INTRODUCTION

The postpartum period, defined as the first 6–8 weeks after delivery, carries a high risk of unintended pregnancy due to unpredictable return to fertility and early resumption of sexual activity (Shiferaw et al., 2023). Postpartum family planning focuses on preventing unintended and closely spaced pregnancies in the first 12 months following childbirth (World Health Organization, 2005).

The immediate postpartum intrauterine device (PPIUD) is a form of contraception placed in the uterus within 48 hours of placental delivery (Guye et al., 2023). It is safe, highly effective (99.2–99.8% in the first year), and reversible (Geda et al., 2021).

The immediate postpartum period is optimal for insertion as women are motivated to adopt family planning methods (Kanakuze et al., 2020). Infant mortality could be reduced by 10% and under-five child mortality by 21% if women wait at least two years between pregnancies (Silesh et al., 2023).

Globally, an estimated 214 million women of reproductive age in low-income countries wish to avoid pregnancy but are not using modern contraceptives (Kanakuze et al., 2020), leading to approximately 121 million unintended pregnancies annually (Rosa Bolling et al., 2023). In East and Southeast Asia, 18.6% of women choose PPIUD, while uptake in the United States is 6 per 10,000 deliveries (Rosa Bolling et al., 2023). In Africa, rates vary from 0.9% in Tanzania to 22.1% in some settings (Rosa Bolling et al., 2023).

In Kenya, the FIGO initiative to institutionalize PPIUD (2014–2017) reported uptake of approximately 2.4% (Kirigia et al., 2019). A study at Meru Hospital found low uptake of 3.4%, attributed to sociodemographic factors and untimely counselling (Kirigia et al., 2019). Conversely, a tertiary facility in Embu reported 47% uptake after intensive antenatal counselling (Rosa Bolling et al., 2023).

At Coast General Teaching and Referral Hospital (CGTRH), the factors influencing PPIUD uptake have not been investigated. This study aimed to determine the prevalence and factors associated with PPIUD uptake among women delivering at CGTRH, Mombasa, Kenya.

METHODS

Study Design and Setting

This hospital-based cross-sectional study was conducted from January 2025 to June 2025 at the postnatal ward of maternity unit of a tertiary referral hospital in coastal Kenya. The study site is a county teaching and referral hospital handling approximately 7,000 deliveries annually, with a 154-bed maternity unit.

Study Population and Sampling

The study population comprised women who delivered vaginally at the facility. Consecutive sampling was employed to enrol eligible women within 48 hours postpartum. Using a single proportion formula with an expected prevalence of 45% from a previous study (Ndegwa et al., 2014), a sample size of 380 was calculated. To account for potential non-response, 431 women were ultimately enrolled.

Inclusion and Exclusion Criteria

Women aged ≥18 years who delivered vaginally and met the WHO Medical Eligibility Criteria (MEC) for IUD insertion were included. Those who delivered by caesarean section, refused participation, or did not meet WHO MEC criteria were excluded.

Data Collection

A structured, pretested, investigator-administered questionnaire was used to collect data on demographic characteristics, reproductive factors, family social factors, knowledge and awareness, and willingness to accept PPIUD. The questionnaire was available in English and Kiswahili. Data were collected by the principal investigator and three trained research assistants.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 28. Descriptive statistics were summarized as frequencies, percentages, means, and standard deviations. Bivariate and multivariate logistic regression analyses were performed to identify factors associated with PPIUD uptake. Variables with p < 0.20 in bivariate analysis were included in the multivariate model. A p-value < 0.05 was considered statistically significant.

Reporting Guidelines

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Ethical Considerations

Ethical approval was obtained from the institutional ethics review committee. Written informed consent was obtained from all participants. Confidentiality was maintained by anonymizing data and restricting access to study records.

RESULTS

Participant Characteristics

A total of 431 women participated in the study. The mean age was 26.87 years (SD = 5.77; range 18–42). Most participants were married (76.8%, n = 331), and the majority resided in Mombasa County (96.8%, n = 417).

Educational attainment was predominantly secondary (42.5%, n = 183) and primary (35.5%, n = 153). Religious affiliation included Protestant (29.2%, n = 126), Islam (27.6%, n = 119), Catholic (19.3%, n = 83), and SDA (9.3%, n = 40). Most participants were unemployed (73.1%, n = 315) (Table 1).

Table 1.Socio-demographic Characteristics of Women Delivering at a Tertiary Referral Hospital in Coastal Kenya (N = 431)
Variable Category n (%)
Age (years) Mean (SD), 95% CI 26.87 (5.77), (26.33–27.41), range 18-42
County Mombasa 417 (96.8)
Kilifi 11 (2.6)
Kwale 1 (0.2)
Lamu 1 (0.2)
Nairobi 1 (0.2)
Education level Primary 153 (35.5)
Secondary 183 (42.5)
College 60 (13.9)
University 9 (2.1)
None 26 (6)
Marital status Married 331(76.8)
Single 86 (20)
Divorced 14 (3.2)
Religion Protestant 126 (29.2)
Islam 119 (27.6)
Catholic 83 (19.3)
Other 63 (14.6)
SDA 40 (9.3)
Employment Status Unemployed 315 (73.1)
Self-employed 70 (16.2)
Employed 46 (10.7)

Reproductive Characteristics

Participants had a mean of 2.40 pregnancies (SD = 1.60) and 2.25 living children (SD = 1.39). The desired number of children averaged 3.38 (SD = 1.41). Most pregnancies were planned (61.7%, n = 266). Prior family planning (FP) use was reported by 56.6% (n = 244), with injectables (42.1%) and implants (38.3%) being the most common methods. A majority desired another child (59.4%, n = 256). Antenatal care (ANC) attendance was high, with 84.9% (n = 366) attending more than twice (Table 2).

Table 2.Reproductive Characteristics of Women Delivering at a Tertiary Referral Hospital in Coastal Kenya (N = 431)
Variable Category n (%)
Gravidity Mean (SD) 2.4 (1.6), range 1-11
Living Children Mean (SD) 2.25 (1.39), range 0-8
Desired Family Size Mean (SD) 3.38 (1.41), range 1-12
Pregnancy Intention Planned 266 (61.7)
Unplanned 165 (38.3)
Age of Youngest Child Less than 2 years 191 (44.3)
More than 2 years 240 (55.7)
History of Family Planning Use Yes 244 (56.6)
No 187 (43.4)
Desire for Additional Children Yes 256 (59.4)
No 175 (40.6)
Discussed FP during ANC Yes 203 (47.1)
No 228 (52.9)
Postpartum Contraceptive Plan Yes 291 (67.5)
No 140 (32.5)
FP used before (n=244) Condom 6 (2.5)
Implant 92 (38.3)
Injectable 101 (42.1)
IUD 10 (4.2)
Natural methods 2 (0.8)
Oral pills 29 (12.1)

Knowledge and Awareness

Awareness of postpartum family planning methods was high, with Depo injection (95%), condoms (93%), and implants (91%) most recognized. Awareness of IUDs was 83% (n = 350). Provider discussion of afterbirth family planning occurred for 45.9% (n = 198). Knowledge of PPIUD was 79.6% (n = 343), but only 14.2% (n = 61) expressed willingness to use it if offered (Table 3).

Table 3.Knowledge and Awareness Characteristics of Women Delivering at a Tertiary Referral Hospital in Coastal Kenya (N = 431)
Variable Category n (%)
Awareness of PPFP Methods (n = 420) Depo injection 399 (95)
Condoms 390 (93)
Implants 384 (91)
Combined oral contraceptives 378 (90)
Progesterone only pill 376 (90)
Intrauterine device (IUD) 350 (83)
Natural methods 232 (55)
Sterilization 203 (48)
Lactational amenorrhea (LAM) 139 (33)
Preferred timing for initiating FP after delivery (N = 431) 0-6 weeks 120 (27.8)
2-3 months 151 (35.0)
4-7 months 46 (10.7)
Does not know 114 (26.5)
Preferred timing for possible pregnancy after delivery (N = 431) 0–1 month 30 (7.0)
2–3 months 49 (11.4)
4 months-2 years 67 (15.5)
After resuming menses or sex 70 (16.2)
Does not know 215 (49.9)
Sources of information (n = 408) Media 26 (6)
Relatives 25 (6)
Friends 104 (25)
Healthcare worker 253 (62)
ANC attendance (N = 431) More than twice 366 (84.9)
Twice 36 (8.4)
Once 27 (6.3)
None 2 (0.5)
Provider discussed afterbirth FP (N = 431) Yes 198 (45.94)
No 233 (54.06)
Knowledge of PPIUD (N = 431) Yes 343 (79.6)
No 88 (20.4)
Perceptions of PPIUD (N = 431) Do not know 181 (42.0)
Heard it is a bad method 104 (24.1)
Heard it is a good method 96 (22.3)
Knows it is a good method 14 (3.2)
Other views 36 (8.4)
Willingness to use PPIUD (N = 431) Yes 61 (14.2)
No 346 (80.3)
Need to think about it 18 (4.2)
Unsure 6 (1.4)

PPIUD Uptake

Immediate PPIUD uptake was 0.9% (4/431). An additional 11.6% (n = 50) indicated willingness to use it later, while 87.5% (n = 377) declined. The main reasons for refusal were fear of pain or invasiveness (28.6%, n = 108), lack of knowledge or need for more information (28.4%, n = 107), safety or side-effect concerns (8.8%, n = 33), and partner-related issues (5.3%, n = 20) (Table 4).

Table 4.Summary of Reasons for PPIUD Refusal by Category
Variable Category n (%)
Willingness to accept PPIUD (N=431) Yes, immediately 4 (0.9)
Yes, later 50 (11.6)
No 377 (87.5)
Reasons for refusal (n = 377) Lack of knowledge or need more information 107 (28.4)
Fear of procedure, pain, or invasiveness 108 (28.6)
Safety or side-effect concerns 33 (8.8)
Concerns about displacement or perforation 18 (4.8)
Preference for other methods 24 (6.4)
No intention to use any method 19 (5.0)
Partner-related issues 20 (5.3)
Concern about long-acting nature 6 (1.6)
Other 41 (10.9)

Factors Associated with PPIUD Uptake

In bivariate analysis, being married (OR = 0.17, p < 0.001), higher education, Catholic and SDA religious affiliation, employment, prior family planning use, planned pregnancy, ANC attendance, ANC counselling, partner support, and awareness of birth spacing benefits were associated with higher odds of uptake.

In multivariate analysis, Muslim religious affiliation remained significantly associated with lower odds of PPIUD uptake (AOR = 0.31; 95% CI: 0.10–0.96; p = 0.043) compared to SDA. Attending only one antenatal care visit was associated with higher odds of uptake (AOR = 9.11; 95% CI: 1.56–53.21; p = 0.013) compared to attending twice. Other demographic, reproductive, and social factors did not retain independent significance after adjustment (Table 5).

Table 5.Regression Analysis for Factors Associated with PPIUD Uptake
A. Bivariate Analysis
Variable Category OR 95% CI p-value
Marital status Married 0.17 0.07–0.41 <0.001
Education Secondary 0.14 0.02–1.14 0.065
Religion Catholic 0.20 0.08–0.54 <0.001
Islam 0.08 0.03–0.22 <0.001
Employment Status Employed 0.18 0.06–0.53 <0.001
ANC counselling Yes 0.12 0.06–0.22 <0.001
Partner support Yes 0.09 0.04–0.19 <0.001
B. Multivariate Analysis
Variable Category AOR 95% CI p-value
Religion Islam 0.31 0.10–0.96 0.043
ANC visits Once 9.11 1.56–53.21 0.013

Reference categories: SDA for religion; Twice for ANC visits. Model adjusted for age, marital status, education, occupation, prior FP use, pregnancy planning, ANC counselling, partner support, and decision-maker.

DISCUSSION

This study evaluated the uptake of immediate postpartum intrauterine device (PPIUD) and associated factors among women delivering at a tertiary referral hospital in coastal Kenya. The findings reveal extremely low uptake (0.9%), despite high general awareness of family planning methods. The primary barriers were method-specific misconceptions, fear of pain, and sociocultural factors, particularly religious affiliation.

Uptake of PPIUD

The immediate PPIUD uptake of 0.9% is comparable to findings from Meru Hospital (3.4%) (Kirigia et al., 2019) and lower than rates reported in Embu (47%) after intensive counselling (Ndegwa et al., 2014). This low uptake reflects persistent barriers in routine clinical settings where intensive counselling protocols are not consistently implemented. The majority of women who declined (87.5%) cited fear of pain, lack of knowledge, and safety concerns, consistent with findings from Ethiopia (Geda et al., 2021), Uganda (Omona & Namuli, 2020), and India (Yadav et al., 2017).

Demographic Factors

The finding that Muslim women had significantly lower odds of PPIUD uptake (AOR = 0.31) aligns with evidence from sub-Saharan Africa where religious norms influence contraceptive acceptance (Berger & Dasré, 2024). Similar patterns have been reported in Ethiopia and Nigeria, where religious beliefs shape family planning decisions (Demissie et al., 2025; Mandal et al., 2022).

The lack of independent association with education and age after adjustment suggests that the influence of these factors is mediated by other variables such as counselling exposure and partner support, consistent with findings from Ethiopia (Assefaw et al., 2021).

Reproductive Factors

The association between attending only one ANC visit and higher odds of uptake (AOR = 9.11) is counterintuitive but may reflect variation in counselling quality rather than quantity. Women who attended fewer visits may have received more intensive, targeted counselling or may represent a self-selected group with stronger pre-existing motivation. This finding underscores that the content and quality of counselling, not merely frequency, are critical determinants (Geltore et al., 2024).

Prior family planning use, planned pregnancy, and desire for birth spacing were positive facilitators in bivariate analysis, consistent with studies from Ethiopia and Rwanda (Geda et al., 2021; Kanakuze et al., 2020).

Family Social Factors

Partner support was a significant facilitator in bivariate analysis, with 75.9% of acceptors reporting spousal support compared to 60.7% of non-acceptors. This aligns with evidence from Uganda, Ethiopia, and Rwanda that partner involvement is crucial for postpartum contraceptive uptake (Kabagenyi et al., 2014; Tesfu et al., 2022). The 5.3% of women citing partner opposition as a reason for refusal underscores the need for male engagement strategies (Table 6).

Table 6.Family Social Characteristics of Women Delivering at a Tertiary Referral Hospital in Coastal Kenya (N = 431)
Variable Category n (%)
Spousal FP Communication Yes 190(44.1)
No 241(55.9)
Partner FP Support Yes 270(62.6)
No 161(37.4)
Primary FP Decision Maker Myself 221(51.3)
Husband 198(45.9)
Husband’s parents 3(0.7)
My parents 2(0.5)
Close friends 7(1.6)
Religious Acceptance of Modern FP Yes 317(73.6)
No 114(26.4)
Cultural Barriers to Postpartum FP Yes 1(0.2)
No 430(99.8)

Knowledge and Awareness

Despite high general awareness of family planning (97.9%), knowledge of PPIUD was lower, and only 14.2% expressed willingness to use it. This discrepancy highlights a method-specific knowledge gap. The primary reasons for refusal—fear of pain, lack of knowledge, and safety concerns—indicate that routine family planning messages are insufficient to address PPIUD-specific misconceptions. Studies from Ethiopia and Nepal demonstrate that targeted counselling significantly improves uptake (Puri et al., 2023; Yemane et al., 2021).

Strengths and Limitations

Strengths include the large sample size, comprehensive assessment of multiple factors, and use of multivariate analysis to control for confounders. Limitations include the cross-sectional design, which precludes causal inference; reliance on self-reported data with potential recall and social desirability bias; and the single-centre setting, which may limit generalizability. The very low uptake (0.9%) resulted in small acceptor group and wide confidence intervals, reducing precision in estimating some associations.

CONCLUSION

This study demonstrates that immediate PPIUD uptake at this tertiary referral hospital is extremely low (0.9%), driven primarily by method-specific misconceptions, fear of pain, and sociocultural factors including religious affiliation. Muslim women had significantly lower odds of uptake compared to Seventh-day Adventists. Attending only one antenatal care visit was associated with higher uptake, suggesting that counselling quality is as important as the visit frequency.

Despite high general awareness of family planning, PPIUD-specific knowledge gaps persist. Addressing these requires targeted, early, and high-quality counselling that directly addresses concerns about pain, safety, and reversibility. Engaging partners and leveraging community and religious leaders may help overcome sociocultural barriers.

Future research should explore determinants influencing PPIUD acceptance and evaluate effective counselling and community engagement strategies to improve uptake.

Ethical approval was obtained from the institutional ethics review committee. Written informed consent was obtained from all participants.

Not applicable.

Availability of Data and Materials

The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request.

Competing Interests

The authors declare no competing interests.

Funding

This research received no specific grant from any funding agency.

Authors’ Contributions

ZKB: conceptualization, data collection, analysis, drafting; BV: supervision, methodology, review; AL: supervision, clinical oversight, review. All authors read and approved the final manuscript.

Acknowledgments

The authors thank the staff at the maternity unit and all study participants for their contributions.