We chose a qualitative approach to enable in-depth exploration of postpartum women's perceptions, desires, decision-making autonomy and interactions with healthcare providers. These elements are central to understanding family planning and contraceptive decision-making in the local context. Additionally, our approach aligns with established principles for using qualitative methods in reproductive health research to capture complex social and cultural influences on health behaviors among women in Ghana (11–13).

We recruited postpartum women attending child welfare clinics seeking childhood immunization services at 2 public hospitals representing urban and peri-urban settings in Kumasi, Ghana, to participate in this research. We selected child welfare clinics as recruitment sites because they capture the vast majority of postpartum women. Nearly all mothers bring infants for routine immunizations, regardless of attending their own postpartum visits. Ghana has maintained 90%–95% immunization coverage for the past decade (14). This universal participation makes these clinics ideal for accessing a broad sample of postpartum women. Reproductive-aged women (18–49 years) who had delivered an infant 3–6 months previously and who were comfortable conversing in English or Twi were invited to participate. There were no restrictions to participation based on parity.

We used convenience sampling to recruit participants. Clinic staff made a general announcement and introduction of the study to all women presenting at the child welfare clinic. Women who met the eligibility criteria (having had a baby within 6 months and able to converse in English or Twi, the local language in Kumasi) and who expressed willingness to participate were referred by clinic staff to the study team for further screening after completing their appointments. Due to this recruitment approach, we are unable to report the number of women who were approached but declined participation, as clinic staff conducted initial screening without documenting refusals. The study team introduced the study to these potential respondents and the consenting women were taken to a private office within the hospital for the interview. Interviewers were bilingual female master's level research assistants trained by the Kumasi-based authors.

The interview guide was developed by an experienced international research team consisting of two midwives (one Ghanaian and one American), one reproductive epidemiologist (Ghanaian), and three health services researchers (one Ghanaian, two American). The guide was pilot tested with 5 women at a separate facility, and modifications were made before full implementation. Women were interviewed by trained research assistants using a semi-structured interview guide that included a series of open-ended questions about attitudes and behavior surrounding previous, current, and intended future use of family planning. The interview guide was designed to encourage respondents to express thoughts and feelings that were particularly salient to them. Interviews were conducted in whichever language the participant was most comfortable (English or Twi) by a trained interviewer. Interviews lasted approximately 1 h and were audio recorded, translated to English (if necessary), and transcribed verbatim. While we planned for 50 interviews, we stopped at 48 interviews as data saturation was achieved, and no new themes or insights emerged.

Data collection occurred between September and November 2022. Interviews were conducted evenly across the three-month data collection period. Transcription occurred concurrently with data collection rather than after completion of all interviews, allowing the study team to review and discuss emerging themes to monitor progress toward data saturation.

Participants were asked where they believed they fit on Prochaska and DiClemente's Stages of Change model (15). This model reflects a continuum of “readiness” for behavioral change, from those who are not thinking about changing their behavior at all (pre-contemplators) to those who have already changed their behavior and are in the maintenance phase (maintenance). For this study, the interviewer read a series of 6 statements—4 reflecting Stages of Change (15) and 2 the study team felt were important in this context—and asked which most closely fit their current thoughts about family planning. Figure 1 illustrates the six statements used to assess women's stages of change.

Based on the study team's previous experience interviewing women in Ghana, participants were asked about their own experiences but also asked to reflect on hypothetical scenarios written as vignettes. The vignettes were developed based on previous research conducted by the study team and local clinical knowledge from healthcare providers on the team. These vignettes presented narratives drawn from scenarios in the literature and scenarios the research team had previously encountered, including situations where women reported that health workers would not provide contraceptive methods until postpartum bleeding had returned or instances where husbands were unsupportive of contraceptive use.

All study procedures and materials were reviewed and approved by the University of Michigan Institutional Review Board (HUM HUM00263159) and the Kwame Nkrumah University of Science and Technology Committee for Health Research and Publication Ethics. Additionally, administrative approvals were obtained from the health facilities before commencing the study. Each participant was taken through a comprehensive oral consent process before the interviews began. Women received a small token of appreciation for their time (a bar of soap, valued at approximately $1USD).

Transcripts were imported into NVivo 14.0 for thematic analysis following the Attride-Sterling network analysis methodology (16). Transcripts were read and re-read by at least 2 members of the research team. Initial categories for analyzing data were drawn from the interview guide and discussed amongst the research team. A preliminary codebook was developed, which guided the first round of coding. The research team discussed preliminary coding, including the basic themes, organizing themes, and global themes suggested by Attride-Sterling. A second round of coding was undertaken to better reflect higher level themes and patterns that emerged after initial coding.

Following initial coding, the research team discussed preliminary findings, including the basic themes, organizing themes, and global themes suggested by Attride-Sterling. During this process, it became clear that the most distinguishing themes were based on where women placed themselves within the Stages of Change framework, similar to how the 2022 Ghana Demographic and Health Survey reported on contraceptive use and intention (7).

We assigned women to three groups during our iterative analysis process. After the initial coding round, we created data visualizations for each of the six stages of change categories, mapping participants' previous contraceptive experience, methods tried, reasons for hesitancy, spacing goals, and current contraceptive use. These visualizations revealed clear patterns of similarity across specific stages. Participants who had “thought about using family planning,” “planned to start next month,” and “already started using family planning” shared common characteristics and perspectives. Similarly, those who had “not thought at all about family planning” and “did not want to use family planning now” demonstrated comparable attitudes and experiences. The “do not want family planning ever” group exhibited distinct responses that differed markedly from the other categories. Of note, family planning in the context of these statements was synonymous specifically with modern, Western contraceptive methods. Based on these patterns, we consolidated the six stages into three meaningful groups and conducted a second analytical pass (Figure 1). This approach showed that participants within each of the three groups shared qualitatively similar responses, confirming our grouping strategy and enabling more coherent thematic analysis.

A second round of coding was undertaken to better reflect higher level themes and patterns that emerged after initial coding, with additional child codes added to the original parent codes (Supplementary File 1). Both inductive and deductive coding was used in our process. All coding discrepancies were discussed among the research team and consensus was reached.

This manuscript is reported according to the Standards for Reporting Qualitative Research (SRQR).

Our multidisciplinary team brings together diverse expertise and lived experiences in maternal health, family planning, and reproductive autonomy, with members from both the United States and Ghana. As investigators, we acknowledge that our backgrounds, training, and previous research shape the questions we prioritize, the interpretations we make, and the interventions we seek to implement and evaluate. Our team maintains ongoing dialogue about our positions, privileges, and perspectives, striving for transparency and cultural humility, while remaining committed to centering the voices and preferences of postpartum women in Ghana as the foundation of this work.

A total of 48 postpartum women were interviewed with an average age of 29.5 years and an age range of 19–49 years (Table 1). Additional participant characteristics are included in Table 1.

All of the participants said they did not want to be pregnant again within the next 2 years. Very few of the participants were current users of contraception. For women's birth spacing goals, many women wanted to be pregnant in 2–4 years, fewer expressed interest in longer intervals of 5–9 years, and a small number wanted to wait 10 or more years. Some women reported not wanting any more children and a couple women were unsure of their birth spacing goal.

To better understand the perceptual gap in the number of women wanting to delay birth and the number of women using family planning, participants were distributed across the Stages of Change (15): pre-contemplation, contemplation, preparation, and action/maintenance, as well as 2 additional groups added by the study team—ambivalence and refusal.

From those groups, a few participants reported current use of contraception at the time of the interview, many women were planning to start contraception within the next month, some women thought about using contraception sometime in the future, one woman had not thought about it at all, many women did not want to use contraception at the time of the interview, and another large portion of women did not want to ever use contraception.

We found the most meaningful way to understand women's family planning desire was to stratify participants into 3 groups based on our modified Stages of Change model: active contraceptive users and preparers, potential contraceptive users, and firm contraceptive non-users (Figure 1). Figure 2 presents a thematic network visualization of the key themes and their interconnections across the three participant groups.

Our study should be interpreted in the context of several limitations. Ours was not a random sample and was not designed to be representative. Although we believe selection bias is minimal given that most women seek health services for their infants, we lack information about participants who declined to join the study. Consequently, it is possible that women who chose to participate differ substantially from those who declined. The 48 women were recruited from 2 hospitals in one part of Ghana. While we believe we have accurately presented what they reported to us, we do not suggest these thoughts and feelings represent all postpartum women in Ghana.

Our study also has many strengths. The long interviews meant that women were able to express their thoughts and feelings thoroughly. The use of vignettes has been shown to be an effective way to encourage Ghanaian women to speak more— reflecting not only on the characters in the story, but also on how those relate to their own lives. Our study also expanded upon previous conceptualizations of family planning use/non-use. By incorporating the Stages of Change Model to identify where women are in terms of behavior change, we expanded the approach to unpacking women's attitudes and provided a more nuanced understanding than has been seen previously in this context.

In this qualitative study of postpartum women in Kumasi, Ghana, we found that women's attitudes toward modern contraceptive family planning were shaped by three distinct stages of readiness: active users and preparers who valued contraception for spacing goals, potential users who were curious but deterred by stories of side effects, and firm non-users who preferred traditional methods such as dating or had experienced unacceptable side effects. While all participants wanted to delay pregnancy for at least two years, few were using modern contraceptive methods, with many relying on emergency contraception, condoms, or fertility awareness methods they did not consider “family planning.” These findings suggest that efforts to improve postpartum contraceptive counseling should consider women's readiness for change and provide accurate information to address misconceptions, while respecting women's autonomous choices about contraceptive use.