Findings from the use of a narrative story and leaflet to influence shifts along the behavior change continuum toward postpartum contraceptive uptake in Sylhet District, Bangladesh

Closely spaced pregnancies pose serious health risks to mothers and their children. A multi-country analysis of Demographic and Health Surveys indicated that more than nine of 10 women during their first year postpartum desire to delay the next pregnancy at least two years, or not get pregnant at all, yet there is high unmet need for family planning during this period. Many factors affect women's use of contraception in the first year postpartum, including resumption of sex, breastfeeding practices and resulting postpartum amenorrhea, awareness of the lactational amenorrhea method (LAM), and understanding of return to fecundity. In Sylhet District, Bangladesh, almost half (46.5%) of non-first births occurred at short intervals of less than 36 months since the previous birth. Under-five and neonatal mortality and total fertility are higher, and contraceptive prevalence is lower in Sylhet Division compared to the rest of Bangladesh. The Healthy Fertility Study (HFS) promoted optimal pregnancy spacing by integrating postpartum family planning (PPFP) within a community-based maternal and newborn health program. Female community health workers counseled women on PPFP and provided contraception to women during household visits. A leaflet including "Asma's Story" and a pictorial was developed to address noted gaps in PPFP knowledge and understanding. The leaflet and story were shared and discussed with women during counseling sessions with postpartum women and group meetings with mothers-in-law, postpartum women, and men. Asma's Story tells how one woman incorrectly assessed her risk of pregnancy to be minimal during the months before her menstruation returned. The story highlights risks of not initiating a modern family planning method in a timely manner. The study aimed to assess knowledge and perceptions regarding return to fecundity among postpartum women, husbands, and mothers/mothers-in-law; short-term outcomes of efforts to raise awareness about postpartum return to fecundity and encourage PPFP use; and the ways in which the approach may have affected postpartum women's progression along the steps to behavior change (SBC) continuum toward modern contraceptive use. The study found nearly universal exposure to Asma's Story, with reported shifts in perceived susceptibility to pregnancy, benefits of pregnancy spacing, and increased social support for postpartum family planning. However, only approximately one third of women were using a modern contraceptive method. The study's findings suggest that using a fictional story offers a promising approach for motivating shifts along the continuum. The approach may have affected postpartum women's progression along the SBC continuum toward modern contraceptive use. The study's results contribute to emerging global knowledge about behavioral approaches for PPFP, informing future efforts in Bangladesh and globally. The use of narrative communication, such as Asma's Story, may be an effective way to raise awareness about postpartum return to fecundity and encourage PPFP use.