DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2015 No. 118

Robert Wamala

Allen Kabagenyi

Simon Kasasa

September 2015

This document was produced for review by the United States Agency for 

International Development.

Predictors of Time to Contraceptive Use 

from Resumption of Sexual Intercourse 

after Birth among Women in Uganda 

Predictors of Time to Contraceptive Use from Resumption 

of Sexual Intercourse after Birth among Women in Uganda 

Robert Wamala1

Allen Kabagenyi2

 

Simon Kasasa3

ICF International 

Rockville, Maryland, USA 

September 2015 

1

Department of Planning and Applied Statistics, Makerere University 

2

Department of Population, Makerere University 

3

Department Epidemiology and Biostatistics, Makerere University 

Corresponding author: Allen Kabagenyi, Department of Population, Makerere University; email: 

allenka79@yahoo.com
ACKNOWLEDGEMENTS 

We wish to acknowledge the support from USAID through ICF International for funding this project under 

the 2015 DHS fellowship program. We are indebted to the support received from Dr. Sarah Staveteig and 

Dr. Wenjuan Wang, the facilitators of the workshop. Special thanks go to the co-facilitators: Dr. Ann 

Wangui, Dr. Juma Adinan and Mr. Henock G. Yebyo. Thanks to Ms. Kerry MacQuarrie and Dr. Shireen 

Assaf for reviewing this paper. We also thank the editor Bryant Robey for the valuable comments and edits. 

Editor: Bryant Robey 

Document Production: Natalie La Roche 

The DHS Working Papers series is a prepublication series of papers reporting on research in progress that 

is based on Demographic and Health Surveys (DHS) data. This research is carried out with support provided 

by the United States Agency for International Development (USAID) through The DHS Program (#AIDOAA-C-13-00095). The views expressed are those of the authors and do not necessarily reflect the views 

of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about the DHS Program contact: 

DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. 

Phone: +1 301-407-6500; fax: +1 301-407-6501; email: reports@dhsprogram.com; Internet: www. 

dhsprogram.com. 

Recommended citation: 

Wamala, Robert, Allen Kabagenyi, and Simon Kasasa. 2015. Predictors of Time to Contraceptive Use from 

Resumption of Sexual Intercourse after Birth among Women in Uganda. DHS Working Papers No. 118. 

Rockville, Maryland, USA: ICF International. 
iii 

ABSTRACT 

Introduction 

There is an extensive body of literature on family planning and contraceptive use in Uganda. 

However, hardly any documented study has investigated modern contraceptive use in the period 

from resumption of sexual intercourse after birth among women in Uganda. This paper therefore 

provides an analysis of factors associated with time-to-contraceptive use after resumption of sexual 

intercourse among women in the country. 

Methods 

Data for the study come from the 2011 Uganda Demographic and Health Survey (UDHS). The 

assessment was made based on a sample of married women who had a birth in the three years 

preceding the survey and who had resumed sexual intercourse. A time-to-event approach (time 

from resumption of sexual intercourse to starting family planning) was adopted in the analysis 

based on the Kaplan Meier, Log-Rank Chi-square test and Cox Proportional Hazard regression. 

Results 

The median time-to-contraceptive use (19 months, range 0 - 24) after resumption of sexual 

intercourse demonstrates a delayed initiation of family planning. The time to adoption of modern 

contraceptive use was significantly longer among women who delivered at home or with a 

traditional birth attendant (TBA) rather than a health facility, women in the northern region, 

women who had 1-3 antenatal care (ANC) visits instead of the recommended four or more, women 

with no formal education and women in the poorest wealth quintile. 

Conclusions 

Measures for enhancing modern contraceptive use during and after the postpartum period should 

focus on: (i) addressing hindrances in accessing family planning, particularly among poor and noneducated women, (ii) integration of family planning service delivery into routine ANC through 

counseling; and (iii) promoting deliveries in health facilities. 

Keywords: Postpartum, family planning, contraception use 

1 

1. INTRODUCTION 

A considerable proportion of women especially in the developing countries engage in 

sexual relationships after childbirth without using any contraception (Marcolino and Galastro 

2001). In some instances, resumption of sexual intercourse occurs earlier than the six-week period 

of postpartum abstinence recommended by health workers (Anzaku and Mikah 2014; Borda, 

Winfrey, and McKaig 2011). This has been partly attributed to the existing taboos in many subSaharan Africa countries. Worth noting is the fact that abstinence following a birth is widely 

practiced in most communities of the world, yet with varying and/or unpredictable durations 

(Barber 2007; Fakoya 2008). A recent study among postpartum women in Nairobi revealed that 

women resume sexual activity well before their menstruation (Ndugwa et al. 2011). Use of 

contraceptives, however, is delayed in most instances. A study of postpartum women in 17 

developing countries showed that only women who had resumed menstruation used family 

planning (Borda, Winfrey, and McKaig 2011). This evidence demonstrates that these women are 

at a higher risk of unplanned or unwanted pregnancies compared with their counterparts who use 

contraception before resumption of menstruation. Breastfeeding as an alternative to contraceptive 

use would not offer some of these women protection against unwanted pregnancies due to varying 

levels and intensity of breastfeeding (Barber 2007; Bongaarts 1987; Bongaarts and Potter 1983; 

Haggerty and Rutstein 1999; Ullah and Chakraborty 1994). Therefore, it is debatable whether 

breastfeeding can substitute for the use of modern family planning methods during the postpartum 

period. 

The World Health Organization (WHO) reports a global increase in access to and use of 

modern contraception in the recent past (WHO 2014). However, in most developing countries 

levels of contraceptive use have remained persistently low. This has been attributed, among other 

factors, to poor health infrastructure and transportation facilities that hinder access to family 

planning services (Cleland et al. 2006; UNFPA 2012; Yeakey et al. 2009). The situation is 

worsened by the high level of unmet need for family planning in these countries (WHO 2012). 

Studies further reveal that the preferred long-lasting methods of family planning are not always 

readily available in these countries. Particularly, women in the postpartum period are regarded as 

one of the most vulnerable groups of fecund and sexually active women who do not want to have 

another pregnancy but are not using any method of contraception (WHO 2012). In light of these 

shortfalls, particularly among the vulnerable groups, the high fertility rates of women in these 
2 

countries (Hladik 2009) should not be surprising. This has contributed to high levels of maternal 

mortality rates in most sub-Saharan African countries (Tsui, McDonald-Mosley, and Burke 2010). 

For example, Uganda’s maternal mortality rate of 438 maternal deaths per 1,000 births (Uganda 

Bureau of Statistics (UBOS) and ICF International Inc. (ICF) 2012) does not compare favorably 

with the global estimate of 287 maternal deaths per 1,000 births or the Millennium Development 

Goal (MDG) target of 230 deaths per 1,000 births by 2015 (United Nations Department of 

Economic and Social Affairs 2014). 

With the low level of contraceptive uptake (any method), estimated at 30% (UBOS and 

ICF 2012), it is questionable that the country’s maternal mortality situation will improve 

significantly in the near future. In affirming the low level of contraceptive use, Andi et al. (2014), 

citing the 2011 Uganda Demographic and Health Survey (UDHS) (UBOS and ICF 2012), 

demonstrate that the country’s contraceptive prevalence is one of the lowest among countries in 

the East African community. The low uptake leads to an increase in the number of unwanted 

pregnancies, which are usually characterized by short birth intervals. The fact that the country’s 

level of unmet need for family planning, estimated at 34%, is the highest in Eastern Africa (UBOS 

and ICF 2012) worsens further the situation of unwanted pregnancies. In addition, health 

consequences of short birth intervals include but are not limited to neonatal and infant mortality, 

low birth weight and maternal anemia due to postpartum hemorrhage (Cleland et al. 2012; Johnson 

et al. 2006). Therefore, it is not a matter of debate whether or not use of family planning needs to 

be promoted among women in the country. The contentious issue, however, is the timing for the 

initiation of contraception following a birth, for which to date there is limited evidence. 

The subject of contraceptive use is not new in the literature. Recent studies provide insights 

into factors that determine contraceptive use among: (i) women in the postpartum period (Ndugwa 

et al. 2011; Borda, Winfrey, and McKaig 2011), (ii) sexually active women in the reproductive 

age (Andi et al. 2014; Stephenson et al. 2007; Yadav and Dhillon 2015), and (iii) sexually active 

males (Kabagenyi et al. 2014). However, studies are limited in providing an understanding of the 

factors among women particularly after resumption of sexual intercourse following a birth. 

Subsequently, the issue of time-to-contraceptive use after resumption of sexual intercourse from 

birth has been under-investigated. To this end, it is questionable whether the factors influencing 

contraceptive use also hold true for the period after resumption of sexual intercourse following 
3 

birth. Therefore, this paper attempts to provide an understanding of factors associated with timing 

of contraception after resumption of sexual intercourse following a birth. 

1.1 Theoretical Grounding 

The timing of contraception after birth is evaluated in this study based on a series of 

postpartum behaviors and/or events including breastfeeding, postpartum amenorrhea and 

abstinence. Usually, these events do not follow a sequential pattern; initiation of contraception can 

happen any time after birth depending on, among other factors, a mother’s postpartum situation 

and choice of method to be adopted. For example, initiation can precede resumption of sexual 

intercourse where a mother adopts contraception immediately after birth. Likewise, adoption of 

contraception can precede resumption of menses or weaning. 

Similar to contraception, breastfeeding impacts the timing of a subsequent birth; longer 

durations of breastfeeding are associated with increased birth intervals. A debatable aspect, 

however, is whether breastfeeding could be adopted as a substitute for contraceptive use. This is 

mainly on account of varying intensities of breastfeeding among women in various communities. 

In affirming the relevance of breastfeeding in child spacing, the expert group at the 1988 Bellagio 

meeting determined that the maximum birth spacing effect of breastfeeding is achieved when a 

mother fully or nearly fully breastfeeds and remains amenorrheic (Kennedy, Rivera, and McNeilly 

1989). 

Sexual abstinence can also influence the risk of pregnancy in the postpartum period. In a 

scenario where the duration of abstinence goes beyond that of postpartum amenorrhea, postpartum 

sexual abstinence provides contraceptive benefits. Nevertheless, the duration of postpartum sexual 

abstinence varies across communities (Barber 2007; Fakoya 2008). 

Contraceptive use, breastfeeding and resumption of sexual intercourse may be mediated by 

psychological factors and by the socioeconomic and demographic characteristics of women. 

Figure 1 presents a diagrammatic representation of these factors and how they relate to the timeto-contraceptive use after resumption of sexual intercourse following birth. 
4 

Figure 1. Conceptualization of factors associated with time to contraceptive use from resumption 

of sexual intercourse after birth 

The predisposing factors identified in the study by socioeconomic and demographic 

characteristics of individuals are suggested to impact directly on contraceptive use. There exists a 

wide range of literature in Uganda and elsewhere in support of the impact of these factors. The 

debatable aspect, however, is whether or not the literature is supported among contraceptive users 

in the period from resumption of sexual intercourse after birth. 

With regard to socioeconomic factors, contraceptive use has been associated in the 

literature with education level (Andi et al. 2014; Kravdal 2002; Lutalo et al. 2000; Stephenson et 

al 2007; UBOS and ICF 2012), wealth status (Creanga, et al. 2011; Family Health Initiative 2010), 

residence (Andi, et al. 2014; UBOS and ICF 2012), religion (Ntozi et al. 2000; Olaitan 2011), and 

working status. The consensus with regard to residence is that the level of contraceptive use is 

higher among urban residents compared with rural residents. In a recent study of trends and 

patterns of modern contraceptive use among women in Uganda, Andi et al. (2014) affirm that 

shortfalls in accessibility, availability of method choice and affordability are the major causes of 

the low level of family planning use in the rural areas. Given that the northern region of the country 

is predominantly rural, it is not surprising that the region has lower contraceptive prevalence 

compared with the central region, which is predominantly urban. 
5 

Educated women are regarded as having higher odds of modern contraceptive use 

compared with the non-educated (Kravdal 2002; Lutalo et al. 2000; Stephenson et. al. 2007). The 

contentious issues, however, are: (i) whether contraceptive use increases with education level, and 

(ii) the minimum level of education associated with increased odds of contraceptive use. In a study 

of women in six sub-Saharan African countries, secondary or higher education was associated with 

modern contraceptive use (Stephenson et al. 2007). However, this may not be the case in countries 

elsewhere due to variations in characteristics of individuals and their communities. Certainly, 

household wealth plays an important role in promoting contraceptive use because of the cost 

implications associated with its uptake (Andi et al. 2014; Creanga et al. 2011). In their extensive 

review of the literature, Andi et al. (2014) reveal that other costs associated with the services (for 

example, transport) would hinder people from seeking family planning services even if formal fees 

on the service were non-existent or low. Contraceptive use is reported to be twice as likely among 

the wealthiest women compared with the poorest women (Family Health Initiative 2010). 

The literature on family planning use shows that contraceptive use assumes an inverse Ushape relationship with women’s age. Contraceptive use increases up to about the early 30s and 

declines at older ages (Bongaarts and Potter 1983; Stephenson et. al. 2007). Pertaining to parity, 

Andi et al. (2014) affirm that contraceptive use is more likely among women with a higher number 

of surviving children. 

Discussion of the role of enabling factors in enhancing the use of family planning goes 

back to the early 1990s (Andersen 1995). In a model of health care utilization, Andersen argues 

that the presence or absence of these factors would promote or hinder use of health care. Among 

the reasons why women who do not want to get pregnant do not use contraception are opposition 

from partners and poor access to and quality of family planning services (Robey, Ross, and 

Bhushan 1996; Ross and Winfrey 2001). 

7 

2. DATA AND METHODS 

2.1 Data Source 

The study was based on data from the 2011 Uganda Demographic and Health Survey 

(UDHS) (UBOS and ICF 2012). This cross-sectional survey follows previous DHS surveys in 

2006, 2000 1995 and 1988. The survey compiled data using questionnaires for households, women 

and men. This study was based on data from the Woman’s Questionnaire, which was administered 

to all women age 15-49 in the selected households. A nationally representative sample of 8,624 

women was obtained based on a two-stage cluster sampling. The first and second stages involved 

the selection of the clusters and households in each cluster, respectively. Further, stratification by 

rural-urban areas was taken into account. The sample excluded: (i) women with no births in the 

past three years preceding the survey (n = 4,632); (ii) women who were not in a marital union (n 

= 582) and those whose last birth was not within a union (n = 63); and (iii) women who had not 

resumed sexual intercourse by the time of the survey (n = 434). Thus, contraceptive use was 

investigated using a sample of married women with a birth in the past three years preceding the 

survey who had resumed sexual intercourse (n = 2,983). The study’s focus on women in union was 

based on the indicators of assessing family planning, including contraceptive prevalence and 

unmet need (WHO 2012). The study focused on women who had initiated sexual intercourse 

during the postpartum period because they are at risk of getting pregnant. Figure 2 illustrates how 

the weighted sample used in the study was derived. 
8 

Figure 2. Derivation of weighted sample adopted in the investigations 

2.2 Variables and Their Measurements 

The study assessed time-to-contraceptive use, estimated in months, by the period from 

resumption of sexual intercourse following a birth to the time when a woman used modern 

contraception. The period is recorded using a non-negative integer value between 0 and 24, where 

the value zero denotes women who initiated contraception either before or at the same time as 

resumption of sexual intercourse. The time-to-contraceptive use was compiled from contraceptive 

calendar data containing information about births, pregnancies and contraceptive use in the five 

years preceding the survey. The calendar provides retrospective month-by-month experience of 

each surveyed woman with regard to aspects of reproductive health (Bradley et al. 2012). Reasons 

for discontinuation of each contraceptive method used also are included in the full calendar. 

In this study, postpartum contraceptive use was assessed based on the two-year minimum 

period recommended by WHO before stopping contraception to become pregnant (WHO 2007). 

Nevertheless, some women were not using modern contraception (any method) at the time of the 
9 

study. A status variable, denoted by a value of zero (0), was generated to represent these women. 

Otherwise, the women were represented by a status value of one (1). As earlier indicated, the 

independent variables considered in the investigations were: (i) demographic characteristics of 

women, namely age and marital status, (ii) socioeconomic characteristics, namely education level, 

wealth status, region, residence and working status; (iii) child characteristics, namely sex, birth 

order and type of birth (single or multiple); and (iv) enabling factors, namely women’s 

empowerment, mode of delivery (normal or Caesarean birth), place of delivery (public, 

government and other), number of antenatal care (ANC) visits, breastfeeding and exposure to 

media. 

Worth noting are the generated variables, namely empowerment and exposure to media. 

An index of women’s empowerment was generated based on the survey data on decision-making 

about health, household purchases, visits to family or relatives, and woman’s earnings. Each of 

these aspects was recorded using a binary outcome i.e. whether or not a woman was involved in 

decision-making, denoted by codes one (1) and zero (0), respectively. Using these, the index was 

generated using factor analysis and was later divided into three levels—high, medium and low. 

Likewise, exposure to media was evaluated using a binary outcome—whether or not a woman was 

exposed regularly (at least once a week) to any type of media, namely newspapers, radio or 

television. With regard to region, the variable was converted from the 10 conventional DHS 

classifications to four groups, namely Central (Kampala, Central 1 and Central 2), East (East 

Central and Eastern), North (North, Karamoja and West Nile) and West (Western and South West). 

2.3 Data Analysis 

The analysis was made using STATA 13.1 at three stages: First, a descriptive summary of 

women by their socioeconomic and socio-demographic characteristics was made, using frequency 

distributions. An assessment of the time-to-contraceptive use from resumption of sexual 

intercourse after birth was made using life tables based on the Kaplan-Meier estimate. Second, 

differentials in the time-to-contraceptive use were investigated by socioeconomic and 

demographic characteristics of women as well as child and enabling factors, using the Log-Rank 

Chi-square test. The purpose of the assessment was to select variables for further analysis at the 

subsequent stage. All variables with a relatively high probability value (p > 0.25) were excluded 

from the analysis at the subsequent stage unless otherwise indicated. Third, the predictors of the 
10 

time-to-contraceptive use were investigated using a Cox-Proportional Hazard regression (CoxPH). The time-to-event approach adopted in the study is able to deal with women irrespective of 

whether or not they had used modern contraception by the time of the study. In light of the multistage design adopted in the selection of the respondents, sampling weights were applied in the 

analysis to ensure representativeness across the country and to correct for non-responses, stratified 

by regions and residence (UBOS and ICF 2012). The appropriateness of using the fitted Cox-PH 

regression in modeling time-to-contraceptive use was investigated using a link specification test. 

Further, assessment of multicollinearity was carried out using the Coldiag regression collinearity 

diagnostic procedure (Belsley, Kuh, and Welsch 1980). Using the diagnostic test, based on a 

matrix of independent variables, a condition number of 30 or higher is associated with collinearity 

problems. Subsequently, large variance decomposition portions (50% or more) between any two 

or more variables would suggest collinearity problems. 
11 

3. RESULTS 

The subsequent sections present results on characteristics of women, time-to-contraceptive 

use and predictors of time-to-contraceptive use. As earlier indicated, the assessment was based on 

married women who had resumed sexual intercourse after birth. 

3.1 Characteristics of Women 

Table 1 presents a distribution of the women by their socioeconomic and demographic 

characteristics as well as enabling factors. 
12 

Table 1. Distribution by women’s characteristics and predisposing factors 

Characteristics n=2983 Percentage (%) 

Age 

15-19 178 6.0

20-29 1661 55.7 

30-39 958 32.1

40-49 186 6.2 

Education level 

None 414 13.9 

Primary 1905 63.9

Secondary 664 22.3 

Residence 

Urban 408 13.7 

Rural 2575 86.3 

Wealth status 

Lowest 604 20.3

Second 673 22.6 

Middle 613 20.6 

Fourth 531 17.8

Highest 562 18.8 

Religion 

Catholic 1200 40.2 

Protestant 892 29.9

Muslim 386 12.9 

Pentecostal 398 13.4

Other 107 3.6 

Region 

Central 791 26.5 

East 825 27.7

North 381 12.8 

South 986 33.1 

Working status 

Not working 630 21.1

Working 2353 78.9 

Type of birth 

Normal 2813 94.3 

Caesarean 170 5.7 

Place of delivery 

Public 1,342 45.0

Private 424 14.2 

TBA/Home 1,217 40.8 

Number of ANC visits 

None 163 5.5

1-3 1395 46.8 

4++ 1425 47.8 

Type of birth 

Single 2,924 98.0

Multiple 59 2.0 

Sex of child 

Male 1,492 50.0 

Female 1,491 50.0 

Breastfeeding 

Not Breastfeeding 1,189 39.9

Breastfeeding 1,794 60.1 

Birth order 

First 367 12.3 

2-3 939 31.5

4-5 743 24.9 

6++ 934 31.3 

Empowerment 

Low 1,141 38.2

Medium 1,273 42.7 

High 569 19.1 

Exposure to media 

No exposure 669 22.4

At least one regularly 2,314 77.6 

Note: Estimates are based on weighted scores 
13 

The women assessed in the study were predominantly rural residents (86%), with primary 

(64%) as their highest level of education attained. Forty percent of the women were Catholics, 

while the rest were Protestants (30%), Muslims (13%), Pentecostals (13%) and other religious 

affiliations (4%). With regard to age, the majority of women (56%) were in their 20s, while about 

one-third (32%) were in their 30s, with the rest either below age 20 (6%) or age 40 or older (6%). 

No major variations were noted in the distribution of women with regard to their wealth status. 

Among regions, the highest proportion of women lived in the South (33%), followed by Central 

(27%), East (28%) and North (13%). Nearly eight in every ten women (79%) reported working. 

With regard to the enabling factors, nearly all women (94%) had normal birth delivery; the 

highest proportion of women had deliveries in public facilities (45%) and the lowest proportion in 

private facilities (14%), with the rest delivering elsewhere, whether at home or with a traditional 

birth attendant (TBA). Slightly less than a half of the women (48%) had the recommended number 

of four or more ANC visits, and 47% had 1-3 visits. With regard to breastfeeding, nearly twothirds of women (60%) were breastfeeding at the time of the survey. Nearly eight in every ten 

women (78%) were exposed regularly to at least one form of media, comprising newspapers, radio 

and television. 

Pertaining to child characteristics, Table 1 shows a similar proportion of males and females. By 

birth order, the highest proportion of children were either second or third born (32%), followed 

closely by birth order six or higher (31%), while 25% were birth order 4-5 and 12% were firstborn.

3.2 Time-to-Contraceptive Use 

A total of 1,072 (36%) out of the 2,983 women assessed in the study used a modern 

contraceptive method by the date of interview. Figure 3 presents the distribution of the timing of 

contraception for women who used modern contraception. The figure shows that women initiated 

contraception at three stages: (i) before resumption of sexual intercourse, denoted by negative time 

values (n = 179); (ii) at resumption of sexual intercourse, represented by time zero (n = 135); and, 

(iii) after resumption of sexual intercourse, represented by positive time values (n = 758). 
14 

Figure 3. Distribution by timing of contraception based on resumption of sexual intercourse 

Table 2 presents a life table showing the timing of contraceptive use after resumption of 

sexual intercourse following birth of the most recent child. 

0

2

4

6

8 10

Percent

-20 -10 0 10 20

Time [Months]
15 

Table 2. Timing of contraceptive use after resumption of sexual intercourse 

Time (months) Total FP a Censored Std. Err Survival 

0 2983 314 80 0.0565 0.8934 

1 2589 152 139 0.0464 0.8395 

2 2298 66 119 0.0436 0.8149 

3 2114 75 97 0.0409 0.7853 

4 1942 50 90 0.0394 0.7647 

5 1802 54 116 0.0381 0.7410 

6 1632 28 86 0.0375 0.7278 

7 1518 51 101 0.0365 0.7026 

8 1367 32 93 0.0360 0.6858 

9 1242 27 91 0.0357 0.6702 

10 1123 38 64 0.0354 0.6469 

11 1022 26 76 0.0352 0.6301 

12 920 24 79 0.0352 0.6129 

13 817 22 68 0.0352 0.5960 

14 728 27 56 0.0354 0.5733 

15 646 27 65 0.0358 0.5483 

16 554 18 67 0.0363 0.5294 

17 468 5 59 0.0365 0.5239 

18 405 12 65 0.0374 0.5064 

19 327 9 50 0.0385 0.4916 

20 269 7 60 0.0400 0.4766 

21 201 8 57 0.0432 0.4545 

22 136 2 64 0.0460 0.4436 

23 69 0 48 0.0460 0.4436 

24 21 0 21 0.0460 0.4436 

Notes: Zero (0) denotes women who initiated contraception either before or at resumption of sexual intercourse; a denotes use of 

modern contraception. 

Results in Table 2 reveal an upward trend in the proportion of women using contraception 

after resumption of sexual intercourse following birth. The number using modern contraception 

before or during the time of resumption of sexual intercourse (n =314) denotes a proportion of 

11%. Subsequently, the proportions of women using contraception during the first (n = 466), 

second (n = 532) and third month (n = 607) after resumption of sexual intercourse following birth 

are 16%, 18% and 20%, respectively. The median time-to-contraceptive use from resumption of 

sexual intercourse following birth is about 19 months (range 0–24 months). This estimate is 

influenced by a relatively large proportion of women (64%) who did not use contraception after 

resumption of sexual intercourse by the time of the study. An attempt to provide an estimate of the 

central tendency only among women who used modern contraception would provide results biased 

towards the earlier months. 

3.3 Differentials in Time-to-Contraceptive Use 

Differentials in time-to-contraceptive use were assessed by socioeconomic and 

demographic characteristics of women as well as child and enabling factors. As earlier indicated, 

the purpose of the assessment was to select variables for further analysis at the multivariable stage, 
16 

i.e. variables with a relatively small probability value (p < 0.25). Table 3 presents results of the 

assessment. 

Table 3. Differentials in time-to-contraceptive use 

Independent variables p-value 

Age 15.70 0.0013 

Education level 182.87 0.0000 

Residence 111.25 0.0000 

Wealth status 191.91 0.0000 

Religion 14.52 0.0058 

Region 111.79 0.0000 

Empowerment 5.56 0.0722 

Number of ANC visits 11.85 0.0027 

Place of delivery 71.30 0.0000 

Type of delivery 13.75 0.0002 

Working status 2.60 0.1066 

Breastfeeding 3.74 0.1539 

Exposure to media 48.18 0.0000 

Sex of child 0.69 0.4049 

Type of birth 0.00 0.9792 

Birth order 49.14 0.0000 

With the exception of child characteristics, namely type of birth and sex of child, Table 3 

shows that the rest of the variables assessed were eligible for inclusion at the multivariable stage 

(p < 0.25). However, birth order was excluded from the analysis at the subsequent stage, despite 

being significantly associated with the odds of contraceptive use, based on the results of the Logrank test in Table 3. The exclusion was based on the fact that the variable made only a minimal 

contribution to the final model when adjusted for all the independent variables studied. 

The illustrations in Figures 4-6 provide insights into the nature of associations between 

selected variables and timing of adoption of modern contraception after resumption of sexual 

intercourse following a birth. 

2 χ
17 

Figure 4. Survivorship by education level 

Figure 5. Survivorship by place of delivery 0.00 0.25 0.50 0.75 1.00 Survival

0 5 10 15 20 25

Time [Months]

None Primary

Post-primary

Kaplan-Meier survival estimates

0.00 0.25 0.50 0.75 1.00

Survival

0 5 10 15 20 25

Time [Months]

Public Private

TBA/Home

Kaplan-Meier survival estimates
18 

Figure 6. Survivorship by ANC attendance 

Figures 4-6 show delayed initiation of modern contraceptive use after resumption of sexual 

intercourse following a birth among women with no education compared with women with 

primary or post-primary education. Women who gave birth at home or assisted by a TBA had 

delayed initiation of modern contraceptive use compared with women delivering in a health 

facility. Women who attended 1-3 ANC visits had delayed initiation compared with women who 

attended the recommended four or more visits. However, these findings must be verified after 

adjusting for the rest of the variables at the multivariate analysis stage. 

3.4 Predictors of Time-to-Contraceptive Use 

Table 4 presents results of unadjusted and adjusted hazards for the odds of contraceptive 

use by selected socioeconomic and demographic characteristics, as well as enabling factors. The 

unadjusted hazard ratios denote analysis on each of the independent variables by the timing of 

contraceptive use. The results provide insights into the changes in the impact of the variables when 

all variables are controlled for. 0.00 0.25 0.50 0.75 1.00 Survival

0 5 10 15 20 25

Time [Months]

None 1-3

4++

Kaplan-Meier survival estimates
19 

Table 4. Multivariable analysis of time-to-contraceptive use after resumption of sexual intercourse 

Characteristics 

Hazard Ratio (95% CI) 

Unadjusted Adjusted 

Age 

15-19† 1.00 .

20-29 0.93 (0.63 - 1.46) 0.93 (0.63 - 1.38) 

30-39 0.80 (0.54 - 1.17) 0.81 (0.54 - 1.20) 

40-49 0.64 (0.37 - 1.08) 0.77 (0.44 - 1.37) 

Education level 

None † 1.00 1.00 

Primary 2.25 (1.57 - 3.23)** 1.83 (1.25 - 2.68)** 

Post-primary 4.61 (3.09 - 6.89)** 2.66 (1.66 - 4.26)** 

Residence 

Urban † 1.00 1.00 

Rural 0.43 (0.34 - 0.54)** 0.81 (0.59 - 1.11) 

Religion 

Catholic † 1.00 1.00 

Protestant 1.17 (0.96 - 1.41) 1.05 (0.85 - 1.29) 

Muslim 1.22 (0.88 - 1.69) 0.82 (0.60 - 1.10) 

Pentecostal 1.14 (0.82 - 1.57) 0.99 (0.73 - 1.36) 

Other 1.28 (0.83 - 1.98) 1.14 (0.75 - 1.73) 

Wealth status 

Poorest† 1.00 . 

Poorer 1.31 (1.02 - 1.68)* 1.10 (0.84 - 1.44)

Middle 1.71 (1.28 - 2.28)** 1.30 (0.96 - 1.78) 

Richer 1.74 (1.31 - 2.32)** 1.18 (0.86 – 1.63) 

Richest 3.44 (2.59 - 4.58)** 1.56 (1.05 – 2.32)* 

Region 

Central † 1.00 1.00 

East 0.63 (0.48 - 0.82)** 0.85 (0.64 - 1.13) 

North 0.35 (0.26 - 0.48)** 0.56 (0.40 - 0.78)** 

South 0.56 (0.43 -0.72)** 0.80 (0.60 - 1.05) 

Exposure to media 

No exposure 1.00 1.00 

At least one regularly 1.63 (1.30 - 2.06)** 1.17 (0.92- 1.49) 

Empowerment 

Low 1.00 1.00 

Medium 0.89 (0.75 - 1.07) 0.93 (0.78 - 1.12) 

High 1.05 (0.83 - 1.32) 1.08 (0.83 - 1.40) 

Place of delivery 

Government † 1.00 1.00 

Private 1.13 (0.81 - 1.56) 0.97 (0.73 - 1.30) 

TBA/Home 0.59 (0.48 - 0.74)** 0.75 (0.60 - 0.93)* 

ANC visits 

4 or more † 1.00 1.00 

1-3 0.73 (0.62 - 0.87)** 0.83 (0.70 - 0.98)* 

None 1.25 (0.90 - 1.74) 1.27 (0.92 - 1.75) 

Breastfeeding status 

Not Breastfeeding † 1.00 1.00 

Breastfeeding 1.00 (0.84 - 1.19) 1.10 (0.92 – 1.32) 

Working status 

Not working † 1.00 1.00 

Working 0.87 (0.72 – 1.04) 0.99 (0.82 – 1.19) 

Type of delivery 

Normal † 1.00 1.00 

Caesarean 1.33 (0.93 – 1.90) 0.79 (0.55 – 1.15) 

Birth order 

1st† 1.00 .

2-3 1.07 (0.81 - 1.41) . 

4-5 0.76 (0.57 - 1.00) . 

6++ 0.59 (0.45 - 0.78)** .

Type of birth 

Single† 1.00 .

Multiple 0.78 (0.39 – 1.53) . 

Sex of child 

Male † 1.00 . 

Female 1.09 (0.92 – 1.30) . 

Notes: Assessment is based on weighted data; where n = 2,889, F = 7.85, p < 0.001; hat-statistic = 

0.992, p = 0.00; hat-square = -.034, p = 0.711 
20 

3.5 Regression Diagnostics 

Table 5 presents results of the link specification test for the Cox-PH model fitted in Table 

4. As stated earlier, the assessment evaluates the appropriateness of using the model in the analysis 

of contraceptive use. 

Table 5. Results of specification test of fitted model 

Results of the specification test shows that the model was well specified as predicted by 

the Hat-statistic (p < 0.05). Results of the Hat-square statistic do not reveal otherwise regarding 

the appropriateness of using the fitted model (p > 0.05). Particularly, the Hat-square statistic 

demonstrates that any additional variables do not have much explanatory power. The fact that the 

proportionality hazard assumption is a specification test (Cleves 2008) demonstrates that the model 

has chosen an appropriate specification for the covariates. On the other hand, the conditioning 

number of 14.5 derived from the Coldiag regression collinearity diagnostic test implies no multicollinearity problems with the independent variables adopted in the investigations (Belsley, Kuh, 

and Welsch 1980). 

3.6 Summary of Results 

After adjusting for all the variables adopted in the analysis, the characteristics of women 

that were associated with the time-to-contraception use after resumption of sexual intercourse were 

household wealth, region and education level (p < 0.05). The odds of contraceptive use were about 

56% (HR = 1.56) higher for women in the richest wealth quintile compared with the poorest 

quintile. This implies that women in the richest wealth quintile had a shorter time to adoption of 

modern contraception compared with those in the poorest quintile. Regarding highest education 

attained, women with primary (HR = 1.83) and secondary (HR = 2.66) education were associated 

with higher odds of contraceptive use after resumption of sexual intercourse compared with 

women with no education. This implies that women with primary and secondary education had a 

shorter time to adoption of contraception compared with women who had no formal education. A 

similar pattern was demonstrated by the findings based on the unadjusted ratios. 

Statistic Coef. Std. Err p-value 

Hat 1.029 0.113 0.000 

Hat-square -0.353 0.091 0.700 
21 

Women in the northern region of the country had 44% lower odds of contraceptive use 

after resumption of sexual intercourse compared with women in the central (HR = 0.56). In other 

words, women in the northern region had a longer time to adoption of modern contraception 

compared with their counterparts in the central region. 

After adjusting for all the covariates, the enabling factors that were significantly associated 

with time-to-contraceptive use after resumption of sexual intercourse were ANC attendance and 

place of delivery (p < 0.05). Delivery with a TBA or at home was associated with 25% lower odds 

of contraceptive use after resumption of sexual intercourse compared with deliveries in 

government health facilities (HR = 0.75). This implies that women who delivered at a government 

health facility had a shorter time-to-adoption of modern contraception compared with births at 

home/TBA. Regarding ANC, women who attended 1-3 visits were associated with lower odds of 

contraceptive use after resumption of sexual intercourse compared with women who attended the 

recommended number of four or more visits (HR = 0.83). This implies that women who attended 

four or more ANC visits had a shorter time-to-contraceptive use compared with those attending 1-

3 visits. A similar pattern was demonstrated by the findings based on the unadjusted ratios. 

No significant impact on the odds of contraceptive use was noted in the results by the rest 

of the factors, namely age, empowerment, exposure to media, type of delivery (whether or not by 

Caesarean), woman’s working status and breastfeeding (p > 0.05). 

23 

4. DISCUSSION 

This study analyzed data from the 2011 UDHS using the contraception calendar to 

investigate the timing of contraceptive use after resumption of sexual intercourse following a birth. 

The findings show a low level of modern contraceptive use after resumption of sexual intercourse 

following a birth. The results regarding the timing of adoption of contraception reveal a delay in 

the initiation of contraceptive use after resumption of sexual intercourse, which suggests that a 

considerable proportion of woman in Uganda are at a high risk of unwanted or unplanned 

pregnancies. The issue of unwanted pregnancies is worsened by the country’s high level of unmet 

need for family planning (UBOS and ICF 2012). To this end, it should not be surprising that the 

country has one of the highest fertility rates in sub-Saharan Africa and elsewhere (United Nations 

2013; United Nations 2008). 

The predictors of the time-to-contraceptive use after resumption of sexual intercourse 

following a birth are identified in the study as household wealth, region, education, number of 

ANC visits and place of delivery. Regarding household wealth, the study reveals a shorter timeto-contraceptive use among women in richest quintile compared with the poorest. The findings are 

in agreement with studies that show higher levels of modern contraceptive use among the 

wealthiest women (Creanga et al. 2011; Kayembe et al. 2006; Nakayiza, Wamala, and Kwagala 

2014). These studies attribute the low level of contraceptive use among poor women mainly to the 

costs associated with the services. Further, the studies reveal that other costs associated with the 

services could influence contraceptive use even where fees on the contraception are non-existent. 

One could therefore conclude that the delayed initiation of contraception among the poor women 

is an issue of the costs. To this end, it should not be surprising that unmet need for family planning 

has persistently remained high among poor women. The fact that the northern region is 

predominantly rural gives credence to the argument that the delayed adoption of modern 

contraception among women in the region is, among other factors, an issue of costs associated 

with the services. 

Our findings are in agreement with studies elsewhere that have identified education as a 

predictor of family planning use (Andi et al. 2014; Kravdal 2000; Polis et al. 2011; Riyami, Afifi, 

and Mabry 2004). The finding that contraceptive prevalence is higher among educated women 

compared with non-educated women, however, does not imply that contraceptive use increases 

only with education. A study by Stephenson et al. (2007) on modern contraception among women 

in six sub-Saharan African countries revealed that post-primary education was associated with 

increased odds of modern contraceptive use but the study also arrives at the same conclusion 
24 

among women with primary education. This evidence implies that the minimum level of education 

associated with contraceptive use may vary across countries and regions. 

The longer time-to-contraceptive use among women who delivered at home/TBA 

compared with those who delivered at public health facilities underscores the role played by health 

institutions in promoting family planning use in Uganda. Public and private health facilities 

(hospitals, health centers and clinics) are the major sources of contraception in the country. In light 

of the fact that about six in every ten women (57%) in the country deliver at health facilities 

(Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012), there is a strong need to 

promote programs that target women who do not deliver at health facilities as a measure to promote 

contraceptive use. Examples include the Community Based Distribution (CBD) program aimed at 

bringing family planning services closer to the intended users, satellite clinics, and employer-based 

programs (Malarcher et al. 2010; Nakayiza Wamala, and Kwagala 2014; Stanback, Mbonye, and 

Bekiita 2007). CBD is particularly important in enhancing access to reproductive health services 

among the rural communities. 

In a recent study on family planning advice and contraceptive use, Yadav and Dhillon 

(2015) show that use of critical maternal health services (ANC, institutional delivery and postnatal 

care) encourages subsequent contraceptive use. In our study, the longer time-to-contraceptive use 

observed among women who attended 1-3 ANC visits compared with those who attended the 

recommended four or more visits supports this finding. Thus, strengthening the integration of 

family planning into ANC services (Birungi and Onyango-Ouma 2006; Rutaremwa et al. 2015; 

Yadav and Dhillon 2015) would certainly go a long way in promoting modern contraceptive use, 

particularly during the postpartum period. 

In conclusion, the findings provide evidence about the factors associated with time to 

contraceptive use after resumption of sexual intercourse following a birth. However, the findings 

should be interpreted in light of the following limitations, based mainly on the fact that the study 

used cross-sectional data: (i) all the women were not followed up for a full length of the two-year 

period; (ii) it is highly likely that women who used contraception after resumption of sexual 

intercourse were under-represented; (iii) the analysis does not account for time-varying covariates 

such as education level and household wealth. Further, the investigations were limited to women’s 

most recent birth in the three years preceding the survey. 
25 

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