Ecological Systems Theory, originally theorized to understand child development [35], was used to define and frame the interconnected system of influencers who guided women’s agency and choice. Levels within the theory were used to define women’s postpartum contraceptive use as being determined by women’s own agency for use and the role of key family members -husbands and mothers-in-law (family agents), community health workers (institutional agents) and local leaders and elected officials (community agents). This conceptual framework guided the thematic areas of investigation, instrument development, analysis and the synthesis of findings.

Interview probes with postpartum women (n = 20) focused on: a) postpartum counseling during antenatal care and delivery and PPFP services; b) issues related to women’s agency in the uptake of PPFP and factors that may improve agency and PPFP; c) knowledge of PPFP services, decision-making preferences and any experience of family or provider coercion; d) norms affecting contraceptive use and expectations related to fertility/childbearing and around spacing, son preference and specific contraceptive types; e) feasibility and challenges related to community based FP service delivery; and e) preferences related to PPFP and experiences of PPFP access.

Interviews among husbands of postpartum women (n = 10) explored issues related to the role of men in PPFP decision-making and community norms related to male engagement in family planning; husbands’ expectations related to early in marriage pregnancy; and their views on community-based provision of postpartum contraception availability.

Interviews among mothers-in-law (MILs) (n = 10) of women who had recently given birth focused on family involvement in PPFP decision-making; family dynamics of young couples; norms related to women’s fertility early in marriage and son preference; and their role in family planning and views on community-based provision of PPFP.

Interviews with frontline health workers (n = 10) including female auxiliary nurse midwives (ANMs) and ASHAs (accredited social health activists) focused on provision of contraceptive counseling and PPFP care; PPFP and decision-making norms related to postpartum contraceptive uptake; spacing and son preference; myths and misconceptions related to contraception use; feasibility and challenges of delivering community based PPFP services; barriers to implementation and infrastructure challenges related to PPFP service provision.

Interviews among community leaders (n = 10), including male and female village panchayat members (local elected officials), NGO workers, and private and government medical officers explored issues related to implementation, cultural factors and the access of PPFP; quality of existing PPFP services; and views related to provision of community-based FP services.

Data analysis

Throughout data collection, interview data were iteratively assessed for completeness and understanding; probes were refined as needed and assessed for thematic saturation. Interviews were transcribed and translated, and subsequently the transcripts were uploaded onto ATLAS.ti (v. 22) for analysis. A sub-sample of 10 interviews were reviewed to generate a codebook for analysis, which was refined further for code saturation. Two coders reviewed the first 10 interviews independently, and inter-coder agreement reliability was 89% agreement. Data were analyzed by a team of six trained staff members and were regularly reviewed for quality control by lead investigators. Disagreements or conflicts were resolved by the senior author. In case of any issues with the quality of the transcript, the Maharashtra-based scientist assessed quality concerns and discussed with the project team. Lead investigators also performed occasional spot-checks for quality control.

While the study had used Bronfenbrenner’s Ecological Systems Theory in developing the sampling frame and the nature of respondents in the study, this approach was not mirrored in the analysis due to cross-cutting themes that could not be synthesized within one stakeholder group. We did not use a pure grounded theory approach for analysis. However, we used principles of grounded theory to generate codes and guide the development of a framework to understand emerging themes and to understand the social processes and interactions across stakeholder groups. We identified key constructs, particularly reproductive agency, as described by Can-Act-Resist [19] and the role of social norms in driving the emerging themes. We used an inductive approach developed through workshops that synthesized the emergent themes into a framework developed by the study team. A number of inter-connected themes and sub-themes emerged. Coders mapped the themes by constructs as they emerged. Finally, the codes and quotes were organized into five key thematic areas which were synthesized into learnings for FP programming.

Positionality

The study team comprised a mix of nationalities, ethnicities and genders. The study team was not invested in development of FP programming that promotes women using contraception, but rather our aim is to understand barriers to contraceptive use if desired. The study team was cognizant of the power asymmetries between researchers and the participants, as well as power dynamics in the community that might influence the study. The study team were engaged in detailed planning of stakeholder interviews, and study instrument was designed keeping in mind the constraints faced by the participants such as time. One of the investigators was also a local community expert with decades of experience in both research and project management in the area. With his guidance, the study team followed local protocols and cultural etiquette in the outreach, recruitment, communication and data collection, respecting the priorities and time of the participants. Any discomfort or issue with the interview were brought to the attention of the study team and addressed as swiftly as possible.

I. Access to Postpartum Family Planning Services and Counselling: Few women received PPFP counselling or services, with marginalized communities disproportionately affected by lack of access

Most participants reported that they had not received any information related to PPFP services in their interactions with clinicians during their antenatal care visits or post-delivery.

No. Family planning was not discussed during their visit. She discussed with me only about investigations such as blood test, weight, BP, urine etc. to be done. Pills were given if they noticed anemia. She came once and then called me and told me where the vaccination will be. (postpartum woman, age 23)

I had my all 3 of my deliveries at the primary health center. I visited the primary health center on number of occasions earlier. I used to go once in two months. There was no discussion on family planning as such. (postpartum woman, age 23)

Only a few participants reported that they received FP information during prenatal care.

Yes, he said, “If you want to keep spacing between this and the next baby, you can put a CuT (Copper T) in next three months.” There was not much talk, only when he visited to remove the stitches on the tenth day after the delivery. We told him that we will do it (CuT) after three months. (postpartum woman, age 25)

Health providers noted that reaching marginalized groups was challenging, and tribal and migrant populations were often disconnected from FP programs and from PPFP services.

There are some special religions or societies such as tribal society or migrant workers, in which even if there were four or five children, they would continue having more. This is due to the fact that information does not reach to them and there is illiteracy. They are taken directly to the hospital at the time of delivery after becoming pregnant. They have no reports. What will you tell them then? The story has not yet reached them. Reaching out to migrants can be difficult at times (medical officer, male, age 36).

In some cases, permission or approval of community leaders (the Sarpanch) was also needed to seek FP access, with implications for PPFP use.

Many couples will not participate because they do not know much about it. Sarpanch’s permission has to be sought at the village level. Such a question needs to be discussed. (husband, age 33)

The COVID-19 pandemic had also disrupted FP access, particularly affecting PPFP services in the community. However, disrupted services were being resumed.

Last 2 years, there have been no (health) camps. So, what happened in the past has not been very effective. Health services were supposed to reach the grassroots level have not reached or what is being disseminated through social media has not been done as much as it should have been. (village panchayat representative, male, age 38)

Earlier we had a primary health care vehicle to take pregnant mothers, but now the vehicle facility has stopped, because of the COVID pandemic. People arrange transport on its own either via four wheelers or two wheelers. (ASHA, age 38)

II. Women’s reproductive agency and pressures: Postpartum women lacked agency in contraceptive decision-making and often needed their husband’s approval to access PPFP services

Participants viewed education as an important instrument for transformative change that determined contraceptive awareness and communication among couples. Higher education improved knowledge of family planning and elevated women’s ability to convey and convince their families to use PPFP services.

The problem is that whatever the information is provided to them (women), we don’t know how far this reaches. They will not know the advantages and disadvantages of [contraception]. As she is non- literate, she can’t read about it anywhere. They may also have the influence of their family members assuming that as she is not learned and she does not have capacity to understand. She can’t make that decision. She can’t explain or convince her family members in a good way because she is not well educated. If there is an educated woman in that place, she can come here and read the poster and we explain to her directly or tell her to come to us and we tell her about the method that she would like to adopt. (ANM, age 28)

However, despite increasing levels of education in the community, women experienced backlash through verbal or physical abuse when they exercised their choice to use FP against the wishes of their family members. In cases where health providers counseled women to access postpartum contraception, couples often believed that their families knew better and eventually the will of their families prevailed.

If she has any side effects after insertion, household members will blame her and will question her about insertion. In some cases, there can be abuse by family members. If she informs her family members, they will help her when she is in trouble. But if she goes and gets service on her own, then some family members will understand and some may not. (postpartum woman, age 25)

We hardly discussed about our contraceptive need and use of family planning with the health care provider. We just asked about how to take care of baby. We have in-laws at home, they have more experience.“(postpartum woman, age 28)

Family planning decision-making represented a dialogue and often a negotiation for couples. These negotiations led to experiences of pressure relating to use or non-use of contraception, from other family members (usually in-laws).

“No, it is a couple’s decision meaning husband and wife will discuss first. If we agree with each other, we can take a chance, or if the husband does not think he wants to take a chance, we can discuss our plan with my mother/mother-in-law about family planning and when they would like to take a chance.” (postpartum woman, age 23)

Sometimes her husband tells her not to use the CuT (Copper T IUD), then at that time the woman can do nothing. It requires the consent of both partners. But if a woman insists on opposing her husband’s wishes, then there is a quarrel between them. (MIL, age 60)

Distance was often reported as a barrier preventing PPFP access and role of the husband in overcoming this barrier was critical. Male approval, support for transport and male company was commonly needed by women to reach health services.

If the distance from home to the hospital is too long, the woman cannot go to the place. At the same time, they may face financial difficulties. It may also be a question of safety, someone will have to accompany her from her home to the hospital. Will the doctors who are there do the proper checkup or treatment when they go to the hospital? They will have to face these difficulties/challenges. (Husband, age 31)

The desire for a male child continued to be a source of childbearing pressure for couples. This has, in previous research, been known to affect women more than men [36] and can influence the decision-making around spacing contraception, especially when the previous born child was female. Son preference also influenced women’s use of contraception and abortion early in marriage and even led to reports of covert use of contraception. The use of contraception often depended on the sex of the previous child, and if in case the previous birth was a girl, often led to lower use of subsequent contraception. In this scenario, if women did not desire another baby but were unable to voice this desire, they exercised their choice via covertly using contraception. They reported sharing varying degrees of information with their husbands, family members and health workers, depending on whom they considered an ally. These instances of information sharing and hiding were important facets of their exercise of agency and choice, even when the ultimate decision may not have gone their way.

There is no need of taking permission from anyone in the community. Because it’s up to you to decide whether or not to use family planning. The role of the family may be if it is a boy, but now we have said that when there are girls and if the couple wants to undergo sterilization, they will not get ready easily, so they should be told after the operation that the operation has been done. (postpartum woman, age 31)

Yes, they tell us that they want to insert CuT (Copper T IUD). We tell them to come on the fourth or fifth day of menstruation. She will tell some false reason to her family members that she is not feeling well and wants to get some medicines, so she wants to go out and then she visits the health centre and gets the CuT inserted. She also instructs us not to tell her family members regarding her method use. We tell her that we will not disclose. If you come and do not get an IUD then at least start using pills. (ASHA, age 43)

III. Informed choice for postpartum family planning: Health providers identified misinformation, lack of education, and beliefs in contraceptive myths for lack of informed choice

Health providers participating in our study acknowledged that informed choice was important to enable women’s agency and decision-making, as well as that of their family members. However, if there was a conflict between the provider and the family, the latter prevailed. It was not unexpected or unreasonable for women to consult their family members on PPFP, but it was concerning for health providers when family members superseded women’s choice or desire for PPFP counselling or services. Health providers were particularly concerned about the spread of contraception-related misinformation, especially those related to side effects within women’s social networks as they believed this deterred contraceptive use. In general, providers blamed this misinformation on culturally determined beliefs or on adverse experiences faced by women themselves or someone in their social circle. Providers believed that poor education often led to negative contraceptive beliefs thereby compromising women’s ability to exercise choice, navigate family pressures and participate in PPFP decision-making.

Yes because, if they want to use contraception, they need to be fully informed about it. If there is no information then it is going to affect another beneficiary. This is because when the CuT (Copper T IUD) is inserted without providing complete information about side effects she might get more bleeding during first few months of menstruation or she may get acidity when she starts taking pills. So, you need to know all these things as it affects other beneficiaries as well. If not, then she goes on spreading wrong information to other women. (ANM, age 28)

Yes, there are two or three examples of people who had a hard time after inserting a CuT (Copper T IUD) and removed it immediately within a month. Some people say that they don’t want to insert a CuT after listening to the experiences of others. (medical officer, female, age 32)

IV. Social norms related to postpartum family planning: While the norms for limiting family size and son preference were strong, contraception was considered a ‘sensitive’ subject and confidentiality was valued

All participants reported having inhibitions about discussing FP with their families including postpartum contraceptive. As a result, women’s ability to initiate conversation about their desire to plan children, use contraception, or negotiate family planning within their families was limited. Postpartum women were reluctant to discuss the subject even with clinicians and valued confidentiality in counseling.

Women in the villages are shy and they think that other people will come to know about the method they are using. They have these kinds of negative attitudes. Then I tell them that you have had your second and third injection and even if you do not come for collecting condoms, your husband can come and collect. It is available with health workers as well ASHAs and he can collect them from her also. This kind of discussion helps them to reduce their shyness. She sends her husband and he collects the condom. I have such beneficiaries in my center. (ANM, age 57)

There was a sense that this lack of openness to discussing contraception would affect PPFP programming and limit couples’ participation in counseling or services delivered in public venues or through public platforms (e.g., panchayat-ghar). Multiple participant groups indicated that women may feel embarrassed when seeking PPFP counseling or services in front of others.

Family planning is a very sensitive subject. It can be embarrassing to take the methods if you decide to go through camps or gatherings. If there are a large number of men in a camp, a woman may feel shy to ask for a family planning method. This can also prevent people from attending camps or gatherings. (Husband, age 34)

V. Postpartum Family Planning Quality of Care Issues: Counseling for PPFP was affected by resource shortages, often tended to be prescriptive, and failed to provide information on side effects of contraceptive methods leading to dissatisfaction with available PPFP health services

Women reported few avenues for PPFP counseling and often relied on alternative sources such as medical stores, community health events, and private providers for counseling and contraception access. In contrast, health providers blamed women’s poor health literacy for delays in PPFP counselling. This often led to low uptake of existing contraception services. Health workers reported that the two-child norm in the community was strong and both influences contraceptive choices and leading to inadvertent consequences such as women hesitating to avail antenatal care services for their third pregnancy.

Sometimes what happens is that the women do not tell us about their missed period. They come to us four months later after getting pregnant to register for the ANC checkup. They come in time for the first two babies, but if she is pregnant for the third time, she doesn’t tell the ANM or the ASHA worker. They say don’t tell them right away that she is pregnant. While there are injections/pills available, but they are late to avail these services. (ANM, age 43)

Participants reported that existing counseling availability and quality was limited due to staffing shortages, lack of trained health workers and supply chain issues. Where counselling existed, it was often prescriptive and even coercive instead of being person-centered or focusing on client preferences or goals. The method mix offered to postpartum women usually comprised IUDs and permanent female contraception.

Camps organized for permanent female contraception had limited information on the risks of procedure or side effects. Several women reported dissatisfaction with PPFP services as information on side effects and bodily changes related to contraceptive use and discontinuation (e.g., removal of IUD) was limited. However, health providers attributed women’s dissatisfaction on their poor knowledge rather than the service quality or counseling.

There was some problem faced by my aunt’s daughter. Her CuT (Copper T IUD) was perforated and she was very upset. Her CuT was inserted at the government hospital. She suffered a lot due to this perforation. (postpartum woman, age 31)

They do not know how to use it. After CuT insertion, it might expel which a woman does not understand. If it hurts a little after the CuT insertion, they do not understand it and ask service providers to remove it. They realize that there is bleeding and sometimes the menstruation does not come on time. (medical officer, male, age 36)