A life saving intervention within our grasp: Postpartum Family Planning Catharine McKaig 31 August 2001

CHW and Mother, Healthy Fertility Study ,Bangladesh

Photo Credit: Salahuddin Ahmed

Jhpiego

in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health

PPFP context

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Progress in maternal health- increased emphasis on FANC, facility deliveries, immediate postpartum New efforts in newborn care community based with emphasis on the first week FP was in policies linked to postpartum (6 wk) and MNCH, but not being implemented

 Some FP in FANC;    Not much PNC or PPFP; LAM not known or trusted; PPIUCD provision limited. Father and Infant at Well baby Visit, Albania

Photo Credit: Galina Stolarsky

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Postpartum family planning

Through one year postpartum

 Return to fertility=pregnancy risk   Return to sexual activity Immediate, exclusive and continued breastfeeding   LAM and transition Method considerations: timing and breastfeeding status   Healthy spacing of the next pregnancy Integration — tailoring to fit with timing and service

Factors influencing fertility return in Bangladesh 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sexually active Return to menses Exclusively breastfdg 0-3 4-6 7-9 10-12

Winfrey and Borda. 2007: Addressing the Family Planning Needs of Women in the First Year Postpartum: Bangladesh. ACCESS-FP

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High levels of unmet need -

potential for addressing maternal and child health

Ethiopia 2005 Rw anda 2005 Ghana 2003 Uganda 2006 Madagascar 2003-2004 Tanzania 2004-2005 Kenya 2003 Pakistan 2006-2007 India 2005-2006 Nigeria 2003 Zam bia 2007 Bangladesh 2007 0 20 40 60 Percent unmet need 80 100

Winfrey and Borda. 2010. Postpartum fertility and contraception: An analysis of findings from 17 countries. ACCESS-FP

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FP use in the first year postpartum

LAM use 3-6 months Zambia 2007 Madagascar 2003-2004 Haiti 2005-2006 Guinea 2005 Nigeria 2003 Mali 2006 Ghana 2003 Rwanda 2005 Tanzania 2004-2005 Ethiopia 2005 Uganda 2006 Pakistan 2006-2007 Malawi 2004 Kenya 2003 India 2005-2006 Congo, DRC 2007 Bangladesh 2007 0 15 30 FP use 9-12 months Bangladesh 2007 Zambia 2007 Malawi 2004 India 2005-2006 Kenya 2003 Pakistan 2006-2007 Tanzania 2004-2005 Haiti 2005-2006 Ghana 2003 Nigeria 2003 Madagascar 2003-2004 Uganda 2006 Congo, DRC 2007 Rwanda 2005 Ethiopia 2005 Mali 2006 Guinea 2005 0 15 30 45

Winfrey and Borda. 2010. Postpartum fertility and contraception: An analysis of findings from 17 countries. ACCESS-FP

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LAM transition- barrier analysis

CHW counseling woman 30 day visit, Sylhet Bangladesh (Credit: C. McKaig)

Compared 40 transitioners and 40 non-transitioners

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Higher education for transitioners (5 yrs) than non (3 yrs)

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Transitioners

 More likely to have menses return  More likely to report believing they could become pregnant when any of the criteria changed  Report they had social support R. Anthony-Kouyate et al. Barrier Analysis LAM and Transition in Sylhet, Bangladesh, ACCESS-FP, Report Forthcoming

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Revisiting the PPIUCD

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Very effective, reversible, long-term method Does not effect quantity/quality of breastmilk Convenient for women (don’t need to return) – Egypt: 71.2% chose PP insertion and 7.2% chose interval insertion in Skilled birth attendants as providers Less expensive than interval – in Peru $9 for PPIUCD insertion and $24 for interval insertion Increased cramping/bleeding masked by normal PP symptoms

Mohamed,

Med Princ Pract

2003;12: 170-175 Foreit et al. 1993. International FP Perspectives. 19(1),19-24,33.

Postpartum systematic screening in Nigeria

Among women attending immunization and pediatric care in two sites, (88%) wanted to wait before getting pregnant again or did not want any more children but were not using FP Intervention effectively improved counseling referring 41% for services, but only 15% of women went for referrals on the same day

E. Charurat et al. Postpartum Systematic Screening in Northern Nigeria: A Practical Application of Family Planning and Maternal Newborn and Child Health Integration, ACCESS-FP, Report Forthcoming

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PROGRAMMATIC FRAMEWORK: PPFP IN AN INTEGRATED CONTEXT

FAMILY PLANNING MATERNAL HEALTH HIV NEONATAL & CHILD HEALTH ANC-FP messages Birth Preparedness ANC Delivery care P M T C T TT Immunization Immediate Post Partum Family Planning 0-48 hours Immediate postpartum 6-12 hrs Neonatal care 6-12 hrs Later postnatal 3-6 days Postpartum FP 6 wk visit 3-6 days POSTPARTUM 6 weeks Immunization EBF 6 wks Extended postpartum FP 6 weeks to 12 months Opportunities? P E D C A R E Immunization EBF 10 wks Immunization EBF 14 wks Complementary Feeding 6 mo Immunization-Measles 9 mo

Integrated services to prevent unintended pregnancies

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Early community level contacts- LAM and effective transition through provision of other modern methods

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Increased skilled birth assistance provision of PPIUCD

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More effective integration in postnatal and infant care- multiple contacts including provision of services 10

Make every pregnancy- an intended pregnancy

Satisfied PPIUCD Users, Embu, Kenya Photo credit E. Charurat New mothers with their newborns outside the postpartum ward. Photo credit: B. Deller

PPFP e-learning course at http://www.globalhealthlearning.org/ PPFP tool kit at http://www.k4health.org/toolkits/ppfp

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