Time to uptake of long-term postpartum family planning and factors associated with it among Ethiopian mothers: A shared frailty survival analysis

Abstract Long-term postpartum family planning (LTPPFP) involves the use of long-acting contraceptive methods within one year after childbirth. Delayed initiation increases the risk of unintended and closely spaced pregnancies, leading to adverse maternal and neonatal outcomes. This study assessed the time to LTPPFP uptake and associated factors during the extended postpartum period among mothers in Ethiopia. A secondary analysis of data from the Performance Monitoring for Action (PMA) Ethiopia Cohort II, 2021 to 2023 was performed. A total of 2,167 postpartum mothers were included using a multistage stratified sampling technique. Data management and analysis were conducted using Stata 17 and R. Multicollinearity was checked using the variance inflation factor, while the proportional hazards assumption was assessed using the global Schoenfeld residual test. Three shared frailty survival models (cluster-level, region-level, and nested frailty models) were fitted and compared. Adjusted hazard ratios (AHRs) with 95% confidence intervals (CIs) were presented, and statistical significance was declared at p ≤ 0.05. During the one-year follow-up period, 396 women initiated LTPPFP. Among users, implants accounted for 94% of methods used, while female sterilization represented only 1%. The weighted prevalence of LTPPFP utilization was 14.8% (95% CI: 13.2–16.4). A total of 1,748.37 person-years were observed, yielding an incidence rate of 183.5 per 1,000 person-years. The cumulative survival probability for one year was 0.809. Earlier initiation of LTPPFP was significantly associated with having a plan to use family planning (AHR = 2.45; 95% CI: 1.58–3.81), previous family planning use (AHR = 1.90; 95% CI: 1.48–2.43), institutional delivery (AHR = 1.52; 95% CI: 1.03–2.26), postnatal care utilization (AHR = 1.63; 95% CI: 1.00–2.66), complications during delivery (AHR = 1.28; 95% CI: 1.02–1.60), and age at sexual debut > 18 years (AHR = 2.04; 95% CI: 1.20–3.46). LTPPFP initiation remains substantially delayed among postpartum mothers in Ethiopia. Key determinants of earlier uptake included prior family planning experience, service contact points (institutional delivery and postnatal care), and reproductive history characteristics. Strengthening integrated postpartum counseling during maternity care services is essential to facilitate timely LTPPFP adoption.