Title: Bridging the Gap Between Awareness and Practice: A Cross-Sectional Study on

Postpartum Contraception in Jhansi, Uttar Pradesh

Authors:
Affiliations: Department of Obstetrics and Gynaecology, Maharani Laxmi Bai (MLB) Medical
College, Jhansi, Uttar Pradesh, India
Corresponding Author:

ABSTRACT

Background: The initiation of family planning during the immediate postpartum period is a
crucial strategy for lowering maternal morbidity and achieving safe birth spacing. Nevertheless,
deeply rooted sociocultural norms frequently hinder its clinical adoption. This research assesses
the knowledge, attitudes, and practices (KAP) related to postpartum contraceptive methods
among women residing in the agrarian Bundelkhand region of Uttar Pradesh. Methods: An
institutional, descriptive cross-sectional analysis was carried out in the postnatal wards of
Maharani Laxmi Bai (MLB) Medical College, Jhansi, from November 2025 to April 2026.
Following strict clinical eligibility protocols, a targeted cohort of 300 postpartum women was
enrolled. Data was acquired through semi-structured, face-to-face interviews that evaluated
sociodemographic backgrounds, baseline contraceptive awareness, and the behavioral decision
to accept or decline family planning prior to discharge. Results: Although 74.3% of the 300
participants exhibited baseline awareness of at least one contraceptive method, the actual
clinical acceptance rate remained remarkably low at 31.3%. For those who accepted a method,
the intrauterine device (IUD) was predominantly chosen (54.3%), while hormonal options (oral
pills and injectables) experienced total rejection. The leading obstacles to adoption were a
definitive desire for subsequent pregnancies (50.0%)—largely driven by a regional preference
for male offspring—and direct refusal by a spouse or senior family member (29.1%).
Conclusions: A severe disconnect exists between cognitive contraceptive awareness and
practical clinical utilization within this population. The diminished uptake is primarily dictated by
rigid patriarchal family structures and agrarian cultural expectations, rather than an absence of
health education. To meaningfully elevate postpartum contraceptive acceptance and align with
Uttar Pradesh's maternal health objectives, medical institutions must shift from isolated patient
education to inclusive, couple-oriented counselling that begins during early antenatal care.
Keywords: Postpartum contraception, Family planning, KAP study, Bundelkhand, Maternal
health, Sociocultural barriers, Uttar Pradesh.

INTRODUCTION
The World Health Organization (WHO) characterizes family planning as a voluntary, informed
decision-making process that allows individuals to anticipate and attain their desired number of
children, as well as the timing of their births [1]. The postpartum period, specifically the first 12
months following childbirth, represents a highly vulnerable timeframe for women regarding
subsequent unintended conceptions. Postpartum Family Planning (PPFP) is strategically
designed to address this clinical vulnerability. Initiating contraception during this period is critical
for achieving an optimal birth-to-pregnancy interval of at least 24 months, which significantly
reduces the risk of maternal and infant mortality [2, 3]. Epidemiological evidence suggests the
risk of maternal death can be up to two times higher among women who do not utilize
postpartum contraceptives [4].
Currently, India is navigating a complex demographic transition. While the National Family
Health Survey-5 (NFHS-5) reports a stabilization of the national Total Fertility Rate (TFR) at 2.0,
stark regional disparities persist [5]. The integration of PPFP remains markedly inadequate in
socioeconomically marginalized territories, particularly in Uttar Pradesh (UP). UP continues to
bear a high Maternal Mortality Ratio (MMR), and the state's healthcare infrastructure is heavily
strained by a high volume of unplanned pregnancies [6]. In rural UP specifically, unintended
pregnancies are directly linked to severe maternal health complications, driven largely by a lack
of economic support and immense societal pressures regarding the sex composition of living
children [7, 8].
Despite well-documented clinical guidelines by the Ministry of Health and Family Welfare
promoting Postpartum Intrauterine Contraceptive Devices (PPIUCDs) [9], PPFP integration in
UP remains challenging. The Bundelkhand region, with Jhansi at its center, represents a critical
intervention zone for UP’s state healthcare framework. It is a largely agrarian society defined by
rigid patriarchal customs and reduced female educational attainment. These socioeconomic
factors routinely eclipse professional medical advice, creating a massive void between basic
contraceptive awareness and actual clinical adoption [10, 11].
While state-level initiatives endeavor to expand PPFP, dismantling these regional hurdles
demands highly localized clinical data. Studies in North India indicate that while some primary
health centers achieve an acceptance rate of around 38.9% for PPIUCD, it is heavily dependent
on parity and familial dynamics [12, 13]. To design culturally competent counselling, it is
imperative to deeply understand the target demographic's knowledge, attitudes, and practices
(KAP) [14]. This cross-sectional study was conducted at Maharani Laxmi Bai (MLB) Medical
College, Jhansi, to systematically investigate KAP surrounding immediate postpartum
contraception, pinpoint the primary sociocultural deterrents in this cohort of 300 participants,
and generate actionable insights to refine maternal health policies across Uttar Pradesh.

MATERIALS AND METHODS

Study Design and Setting A facility-based, descriptive cross-sectional investigation was
implemented within the Department of Obstetrics and Gynaecology at Maharani Laxmi Bai
(MLB) Medical College, Jhansi. Functioning as a primary tertiary referral center, this institution
provides healthcare to a highly diverse demographic across the Bundelkhand region.
Study Duration Data collection and patient interviews were conducted over a continuous six-
month timeframe, spanning from November 2025 to April 2026.
Study Population and Eligibility Criteria The investigative cohort comprised mothers admitted
to the postnatal care units following spontaneous vaginal deliveries or lower segment cesarean
sections. Enrollment was restricted to hemodynamically stable postpartum women who had
received standardized family planning counselling and provided voluntary written consent.
Women suffering from severe obstetric complications requiring intensive care, those with a
documented prior history of infertility, and those experiencing a stillbirth were omitted from the
analysis.
Sample Size Determination and Cohort Selection The target sample size was
mathematically derived utilizing Cochran’s standard epidemiological formula for cross-sectional
studies. Based on institutional delivery records at Maharani Laxmi Bai (MLB) Medical College,
which average 180 deliveries per month, the total eligible population (N) over the six-month
study window was projected at approximately 1,080 admissions.
To ensure maximum statistical power, the anticipated regional prevalence of contraceptive
awareness (p) was conservatively estimated at 50% (0.5). Utilizing a 95% confidence level (Z =
1.96) and a 5% margin of error (d = 0.05), the initial unadjusted sample requirement (n_0) was
calculated as follows:
n_0 = \frac{Z^2 p(1-p)}{d^2}

n_0 = \frac{1.96^2 \times 0.5 \times (1-0.5)}{0.05^2} = 384

Because the total population of 1,080 is relatively small and known, the finite population
correction factor was applied to determine the minimum requisite sample size (n):
n = \frac{n_0}{1 + \frac{n_0 - 1}{N}}

n = \frac{384}{1 + \frac{384 - 1}{1080}} \approx 283.4

The minimum required sample size was determined to be 284. To proactively accommodate for
potential drop-outs, incomplete survey responses, or early hospital discharges, the final sample
target was expanded. Ultimately, a cohort of exactly 300 participants who successfully met all
clinical eligibility parameters was enrolled in the study.
Data Collection Framework Primary data was harvested using a pre-tested, semi-structured
questionnaire, translated into Hindi to ensure total semantic clarity among the rural
Bundelkhand demographic. The survey evaluated Socio-demographic profiles, Cognitive
Assessment regarding baseline contraceptive awareness, and Behavioral Practices regarding
PPFP acceptance or rejection prior to discharge.
Ethical Compliance The complete study protocol received formal ethical clearance from the
Institutional Ethics Committee (IEC) at MLB Medical College. Written informed consent (or a
witnessed thumbprint for illiterate participants) was strictly required.
Statistical Evaluation Data from the 300 subjects were digitized using Microsoft Excel, and
final statistical evaluations were executed utilizing SPSS software. Categorical variables were
summarized utilizing standard descriptive statistics, presenting the data as frequencies and
exact percentages.

RESULTS
A total of 300 participants strictly meeting the inclusion criteria were successfully enrolled,
yielding a 100% response rate among eligible subjects.
Table 1: Sociodemographic profile of the participants.
Variables N (Total = 300) Percentage (%)
Age (in years)
18-25 129 43.0
25-30 129 43.0
>30 42 14.0
Religion
Hindu 257 85.7
Muslim 43 14.3
Maternal education
Illiterate 120 40.0
10th pass or under 103 34.3
12th pass 60 20.0
Degree holder 17 5.7
Occupation
Housewife 214 71.3
Labour / Agriculture 69 23.0
Service 17 5.7
Income (INR/month)
<10000 171 57.0
10000-25000 103 34.3
>25000 26 8.7
Parity
1 86 28.7
Variables N (Total = 300) Percentage (%)
2-3 154 51.3
4 or more 60 20.0
Age at marriage (in years)
≤18 86 28.7
19-25 189 63.0
>25 25 8.3
As indicated in Table 1, the participant demographics accurately reflect the socioeconomic
realities of the Bundelkhand region. A substantial 40.0% of the 300 women possessed no formal
education, and 57.0% reported a monthly household income of less than INR 10,000. Parity
was notably high, with 71.3% of the women reporting two or more children. Early marriage is
also highly prevalent, as 28.7% of the cohort was married at 18 years of age or younger.
Table 2: Details of last pregnancy planning.
Last pregnancy N (Total = 300) Percentage (%)
Planned 60 20.0
Unplanned 240 80.0
Table 2 highlights the intention behind the most recent conception. Aligning with the cohort's
overall lower educational attainment and restricted reproductive autonomy, 80.0% of the women
identified their current postpartum pregnancy as strictly unplanned.
Table 3: Baseline knowledge of contraceptives.
Variables N (Total = 300) Percentage (%)
Possesses knowledge of any
contraception
Yes 223 74.3
No 77 25.7
Prior to their postnatal admission, 74.3% of the participants demonstrated a baseline cognitive
awareness of at least one contraceptive modality (Table 3), illustrating a discernible gap in
primary reproductive education when compared to more urbanized populations.
Table 4: Acceptance and preferred method of postpartum contraception.
Variables N Percentage (%)
Accepted contraceptives in
current postpartum period
Yes 94 31.3
No 206 68.7
Preferred methods of
accepted contraception
IUD 51 54.3
Barrier 26 27.7
Sterilization 17 18.0
OCPs 0 0.0
DMPA 0 0.0
Table 4 reveals a severe disconnect between theoretical knowledge and practical application.
Only 31.3% (n=94) of the 300 women agreed to initiate a contraceptive method during the
immediate postpartum window. Of the 94 acceptors, the intrauterine device (IUD) was the most
favored modality (54.3%), followed by barrier methods (27.7%). Hormonal options experienced
total rejection.
Table 5: Reasons for accepting a contraceptive in the postpartum period.
Reasons for accepting N (Total = 94) Percentage (%)
Child spacing (temporary delay)68 72.3
Definitive desire for no more 26 27.7
children
For the minority who successfully adopted a family planning method (n=94), the overwhelming
motivating factor was the necessity for adequate child spacing, cited by 72.3% of the acceptors
(Table 5).
Table 6: Reasons for not accepting contraceptives in the current postpartum period.
Reasons for not accepting N (Total = 206) Percentage (%)
Desire for more children 103 50.0
Spouse/Family refusal 60 29.1
Fear of future infertility 34 16.5
Religious beliefs 9 4.4
Table 6 details the primary barriers reported by the 206 women (68.7% of the cohort) who
rejected postpartum contraception. A direct desire to conceive additional children was the most
frequently cited reason (50.0%), a factor heavily intertwined with the region's cultural son
preference. Furthermore, explicit refusal by a husband or mother-in-law accounted for 29.1% of
non-acceptance, sharply underscoring the deep patriarchal limitations placed on female
reproductive choices.

DISCUSSION
This facility-based, cross-sectional evaluation investigated the knowledge, attitudes, and
practices (KAP) concerning immediate postpartum contraception among a targeted cohort of
300 women admitted to the obstetrics and gynaecology wards at MLB Medical College, Jhansi.
Within this study group, basic awareness of at least one contraceptive method was documented
in 74.3% of the participants. While substantial, literature consistently proves that robust
awareness does not automatically translate to clinical utilization; usage rates frequently remain
devastatingly low compared to baseline knowledge due to deeply ingrained regional
misconceptions [15, 16]. Furthermore, research clearly associates lower formal education levels
with an increased incidence of unplanned pregnancies and poorer attitudes towards modern
contraception [17, 18]. In the current cohort, 40.0% of the surveyed women possessed zero
formal education, a statistic that aligns perfectly with the 80.0% rate of unplanned pregnancies
observed.
Methodological Preferences and Pharmacological Aversions Despite a 74.3% basic
awareness rate, actual postpartum contraceptive adoption was profoundly poor, with a mere
31.3% (94 out of 300) of the women electing to initiate a family planning method prior to hospital
discharge. Among those who did accept, the Intrauterine Device (IUD) emerged as the
dominant preference (54.3%). This specific preference aligns with broader trends in North India,
where PPIUCDs are heavily promoted for their immediate institutional availability, though actual
acceptance rates can fluctuate significantly based on demographic factors [12]. Additionally,
targeted and focused antenatal counselling has been proven to double the acceptance rate of
PPIUCDs compared to routine, generalized postpartum counselling [19].
In stark contrast, oral contraceptive pills (OCPs) and injectable hormones (such as DMPA)
experienced a 0.0% acceptance rate in this study. This absolute rejection is routinely fueled by
pervasive regional misinformation; for instance, studies from India frequently cite the fear of
weight gain, long-term sterility, and irregular bleeding as major deterrents for hormonal adoption
[13, 20].
Sociocultural Impediments: Agrarian Economics and Son Preference The barriers
preventing contraceptive acceptance in this study serve as a direct reflection of Bundelkhand’s
sociocultural fabric. Half of the non-accepting women (50.0%) refused contraception due to an
explicit desire for additional children. Within the context of Bundelkhand's predominantly
agrarian economy, this is not merely a preference for large families; it is heavily governed by an
entrenched cultural "son preference." Evidence explicitly shows that the sex composition of
living children profoundly impacts pregnancy intendedness; women face immense societal
pressure to continue childbearing—and systematically avoid contraception—until a sufficient
number of male heirs are produced [21, 22].
Patriarchal Dynamics and Actionable Clinical Interventions Additionally, explicit spousal
and familial refusal accounted for 29.1% of non-acceptance, while unfounded paranoias
regarding permanent, medically-induced infertility deterred a further 16.5%. These figures
sharply illuminate the deeply patriarchal family structures dominating the region, where male
control over contraceptive decision-making drastically impedes a woman's reproductive
autonomy [23, 24].
To effectively bridge this gap between theoretical awareness and clinical practice, medical
institutions in Uttar Pradesh must radically redesign their family planning protocols. Interventions
must move beyond simple accommodation and actively become gender-transformative [10, 25].
A vital public health improvement requires the mandatory integration of inclusive, "couple-
counseling" sessions beginning in early antenatal care to actively incorporate husbands and
senior family decision-makers into reproductive health dialogues months prior to delivery.

CONCLUSION
This investigation exposes a profound discrepancy between foundational contraceptive
awareness and the actual clinical utilization of family planning methods among postpartum
women in the Bundelkhand region. While basic theoretical knowledge is present, the translation
of this awareness into active clinical practice within this cohort of 300 participants remains
severely deficient.
The critically low acceptance rate, defined by a heavy reliance on intrauterine devices and a
total rejection of hormonal modalities, is governed by deeply entrenched sociocultural realities.
To substantively elevate postpartum contraceptive uptake and align with Uttar Pradesh's state
maternal health targets, healthcare facilities must progress beyond standard, patient-isolated
postnatal education. Establishing culturally competent, family-inclusive interventions that involve
spouses during the antenatal phase is essential to overcoming the patriarchal and
pharmacological barriers unique to this demographic.

ACKNOWLEDGEMENTS
The authors express their deepest gratitude to the resident physicians, medical officers, and
nursing personnel of the Department of Obstetrics and Gynaecology at Maharani Laxmi Bai
(MLB) Medical College, Jhansi.
Funding: No funding sources. Conflict of interest: None declared. Ethical approval: The
study protocol was formally reviewed and granted approval by the Institutional Ethics Committee
(IEC) of Maharani Laxmi Bai (MLB) Medical College, Jhansi.

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