Spatial analysis of modern contraceptive use among women who need it in Ethiopia: Using geo-referenced data from performance monitoring for action.

INTRODUCTION: The challenge of achieving maternal and neonatal health-related goals in developing countries is significantly impacted by high fertility rates, which are partly attributed to limited access to family planning and access to the healthcare systems. The most widely used indicator to monitor family planning coverage is the proportion of women in reproductive age using contraception (CPR). However, this metric does not accurately reflect the true family planning coverage, as it fails to account for the diverse needs of women in reproductive age. Not all women in this category require contraception, including those who are pregnant, wish to become pregnant, sexually inactive, or infertile. To effectively address the contraceptive needs of those who require it, this study aims to estimate family planning coverage among this specific group. Further, we aimed to explore the geographical variation and factors influencing contraceptive uptake of contraceptive use among those who need. METHOD: We used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) survey of women of reproductive age and the service delivery point (SDP) survey conducted in 2019. A total of 4,390 women who need contraception were considered as the analytical sample. To account for the study design, sampling weights were considered to compute the coverage of modern contraceptive use disaggregated by socio-demographic factors. Bayesian geostatistical modeling was employed to identify potential factors associated with the uptake of modern contraception and produce spatial prediction to unsampled locations. RESULT: The overall weighted prevalence of modern contraception use among women who need it was 44.2% (with 95% CI: 42.4%-45.9%). Across regions of Ethiopia, contraceptive use coverage varies from nearly 0% in Somali region to 52.3% in Addis Ababa. The average nearest distance from a woman's home to the nearest SDP was high in the Afar and Somali regions. The spatial mapping shows that contraceptive coverage was lower in the eastern part of the country. At zonal administrative level, relatively high (above 55%) proportion of modern contraception use coverage were observed in Adama Liyu Zone, Ilu Ababor, Misrak Shewa, and Kefa zone and the coverage were null in majority of Afar and Somali region zones. Among modern contraceptive users, use of the injectable dominated the method-mix. The modeling result reveals that, living closer to a SDP, having discussions about family planning with the partner, following a Christian religion, no pregnancy intention, being ever pregnant and being young increases the likelihood of using modern contraceptive methods. CONCLUSION: Areas with low contraceptive coverage and lower access to contraception because of distance should be prioritized by the government and other supporting agencies. Women who discussed family planning with their partner were more likely to use modern contraceptives unlike those without such discussion. Thus, to improve the coverage of contraceptive use, it is very important to encourage/advocate women to have discussions with their partner and establish movable health systems for the nomadic community.

Magnitude and determinants of early initiation and exclusive breastfeeding at six weeks postpartum: evidence from the PMA Ethiopia longitudinal survey.

BACKGROUND: Early initiation and exclusive breastfeeding are crucial in preventing child morbidity and mortality. Despite the importance of these practices, rates of timely initiation of breastfeeding and exclusive breastfeeding remain suboptimal in many sub-Saharan countries, including Ethiopia. This paper aimed to estimate the prevalence and identify determinants of breastfeeding initiation within the first hour after birth and exclusive breastfeeding in Ethiopia. METHODS: Data from the Performance Monitoring for Action Ethiopia project, a national survey conducted from August 2019 to September 2020, were used. The analytical sample comprises 2564 postpartum women and their children; data reported at baseline during enrollment and six weeks postpartum were used in this analysis. A multi-level binary logistic regression model was employed to identify determinant factors linked with initiation breastfeeding and exclusive breastfeeding. RESULTS: Of the 2564 mothers, 77.8% of infants breastfed within the first hour of birth and 68.4% of women practiced exclusive breastfeeding at six weeks postpartum with significant variation across regions. In the multivariate analysis, mothers who had cesarean delivery were less likely to initiate early breastfeeding as compared to mothers with vaginal delivery (AOR 0.27; 95% CI 0.17, 0.41). The odds of early initiation of breastfeeding were higher for mothers whose baby cried immediately after birth (AOR 3.31; 95% CI 1.95, 5.62) and who had skilled assisted delivery (AOR 2.13; 95% CI 1.01, 4.48). Other factors that were significantly associated with early initiation of breastfeeding were obstetric complication(s), parity, immediate mother-to-baby skin-to-skin contact, immediate postnatal care and the region. Similarly, mothers whose babies had a good neonatal birth status (AOR 1.81; 95% CI 1.09, 2.99) were more likely to exclusively breastfeed their child at six weeks postpartum. CONCLUSIONS: Early initiation of breastfeeding and exclusive breastfeeding is sub-optimal in Ethiopia. Nutrition programmers should consider regional variations in designing intervention programs to enhance breastfeeding practices. Healthcare providers should give special attention to women at risk such as those giving birth through cesarean section and having obstetric complications during delivery.

Contraceptive Intentions and Use throughout the Extended Postpartum Period: A Panel Study in Ethiopia.

The postpartum period is an ideal time for women to access contraception, but the prevalence of postpartum contraceptive use remains low in sub-Saharan Africa. To better understand the gap between women's desires to space or limit births and their contraceptive behaviors, intention to use contraception has been proposed as a person-centered measure of contraceptive demand. Using data from a panel study of Ethiopian women aged 15-49 who were interviewed at six weeks, six months, and one year postpartum, we examined the dynamics of contraceptive intention in the first year postpartum and its relationship with contraceptive use. Contraceptive intention fluctuated considerably in the year after childbirth. At six weeks, 60.9 percent of women intended to use a contraceptive method in the next year; 23.2% did not. By one year, less than half (43.5 percent) were using a method, and those who had no intention to use doubled (44.5 percent). Women who developed or sustained their intention to use a method in the postpartum period were more likely to adopt a method by one year than those who did not, showing that contraceptive intention is a strong predictor of use and has the potential to inform person-centered reproductive health programming in the extended postpartum period.

Evaluation of the London Measure of Unplanned Pregnancy (LMUP) among a nationally representative sample of pregnant and postpartum women Ethiopia.

Objectives: Rigorous measurement of pregnancy preferences is needed to address reproductive health needs. The London Measure of Unplanned Pregnancy (LMUP), developed in the UK, has been adapted for low-income countries. Psychometric properties of LMUP items remain uncertain in contexts with limited access to and use of health services. Study design: This cross-sectional study examines the six-item LMUP's psychometric properties among a nationally representative sample of 2855 pregnant and postpartum women in Ethiopia. Principal components analysis (PCA) and confirmatory factor analysis (CFA) estimated psychometric properties. Hypothesis testing examined associations between the LMUP and other measurement approaches of pregnancy preferences using descriptive statistics and linear regression. Results: The six-item LMUP had acceptable reliability (α = 0.77); two behavioral items (contraception, preconception care) were poorly correlated with the total scale. A four-item measure demonstrated higher reliability (α = 0.90). Construct validity via PCA and CFA indicated the four-item LMUP's unidimensionality and good model fit; all hypotheses related to the four-item LMUP and other measurement approaches were met. Conclusions: Measurement of women's pregnancy planning in Ethiopia may be improved through use of a four-item version of the LMUP scale. This measurement approach can inform family planning services to better align with women's reproductive goals. Implications: Improved pregnancy preference measures are needed to understand reproductive health needs. A four-item version of the LMUP is highly reliable in Ethiopia, offering a robust and concise metric for assessing women's orientations toward a current or recent pregnancy and tailoring care to support them in achieving their reproductive goals.

What is the relationship between contraceptive services and knowledge of abortion availability and legality? Evidence from a national sample of women and facilities in Ethiopia.

In Ethiopia, abortions are legal for minors and for rape, incest, foetal impairment or maternal disability. Knowledge of abortion legality and availability is low, and little effort has been made to disseminate this information for fear of invoking anti-abortion sentiment; instead, systems rely on health providers as information gatekeepers. This study explores how exposure to and interaction with family planning service delivery environment, specifically (1) availability of contraceptive and facility-based abortion services within 5 km of one's residence and (2) contact with a health provider in the past 12 months, relate to women's knowledge of the legality of accessing abortion services and of where to access facility-based abortion services. We used data from a nationally representative sample of 8719 women in Ethiopia and a linked health facility survey of 799 health facilities. Our outcome of interest was a categorical variable indicating if a woman had (1) knowledge of at least one legal ground for abortion, (2) knowledge of where to access abortion services, (3) knowledge of both or (4) knowledge of neither. We conducted multilevel, multinomial logistic regressions, stratified by residence. Approximately 60% of women had no knowledge of either a legal ground for abortion or a place to access services. Women who visited a health provider or who were visited by a health worker in the past 12 months were significantly more likely to know about abortion legality and availability. There were no differences based on whether women lived within 5 km of a facility that offered contraception and abortion services. We find that health workers are likely valuable sources of information; however, progress to disseminate information may be slowed if it relies on uptake of services and limited outreach. Efforts to train providers on legality and availability are critical, as is additional research on knowledge dissemination pathways.

Availability of postabortion care services in Ethiopia: Estimates from a 2020 national sample of public facilities.

Objectives: Unsafe abortion is a leading cause of global maternal mortality and morbidity. This study sought to estimate availability of essential postabortion care (PAC) services among publicly managed health facilities in Ethiopia. Study design: Data from public hospitals and health centers in Ethiopia were collected in 2020. Among facilities offering labor and delivery, we assessed the proportion that: (1) offered PAC, (2) were equipped for each PAC signal function, and (3) were equipped for all PAC signal functions falling within their scope of care by facility type. Analysis: Our primary outcome was PAC service provision status. Descriptive statistics summarized the proportion of hospitals and health centers, respectively, categorized as each PAC status and with necessary equipment for individual signal functions. Per Federal Ministry of Health (FMOH) guidelines, hospitals are expected to provide comprehensive PAC, while health centers are expected to provide basic PAC. Results: Altogether, 69.1% (n = 94) of hospitals were equipped to provide comprehensive PAC, and 65.2% (n = 131) of health centers were equipped for basic PAC. Least available signal functions included obstetric surgery among hospitals (83.8%; n = 114) and uterine evacuation among health centers (84.6%; n = 170). Conclusion: Meaningful progress has been made toward achieving the Ethiopian FMOH's goal of universal PAC service availability at hospitals and health centers by 2020. Despite this, sizable gaps remain and may endanger maternal health in Ethiopia, underscoring a need for continued prioritization of PAC services. Implications: Ethiopia's commitment to PAC has fostered a service landscape that is stronger than many other low-resource settings; however, notable shortcomings are present. Further research is needed to understand the potential role of clinical training and supply-side interventions.

Pregnancy coercion and partner knowledge of contraceptive use among Ethiopian women.

Objective: To examine the relationship between pregnancy coercion and partner knowledge of contraceptive use. Study design: Cross-sectional Performance Monitoring for Action-Ethiopia data were collected in October-November 2019 from a nationally representative sample of women ages 15 to 49. The analytical sample (n = 2,469) included partnered women using contraception in the past year. We used multinomial logistic regression to examine associations between past-year pregnancy coercion (none, less severe, more severe) and partner knowledge/couple discussion of contraceptive use (overt use with couple discussion before method initiation (reference group), overt use with discussion after method initiation, and covert use of contraception). Results: Most women reported their partner knew they were using contraception and had discussed use prior to method initiation (1,837/2,469, 75%); 16% used overtly and discussed use after method initiation, and 7% used contraception covertly. The proportion of covert users increased with pregnancy coercion severity (4%none, 14%less severe, 31%more severe), as did the proportion of overt users who delayed couple contraceptive discussions, (14%none, 23%less severe, 26% more severe); however, overt use with couple discussion before method initiation decreased with pregnancy coercion severity (79%none, 60%less severe, 40%more severe). The risk of covert use among women experiencing less severe pregnancy coercion was four times greater than women who experienced no pregnancy coercion (adjusted relative risk ratio, (aRRR) = 3.95, 95% confidence interval (CI) 2.20-7.09) and ten times greater for women who experienced the most severe pregnancy coercion (aRRR = 10.42, 95% CI 6.14-17.71). The risk of overt use with delayed couple discussion also increased two-fold among women who experienced pregnancy coercion compared to those who did not (less severe aRRR = 2.05, 95% CI 1.39-2.99; more severe aRRR = 2.89, 95% CI 1.76-4.73). Conclusion: When experiencing pregnancy coercion, women may avoid or delay contraceptive conversations with their partners. Increased pregnancy coercion severity has the greatest association with covert use and couple contraceptive discussions. Implications: The presence and timing of couple discussions about contraception are critical for ensuring safety for women experiencing pregnancy coercion. Screening for pregnancy coercion must be included within contraceptive counseling so that women can choose methods that maximize their reproductive autonomy.

Measuring experiences and concerns surrounding contraceptive induced side-effects in a nationally representative sample of contraceptive users: Evidence from PMA Ethiopia.

Objective: Our objectives were to assess the prevalence of specific side-effects experienced by current and recent contraceptive users, describe patterns of side-effects that users were concerned about, and share measurement lessons learned. Study design: Data come from the PMA Ethiopia 2019 nationally-representative, cross-sectional survey. Our analytic sample included women who were current (weighted n = 2190; unweighted n = 2020) or recent (past 24 months; weighted n = 627; unweighted n = 622) users of a hormonal method or IUD. We provide descriptive statistics of the percentage of current/recent users who report currently/ever experiencing specific side-effects, not experiencing but being concerned about experiencing specific side-effects, and both currently experiencing and being concerned about experiencing specific side-effects. All analyses are stratified by method type (implant, injectable, pill) to explore variation by method. Results: Among current users, 648/2190 women (30%) reported experiencing any side-effect, while 252/644 (40%) of recent users reported ever experiencing any side-effect. Bleeding changes were reported most frequently and were higher among implant and injectable users. More recent users reported side-effects that were associated with physical discomfort, such as headaches, than current users. About one-third of current and recent users reported being concerned about at least one side-effect that they had not experienced, with about 15% of current and recent users reporting concerns about bleeding changes (307/2190 and 112/627, respectively) and concerns about physical discomfort (334/2019 and 98/627, respectively). Conclusions: While bleeding changes are common, users report a range of side-effects related to physical discomfort underscoring the need for comprehensive counseling. We highlight challenges in measuring side-effects using quantitative tools and pose recommendations for future research and measurement efforts. Implications: : Experiencing and fearing contraceptive-induced menstrual bleeding changes and physical discomfort, particularly headaches, is high among hormonal contraceptive and IUD users in Ethiopia. counseling that addresses an array of side-effects is needed. Additional research is also needed to disentangle the effect of experiencing versus fearing side-effects on contraceptive use.

Individual and facility-level factors associated with women's receipt of immediate postpartum family planning counseling in Ethiopia: results from national surveys of women and health facilities.

BACKGROUND: Immediate postpartum family planning (IPPFP) helps prevent unintended and closely spaced pregnancies. Despite Ethiopia's rising facility-based delivery rate and supportive IPPFP policies, the prevalence of postpartum contraceptive use remains low, with little known about disparities in access to IPPFP counseling. We sought to understand if women's receipt of IPPFP counseling varied by individual and facility characteristics. METHODS: We used weighted linked household and facility data from the national Performance Monitoring for Action Ethiopia (PMA-Ethiopia) study. Altogether, 936 women 5-9 weeks postpartum who delivered at a government facility were matched to the nearest facility offering labor and delivery care, corresponding to the facility type in which each woman reported delivering (n = 224 facilities). We explored women's receipt of IPPFP counseling and individual and facility-level characteristics utilizing descriptive statistics. The relationship between women's receipt of IPPFP counseling and individual and facility factors were assessed through multivariate, multilevel models. RESULTS: Approximately one-quarter of postpartum women received IPPFP counseling (27%) and most women delivered government health centers (59%). Nearly all facilities provided IPPFP services (94%); most had short- and long-acting methods available (71 and 87%, respectively) and no recent stockouts (60%). Multivariate analyses revealed significant disparities in IPPFP counseling with lower odds of counseling among primiparous women, those who delivered vaginally, and women who did not receive delivery care from a doctor or health officer (all p < 0.05). Having never used contraception was marginally associated with lower odds of receiving IPPFP counseling (p < 0.10). IPPFP counseling did not differ by age, residence, method availability, or facility type, after adjusting for other individual and facility factors. CONCLUSION: Despite relatively widespread availability of IPPFP services in Ethiopia, receipt of IPPFP counseling remains low. Our results highlight important gaps in IPPFP care, particularly among first-time mothers, women who have never used contraception, women who delivered vaginally, and those who did not receive delivery care from a doctor or health officer. As facility births continue to rise in Ethiopia, health systems and providers must ensure that equitable, high-quality IPPFP services are offered to all women.

Regional and residential disparities in knowledge of abortion legality and availability of facility-based abortion services in Ethiopia.

OBJECTIVES: To generate regional, residential, and nationally representative estimates of knowledge of abortion legality and availability among women of reproductive age in Ethiopia, and examine how knowledge varies across regions and by urban/rural residence. STUDY DESIGN: Our study draws on data from a nationally representative, cross-sectional survey implemented in 2019 in each of Ethiopia's regional and administrative states, yielding a sample of 8,837 women aged 15 to 49. We compare weighted estimates and regional distributions of 3 outcomes: (1) general awareness and (2) correct knowledge of the abortion law, and (3) knowledge of facility-based abortion service availability. RESULTS: Significant regional and urban/rural disparities in knowledge of abortion legality and availability exist. Nationally, 27% of women are aware of the abortion law and just 5% of women have comprehensive knowledge of the law, while 30% know where to access facility-based abortion services. Regionally, estimates range significantly, from 2% in Somali to 45% in Addis Ababa for general awareness of the law, 0% in Afar to 27% in Harare for comprehensive knowledge of the law, and 8% in Afar to 57% in Tigray for knowledge of abortion availability. Knowledge of all measures is higher in urban than in rural areas. CONCLUSIONS: Regional disparities in abortion knowledge may contribute to geographic inequities in access to and use of safe abortion care. Efforts to expand knowledge of abortion legality and availability are needed and should be tailored to regional contexts. IMPLICATIONS: Knowledge of abortion legality and availability is imperative to protecting and expanding access to safe abortion care, especially in contexts like Ethiopia where abortion is available for multiple indications. Efforts to improve knowledge of abortion legality and availability are needed, and should be locally tailored to address regional inequities.

Regional and residential disparities in knowledge of abortion legality and availability of facility-based abortion services in Ethiopia.

OBJECTIVES: To generate regional, residential, and nationally representative estimates of knowledge of abortion legality and availability among women of reproductive age in Ethiopia, and examine how knowledge varies across regions and by urban/rural residence. STUDY DESIGN: Our study draws on data from a nationally representative, cross-sectional survey implemented in 2019 in each of Ethiopia's regional and administrative states, yielding a sample of 8,837 women aged 15-49. We compare weighted estimates and regional distributions of three outcomes: 1) general awareness and 2) correct knowledge of the abortion law, and 3) knowledge of facility-based abortion service availability. RESULTS: Significant regional and urban/rural disparities in knowledge of abortion legality and availability exist. Nationally, 27% of women are aware of the abortion law and just 5% of women have comprehensive knowledge of the law, while 30% know where to access facility-based abortion services. Regionally, estimates range significantly, from 2% in Somali to 45% in Addis Ababa for general awareness of the law, 0% in Afar to 27% in Harare for comprehensive knowledge of the law, and 8% in Afar to 57% in Tigray for knowledge of abortion availability. Knowledge of all measures is higher in urban than in rural areas. CONCLUSIONS: Regional disparities in abortion knowledge may contribute to geographic inequities in access to and use of safe abortion care. Efforts to expand knowledge of abortion legality and availability are needed and should be tailored to regional contexts. IMPLICATIONS: Knowledge of abortion legality and availability is imperative to protecting and expanding access to safe abortion care, especially in contexts like Ethiopia where abortion is available for multiple indications. Efforts to improve knowledge of abortion legality and availability are needed, and should be locally tailored to address regional inequities.

Effect of the COVID-19 pandemic on health facility delivery in Ethiopia; results from PMA Ethiopia's longitudinal panel.

OBJECTIVES: To examine the effect of COVID-19 on health facility delivery in Ethiopia. DESIGN: We used longitudinal data with a pre-post exposure to the pandemic to assess change in facility delivery patterns nationally and by urban and rural strata. We conducted design-based multivariable multinomial logistic regression comparing home, lower-level facility, and hospital delivery with date of birth as a spline term, with a knot indicating births before and on/after April 8, 2020. SETTING: Six regions in Ethiopia, covering 91% of the population. PARTICIPANTS: Women were eligible to participate if they were currently pregnant or less than six weeks postpartum and were recontacted at six weeks, six months, and one year postpartum. 2,889 women were eligible and 2,855 enrolled. Data used in this paper come from the six-week interview, with a follow-up rate of 88.9% (2,537 women). RESULTS: In urban areas, women who delivered during the COVID-19 pandemic had a 77% reduced relative risk of delivering in a hospital relative to women who delivered prior to the pandemic (aRRR: 0.23, 95% CI: 0.07-0.71). There were no significant differences between the pre- and COVID-19 periods within rural strata where the majority of women deliver at home (55.6%). Overall, the effect was non-significant at a national level. Among women who delivered during the COVID-19 pandemic, 20.0% of urban women said COVID-19 affected where they delivered relative to 8.7% of rural women (p-value = 0.01). CONCLUSION: We found that delivery patterns in urban areas changed during the early months of the COVID-19 pandemic, but there was no evidence of large-scale declines of hospital delivery at the national level. Concerns about COVID-19 transmission in health facilities and ensuring lower-level facilities are equipped to address obstetric emergencies are critical to address. COVID-19 will likely slow progress towards increasing rates of institutional delivery in urban areas in Ethiopia.

Protocol for PMA-Ethiopia: A new data source for cross-sectional and longitudinal data of reproductive, maternal, and newborn health.

Background: Performance Monitoring for Action Ethiopia (PMA-Ethiopia) is a survey project that builds on the PMA2020 and PMA Maternal and Newborn Health projects to generate timely and actionable data on a range of reproductive, maternal, and newborn health (RMNH) indicators using a combination of cross-sectional and longitudinal data collection.  Objectives: This manuscript 1) describes the protocol for PMA- Ethiopia, and 2) describes the measures included in PMA Ethiopia and research areas that may be of interest to RMNH stakeholders. Methods: Annual data on family planning are gathered from a nationally representative, cross-sectional survey of women age 15-49. Data on maternal and newborn health are gathered from a cohort of women who were pregnant or recently postpartum at the time of enrollment. Women are followed at 6-weeks, 6-months, and 1-year to understand health seeking behavior, utilization, and quality. Data from service delivery points (SDPs) are gathered annually to assess service quality and availability.  Households and SDPs can be linked at the enumeration area level to improve estimates of effective coverage. Discussion: Data from PMA-Ethiopia will be available at www.pmadata.org.  PMA-Ethiopia is a unique data source that includes multiple, simultaneously fielded data collection activities.  Data are available partner dynamics, experience with contraceptive use, unintended pregnancy, empowerment, and detailed information on components of services that are not available from other large-scale surveys. Additionally, we highlight the unique contribution of PMA Ethiopia data in assessing the impact of coronavirus disease 2019 (COVID-19) on RMNH.

Improving the demand for birth registration: a discrete choice experiment in Ethiopia.

INTRODUCTION: Birth registration remains limited in most low and middle-income countries. We investigated which characteristics of birth registration facilities might determine caregivers' decisions to register children in Ethiopia. METHODS: We conducted a discrete choice experiment in randomly selected households in Addis Ababa and the Southern Nations, Nationalities, and People's Region. We interviewed caregivers of children 0-5 years old. We asked participants to make eight choices between pairs of hypothetical registration facilities. These facilities were characterised by six attributes selected through a literature review and consultations with local stakeholders. Levels of these attributes were assigned at random using a fractional design. We analysed the choice data using mixed logit models that account for heterogeneity in preferences across respondents. We calculated respondents' willingness to pay to access registration facilities with specific attributes. We analysed all data separately by place of residence (urban vs rural). RESULTS: Seven hundred and five respondents made 5614 choices. They exhibited preferences for registration facilities that charged lower fees for birth certificates, that required shorter waiting time to complete procedures and that were located closer to their residence. Respondents preferred registration facilities that were open on weekends, and where they could complete procedures in a single visit. In urban areas, respondents also favoured registration facilities that remained open for extended hours on weekdays, and where the presence of only one of the parents was required for registration. There was significant heterogeneity between respondents in the utility derived from several attributes of registration facilities. Willingness to pay for access to registration facilities with particular attributes was larger in urban than rural areas. CONCLUSION: In these regions of Ethiopia, changes to the operating schedule of registration facilities and to application procedures might help improve registration rates. Discrete choice experiments can help orient initiatives aimed at improving birth registration.

Effect of integrating maternal health services and family planning services on postpartum family planning behavior in Ethiopia: results from a longitudinal survey.

BACKGROUND: Very few postpartum women want to become pregnant within the next 2 years, but approximately 60% of postpartum women in low- and middle-income countries are not using contraceptive methods. The World Health Organization recommends that women receive postpartum family planning (PPFP) counseling during antenatal, immediate postpartum, and postnatal services. Our objective was to establish whether PPFP counseling is being provided in antenatal and postnatal care services in SNNPR, Ethiopia and whether receipt of PPFP counseling improved uptake of postpartum family planning use by 6 months postpartum. METHODS: Longitudinal data from the Performance Monitoring for Accountability 2020 - Maternal and Newborn Health study were used. At screening, 329 women were identified as six or more months pregnant; 307 completed the survey at 6 months postpartum. We used weighted parametric survival analysis with Weibull distribution to assess the effect of receipt of postpartum counseling in antenatal and/or postnatal care by 6 weeks postpartum on contraceptive uptake, after adjusting for intention to use family planning, wantedness of the index pregnancy, delivery location, amenorrhea, exclusive breastfeeding, residence, parity, and education. RESULTS: Coverage of PPFP counseling is low; by six-weeks postpartum only 20% of women had received counseling. Women who received counseling in postnatal care only and postnatal care and antenatal care took up contraception at significantly higher rates than women who did not receive any counseling (HR: 3.4, p < .01 and HR: 2.5, p = .01, respectively). There was no difference between women who received PPFP counseling only in ANC and women who did not receive counseling at all. Women who did not want the child at all took up contraception at significantly lower rates than women who wanted the child at that time (HR: 0.3, p = .04). Women who had four or more children took up contraception at significantly lower rates than woman with 1-3 children (HR: 0.3, p = .01). There were no significant differences by delivery location, exclusive breastfeeding, residence, or education. CONCLUSION: Integration of postpartum family planning counseling into postnatal care services is an effective means to increase postpartum contraceptive uptake, but significant gaps in coverage, particularly in the delivery and postnatal period, remain.