Assessing the association between a postpartum intrauterine device intervention and perceived pressure to adopt contraception in Sri Lanka

Brooke W Bullington; Katherine Tumlinson; Leigh Senderowicz; Joanna Maselko; Kavita Shah Arora; Jessie K Edwards; Audrey Pettifor

doi:10.1016/j.contraception.2025.111242

Assessing the association between a postpartum intrauterine device intervention and perceived pressure to adopt contraception in Sri Lanka

Contraception. 2025 Oct 1:111242. doi: 10.1016/j.contraception.2025.111242. Online ahead of print.

Authors

Brooke W Bullington¹, Katherine Tumlinson², Leigh Senderowicz³, Joanna Maselko⁴, Kavita Shah Arora⁵, Jessie K Edwards⁶, Audrey Pettifor⁴

Affiliations

¹ Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States; Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, United States. Electronic address: brooke.bullington@hsc.utah.edu.
² Carolina Population Center, University of North Carolina, Chapel Hill, NC, United States; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States.
³ Department of Gender and Women's Studies, University of Wisconsin, Madison, WI, United States; Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, United States.
⁴ Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States; Carolina Population Center, University of North Carolina, Chapel Hill, NC, United States.
⁵ Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States.
⁶ Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States.

PMID: 41043539
DOI: 10.1016/j.contraception.2025.111242

Abstract

Objective(s): Traditional measures of success in family planning research focus on contraceptive uptake and use. Scholars have increasingly challenged these outcomes, calling for rights-based, person-centered measures that capture whether individuals can fulfill their reproductive preferences or desires. We sought to evaluate a family planning program using a novel, person-centered measure of perceived pressure to adopt contraception.

Study design: We use secondary data collected as part of the Postpartum Intrauterine Device (PPIUD) Study, a step-wedged, cluster-randomized trial of a provider-focused PPIUD intervention conducted in Sri Lanka from 2015 to 2018. We used logistic regression to assess the association between the PPIUD intervention and perceived pressure to adopt contraception at 18-month follow-up and converted estimates into risk differences.

Results: About 18 months following the PPIUD intervention, 13% of participants were not using contraception, most (82%) were using contraception and did not report feeling pressured to adopt their method, and 5% were using contraception and did report feeling pressured. While the PPIUD intervention was associated with increased contraceptive use, it was also associated with increased perceived pressure to adopt contraception (risk difference comparing intervention and control group: 4.5%; 95% confidence interval: -2.7%, 11.7%). Perceived pressure to adopt contraception was higher among IUD users compared to users of other contraceptive methods.

Conclusion: While expanding access to contraceptive methods - including the IUD - is imperative to promote choice in contraceptive decision-making, our findings highlight the importance of evaluating interventions not just based on use or uptake of specific contraceptive methods, but also using person-centered outcomes that capture reproductive autonomy.

Implications: Evaluating family planning programs solely on contraceptive use overlooks critical aspects of reproductive autonomy. We find that a postpartum IUD intervention in Sri Lanka was associated with increased contraceptive use but also increased perceived pressure to adopt contraception. Our findings emphasize the importance of assessing programs using rights-based, person-centered measures.

Keywords: Autonomy; Choice; Intrauterine device (IUD); Long-acting reversible contraception (LARC); Postpartum.