Postpartum contraceptive use after vaginal and caesarean birth in Nigeria: a nationwide population-based analysis

Abstract

Background

Despite prior research suggesting that the mode of delivery (MOD) may influence subsequent postpartum behaviour, limited evidence exists about how contraceptive use and method choice differ following caesarean section (CS) compared with vaginal delivery (VD). This study aimed to explore variation in self-reported postpartum contraceptive use by MOD and to examine whether MOD was associated with contraceptive method choice among a nationally representative sample of postpartum women in Nigeria.

Methods

We analysed nationally representative cross-sectional data from the 2021 Nigeria Multiple Indicator Cluster Survey. The study sample included all women aged 15–49 years who had a live birth in the 2 years preceding the survey (n=4277). We employed multivariable logistic regression to assess the association between MOD and any postpartum contraceptive use and multinomial logistic regression to evaluate the association between MOD and contraceptive method choice (categorised as highly effective, moderately effective or least effective).

Results

Overall, 1074 women (28.7%) reported using a contraceptive method within 2 years postpartum (vaginal, 27.7%; caesarean, 40.1%; p=0.0025). Compared with women who had VD, those who had CS had significantly higher odds of postpartum contraceptive use (adjusted OR (aOR) = 1.52; 95% CI 1.03 to 2.25). However, when disaggregated by contraceptive method choice, the associations were not statistically significant: least effective methods (aOR=1.37; 95% CI 0.71 to 2.66), moderately effective methods (aOR=1.49; 95% CI 0.89 to 2.52) and most effective methods (aOR=1.84; 95% CI 0.97 to 3.49), although all estimates were suggestive of higher odds among caesarean births.

Conclusion

Caesarean delivery was independently associated with higher overall postpartum contraceptive use and showed a positive—though not statistically significant—association with the use of least, moderately and most effective methods. These findings underscore the importance of person-centred counselling to ensure that all postpartum women, regardless of delivery mode, receive comprehensive information on the full range of contraceptive options, thereby promoting informed choice and equitable access.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

WHAT THIS STUDY ADDS

• Our study demonstrates that MOD may influence whether women use postpartum contraception, but not the effectiveness of the contraceptive methods they use.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Sexual and reproductive health providers should offer comprehensive, person-centred contraceptive counselling and ensure equitable access to effective postpartum contraceptive options, regardless of MOD, to support optimal contraceptive use and promote reproductive well-being.

Introduction

The use of contraception and specific contraceptive methods is well-documented strategies for preventing unintended pregnancies and reducing short interpregnancy intervals, both of which are associated with adverse maternal and perinatal outcomes.1,3 Short interpregnancy intervals have been linked to an increased risk of miscarriage, preterm birth, uterine rupture, low birth weight and perinatal mortality.^{4 5} Addressing these risks is particularly important in the postpartum period, as evidence suggests that unmet need for contraception is highest within the first 12–24 months after childbirth.⁶

Postpartum family planning (PPFP) refers to the prevention of unintended and closely spaced pregnancies within the first year following delivery.⁷ Given the health risks associated with short birth intervals, the WHO recommends waiting at least 24 months after a live birth before attempting another pregnancy to reduce maternal, perinatal and infant morbidity.⁸ Despite these recommendations, the use of postpartum contraception remains low in many settings. In Nigeria, only 27% of postpartum women use any form of contraception,⁹ and a recent study found that, approximately, 45% of women within the first 12 months postpartum have an unmet need for family planning.¹⁰ Furthermore, the data from the 2021 Nigeria Multiple Indicator Cluster Survey (MICS) indicate that 6.7% of women who had a live birth within the 2 years preceding the survey were already pregnant at the time of the survey.¹¹ While this may appear low relative to countries such as Ethiopia, where the prevalence of short interpregnancy intervals is estimated to be approximately 45.8%,¹² its significance must be evaluated within the Nigerian context. Nigeria has one of the highest maternal morbidity and mortality rates in sub-Saharan Africa (>1000 per 100 000 live births),¹³ yet contraceptive use remains persistently low. Thus, even a modest proportion of closely spaced pregnancies can have serious implications for maternal and child health in this setting. Consequently, the postpartum period represents a critical window of opportunity to improve contraceptive uptake, mitigate the risks associated with short interpregnancy intervals and improve the overall maternal and child health outcomes.¹⁴

While interest in PPFP is increasing, there remains limited evidence on how the mode of delivery (MOD) may influence women’s postpartum contraceptive choices and behaviours. Some studies suggest that caesarean section (CS) may negatively impact postpartum maternal behaviours.¹⁵ For example, a meta-analysis of data from 33 sub-Saharan African countries found that women who delivered by CS had a 46% lower prevalence of early initiation of breastfeeding and a 6% lower prevalence of exclusive breastfeeding compared with those who had a vaginal delivery (VD).¹⁶ In Nigeria, CS was associated with an even greater reduction, with a 51% lower prevalence of early initiation of breastfeeding and a 33% lower prevalence of exclusive breastfeeding compared with VD. These associations suggest that CS may undermine the effectiveness of lactational amenorrhea (LAM), a natural form of contraception.

Prior studies have also linked MOD with subsequent fertility patterns, including interpregnancy intervals and subfertility.^{17 18} For example, a systematic review of 750 407 women found that those who had a previous CS were 14% more likely to experience longer interpregnancy and interbirth intervals compared with those with VD.¹⁸ Another study showed that women who delivered by CS were less likely to have a second pregnancy compared with those with a VD (emergency CS: HR 0.85, 95% CI 0.84 to 0.86 and elective CS: HR 0.82, 95% CI 0.80 to 0.83).¹⁹ These findings raise questions about whether such outcomes reflect intentional contraceptive use rather than the consequences of the CS itself.^{18 20 21}

Several plausible mechanisms may explain how MOD influences postpartum contraceptive behaviour. Women who undergo CS often require longer recovery periods and face a higher risk of uterine rupture in subsequent pregnancies, making short interpregnancy intervals particularly risky.²² Additionally, CS often involves longer hospital stays and more frequent postpartum visits, offering increased opportunities for healthcare provider interaction and contraceptive counselling—both of which are associated with higher contraceptive uptake.^{23 24} Despite these potential links, the relationship between MOD and postpartum contraceptive behaviour remains underexplored.

With CS rates rising globally, particularly in low- and middle-income countries, a better understanding of how MOD influences postpartum contraceptive behaviour is essential.²⁵ Such understanding can inform evidence-based family planning interventions and strengthen strategies to promote equitable postpartum contraceptive access and use. These efforts are crucial for achieving sustainable development goal (SDG) 3 (good health and well-being), especially target 3.7, which calls for universal access to sexual and reproductive healthcare services. They also support SDG 5 (gender equality), particularly target 5.6, which focuses on ensuring reproductive rights for all.

Given these considerations, this study aimed to assess the relationship between MOD and postpartum contraceptive use among women in Nigeria. Specifically, we sought to answer the research question: does postpartum contraceptive use and method choice vary by MOD? We hypothesised that, compared with those who had VDs, (1) women who delivered by CS would be more likely to use postpartum contraception and (2) women who delivered by CS would be more likely to use effective contraceptive methods.

Methods

Study design, data source and study population

Data for this cross-sectional secondary analysis were drawn from a nationally representative Nigeria MICSs. The MICS, implemented by the National Bureau of Statistics (NBS), Nigeria and supported by UNICEF, is a cross-sectional survey, which employs a multistage stratified cluster sampling approach to collect data on socioeconomic, demographic and health variables from households, children (0–5 years), women aged 15–49 years and men aged 15–49 years.

The sampling technique first involves a selection of clusters (enumeration areas) using a probability proportional to size of the number of households based on the 2006 Population and Housing Census of the Federal Republic of Nigeria. Thereafter, 20 households were chosen randomly within each cluster. Where households had more than one eligible respondent, only one respondent was randomly selected for interview. Data were captured using computer-assisted personal interviewing technology through face-to-face interviews with respondents in their respective households. Additional details regarding the sampling methodology of the surveys used have been published elsewhere.¹¹

For this analysis, we used data from Round 6 of the MICS conducted in 2021. In the 2021 survey rounds, a total of 40 326 women were interviewed. We restricted our analysis to the women of reproductive age (15–49 years) who had a live birth in the 2 years preceding the survey and who were not pregnant at the time of the survey. Those with missing or invalid data on MOD, contraceptive use and method, those who had a hysterectomy or who were menopausal as well as the covariates of interest were excluded from the analyses (figure 1). A total of 4277 non-pregnant women who had a live birth in the past years were included in the present study.

Figure 1. Flowchart of the study population (unweighted n=4277). Final sample includes women with a live birth within 2 years before the survey, with valid data on MOD, contraceptive use and covariates. MICS, Multiple Indicator Cluster Survey; MOD, mode of delivery.

Patient and public involvement statement

This study was a secondary data analysis involving participants from a survey previously conducted by the NBS supported by UNICEF. As the data were deidentified, participant involvement in the development of the research question, outcome measures, study design, conduct of the study or dissemination of the results was not possible.

Measures

Outcomes

The primary outcome of interest was postpartum contraceptive use. As a part of the MICS, women were asked whether they were currently using any method to prevent pregnancy. Those who responded ‘no’ were categorised as non-users, while those who answered ‘yes’ were further asked to specify the method they were using. We first created a binary variable indicating the use of any contraceptive method (yes vs no). Next, we constructed a nominal, four-category variable representing contraceptive method choice based on the method effectiveness. These categories were most effective (sterilisation, IUD and implants), moderately effective (injectables, pills or diaphragms), least effective (condoms, other barrier or traditional methods, emergency contraception, standard days method and LAM) and no method. Women who reported using more than one contraceptive method were classified according to the method with the highest effectiveness, based on typical-use failure rates (<1%), as documented in the previous studies.^{26 27}

Exposure

The primary independent variable was self-reported MOD, categorised as either CS or VD. Among women with a live birth in the 2 years preceding the survey, MOD was assessed through the question: ‘was (name) delivered by CS? That is, did they cut your belly open to take the baby out?’ Responses were coded dichotomously: women who answered ‘yes’ were classified as having had a CS (coded as 1), and those who answered ‘no’ were classified as having had a VD (coded as 0).

Covariates

Potential confounders were identified a priori based on the existing literature and assumptions and were selected for inclusion in the analysis based on their availability in the dataset.1519,21 27 These variables were adjusted for in the analyses to account for their potential influence on postpartum contraceptive behaviour. Maternal age was categorised into three groups: 15–24 years, 25–34 years and 35–49 years. Relationship status was classified as either single or partnered, while religious affiliation was grouped into Christianity and non-Christian. Parity was categorised into low (1–2 births), average (3–4 births) and high (5 or more births). Health insurance coverage was classified as either having insurance or not. Pregnancy intendedness was defined as either unplanned or planned. Prenatal care utilisation was determined by whether the woman received prenatal care for the index pregnancy and was classified as either yes or no. Place of delivery was categorised as either a private or public health facility. Fertility intentions were grouped into three categories: women who wanted more children, those who wanted no more children and those who were undecided. Place of residence was classified as either urban or rural. Household wealth was measured using a wealth index and categorised into five quintiles ranging from the poorest (quintile 1) to the richest (quintile 5). The geographical region was categorised into North Central, North East, North West, South East and South South.

Statistical analysis

All analyses were performed using SAS V.9.4 (SAS Institute Inc.), with data visualisations generated using R V.4.3.1 (R Project for Statistical Computing). Survey weights, strata and cluster variables were applied to account for the complex sampling design. Approximately, 9.8% of observations had missing or invalid data on at least one variable. We performed a complete case analysis, excluding all such observations. Descriptive statistics included means and SD for continuous variables and frequencies with percentages (%) for categorical variables. The Rao–Scott χ² test was used to assess associations between MOD and categorical variables.

To evaluate the relationship between MOD and postpartum contraceptive behaviour, we ran weighted binomial and multinomial logistic regression models. We reported both crude and adjusted ORs (aORs) with 95% CIs. Contraceptive use (yes/no) was treated as a binary outcome, while contraceptive method choice (by effectiveness category) was analysed as a polytomous outcome, with non-use serving as the reference category. All statistical tests were two tailed, with significance set at p<0.05. Given the exploratory nature of this study, we did not apply corrections for multiple testings.

Results

The final study sample comprised 4277 women, weighted to represent 4342, with a mean (SD) age of 29.4 (6.7) years. Table 1 presents the MOD alongside key demographic, socioeconomic, reproductive and healthcare utilisation characteristics of women aged 15–49 years who had a live birth within 2 years preceding the survey. Among these women, 7.3% reported CS, while 92.7% reported VD (p<0.0001).

Table 1. Characteristics of study population, by MOD, Nigeria, MICS, 2021 (unweighted n=4277).

Variables			MOD				P value
	Full sample		VD		Caesarean delivery
	N	%	N	%	N	%
Sample size	4277	100	3964	92.36	313	7.64	<0.001
Maternal age, years
15–24	1094	23.27	1041	24.07	53	13.60	0.0147
25–34	2136	49.42	1979	49.19	157	52.21
35–49	1047	27.31	944	26.74	103	34.19
Relationship status
Single	283	5.67	266	5.59	17	6.68	0.6076
Partnered	3994	94.33	3698	94.41	296	93.32
Religious affiliation
Christianity	2414	59.18	2255	59.11	159	60.06	0.0592
Non-Christian	1863	40.82	1709	40.89	154	39.94
Parity
Low (1–2)	1719	42.88	1570	42.02	149	53.23	0.0263
Average (3–4)	1353	32.09	1276	32.62	77	25.60
High (5+)	1205	25.03	1118	25.36	87	21.07
Health insurance coverage
No	4115	95.99	3834	95.32	281	91.16	0.1077
Yes	162	5.00	130	4.68	32	8.84
Pregnancy intendedness
Unplanned	1006	24.86	942	24.91	64	24.23	0.8582
Planned	3271	75.14	3022	75.09	249	75.77
Received prenatal care
No	168	3.62	156	3.66	12	3.12	0.6911
Yes	4109	96.38	3808	96.34	301	96.88
Place of delivery
Private health facility	1115	33.75	1016	32.83	99	44.96	0.005
Public health facility	3162	66.25	2948	67.17	214	54.04
Fertility intentions
Wants more	2916	66.24	2718	66.64	198	61.43	0.0070
Wants no more	986	25.47	889	24.74	97	34.32
Undecided	375	8.29	357	8.62	18	4.25
Place of residence
Urban	1646	54.74	1493	53.91	153	64.88	0.0089
Rural	2631	45.26	2471	46.09	160	35.12
Household wealth quintile
1 (Poorest)	610	10.62	579	10.86	31	7.59	<0.0001
2	872	15.54	827	15.86	45	11.75
3	1000	19.29	935	19.80	65	13.25
4	945	23.49	881	23.94	64	18.14
5 (Richest)	850	31.05	742	29.54	108	49.26
Geographical region
North Central	1031	17.08	963	17.16	68	16.12	0.6396
North East	798	10.85	716	10.74	83	12.12
North West	484	13.40	444	13.31	40	14.54
South East	721	15.38	686	15.75	35	10.93
South South	536	14.44	502	14.52	34	13.54
South West	707	28.85	653	28.52	54	32.76

Note: Sample sizes (N) are unweighted. Percentages are weighted by adjusting for sample weight, stratification and clustering in order to account for the complex survey design of the MICS. Percentages might not total 100.0 because of rounding.

MICS, Multiple Indicator Cluster Survey; MOD, mode of delivery; VD, vaginal delivery.

Nearly, half of the women (49.9%) were between 25 and 34 years of age. The majority were married or cohabiting (94.3%) and identified as Christians (94.3%). About 42.9% of the women had low parity, and nearly two-third (66.2%) expressed a desire for more children. Most respondents (95.9%) did not have health insurance coverage.

Approximately, one-quarter (24.9%) reported that their most recent pregnancy was unplanned, while 96.4% received prenatal care during the index pregnancy. Two-third (66.3%) gave birth in public health facilities. More than a quarter (26.1%) belonged to the poorest wealth quintile. A slight majority resided in urban areas (54.7%) and more than half (58.7%) lived in the southern region. χ² analyses revealed that maternal age, parity, receipt of prenatal care, fertility intentions, place of residence and household wealth quintile were significantly associated with MOD (p<0.05) (table 1).

Overall, 28.7% of women reported using contraception within 2 years postpartum, regardless of delivery mode. As shown in table 2, 7.1% of postpartum women were using the most effective contraceptive methods, while 10.7% and 10.9% were using moderately effective and less effective methods, respectively. Regarding specific contraceptives, injectables were most commonly used (24.3%), followed by implants (21.2%), male condoms (17.5%) and pills (12.3%).

Table 2. Postpartum contraceptive use, overall and by specific contraceptive options, according to MOD, among women with a live birth within 2 years after a live birth, Nigeria, MICS, 2021.

	Overall		VD		Caesarean delivery		P value
	N	%	N	%	N	%
Total	4277	100	3964	92.36	313	7.74
Any contraceptive use	1074	28.68	964	27.74	110	40.08	0.0025
Contraceptive method choice, by group
Least effective	381	10.88	351	10.62	30	14.09	0.045
Moderately effective	433	10.65	385	10.32	48	14.57
Most effective	260	7.15	228	6.79	32	11.41
Contraceptive method choice, by type*
Male/female sterilisation	2	0.22	2	0.24	0	0
IUD	35	3.52	32	3.45	3	4.11
Implant	223	21.18	194	20.79	29	24.37
Injectable	287	24.29	272	25.50	15	14.14
Pill	138	12.29	107	11.24	31	20.98
Diaphragm	8	0.55	6	0.47	2	1.23
Foam/jelly	2	0.06	2	0.07	0	0
Male/female condom	142	19.07	130	19.76	12	13.38
Withdrawal	49	4.81	47	4.80	2	4.86
Abstinence	72	7.31	66	7.00	6	9.93
LAM	95	5.21	89	5.56	6	5.64
Others	21	1.49	17	1.51	4	1.38

Note: Data represent unweighted frequencies (N) and weighted percentages (%). All analyses were weighted by adjusting for sample weight, stratification and clustering in order to account for the complex survey design.

^*No p value due to null (0) values in some cells.

LAM, lactational amenorrhea; MICS, Multiple Indicator Cluster Survey; MOD, mode of delivery; VD, vaginal delivery.

Figure 2 shows the state-level variation in postpartum contraceptive use, ranging from 4.1% in Taraba to 52.4% in Ebonyi. The use of the most effective methods ranged from 0% in Jigawa to 17% in Osun. Moderately effective method use ranged from 0.9% in Sokoto to 37.2% in Taraba, while use of least effective methods ranged from 0.3% in Nasarawa to 45.3% in Akwa Ibom. Regional disparities were also evident: the South West had the highest prevalence of postpartum contraceptive use (31.8%), followed by the South East (18.4%) and South South (16.6%). The North East reported the lowest prevalence (6.6%).

Figure 2. Prevalence of highly effective contraceptive, moderately effective and least effective contraceptive method use, by state, within 2 years postpartum among women in the 2021 Nigeria MICS. Most effective contraceptives include male and female sterilisation, Intrauterine Devices (IUDs) and implants. Moderately effective contraceptives are injectables, pills or diaphragms, while least effective include condoms, other barriers or traditional methods, emergency contraception, standard days method and LAM. IUD, intrauterine devices; LAM, lactational amenorrhea; MICS, Multiple Indicator Cluster Survey.

In bivariate analyses (table 2), MOD was significantly associated with both overall contraceptive use (F=9.15, p=0.0025) and method choice (F=2.68, p=0.045). Women who had a CS were more likely to use contraception postpartum compared with those who had a VD (40.1% vs 27.7%). Specifically, women who had a CS were more likely to use least effective (14.1% vs 10.6%), moderately effective (14.6% vs 10.3%) and most effective methods (11.4% vs 6.8%) and less likely to use no method at all (59.9% vs 72.3%).

The full results of the multivariable regression analyses are presented in the online supplemental materials (online supplemental tables 1,2). In the adjusted models, women who had a CS had 52% higher odds of using postpartum contraception than those who had a VD during the same period (aOR=1.52; 95% CI 1.03 to 2.25) (figure 3). However, in the multinomial logistic regression analyses (figure 3), MOD was not significantly associated with increased odds of using a least effective method (aOR=1.37; 95% CI 0.71 to 2.66), a moderately effective method (aOR=1.49; 95% CI 0.89 to 2.52) or a most effective method (aOR=1.84; 95% CI 0.97 to 3.49) (figure 3).

Figure 3. aORs (and 95% CIs) from the binomial and multinomial logistic regression analysis examining associations between obstetric delivery mode and postpartum contraceptive use. Note: All models were adjusted for maternal age, partnership status, religion, parity, health insurance coverage, pregnancy intendedness, prenatal care, place of delivery, fertility preferences, residence, household wealth index and geographic region. *Results are based on binary logistic regression. aORs, adjusted ORs.

Discussion

In this cross-sectional study, we examined postpartum contraceptive use in relation to MOD using a nationally representative, population-based sample of Nigerian women. We hypothesised that CS would be associated with increased likelihood of contraceptive use after childbirth and a preference for more effective methods, given the clinical risks linked to short interpregnancy intervals following CS. Indeed, our findings showed that women who had a CS were more likely to use contraception postpartum compared with those who had a VD. After adjusting for relevant covariates, the odds of postpartum contraceptive use remained significantly higher among women who had a CS. However, when we disaggregated postpartum contraceptive use by method effectiveness, we did not find significant differences in the use of highly, moderately or least effective methods between women who had a CS and those who delivered vaginally. These findings contribute to the growing body of evidence examining how MOD may shape subsequent contraceptive and reproductive behaviours.

Our results are consistent with prior studies reporting a positive association between CS and postpartum contraceptive use. For instance, a hospital-based study in Nigeria reported higher contraceptive uptake among women who had a CS.²⁸ However, our findings differ from a large U.S.-based study by Sheyn and Arora, which found a strong association between CS and the use of long-acting and permanent methods (LAPMs).²⁹ Our study did not observe a significant relationship between CS and the use of highly effective contraceptive methods. One possible explanation for this discrepancy is the low prevalence of LAPM (ie, highly effective contraceptive methods) use in our sample (7.2%), which may have limited the statistical power to detect a significant difference. Conversely, Starr et al found higher contraceptive use following VD than CS (68.8% vs 27.1%),³⁰ but their study focused on women 2–4 months postpartum, whereas our analysis included women up to 24 months postpartum, potentially accounting for the divergent findings. Given the limited evidence in this area in sub-Saharan Africa, additional empirical research is needed to validate these findings and further explore the comparative impact of different MOD on postpartum contraceptive behaviours.

Overall, our results emphasise the importance of person-centred family planning counselling for all women, regardless of delivery mode, to ensure informed decision-making and equitable access to preferred contraceptive methods. While caesarean delivery may offer opportunities for postpartum contraceptive counselling, given the potential risks associated with short interpregnancy intervals, women who deliver vaginally are equally at risk of unintended pregnancies and short interpregnancy interval—both of which are associated with adverse maternal and child health outcomes. The absence of significant differences in method-specific contraceptive use by delivery mode also suggests that other factors beyond MOD may play a more critical role in postpartum contraceptive decision-making. Furthermore, the observed differences between CS and VD groups highlight underlying disparities in characteristics that may influence postpartum contraceptive use.

Beyond our primary focus on delivery mode, we identified two important contextual insights. First, fewer than one-third (28.7%) of postpartum women reported using any contraceptive method, underscoring the persistently low uptake of postpartum contraception in Nigeria. Second, we observed substantial state-level variation in postpartum contraceptive method use. These differences may reflect contextual influences, such as provider practices, health system capacity, sociocultural norms and access to quality care. Therefore, state-specific strategies may be warranted to ensure equitable access to high-quality PPFP services.³¹ Additionally, we also found that fewer women used more effective contraceptive methods, with most relying on less effective options. Therefore, there is a need for a better understanding of the complex interplay of patient-, provider- and facility-level factors that drive postpartum contraceptive method choices. Identifying these factors could inform targeted interventions to enhance the use of effective contraceptive methods and improve maternal and reproductive health outcomes in Nigeria.

The strengths of this study include the large, nationally representative sample and the clear temporal relationship between the exposure (MOD) and the outcome (contraceptive use). However, several limitations must be acknowledged. We were unable to further disaggregate MOD by specific indications. For example, we could not classify VD as spontaneous, induced or assisted, or between emergency and elective CS. Additionally, we lacked data on several demographic and obstetric variables (eg, maternal education, employment status, gestational age at delivery, pregnancy complications and infant birth weight), which could have confounded our findings. Finally, while we focused on method effectiveness, other relevant aspects of postpartum contraceptive behaviour—such as mode of administration, user control versus provider dependence and timing of fertility return—were not assessed. These remain important areas for future inquiry.

Improving access to postpartum contraception and expanding method choice remain important public health priorities. This is especially critical for countries like Nigeria, where maternal morbidity and mortality remain high. The findings of this study have important implications for research, policy and practice. Reproductive health providers, including general practitioners, midwives and obstetricians, should deliver high-quality contraceptive counselling and services during both the prenatal and postpartum periods, particularly for women who deliver vaginally. As our findings suggest, postpartum contraceptive behaviours may be influenced more by individual, provider and contextual factors than by delivery mode alone. Future studies should explore women’s contraceptive intentions and preferences during pregnancy and examine how postpartum contraceptive behaviours evolve across time and delivery modes. Additionally, qualitative research guided by behavioural theories could shed light on the underlying determinants of postpartum contraceptive choices and inform the development of tailored interventions.

Conclusion

Postpartum contraception remains a cost-effective strategy to reduce short interpregnancy intervals and unintended pregnancies. Using data from a nationally representative sample of postpartum women in Nigeria, we examined whether contraceptive use varied by MOD. Our findings indicate that women who had a CS were more likely to report using contraception postpartum, even after adjusting for relevant confounders. However, no significant differences were observed in the effectiveness level of the contraceptive method choice used by delivery mode. These results underscore the need for person-centred contraceptive counselling that prioritises informed choice, equity and access to the full range of PPFP options, regardless of MOD and across geographic settings.

Data availability statement

Data are available on reasonable request.