Skip to main content
NCBI home page
BMC Public Health logoLink to BMC Public Health
. 2025 Nov 28;26:37. doi: 10.1186/s12889-025-25311-6

Postpartum emotional fertility intentions in Ethiopia: an insight and correlates from a national women and newborns cohort study

Solomon Abrha Damtew 1,5,✉, Solomon Shiferaw 2, Tariku Dejene Demissie 3, Adamu Addissie 2, Tesfamichael Awoke Sisay 5, Ayanaw Amogne 5, Fitsum Tariku Fantaye 4, Hailay Gebremichael Gebrekidan 6, Tariku Tesfaye Bekuma 7, Bezawork Ayele Kassa 8, Kelemua Mengesha Sene 9, Niguse Tadele Atnafu 10, Mahari Yihdego Gidey 5, Addisalem Zebene Armide 5, Zelalem Nigussie Azene 11,12, Metages Yohannes 13, Assefa Seme 2
PMCID: PMC12764142  PMID: 41316181

Abstract

Background

Women´s emotional fertility intentions to conceive are an integral part of Reproductive Health (RH) right which can also be considered as decision-making over their fertility. In this study, postpartum emotional fertility intention was measured by asking a cohort of women how they would feel if they became pregnant by their one year postpartum following the index birth. Emotional health and couples communication are key during pregnancy, childbirth and in the postpartum period coupled with the simultaneous reproductive coercion (RC) minimization. The postpartum period is a key for the newborns milestones development and in maintaining maternal emotional, psychosocial, and mental health. Therefore, this study aimed at determining the level of one-year postpartum emotional fertility intention and identifying its correlates among a cohort of one-year postpartum women. The Ethiopian Federal Ministry of Health and relevant developmental partners can use this evidence as an action point to empower women to exercise their reproductive health rights and rights related to reproduction.

Methods

Nationally representative Ethiopia Performance Monitoring for Action (EPMA) women and newborns cohort survey data collected from eligible women in four rounds were further analyzed in this study. This study collected real-time data on various sexual, reproductive, maternal and newborns nationwide priority indicators using customized Open Data Kit Mobile application. These data were collected using a standard pretested questionnaire prepared in English and translated in three local languages (Amharic, Afan Oromo and Tigrigna) by well-experienced resident enumerators. This study was limited to the further analysis of 1,703 non-pregnant women by their one-year postpartum. Frequencies were computed to describe the study participant’s characteristics. The partial proportional odds statistical modeling was fitted to identify correlates for the hierarchical variation in one-year postpartum emotional fertility intention. Results were presented in the form of percentages and odds ratios alongside with 95% Confidence Interval. Statistical significance was declared at a p-value of 0.05.

Results

The proportion of one-year postpartum emotional fertility intention of being unhappier was found to be nearly two thirds, 64.87% (62.20%, 67.45%). Nearly one in 6, (17.12% (15.15%, 19.29%)) and one in 20, (4.63% (3.60%, 5.94%)) women reported that they have experienced a mixed and very happy feelings in the same period. The proportional cumulative odds of one-year postpartum emotional fertility intention were 0.66 (0.44, 0.97) and 0.43 (0.29, 0.63) respectively among women who reported that they had ever used contraceptive and those who reported that they have resumed their contraceptive use by one-year postpartum compared with their counterparts. The proportional cumulative odds of one-year postpartum emotional fertility intention were found to be lower and asymmetrical among women with higher birth order and those who do not want to have additional children.

Conclusion

One-year postpartum emotional fertility intention of being unhappier is more pronounced in Ethiopia which calls for enhancing intended and spaced pregnancies by ensuring women reproductive health decision making autonomy. Activities and efforts that promote spaced pregnancies, and diversifying access to postpartum contraceptives are likely to improve the level of one-year postpartum emotional fertility intention. Activities and interventions that enable women to decide over their contraceptive use alongside patient-centered contraceptive use counseling could also contributed to the improvement of one-year postpartum emotional fertility intention as well. The study findings implied that awareness creation on and availing the specific inter–pregnancy contraceptive services and mental health preconception care packages could also contribute in addressing the varying level of one-year postpartum emotional fertility intention. The other implication of the findings calls for strengthening postpartum contraceptive counseling and intensifying actual service provision. Besides, enabling high parity women to use contraceptive through access and diversification of the methods could help in this regard. Moreover, installing the inter-pregnancy preconception care packages in the health care system, enhancing informed contraceptive use decision making and improving one-year postpartum contraceptive uptake are imperative. Provision of one-year post-partum contraceptive could reduce maternal and newborns morbidity and mortality through spacing, improving women´s emotional and mental health in the postpartum period. These activities and interventions are very critical to improve postpartum emotional fertility intention.

Keywords: Women health, Emotional health, Women’s postpartum psychosocial health, Women postpartum mental health, Postpartum emotional fertility intention, Ethiopian PMA, Women and newborns cohort, One year postpartum period, Perinatal period

Background

Emotional fertility intention [1–3] and couples communication [4] are key during pregnancy, child birth and in the postpartum period. Besides, the simultaneous minimization of reproductive coercion (RC) coupled with reduction of perinatal intimate partner violence [5, 6] is very critical. Intimate partner violence reduction and provision of postpartum contraception are proofed to improve women emotional well-being in the postpartum period and are imperative for better maternal and newborns health outcomes [6–9]. Women emotional health should be maintained in the postpartum period for a healthy inter-pregnancy period and to make the subsquent pregnancies successful [10, 11]. Besides, the postpartum period is a key milestone in the newborns developmental process; and maintaining this milestone is crucial for maintaining maternal emotional health at its optimum level. It can also serve as an entry point to provide the inter-pregnancy maternal and newborns care continuum [12] and preconception care packages during the inerter-pregnancy period [13]. Therefore, this study aimed at measuring one-year postpartum emotional fertility intention during this critical period. In this study, one-year postpartum emotional fertility intention was measured by asking a cohort of women how they would feel if they became pregnant by their one-year postpartum following the index birth [1, 2, 14].

Moreover, the World Health Organization defined health as a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity. Accordingly, since pregnancy and childbirth are communal events in the Ethiopian context, this study aimed at addressing the mental, emotional and psychosocial aspects of women health [15]. Emotional fertility intention may be related with religious blessing and the cultural acceptability of large families [16]. Besides, evidence has shown that there is a link between happiness and fertility behavior. Spéder & Kapitány stated that happier men and women prefer to become parents sooner arguing the link between intention and behavior towards fertility [17, 18]. Moreover, couples´ happiness and emotion determines having a child, particularly, women's happiness matters more in the decision-making process towards having a subsequent child [19]. Another evidence showed that fertility intention and behavior have a closer link [20], indicating emotional fertility intententions and behavior influences the demographic dividend of countries. However, the emotional aspect of fertility intention among women has been understudied.

Additionally, in a patriarchal society such as Ethiopia, husband fertility desire is one of the core determinants of couple´s fertility desire [11, 21]. Males´ dominance in the decision making as far as sexual and reproductive health is concerned was reported to negatively affecting women intentions to conceive and their reproductive health rights [22–25]. Further evidence has also showed the existence of discordance in fertility desire among couples [26]. Besides, women´s emotional fertility intentions to conceive are an integral part of reproductive health (RH) rights which can be considered as a decision-making ability over their fertility. However, in low and middle-income countries including Ethiopia, males´ dominance is culturally accepted and socially constructed. Hence, males´ take the lead in the household-level decision making, determining the family size; and lead women RH health service use decision making. In such a scenario women may not have their voices heard and respected.

As a result, women are likely to hold negative emotion and unpleasant feeling whenever they think of becoming pregnant [1, 24]. In addition, the disproportionate huge burden of raising children which is experienced by most women precipitated their negative emotional intention for every additional pregnancy they are going to bear. Amidst in the rapid population growth, such unpleasant feeling is likely to exacerbate the fertility rate and population dynamics a [18, 22, 27].

Therefore, the Federal Democratic Republic of Ethiopia Health Minister and the government of Ethiopia have been showing commitments to make the population growth in line with the country´s economic growth and development. Provision of contraceptive commodities free of charge, improving the quality of contraceptive counseling; policy-level advocacy and the routine health care providers counseling on spaced pregnancies are among the top strategies being employed [10, 28–31]. Unfortunately, achievement of the desired level of change in the fertility rate has become challenging over the last few decades [10, 31–33]. Lack of women emotional fertility intentions in the postpartum period is likely to contribute its share for the sustained higher fertility rate, subsequent health and economic effects and for the demographic dividend as well [34, 35].

Furthermore, evidence revealed that a multifaceted societal and individual-level factors were found to influence fertility desire. At the societal level, the desire for fertility is often influenced by the community and cultural factors [36, 37]. These includes a strong cultural preferences for large families [36, 38] and sex preference for boys. These cultural and social elements, and sex preference also precipitated the emotional aspect of fertility intention [39–42]. This is coupled with the current situation of social unrest, political turmoil, internally displaced people, and the economic crisis across the globe. These are the macro level factors which are further precipitating women emotional well-being [43–46]. Besides, at the individual level, characteristics such as age [47, 48], number of living children [49, 50]; marital status, wealth, educational level [51–55], place of residence [56–58], husband emotional fertility intention [2] and socio-demographic characteristics of the women [51, 52] were found to be associated with fertility desire. Although numerous factors have been shown to influence fertility desire, there is a relative dearth of literature on emotional fertility intention in Ethiopia [1–3] where the desire for additional children is pronounced [51, 59].

To this end, one-year postpartum emotional fertility intention: how would women feel if they became pregnant with a short inter-pregnancy interval, notably by one-year postpartum is understudied and there is a dearth of evidence in Ethiopia. Hence, determining the degree of one-year postpartum emotional fertility intention and identifying its correlates could provide actionable evidence to mitigate the fertility surge by promoting the continuum of care and preconception care packages in the one-year postpartum period and as a life course approach.

Methods and data sources

Study design, population, sample size and field work

The Ethiopian Performance monitoring for action (EPMA) have been collecting both cross-sectional and longitudinal data on selected maternal, newborn health, contraceptive use; and women and girls´ empowerment indicators over the past decade. Pertinent to this study, women were also asked how they would feel if they became pregnant by their one-year postpartum during the one–year follow–up study interview. This variable was regarded as one-year postpartum emotional fertility intentions. It was regard as the outcome variable of this study.

This study utilized community based baseline cross sectional, six weeks postpartum follow up and one–year postpartum follow up cross-sectional data sets from the prospective Ethiopian PMA women and newborns cohort one study. The data were collected in Ethiopia from the six panel survey regions: namely: Addis Ababa, Afar, Amhara, Oromia, SNNPR and Tigray by well experienced resident enumerators. This study collected real time data on various sexual, reproductive, maternal and new born nationwide priority indicators using customized Open Data Kit Mobile application. These data were collected using standard pretested questionnaire prepared in English and the three local languages (Amharic, Afan Oromo and Tigrigna).

The Ethiopian Performance Monitoring for Action (EPMA) cohort one study employed a two stage stratified cluster sampling. The main sampling units or enumeration areas (EAs) were chosen using the recent Ethiopia Population and Housing Census (PHC) as a sampling frame. The Ethiopian Central Statistical Services head office was involved in the sampling of the primary sampling units (enumeration areas) and processed enumeration area maps for selected EAs. Accordingly, a total 265 EAs were chosen in the first stage with independent selection in each sampling stratum and a probability proportional to EA size. In the second stage, a complete census of all households was conducted in 217 EAs to screen and enroll eligible women to obtain adequate sample size of a cohort of eligible women and to improve the study´s power. The overall sample size and cell sample size adequacy was checked and found adequate to generate unbiased estimates for the one-year postpartum women emotional fertility intention. One thousand seven hundred three, (1703) non-pregnant women who completed the follow up interviews were included in this further analysis.

The study was started by recruiting and enrolling pregnant women and puerperal women less than six weeks postpartum through the screening questionnaire. These panel of women were then interviewed at their respective 6 weeks, 6 months and one-year postpartum period as a follow up interviews. Concerning enrollment, in order not to miss all eligible women in the 217 panel survey enumerations areas (EAs), complete census was conducted. This panel survey was executed by Addis Ababa University’s School of Public Health in collaboration with the Ethiopian Public Health Association with assistance from the Federal Democratic Republic of Ethiopia Health Ministry, Ethiopia Statistical Services, Bill & Melinda Gates Institute for Population and Reproductive Health (Johns Hopkins Bloomberg School of Public Health). More details on the sampling design, selection procedures, selection probabilities, design effects, sampling methods and field work implementation were described well in the protocol [60].

Variables

Outcome variable

One-year postpartum emotional fertility intention was the outcome variable for this further analysis. It was measured by a likert scale question with 5 response options with ordinal scale of measurement. By one–year postpartum women were asked how they would feel if they become pregnant? For the seek of getting a meaning out this specific scale of measurement, the scale was reverse coded so that the very happy category gets the larger value on the scale and the very unhappy labeled as the smallest value in the scale.

Independent variables

Independent variables were classified into individual-level variables and enumeration area-level variables. Individual-level independent variables were further categorized into socio-demographic/economic characteristics, parity and other reproductive health characteristics such as contraceptive use history, resuming contraceptive use by one-year postpartum; and husband related characteristics.

The enumeration area (EA) level variables included were the two integral variables namely: region and place of residence and “Region” was grouped into six categories: Tigray, Afar, Amhara, Oromia, SNNPRs and Addis Ababa city administration. The place of residence is classified according to the default urban/rural designation.

Analysis and measurement

Data preparation and merging

To facilitate the merging process, repeatedly asked questions in one or more of the follow up interviews were renamed by giving a prefix 6 W, 6 M and OY to indicate these sets questions were asked in all the six weeks, six months and the one-year postpartum interviews during the data preparation stage. The data sets were merged using a unique participant ID assigned for every participant women at enrollment and/or baseline survey, and updated during each of the follow up interview visits as a linking variable. The unique participant ID was used as a link variable to link the baseline data set with the three follow up data sets.

A merged women and newborns cohort one data sets consisting of baseline, six weeks, six months and one-year postpartum data sets from the Ethiopian PMA cohort one survey were used for this further analysis. Frequencies and percentages were computed to characterize the study population. Chi-square test statistics were computed to check the cell sample size adequacy, and the sample size was found to be adequate to provide unbiased estimates on one-year postpartum emotional fertility intention. Exploratory data analysis were run for data cleaning thereby checking for item nonresponse rate for every variable and don’t know response which were later excluded from the analysis. Following this, variables were recoded to create biological plausible categories alongside with checking the distribution of the recoded variables using proportion. Composite variables were created; namely, baseline and six weeks intimate partner violence.

Generalized ordinal Logistics Regression (GOLR), also is known as the partial proportional odds model was used to identify important correlates of one-year postpartum emotional fertility intention: how would women feel if they became pregnant within one-year post-partum following the index child birth. A p value cutoff 0.25 was used to select candidate variables for the partial proportional odds statistical model building process. Results were presented in the form of percentages, and odds ratios with 95% CI. Significance was declared at a significance level of 0.05. Results were reported based on weighted count and one-year follow-up weight was applied.

Unlike the conservative ordered logistics regression, the GOLR relaxes the assumption of proportional odds for some variables [61]. Since, practically the parallel line assumption is most of the time violated, using the generalized ordered model entertains this practical phenomenon. Unlike the ordered ordinal regression, the generalized ordered model can be less restrictive and more parsimonious than methods that ignore the ordering of categories altogether [61]. Hence, generalized ordinal logistic regression statistical modeling was fitted to identify the correlates of the one-year postpartum emotional fertility intention [61, 62].

Besides, given an ordinal outcome variable, the potential model to be fitted for this type of data is the ordered logit model. For the use of the ordered logit model to be valid, the assumptions that the effect of the independent variables on the odds ratio is constant across all the cutoff points between the categories should be met. These assumptions of the model is referred to as the parallel lines or parallel regressions assumptions. The Brant test is the commonly used approach to assess whether the proportional odds assumption has been violated. During the analysis, the Brant test yielded that the assumption of the proportional odds was violated for the two independent variables, namely: ‘fertility desire at baseline’ and ‘birth order’. Consequently, generalized ordered logit model, an alternative to the ordered logit model, was fitted to the data. Generalized ordered logit statistical modeling is an alternative approach that relaxes the proportional odds assumptions. While using this approach, the effect of the explanatory variables on the odds of being in a higher category versus a lower category or vice versa can vary across the different cut-points of the ordinal outcome. This flexibility of the model comes with the increased number of parameters estimated than the conventional ordered logit model. Since these two independent variables were found to violate the proportional odds assumption, a generalized ordered logistics regression statistical model building process was employed. The generalized logit model is also called cumulative logit model, as it determines the cumulative probability of being in different combination of the higher-level categories of the outcome variable [61].

Data quality management and control

The four data sets were prepared for analysis by introducing the 6 W, 6 M and OY prefixes for questions that were repeatedly asked. Then a link variable called a unique participant ID was used to merge the data sets. The necessary data cleaning and completeness check were performed. Data completeness for variables and items for creating composite variables was verified through exploratory data analysis, after which any item nonresponse was excluded from the analysis. Frequencies were run to exclude responses with do not know (DNK) and no response (NR).

The Ethiopian PMA (EPMA) has employed a standard and pretested tool, providing ToT for regional coordinators and supervisors; intensive training with mock interviews for resident enumerators; pilot testing the survey instruments, close supervision during the field work, timely progress report and correction, 10% random check were some of the modalities used to maintain the quality of the collected data, the detail is reported somewhere else [60]. Furthermore, frequent field supervision were made during the follow-up interview visits. Besides, supervisors regularly follow up resident enumerators to plan and schedule follow up interviews together and reminding them the scheduled dates for follow up interviews. To minimize the lost to follow up and for logistics reasons, the follow-up six weeks interviews and one year follow up interviews were conducted within a plus or minus two weeks window period as of the delivery date. The six months follow up interviews, however, were conducted within a three weeks interview window period after the newborns have celebrated their 6 months birthday.

Results

Magnitude of one-year postpartum emotional fertility intention among one-year postpartum women

This study reported the magnitude of one-year postpartum emotional fertility intention. Two thousand eight hundred sixty eight (2,868) pregnant and 6 weeks postpartum women were enrolled, ¾ (78%) of them were pregnant women at enrolment. Among those, 2094, 87% of the enrolled women competed the one year follow-up interview, of which 54 became pregnant at one-year postpartum. Among them, 1,703 of them provided response for the one-year postpartum emotional fertility intention question item, the outcome variable for this study. The number of enrolled women who missed the six weeks, 6 months and one-year postpartum follow up interviews was 255, 250 and 320 respectively. The number of women who completed the respective three follow up interviews was 2664, 2414 and 2094 with an equivalent response rate of 93%, 91% and 87% respectively.

The proportion of one-year postpartum emotional fertility intention of being felt very unhappy and a sort of unhappy was found to be 31.00% (28.40%, 33.66%) and 34.00% (31.36%, 36.52%) respectively. Similarly, 17.12% (15.15%, 19.29%) had mixed feelings while 13.38% (11.63%, 15.34%) felt a sort of happy and 4.63% (3.60%, 5.94%) reported that they have felt very happy.

The proportion of one-year postpartum emotional fertility intention of being happier about the prospect of becoming pregnant by one-year postpartum was 18.01% (16.00%, 20.20%. Nearly two – third; 64.87% (62.20%, 67.45%) of them have reported that they have felt unhappier (Fig. 1).

Fig. 1.

Fig. 1

Open in a new tab

Magnitude of one-year postpartum emotional fertility intention among one-year postpartum women

Proportion of one-year postpartum emotional fertility intention among one-year postpartum women by socio-demographic characteristics

The proportion of one-year postpartum emotional fertility intention of being felt very unhappy, a sort of unhappy, mixed feelings, a sort of happy and very happy was found to be 39.75%, 34.79%, 15.80%, 6.98% and 2.68% respectively among women in the age group 40 to 49 years. Similarly, of women with secondary or above educational status, the proportion of those who reported that they have felt very unhappy, a sort of unhappy, a mixed feelings, a sort of happy and very happy was found to be 27.84%, 29.86%, 21.47%, 14.73% and 6.33% respectively (Table 1).

Table 1.

Proportion of one-year postpartum emotional fertility intention among one-year postpartum women by socio-demographic characteristics

Variables Very unhappy % Sort of unhappy % Mixed feeling % Sort of happy % Very happy % Total
Age Category 15 to 19 years 42 24.51 59 34.34 31 18.06 31 18.34 8 4.76 171
20 to 24 years 100 25.52 145 37.03 69 17.49 62 15.83 16 4.13 392
25 to 29 years 148 29.17 172 33.82 94 18.47 58 11.45 36 7.10 509
30 to 34 years 126 37.15 101 29.60 59 17.36 44 12.87 10 3.02 340
35 to 39 years 83 37.57 76 34.46 28 12.67 27 12.45 6 2.85 220
40 to 49 years 28 39.75 25 34.79 11 15.80 5 6.98 2 2.68 71
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Religion Other religion* 10 27.94 9 22.98 6 15.30 11 29.26 2 4.51 37
Orthodox 181 28.80 203 32.43 126 20.10 91 14.46 26 4.21 627
Protestant 152 33.44 195 42.98 57 12.50 37 8.17 13 2.91 454
Muslim 185 31.60 170 29.11 103 17.63 89 15.25 38 6.42 585
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Wealth Quintile Lowest quintile 89 25.62 130 37.39 50 14.43 60 17.14 19 5.42 348
Lower quintile 128 37.90 107 31.82 54 16.01 34 10.19 14 4.09 337
Middle quintile 126 35.13 114 31.81 57 15.96 46 12.88 15 4.22 358
Higher quintile 107 31.31 129 37.92 50 14.73 39 11.44 16 4.61 341
Highest quintile 78 24.49 97 30.29 80 25.11 49 15.28 15 4.83 319
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Family Size 1 to 3 members 140 25.44 197 35.71 108 19.56 70 12.76 36 6.54 551
4 to 5 members 166 28.57 205 35.25 98 16.75 85 14.58 28 4.85 582
6 to 14 members 221 38.79 175 30.75 86 15.15 73 12.74 15 2.56 570
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Educational Status No Formal 243 32.99 245 33.21 115 15.68 99 13.41 35 4.71 736
Primary 202 30.16 244 36.52 112 16.79 85 12.74 25 3.78 668
Secondary Plus 83 27.84 89 29.68 64 21.42 44 14.73 19 6.33 298
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Place of Residence Urban 101 27.92 107 29.61 88 24.26 52 14.34 14 3.88 361
Rural 427 31.80 470 35.04 204 15.20 176 13.12 65 4.83 1342
Region Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Tigray 48 62.87 9 12.25 6 8.18 11 13.74 2 2.95 77
Afar ___ ____ 4 10.95 5 16.20 16 48.37 8 23.96 33
Amhara 102 28.26 111 30.84 79 21.99 51 14.05 18 4.87 361
Oromiya 231 30.51 235 30.96 141 18.59 109 14.45 42 5.49 758
SNNP** 131 31.72 203 48.97 41 9.93 32 7.71 7 1.68 414
Addis 14 23.97 15 25.62 19 30.85 9 15.28 3 4.28 60
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Open in a new tab

**former Southern Nations Nationalities and Peoples Region which consists of the current South Ethiopia, Central Ethiopia, South West Ethiopia, and Sidama Regions

*Wakefeta and traditional religion

The proportion of one-year postpartum emotional fertility intention for women belonging to the households with the lowest wealth quintile was found to be 25.62%, 37.39%, 14.43%, 17.14% and 5.42% for the respective feeling categories. Likewise, for the residents of Tigray region, 62.87%., 12.25%, 8.18%, 13.74% and 2.95% of one year postpartum women have reported that they were very unhappy, a sort of unhappy, in a mixed feelings, a sort of happy and very happy respectively. Similarly, for urban residents, this similar proportion for the respective feeling categories was 27.92%, 29.61%, 24.26%, 14.34% and 3.88%. Besides, for Muslim religion followers, this respective proportion was reported to be 31.60%, 29.11%, 17.63%, 15.25% and 6.42% respectively. Among those women who reported a larger family size of 6 to 14, the proportion of very unhappy and a sort of un happy was 38.79% and 30.75% while mixed feelings, a sort of happy and very happy accounted for 15.15%, 12.74% and 2.56% respectively (Table 1).

Proportion of one-year postpartum emotional fertility intention among one-year postpartum women by reproductive, contraceptive use and related characteristics

The proportion of one-year postpartum emotional fertility intention among those with higher birth order was found to be 37.22%,33.94%,13.44%, 12.26% and 3.14% for the feeling categories of very unhappy, a sort of unhappy, mixed feelings, a sort of happy and very happy respectively. Similarly, this same proportion for women who did not decided whether to have a child was 24.07%, 34.17%, 25.75%, 11.02% and 4.99% respectively. Likewise, among women whose husband have other wives, 26.28%, 35.51%, 20.16%, 12.85% and 5.20% of them have felt very unhappy, a sort of unhappy, a mixed feelings, a sort of happy and very happy. The proportion of one-year postpartum emotional fertility intention of being very unhappy, a sort of unhappy, a mixed feelings, a sort of happy and very happy was 32.14%, 33.05%, 17.32%, 12.31% and 4.91% among women who have married more than once respectively. Similarly, this same proportion was 28.87%, 32.07%, 17.37%, 15.63% and 6.05% among those who perceived that their husband were very happy when learned the index pregnancy (Table 2).

Table 2.

Proportion of one-year postpartum emotional fertility intention among one-year postpartum women by reproductive, contraceptive use and related characteristics

Variables Very unhappy % Sort of unhappy % Mixed feeling % Sort of happy % Very happy % Total
Birth Order No Child 71 22.70 97 31.07 71 22.90 56 17.96 17 5.37 312
1_2 Children 170 27.45 219 35.29 117 18.80 77 12.47 37 5.99 620
3_14 Children 286 37.22 261 33.94 103 13.44 94 12.26 24 3.14 768
Total 527 30.99 576 33.91 291 17.13 228 13.38 78 4.59 1700
Fertility Intention Undecided 31 24.07 44 34.17 33 25.75 14 11.02 6 4.99 128
Have a/another child 260 25.93 360 35.89 167 16.67 156 15.57 60 5.94 1002
No more no children 130 42.44 98 31.86 52 17.04 25 8.02 2 0.64 306
Total 421 29.28 501 34.88 252 17.56 195 13.55 68 4.72 1437
Hus-Other Wives No 485 31.47 519 33.72 259 16.80 207 13.43 70 4.57 1540
Yes 43 26.28 58 35.51 33 20.16 21 12.85 8 5.20 163
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Marriage History Only once 455 30.76 503 34.02 253 17.09 200 13.54 68 4.59 1478
More than once 73 32.41 74 33.05 39 17.32 28 12.31 11 4.91 225
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Contraceptive Ever Use History No 177 27.43 203 31.36 118 18.31 107 16.57 41 6.33 647
Yes 350 33.16 374 35.45 173 16.40 120 11.40 38 3.59 1055
Total 527 30.98 577 33.90 291 17.12 227 13.36 79 4.63 1702
Desired place of delivery at enrollment Home 168 28.91 215 37.11 85 14.66 80 13.74 32 5.58 581
Government HF 250 29.84 282 33.63 160 19.03 113 13.45 34 4.05 839
Private HF 3 14.83 4 20.68 8 43.68 2 12.25 1 8.56 17
Total 421 29.28 501 34.88 252 17.56 195 13.55 68 4.72 1437
Desired Birth Attendant at enrollment No One 32 36.59 30 34.43 13 14.35 7 8.24 6 6.39 88
Health Professional 245 28.14 291 33.43 176 20.15 121 13.87 38 4.42 872
HEW 7 48.65 4 30.78 0 0.00 1 5.12 2 15.44 14
TBA 55 29.28 60 31.81 30 15.81 34 17.96 10 5.14 188
Family Member 81 29.67 115 42.03 34 12.25 32 11.71 12 4.34 275
Total 421 29.30 501 34.90 252 17.52 195 13.56 68 4.73 1436
Perinatal IPV at enrollment No 413 29.35 477 33.92 248 17.61 197 14.00 72 5.13 1408
Yes 107 39.72 95 35.41 31 11.63 30 11.06 6 2.18 268
Total 520 31.01 573 34.16 279 16.65 227 13.53 78 4.66 1676
Perinatal IPV at Six Week postpartum No 445 29.78 510 34.12 264 17.65 204 13.68 71 4.77 1493
Yes 75 38.67 62 32.24 27 13.96 22 11.16 8 3.97 194
Total 520 30.80 572 33.91 291 17.22 226 13.39 79 4.68 1687
most recent pregnancy husband feeling Very unhappy 24 65.47 7 19.53 4 10.00 2 5.00 .. .. 37
A Sort unhappy 30 39.81 26 34.56 7 10.07 8 11.17 3 4.39 74
Mixed Feeling 52 39.31 39 29.36 25 18.59 15 11.43 2 1.31 133
A sort Happy 164 27.42 226 37.68 108 17.96 77 12.80 25 4.15 599
Very Happy 226 28.87 251 32.07 136 17.37 122 15.63 47 6.05 783
Total 497 30.52 549 33.74 280 17.19 224 13.80 77 4.75 1627
One Year Postpartum Contraceptive No 300 31.33 280 29.17 159 16.60 162 16.90 58 6.00 959
Yes 227 30.53 297 39.97 132 17.80 66 8.83 21 2.87 744
Total 528 30.98 577 33.89 292 17.12 228 13.38 79 4.63 1703
Open in a new tab

Concerning contraceptive use, among ever contraceptive users, the proportion of one-year postpartum emotional fertility intention of feeling unhappy, a sort of unhappy, mixed feelings, a sort of happy and very happy was found to be 33.16%, 35.45%, 16.40%, 11.40%, and 3.59% respectively. Similarly, the respective proportion was found to be 30.53%, 39.97%, 17.80%, 8.83% and 2.87% among those who reported that they have resumed their contraceptives use by one-year postpartum (Table 2).

The proportion of one-year postpartum women´s emotional fertility intention of being very unhappy, a sort of unhappy, in a mixed feelings, a sort of happy and very happy was 4 in 10 (39.72%), 35.41%, 11.63%, 11.06% and 2.18% respectively among those who have reported that they have experienced at least one form of perinatal physical and/or sexual violence during the baseline survey. Similarly, this respective proportion was 38.67%, 32.23%, 13.96%, 11.16% and 3.97% among those who reported that they have experienced at least one form of perinatal physical and/or sexual violence as reported at their six weeks postpartum. Last but not least, the proportion of one-year postpartum emotional fertility intention of being very unhappy, a sort of unhappy, in a mixed feelings, a sort of happy and very happy was 28.91%, 37.11%, 14.66%, 13.74% and 5.58% among those whose desired place of delivery was home. Besides, the respective proportion was found to be 29.28%, 31.81%, 15.81%, 17.96% and 5.14% among those whose preferred birth attendant was traditional birth attendant (Table 2).

Correlates of one year postpartum emotional fertility intention among one-year postpartum women

This study has investigated and reported the hierarchal variation of one-year postpartum emotional fertility intention and factors contributing among a cohort of women who were followed for a maximum of 2 years. The proportional cumulative odds from the cumulative logit regression modeling was reported.

The two variables namely: women´s ´baseline fertility desire´ and ´birth order´ were found to have disproportional association across the cumulative logit resulting in an asymmetrical odds on one-year postpartum women emotional fertility intention. For these two independent variables the association was presented separately for the ´two´ ordinal outcome categories. This implies that the effect of these two independent variables on the odds ratio across all the cutoff points between the categories can vary while fitting the generalized ordered logistics regression, resulting the reported different odds ratio for these two variables unlike for the other independent variables where there effect is on the odds ratio is constant across all the cutoff points (Table 3).

Table 3.

Generalized ordered logistics regression modeling result of one-year postpartum emotional fertility intention among one-year postpartum women

Variables Very unhappy feeling AOR Mixed feeing AOR+
AOR
15 to 19 years 1
20 to 24 years 1.10 (0.63,1.93)
25 to 29 years 1.26 (0.74,2.16)
30 to 34 years 1.17 (0.64,2.16)
35 to 39 years 1.01 (0.51, 2.01)
40 to 49 years 0.62 (0.21, 177)
Religion Other Religion 1
Orthodox 0.94 (0.25, 3.51)
Protestant 0.38 (0.12,1.25)
Moslem/Muslim 0.80 (0.20,3.16)
Wealth Quintile Lowest quintile 1
Lower quintile 0.74 (0.43,1.28)
Middle quintile 0.88 (0.45,1.72)
Higher quintile 0.66 (0.32,1.40)
Highest quintile 1.17 (0.62,2.19)
Family Size 1 to 3 members 1
4 to 5 members 1.34 (0.95,1.89)
6 to 14 members 1.26 (0.73,2.19)
Educational Status No Formal Education 1
Primary Education 0.92 (0.59,1.44)
Secondary Plus Education 1.14 (0.65, 2.00)
Birth Order+ No Child 1 1
1_2 Children 0.63 (0.41,0.97)* 0.67 (0.40,1.12)
3_14 Children 0.42 (0.22,0.83)* 0.65 (0.35,1.20)
Fertility Desire at baseline+ Undecided/Don’t know 1 1
Have a/another child 0.62 (0.381.01) 0.37 (0.61,2.16)
No more/prefer no children 0.51 (0.29,0.89)* 0.26 (0.22, 1.40)
Most recent pregnancy husband feeling Very Unhappy 1
Mixed Feeling 1.03 (0.42,2.54)
A Sort Happy 1.15 (0.52,2.51)
Very Happy 1.51 (0.66,3.43)
Contraceptive Ever Use History No 1
Yes 0.66 (0.44,0.97)*
Perinatal IPV experience at baseline No 1
Yes 0.69 (0.45, 1.08)
Variables Very unhappy feeling AOR Mixed feeing AOR+
 Perinatal IPV experience at 6 weeks No 1
Yes 0.99 (0.61,1.60)
 One Year Postpartum Contraceptive use No 1
Yes 0.43 (0.29, 0.63)***
Open in a new tab

*P < 005 *** P < 0.000

***p < .001, ** p < 0.01, * p < 0.05

+Only results for two independent variables presented in both outcome variable categories since these two variables violated the assumptions of parallel regressions assumptions

The proportional cumulative odds of one-year postpartum emotional fertility intention was found to be 34% (AOR: 0.66 (95%CI: 0.44, 0.97)) lower among women who reported that they ever used contraceptives compared with non-ever users. Similarly, the proportional cumulative odds of one-year postpartum emotional fertility intention was found to be only (AOR: 0.43 (95%CI:0.29, 0.63)) among women who reported that they had resumed their contraceptive use by one-year postpartum compared with those women who had not commenced contraceptive use by then (Table 3).

The cumulative odds of one-year postpartum emotional fertility intention were found to be disproportional for fertility desire and birth order variables, yielding an asymmetrical cumulative logit result. Hence, fertility desire at baseline and higher birth order had a disproportionate cumulative effect on one-year postpartum emotional fertility intention. The disproportionate cumulative odds of postpartum emotional fertility intention was found to be (AOR: 0.63, 95%CI:(0.41, 0.97)) and (AOR 0.42, 95%CI: (0.22, 0.83)) for the birth order categories of having one to two child and for women who had 3 to 14 children respectively as compared with those with no child. Similarly, women who reported that they do not wanted more child at one-year postpartum had a disproportionate cumulative odds of (AOR: 95CI: 0.51 (0.29, 0.89) (Table 3).

Discussion

The postpartum period is a key timing in shaping women´s postpartum emotional, psychosocial and/or mental health and newborns health outcomes. Determining the level of one-year postpartum emotional fertility intention among one-year postpartum women and identifying the factors contributing for this variation has paramount importance for building and sustaining a healthy family with a better maternal and newborns health outcomes. The study´s relevance is very important in the settings such as Ethiopia where male’s dominance in household decision making and reproductive health services use decision making is culturally accepted and social constructed. Generating such an evidence is hoped to provide an actionable evidence for the Federal Democratic Republic of Ethiopia Health Minister and relevant developmental partners to improve women´s decision making over their emotional fertility intention in particular and reproductive health rights in general. The findings could contributed for tracking SDG 5.6.1.

The finding that two third (64.0%) of one-year postpartum women emotionally felt unhappier is worth to consider while revising the current national reproductive health policy to improve women postpartum emotional fertility intention and psychosocial health. This has an implication on women postpartum emotional and mental health. This finding was found higher than the proportion of women emotional fertility intention of being unhappier for the index pregnancy for this same cohort of women, 48.73% (95% CI: 46.21%, 51.23%) and 16.4% [1, 3] while lower than 74.9% (95% CI; 72.5%—77.1%) [63]. This higher proportion of one -year postpartum emotional fertility intention of being unhappier might be related to women experience of low-quality antenatal care (ANC) received during their index pregnancy and had not able to receive the recommended ANC visits during their most recent pregnancy and childbirth. A recent study conducted in Ethiopia [64] reported that the overall effective ANC coverage was low. On the other hand, the success of health extension program (HEP), Health Sector Transformational Plans and the new reproductive health policy in the country [30, 31] might have contributed for the observed 18.01% proportion of one-year postpartum emotional fertility intention of being happier.

To this end, the implication of the finding that only one in five post-partum women reported that they have felt happier underscored that we have a long way to go to make women decided over their emotional fertility intention. Besides, installing the inter-pregnancy preconception care packages which are relatively new for our country was implied [10, 13, 65]. Furthermore, the expansion of the urban health extension professional and addition of level IV health extension workers in rural areas should be used as a stepping stone to improve the quality of care [66] at the community level. This could enable women to get informed counseling about their reproductive health needs and rights, including planning and spacing their pregnancies and consequently feeling happier. Moreover, the effort to improve quality of maternal and newborns health care; and provision respectful maternity care [67] along with the quality maternal and newborns continuum of care are likely to encourage women to plan their pregnancies and subsequently to be happier. Besides, the variation in community support for pregnant women to utilize the three domains of the maternal and new born continuum of care packages could also contributes to the observed variation in the postpartum emotional fertility intention [68].

Furthermore, the variation in the degree of women emotional fertility intention might be related with the socially constructed and culturally accepted male dominance in matters that affect women, this dominance negatively interferes on women reproductive autonomy and the control they have over their fertility among others in low and middle-income countries including Ethiopia. A recent nationally representative study from Ethiopia revealed that partner-perpetrated pregnancy coercion inhibits women’s reproductive autonomy reported that approximately 20% of Ethiopian women reported past-year pregnancy coercion (11.4% less severe; 8.6% more severe), ranging from 16% in Benishangul-Gumuz to 35% in Dire Dawa [7]. This led women being emotionally unhappier whenever they thought of becoming pregnant. Addressing this gap in women´s emotional fertility intention would help to track the success of SDG goal 5.6.1 [65] and the reproductive health targets [10]. Besides, poor patient-provider communication and inadequate support of women’s autonomy during antenatal and postnatal cares visits contributed most to poor person-centered maternity care might be possible explanation for this variation in the level of postpartum emotional fertility intention [4].

Those women with a contraceptive use history and those who have reported to have commenced contraceptive use by their one-year postpartum following the index birth were found to have lower symmetrical cumulative logit of one-year postpartum emotional fertility intention. This finding was found in line with findings from studies [25, 51, 69, 70]. The possible explanation for the link between contraceptive use and emotional fertility intention might be related to contraceptive access [71, 72]; pregnancy and child bearing [71]. Besides, it might be also be related with contraceptive use and fertility transition [73] and women fertility desire and contraceptive behavior might also be one of the possible explanations [70]. Moreover, the poor quality contraceptive counseling [74, 75] could be another explanation for the observed variation. This implied that we need a long way to go to empower women on their contraceptive use decision making [76, 77]. The poor patient-provider communication and inadequate support of women’s autonomy contributed most to poor person-centered maternity care [4] might be another possible explanation.

The finding that women intended to have another child had lower one-year postpartum emotional fertility intention but disproportionate across the cumulative logit might be related the families’ aspiration to achieve the desired family size. This can be seen as exercising their reproductive right and reproductive autonomy [1, 3, 78]. Moreover, the lower and asymmetrical effect of higher birth order on one-year postpartum emotional fertility intention was also found in line with findings from studies [51, 79]. This observed finding might be related with women prior pregnancy experience [1, 63, 80] and is likely related with male decision making on the number of children [22, 81, 82]. In line with studies [1, 3] birth order was found associated with emotional fertility intentions. Lastly, unlike studies [1, 53, 63, 83] individual women related factors such as age, religion, family size, and educational status of women, intention to use contraception were not found to affect one-year post-partum women emotional fertility intentions. Besides, studies on emotional fertility intention [1, 3] reported that age, region, educational status and desired birth attendant were significantly associated with emotional fertility unlike this study. The use of data collected at different time points through the follow up period [3] and the difference in the statistical model fitted by the one study [3] might explain the observed discrepancy while cross-sectional data was used by the other study [1].

This study is not spared of limitations. To begin with, the reliance on personal history report response by asking women to learn about how they would feel if they became pregnant within one-year postpartum has its own limitations. This led to potential biases such as social desirability bias. Besides, owing to social prestige, women seldom discuss negatively about their emotional fertility intentions in our context. However, such findings offer a meaningful insights which are important and relevant for outlining care for pregnant women and their partners. Moreover, further research is needed to validate and build upon this initial result including studies that develop with alternative and direct measures for emotional fertility intentions. In addition, the PMA 2019/21 cohort one follow up survey didn’t collect information on variables such as husband desired number of children, husband employment and women employment. The women's survey did not collect information on these variables either. Hence, future similar surveys need to collect these missing variables along with important paternal indicators regarding contraception, emotional health, indicators related preconception care packages and maternal and newborns care continuum. Further researches with qualitative triangulation aimed at exploring one–year postpartum emotional fertility intention across different cultural or socio-economic groups are need.

Conclusion

One-year postpartum emotional fertility intention of being unhappier is more pronounced in Ethiopia which calls for intended and spaced pregnancies by ensuring women reproductive health services and contraceptive use empowerment. The findings underscored the pivotal role of contraceptive use history and resuming contraceptive use by one-year postpartum in shaping one-year postpartum emotional fertility intentions. Activities and efforts targeting on women with high parity and promoting intended and spaced pregnancies and access to contraceptives do likely improve one-year postpartum emotional fertility intention. Activities that enable women to decide their contraceptive use along with patient-centered counseling during ANC and PNC visits are very crucial to shape one-year postpartum emotional fertility intention. The study results implied that awareness creation on contraceptive use related components of the inter-pregnancy preconception care packages services and more specifically availing the actual inter-pregnancy contraceptive service provision could also be critical to address one-year postpartum emotional fertility intention.

Practical and clinical implications; and policy relevance of the findings

The implication of the findings calls for strengthening postpartum contraceptive use counseling and intensifying actual service provision alongside with enabling high parity women to use contraceptive through access and informed decision making.

The other implications of the study findings include enhancing client-centered informed contraceptive use decision making to sustain contraceptive use among those with a contraceptive use history and improving postpartum contraceptive uptake. Provision of post-partum contraceptive could reduce maternal and newborns morbidity and mortality through spacing, improving women emotional and mental health in the postpartum period. It also improves their emotional fertility readiness and/or intention as well.

At the policy level, the subsequent national reproductive health policy and strategic plans need to entertain the human right approach strategy in providing contraceptive methods and enforcement of women alone decision making on contraceptive use as part of women and girls empowerment [76]. The Federal Democratic Republic of Ethiopia Health Minister need to work strategically with relevant partners and programs working on contraceptive commodity provision and access by streamlining resources and budget. This approach will enable a timely service delivery.

The clinical care implication of the findings is that health care professionals need to counsel on postpartum emotional fertility intention and mental health during antenatal and postnatal care service provision endeavors through patient-centered contraceptive use counseling. Besides, installing the inter-pregnancy contraceptive and mental health care related preconception care packages in the health system are very crucial. Furthermore, extending the continuum of maternal, newborns and child health cares to one-year postpartum and beyound could have paramount importance.

Acknowledgements

We appreciate the huge commitment of PMA Ethiopian data collection team, notably enumerators, supervisors and regional coordinators. We are grateful for study participants for their kindest cooperation. Finally, Staff Ethiopian Red Cross training center and management and staff of Kereyu Resort at Adama deserve huge recognition for their hospitality in facilitating the Ethiopian PMA field staff trainings.

Abbreviations

ANC

Antenatal Care

ARRR

Adjusted Relative Risk

CS

Cross-sectional

EA

Enumeration Areas

HH

Households

HEW

Health extension Workers

HF

Health Facility

HP

Health Professionals

GOLR

Generalized Ordered Logistics Regression

PNC

Postnatal care Care

EPMA

The Ethiopian Performance for Monitoring for Action Ethiopia

SNNPR

The former Southern Nations, Nationalities and Peoples Region

TBA

Traditional Birth Attendants

Authors’ contributions

SA conceptualized the study, conducted the data curation and the formal analysis; and draft the manuscript and wrote the final version, interpreted the results and critically revised the manuscript. He also got involved in survey implementation, preparatory and operational activities and survey tool quality assurance as well. Besides, he also involved in the further analysis of the collected data and communicating the findings on selected survey indicators such as on intimate partner violence among pregnant women and six weeks postpartum women, women contraceptive use decision making, emotional fertility intention and perceived paternal emotional fertility intention, contraceptive use intention among non-users, perceived community acceptance and partner engagement on the use of the recommended components of maternal and newborns care continuum and perceived community acceptance on TBA assisted childbirth care. TD involved in the project data management, guide the analysis and critically review the final manuscript. TD also assisted in the model building process, in the data interpretation and critically reviewing the manuscript. FT contributed to the conception of the idea, involved in writing the draft manuscript and interpretation of the results along with critically reviewing the final manuscript. FT also participated in the field wok supervision, survey tool quality check and project facilitation. HG and TT Participated in the field work, survey operation, tool translation and critically and intellectually review the final manuscript. HG and TT also participated in writing, reviewing and editing the manuscript. KM: critically review the final manuscript including language check. BA contributed for the conception and in intellectually reviewing the manuscript. She also participated in the field work supervision. AA (Author 6) and TA involved in the project data management, guide the analysis and critically review the final manuscript. TA also assisted in the data curation. MY (Author 13) and NT contributed for the conception, served as survey tool developer, coordinating and facilitating the project implementation and contributed intellectually in critically reviewing the manuscript. NT also participated in the data interpretation and the modeling process, led the translation team to insure survey tool quality. MY (Author 13) also participated in the survey operation and management as project coordinator. AA (Author 4) and ZN: intellectually and critically reviewed the final version of the manuscript. MY (author 16) and AZ: Contributed in intellectually and critically reviewing the final manuscript. MY (author 16) participated in the field work. AZ also participated in running the project preparatory and/or facilitation, logistics procurement and management activities and served as an assistant project coordinator. SS and AS contributed for the conception of the idea, provide guidance in the manuscript write up, contributed for the data interpretation and critically and intellectually reviewing the final manuscript. SS led the Ethiopian Performance Monitoring for Action Ethiopia (EPMA) project and the former Performance monitoring for action 2020 Ethiopia. AS co-led the Ethiopian Performance Monitoring for Action Ethiopia (EPMA) project and the former Performance monitoring for action 2020 Ethiopia. All authors reviewed and approved the final version of the manuscript.

Funding

The authors did not obtained any funding.

Data availability

The datasets generated during the study are publicly available from the PMA website and/or the Johns Hopkins Research Data Repository: [https://archive.data.jhu.edu/dataverse/root/?q=PMA+Ethiopia+Cohort+one](https://archive.data.jhu.edu/dataverse/root/?q=PMA+Ethiopia+Cohort+one).

Declarations

Ethics approval and consent to participate

This study involved a secondary analysis of deidentified data from the PMA Ethiopia. The PMA Ethiopia survey was conducted strictly under the ethical rules and regulations of world health organization and IRB of Ethiopian Health and Nutrition Research Institute (EHNRI). Informed consent was obtained from respondents during the data collection process of PMA Ethiopia on the baseline data collection on Oct 2019 and subsequent follow up interviews till Aug 2021. Minors less than 15 years as per the law were not included in this study. Informed verbal consent was take from study participants during the screening, baseline and follow up interviews. PMA surrey has been also conducted after obtaining ethical approval from Addis Ababa University College of Health Sciences and Medicine and Bloomberg School of Public Health at Johns Hopkins University in Baltimore, USA.

Consent for publication

N/A not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  • 1.Damtew SA, Gidey MY, Fantaye FT, Atnafu NT, Kassa BA, Gebrekidan HG, et al. Emotional fertility intention and its correlates in Ethiopia among married contraceptive user women: using linked community and health facility data from performance monitoring for action; a generalized ordered logistics regression modeling. BMC Public Health. 2024;24(1):2049. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Damtew SA, Gidey MY, Fantaye FT, Atnafu NT, Sene KM, Kassa BA, et al. Perceived paternal emotional fertility intention and its correlates in Ethiopia among a cohort of pregnant women: Community based longitudinal survey; a secondary data analysis of the 2019/20 baseline survey. PLoS One. 2025;20(2):e0318654. 10.1371/journal.pone.0318654. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Damtew SA, Demissie TD, Seme A, Atnafu NT, Fantaye FT, Gidey MY, et al. Index pregnancy emotional fertility intention and its correlates in Ethiopia: evidence from a national women and newborns baseline survey. Reprod Health. 2025;22(1). [DOI] [PMC free article] [PubMed]
  • 4.Stierman EK, Zimmerman LA, Shiferaw S, Seme A, Ahmed S, Creanga AA. Understanding variation in person-centered maternity care: results from a household survey of postpartum women in 6 regions of Ethiopia. AJOG Glob Rep. 2023;3(1):1–10. [DOI] [PMC free article] [PubMed]
  • 5.Damtew SA, Atnafu NT, Gidey MY, Sisay TA, Yohannes M. Partner conflict during their index pregnancy and its correlates among a cohort of six weeks postpartum women in Ethiopia. Sci Rep. 2025;15(1). 10.1038/s41598-025-85421-4. [DOI] [PMC free article] [PubMed]
  • 6.Damtew SA, Shiferaw S, Seme A. Intimate partner violence during the index pregnancy and its correlates among a panel of pregnant women in Ethiopia, evidence from performance, and monitoring for action (PMA) 2021 cohort two baseline survey. BMC Pregnancy Childbirth. 2024;24(1). 10.1186/s12884-024-06947-5. [DOI] [PMC free article] [PubMed]
  • 7.Wood SN, Dozier JL, Karp C, Desta S, Decker MR, Shiferaw S, et al. Pregnancy coercion, correlates, and associated modern contraceptive use within a nationally representative sample of Ethiopian women. Sex Reprod Health Matters. 2022;30(1):2139891. 10.1080/26410397.2022.2139891. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.WHO. WHO recommendations on maternal and newborn care for a positive postnatal experience. WHO maternal, newborn, child and adolescent health and ageing data portal: wwwwhoint/data/maternal-newborn-child-adolescent-ageing/maternal-and-newborn-data/maternal-and-newborn---coverage. 2018.
  • 9.WHO. WHO recommendations on health promotion interventions for maternal and newborn health; Recommendation 2. Male involvement interventions for maternal and newborn health (MNH) and Recommenadation 9 on Community mobilization through facilitated participatory learning and action cycles with women’s groups(www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. WHO Library Cataloguing-in-Publication Data ISBN 978 92 4 150874 2 2015:25 to 9.
  • 10.FMoH. RH Strategic Plan - Ethiopia 2021–2025. 2021.
  • 11.Rono, et al. A policy analysis of policies and strategic plans on Maternal, Newborn and Child Health in Ethiopia. Int J Equity Health. 2022;21:73. 10.1186/s12939-022-01656-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;370(9595):1358–69. [DOI] [PubMed] [Google Scholar]
  • 13.Wegene MA, Gejo NG, Bedecha DY, Kerbo AA, Hagisso SN, Damtew SA. Utilization of preconception care and associated factors in Hosanna Town, Southern Ethiopia. PLoS One. 2022;17(1):e0261895. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Addis Ababa University School of Public Health, The Bill & Melinda Gates Institute for Population and Reproductive Health at The Johns Hopkins Bloomberg School of Public Health. Performance Monitoring for Action Ethiopia (PMA-ET) One-Year Postpartum Maternal Newborn Health Technical Report. Ethiopia and Baltimore, Maryland, USA; 2022.
  • 15.Schramme T. Health as complete well-being: the WHO definition and beyond. Public Health Ethics. 2023;16(3):210–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Cranney SJPOs, health r. The association between belief in god and fertility desires in Slovenia and the Czech Republic. Perspect Sex Reprod Health. 2015;47(2):83–9. 10.1363/47e2915. [DOI] [PMC free article] [PubMed]
  • 17.Spéder Z, Kapitány B. Influences on the link between fertility intentions and behavioural outcomes: Lessons from a European comparative study. In book: Dimiter P, Aart C. Liefbroer, Klobas JE, editors. Reproductive Decision-Making in a Macro-Micro Perspective Chapter: 4.  Publisher: Springer 2014; pp. 79–112.10.1007/978-94-017-9401-54.
  • 18.Hashemzadeh M, Shariati M, Mohammad Nazari A, Keramat A. Childbearing intention and its associated factors: a systematic review. Nurs Open. 2021;8(5):2354–68. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Aassve A, Arpino B, Balbo N. It takes two to tango: couples’ happiness and childbearing. Eur J Popul. 2016;32(3):339–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.SpéderZsolt Z, SpéderBalázs Kapitán. Influences on the link between fertility intentions and behavioural outcomes. lessons from a european comparative study. 2014. 10.1007/978-94-017-9401-5_4.
  • 21.Mosisa G, Tsegaye R, Wakuma B, Mulisa D, Etefa W, Abadiga M, et al. Fertility desire and associated factors among people living with HIV in Ethiopia: a systematic review and meta-analysis. Arch Public Health. 2020;78(1):123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Dereje G. Femininity, masculinity and family planning decision-making among married men and women in rural Ethiopia: a qualitative study. J Afr Stud Dev. 2018;10(9):124–33. [Google Scholar]
  • 23.Dereje G, Zewdie Birhanu, Michelle Kaufman, Bezawit Temesgen. Gender norms and family planning decision-making among married men and women, rural ethiopia: a qualitative study. Sci J Public Health. 2015;3(2). 10.11648/j.sjph.20150302.23.
  • 24.Laurie F. DeRose, F. Nii-Amoo Dodoo and, Vrushali Patil. Fertility desires and perceptions of power in reproductive conflict in Ghana Gender and Society. 2002;16(1):53–73. 2002.
  • 25.Babalola S, Oyenubi O, Speizer IS, Cobb L, Akiode A, Odeku M. Factors affecting the achievement of fertility intentions in urban Nigeria: analysis of longitudinal data. BMC Public Health. 2017;17(1):942. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Yeboah I, Okyere J, Duah HO, Conduah AK, Essiaw MN. Analysis of couples’ discordance on fertility desire in Ghana. Genealogy. 2023;7(3):48. 10.3390/genealogy7030048.
  • 27.Diro and Afework. Agreement and concordance between married couples regarding family planning utilization and fertility intention in Dukem. Ethiopia BMC Public Health. 2013;13:903. http://www.biomedcentralcom/1471-2458/13/903. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Kesetebirhan AJFDRoE, Ministry of Health. National guideline for family planning services in Ethiopia. 2011:20–3.
  • 29.Workie NW, Ramana GN. The health extension program in Ethiopia. 2013.
  • 30.Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W. Community health extension program of Ethiopia, 2003–2018: successes and challenges toward universal coverage for primary healthcare services. Glob Health. 2019;15(1):24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.FMoH. Health Sector Transformation Plan II (HSTP-II). 2021.
  • 32.Bielli C, Berhanu G, Isaias A, Orasi A. Population growth and environment. Ethiopia: CSA; 2001. [Google Scholar]
  • 33.Central Statistical Agency. Ethiopia: 2016 Demographic and Health Survey: Key Findings. 2016, full report. 2016.
  • 34.Bongaarts J. Trends in fertility and fertility preferences in sub-Saharan Africa: the roles of education and family planning programs. Genus. 2020;76:32. 10.1186/s41118-020-00098-z.
  • 35.Church AC, Ibitoye M, Chettri S, Casterline JB. Traditional supports and contemporary disrupters of high fertility desires in sub-Saharan Africa: a scoping review. Reprod Health. 2023;20(1):86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.SJ DJHR. Men leave me as I cannot have children: women’s experiences with involuntary childlessness. 2002;17:1663-8. [DOI] [PubMed]
  • 37.Ngure K, Baeten JM, Mugo N, Curran K, Vusha S, Heffron R, et al. My intention was a child but I was very afraid: fertility intentions and HIV risk perceptions among HIV-serodiscordant couples experiencing pregnancy in Kenya. AIDS Care. 2014;26(10):1283–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Matovu JK, Makumbi F, Wanyenze RK, Serwadda D. Determinants of fertility desire among married or cohabiting individuals in Rakai, Uganda: a cross-sectional study. Reprod Health. 2017;14(1):2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Chaudhuri S. The desire for sons and excess fertility: a household-level analysis of parity progression in India. Int Perspect Sex Reprod Health. 2012;38(4):178–86. [DOI] [PubMed] [Google Scholar]
  • 40.Razzaq S, Jessani S, Ali SA, Abbasi Z, Saleem SJJTJotPMA. Desire to limiting child birth and the associated determinants among married females: Sukh Survey-Karachi, Pakistan. 2021;71(11 (Suppl 7)):S70. [PubMed]
  • 41.Motlagh ME, Taheri M, Eslami M, NASROLLAHPOUR SSD. Factors affecting the fertility preferences in Iranian ethnic groups. 2016.
  • 42.Dibaba Y. Factors influencing women’s intention to limit child bearing in Oromia, Ethiopia. Ethiopian journal of health development. 2009;23(1).
  • 43.Borgstede M, Scheunpflug A. The relation between war, starvation, and fertility ideals in sub-Saharan Africa: a life history perspective. Evol Psychol. 2024;22(4):14747049241274622. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Perelli-Harris B, Gerber T, Hilevych Y. Uncertainty and fertility in Ukraine on the eve of Russia’s full-scale invasion: the impact of armed conflict and economic crisis. Eur J Popul. 2024;40(1):28. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Thiede BC, Hancock M, Kodouda A, Piazza J. Exposure to armed conflict and fertility in sub-Saharan Africa. Demography. 2020;57(6):2113–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Lindstrom DP, Berhanu B. The impact of war, famine, and economic decline on marital fertility in Ethiopia. Demography. 1999;36(2):247–61. [PubMed] [Google Scholar]
  • 47.Asfaw HM, Gashe FE. Fertility intentions among HIV positive women aged 18–49 years in Addis Ababa Ethiopia: a cross sectional study. Reprod Health. 2014;11:36. 10.1186/1742-4755-11-36. [DOI] [PMC free article] [PubMed]
  • 48.Wagner GJ, Wanyenze R. Fertility desires and intentions and the relationship to consistent condom use and provider communication regarding childbearing among HIV clients in Uganda. ISRN Infect Dis. 2013. PMID: 25379322 PMCID: PMC4219363. 10.5402/2013/478192. [DOI] [PMC free article] [PubMed]
  • 49.Gutin SA, Namusoke F, Shade SB, Mirembe FJAjorh. Fertility desires and intentions among HIV-positive women during the post-natal period in Uganda. Afr J Reprod Health. 2014;18(3):67–77. [PubMed]
  • 50.Kawale P, Mindry D, Stramotas S, Chilikoh P, Phoya A, Henry K, et al. Factors associated with desire for children among HIV-infected women and men: a quantitative and qualitative analysis from Malawi and implications for the delivery of safer conception counseling. AIDS Care. 2014;26(6):769–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Ahinkorah BO, Seidu AA, Armah-Ansah EK, Budu E, Ameyaw EK, Agbaglo E, et al. Drivers of desire for more children among childbearing women in sub-Saharan Africa: implications for fertility control. BMC Pregnancy Childbirth. 2020;20(1):778. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Muluneh MW, Moyehodie YA. Determinants of desire for more children among women in Ethiopia. BMC Womens Health. 2021;21(1):408. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Ahinkorah BO, Seidu AA, Armah-Ansah EK, Ameyaw EK, Budu E, Yaya S. Socio-economic and demographic factors associated with fertility preferences among women of reproductive age in Ghana: evidence from the 2014 demographic and health survey. Reprod Health. 2021;18(1):2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Lemessa R, Wencheko E. Factors affecting the intention of women to limit childbearing in rural Ethiopia. Ethiopian J Health Dev. 2014;28(2).
  • 55.Kebede E, Striessnig E, Goujon A. The relative importance of women’s education on fertility desires in sub-Saharan Africa: a multilevel analysis. Popul Stud. 2022;76(1):137–56. [DOI] [PubMed] [Google Scholar]
  • 56.Adhikari RJBp, childbirth. Demographic, socio-economic, and cultural factors affecting fertility differentials in Nepal. 2010;10(1):1–11. [DOI] [PMC free article] [PubMed]
  • 57.Negash WD, Belachew TB, Asmamaw DB, Bitew DA. Predictors of desire to limit childbearing among reproductive age women in high fertility regions in Ethiopia. A multilevel mixed effect analysis. BMC Public Health. 2023;23(1):1011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Sathiya Susuman A, Bado A, Lailulo YA. Promoting family planning use after childbirth and desire to limit childbearing in Ethiopia. Reprod Health. 2014;11:53.10.1186/1742-4755-11-53. [DOI] [PMC free article] [PubMed]
  • 59.Charles F. Westoff of the Office of Population Research PU. Desired number of children: 2000–2008, DHS COMPARATIVE REPORTS 25. 2010.
  • 60.Zimmerman L, Desta S, Yihdego M, Rogers A, Amogne A, Karp C, et al. Protocol for PMA-Ethiopia: a new data source for cross-sectional and longitudinal data of reproductive, maternal, and newborn health. Gates Open Res. 2020;4:126. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Williams R. Understanding and interpreting generalized ordered logit models. J Math Sociol. 2016;40(1):7–20. [Google Scholar]
  • 62.Fullerton AS, Anderson KF. Ordered Regression Models: a Tutorial. Prev Sci. 2023;24(3):431–43. [DOI] [PubMed] [Google Scholar]
  • 63.Fantaye FT, Damtew SA, Sene KM. Fertility intention and its correlates with reproductive-aged married women in Ethiopia: an adapted theory of planned behavior (TPB). J Health Popul Nutr. 2025;44(1):82. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Abdissa Z, Alemu K, Lemma S, Berhanu D, Defar A, Getachew T, et al. Effective coverage of antenatal care services in Ethiopia: a population-based cross-sectional study. BMC Pregnancy Childbirth. 2024;24(1):330. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.UN. Transforming Our World: The 2030 Agenda for Sustainable Development. New York; 2015.
  • 66.Federal Democratic Republic of Ethiopia Ministry of Health. Ethiopian Health Care Quality Bulletin: Continuous Health Care Quality Improvement through Knowledge Management, Vol 1. 2019.
  • 67.Habte A, Tamene A, Woldeyohannes D, Endale F, Bogale B. Gizachew A The prevalence of respectful maternity care during childbirth and its determinants in Ethiopia: a systematic review and meta-analysis. PLoS One. 2022;17(11):e0277889. 10.1371/journal.pone.0277889. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Damtew Solomon Abrha, Fentaye Fitsum Tariku, Kassa Bezawork Ayele, Sene Kelemua Menegesha. Pregnant Women Perceived Community Acceptance on Continuum of maternal and newborn care its Correlates in Ethiopia: Community based 2 year Cohort follow up Study. 2024. 10.21203/rs3rs-4230469/v1.
  • 69.Dibaba Y. Factors influencing women’s intention to limit child bearing in Oromia, Ethiopia. Ethiop J Health Dev. 2008;22(3):28–33. [Google Scholar]
  • 70.OlaOlorun F, Seme A, Otupiri E, Ogunjuyigbe P, Tsui A. Women’s fertility desires and contraceptive behavior in three peri-urban communities in sub Saharan Africa. Reprod Health. 2016;13:12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 71.Shiferaw S, Spigt M, Seme A, Amogne A, Skrovseth S, Desta S, et al. Does proximity of women to facilities with better choice of contraceptives affect their contraceptive utilization in rural Ethiopia? PLoS One. 2017;12(11):e0187311. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 72.Bersamin M, Todd M, Remer L. Does distance matter? Access to family planning clinics and adolescent sexual behaviors. Matern Child Health J. 2011;15(5):652–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 73.Alazbih NM, Tewabe GN, Demissie TD. Contraception and fertility transition in Amhara National Regional State of Ethiopia: an application of Bongaarts’ model. Fertil Res Pract. 2017;3(1):12. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 74.Hrusa G, Spigt M, Dejene T, Shiferaw S. Quality of FamiLy Planning Counseling in Ethiopia: trends and determinants of information received by female modern contraceptive users, evidence from national survey data, (2014–2018). PLoS One. 2020;15(2):e0228714. 10.1371/journal.pone.0228714. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 75.Ejigu BA, Seme A, Zimmerman L, Shiferaw S. Trend and determinants of quality of family planning counseling in Ethiopia: evidence from repeated PMA cross-sectional surveys, (2014–2019). PLoS One. 2022;17(5):e0267944. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76.Damtew SA, Fantaye FT. Women alone modern contraceptive use decision making and its correlates, evidence from PMA CS 2021 survey. BMC Women’s Health. 2024;24(1). 10.1186/s12905-024-03050-x. [DOI] [PMC free article] [PubMed]
  • 77.Fantaye FT, Damtew SA. Women decision making on use of modern family planning methods and associated factors, evidence from PMA Ethiopia. PLoS One. 2024;19(2):e0298516. 10.1371/journalpone0298516. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 78.Karp C, Wood SN, Galadanci H, Sebina Kibira SP, Makumbi F, Omoluabi E, et al. “I am the master key that opens and locks”: Presentation and application of a conceptual framework for women’s and girls’ empowerment in reproductive health. Soc Sci Med. 2020;258:113086. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 79.Ahinkorah BO, Seidu AA, Budu E, Agbaglo E, Adu C, Dickson KS, et al. Which factors predict fertility intentions of married men and women? Results from the 2012 Niger demographic and health survey. PLoS One. 2021;16(6):e0252281. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 80.JHPIEGO. monitoring birth preparedness and complication readiness tools and indicators for maternal and newborn health. 2004.
  • 81.Osamor PE, Grady C. Women’s autonomy in health care decision-making in developing countries: a synthesis of the literature. Int J Womens Health. 2016;8:191–202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 82.Erci B. Women’s efficiency in decision making and their perception of their status in the family. Public Health Nurs. 2003;20(1):65–70. [DOI] [PubMed] [Google Scholar]
  • 83.Tsegaye NB. Fertility intention among married women in Ethiopia: a multilevel analysis of Ethiopian demographic health survey 2016. Contracept Reprod Med. 2023;8(1):6. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated during the study are publicly available from the PMA website and/or the Johns Hopkins Research Data Repository: [https://archive.data.jhu.edu/dataverse/root/?q=PMA+Ethiopia+Cohort+one](https://archive.data.jhu.edu/dataverse/root/?q=PMA+Ethiopia+Cohort+one).

Articles from BMC Public Health are provided here courtesy of BMC

RESOURCES