Background: Healthy timing and spacing of pregnancies is important for maternal, infant, and family health. Postpartum family planning (PPFP) services, including comprehensive counseling, are an important part of care following childbirth. Empowerment, defined as the ability to make strategic life choices where this ability was previously denied, is complex and multidimensional, affecting various levels from individual to policy. In India, historical population control policies have influenced current practices, with a high share of sterilizations.

Objective: To investigate the relationship between women's empowerment and PPFP use, aiming to uncover underlying power dynamics and social inequities influencing reproductive health decisions. 

Methods: This cross-sectional analysis used data from India’s National Family and Health Survey (NFHS-4) and includes partnered women whose most recent birth was in the past 6-24 months. We evaluated empowerment across three domains—attitude towards violence, social independence, and decision-making—using the SWPER (Survey-based Women’s emPowERment), and examined the association between empowerment and PPFP use, adjusting for individual and community-level covariates in multivariate logistic regression and mixed-effects models. A secondary outcome of proportion of sterilization among PPFP users was also evaluated using multivariate logistic regression.

Results: Final analytical sample included 13,127 respondents, of whom 35% used PPFP. This subset of 4,581 respondents was included in secondary analysis of sterilizations. Higher empowerment in the domains of attitude towards violence and decision-making were associated with higher PPFP use (AOR (95% CI): 1.21 (1.05, 1.40), 1.28 (1.11, 1.48), respectively), but lower proportion of sterilization (AOR (95% CI): 1.11 (1.11, 1.12), 1.12 (1.11, 1.13), respectively). Mixed-effects modeling yielded a variance partition coefficient (VPC) of 0.4336, indicating that much of the variability in PPFP use is attributable to differences between districts. Wealth, parity, place of delivery, education also emerged consistently as significant explanatory factors in PPFP use.

Conclusions: Contraceptive coercion and the structures that enable it (targets and incentives) warrant further exploration. Our findings point to the need for a shift towards bottom-up development models that emphasize community engagement and empowerment to help all women and birthing people achieve informed, voluntary, and just sexual and reproductive health.

Keywords: global family planning, contraceptive coercion, critical quantitative