Rural-Urban Differences in the Association Between Reproductive Coercion and Postpartum Family Planning

Access to timely postpartum family planning (PPFP) helps safeguard women's reproductive autonomy and supports healthy birth spacing, yet little is known about how reproductive coercion (RC) shapes women's ability to initiate contraception after childbirth. We analyzed prospective cohort data from 1,481 pregnant Ethiopian women followed for 12 months postpartum between 2021 and 2023. Time (in months) to contraceptive uptake by pre-pregnancy RC exposure and residence was assessed using Kaplan-Meier estimators and parametric survival models. Approximately one in seven women experienced pre-pregnancy RC, and, overall, 46.7 percent adopted a modern contraceptive method within 12 months postpartum. Overall differences in PPFP uptake were modest, but residence significantly modified this relationship. Rural women who experienced RC initiated postpartum contraception later and had a 40 percent lower hazard of initiating postpartum contraception compared to unexposed rural women (adjusted hazard ratio: 0.60, 95 percent confidence interval 0.37-0.98), while no significant association was observed among urban women. Urban women initiated PPFP more rapidly than rural women, regardless of RC exposure. These findings suggest that the effects of RC extend beyond pregnancy and are shaped by the wider structural context, particularly in rural settings where access to contraception may be limited. Recognizing RC as part of the PPFP context is essential for designing programs and health systems responses that support women to realize their reproductive goals and address interpersonal and structural barriers to timely contraceptive use.