Prevalence of postpartum family planning uptake and its association with couples' joint decision-making: A community-based cross-sectional study in rural Sindh, Pakistan

Introduction: Postpartum family planning (PPFP) prevents unintended and closely spaced pregnancies, reducing maternal nutritional and physiological strain and improving maternal and child health. In settings like Pakistan, where husbands often influence reproductive choices, couples' joint decision-making, which reflects shared negotiation and mutual agreement rather than general partner support or permission, may shape contraceptive uptake through its emphasis on shared agency. This study aimed to estimate the prevalence of PPFP use and examine its association with couples' joint decision-making.Methods: A cross-sectional study was conducted from April to July 2024 in the Global Network's Maternal and Newborn Health Registry catchment area in Thatta District, Sindh, Pakistan. PPFP use was defined as the current use of any modern contraceptive method among women who were 12 months postpartum (binary outcome), representing contraceptive uptake during the first year after childbirth. Joint decision-making was assessed as a binary variable indicating whether decisions specifically related to contraceptive use or non-use were made jointly with the husband or independently by either spouse/someone else. Data were collected using Epicollect5 after informed consent and analysed using multiple logistic regression to estimate adjusted ORs.Results: Among 524 participants, the mean age was 29.8±4.9 years. The prevalence of PPFP uptake was 39.7% with injectables being the most used method 33.1%. Couples' joint decision-making increased PPFP uptake (adjusted OR 1.7; 95% CI 1.1 to 2.7) while decisions made solely by husbands were more common among non-users. In addition, the number of living children, wife's formal education, husband's education and women's autonomy in at least one household decision were significantly associated with increased PPFP uptake.Conclusion: Joint decision-making between spouses on contraceptive use was associated with increased postpartum contraceptive use, highlighting the importance of male involvement and shared responsibility in reproductive health decisions. Interventions that encourage open partner communication may strengthen contraceptive uptake and contribute to improved maternal and child health outcomes.