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

Catharine McKaig

31 August 2001

A life saving intervention within our grasp: Postpartum Family Planning

CHW and Mother, Healthy Fertility Study ,BangladeshPhoto Credit: Salahuddin Ahmed

PPFP context

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.

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Father and Infant at Well baby Visit, Albania

Photo Credit: Galina Stolarsky

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

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-3 4-6 7-9 10-12

Sexually active

Return to menses

Exclusively breastfdg

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

0 20 40 60 80 100

Bangladesh 2007

Zambia 2007

Nigeria 2003

India 2005-2006

Pakistan 2006-2007

Kenya 2003

Tanzania 2004-2005

Madagascar 2003-2004

Uganda 2006

Ghana 2003

Rwanda 2005

Ethiopia 2005

Percent unmet need

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

FP use in the first year postpartum

LAM use 3-6 months FP use 9-12 months

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0 15 30

Bangladesh 2007

Congo, DRC 2007

India 2005-2006

Kenya 2003

Malawi 2004

Pakistan 2006-2007

Uganda 2006

Ethiopia 2005

Tanzania 2004-2005

Rwanda 2005

Ghana 2003

Mali 2006

Nigeria 2003

Guinea 2005

Haiti 2005-2006

Madagascar 2003-2004

Zambia 2007

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

LAM transition- barrier analysis

Compared 40 transitioners and 40 non-transitioners

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

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

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

R. Anthony-Kouyate et al. Barrier Analysis LAM and Transition in Sylhet, Bangladesh, ACCESS-FP, Report Forthcoming

Revisiting the PPIUCD

Very effective, reversible, long-term method Does not effect quantity/quality of breastmilk Convenient for women (don’t need to return) – in

Egypt: 71.2% chose PP insertion and 7.2% chose interval insertion

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

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

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

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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

FAMILY PLANNING

ANC-FP messages-

Immediate Post Partum Family Planning

0-48 hours

Postpartum FP

6 wk visit

Extended postpartum FP

6 weeks to 12 months

Birth Preparedness

ANC

Delivery care

3-6 days

6 weeks

POSTPARTUM

Immunization EBF 6 wks

Immunization EBF 10 wks

Immunization EBF 14 wks

Complementary Feeding

6 mo

Immunization-Measles

9 mo

TT Immunization

Neonatal care 6-12 hrs

Later postnatal

3-6 days

Immediate postpartum

6-12 hrs

MATERNAL HEALTH NEONATAL & CHILD HEALTH

PMTCT

PED

CARE

PROGRAMMATIC FRAMEWORK: PPFP IN AN INTEGRATED CONTEXT

HIV

Opportunities?

Integrated services to prevent unintended pregnancies

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

Increased skilled birth assistance- provision of PPIUCD

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

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Make every pregnancy- an intended pregnancy

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New mothers with their newborns outside the postpartum ward. Photo credit: B. Deller

Satisfied PPIUCD Users, Embu, Kenya Photo credit E. Charurat

PPFP e-learning course at http://www.globalhealthlearning.org/

PPFP tool kit at http://www.k4health.org/toolkits/ppfp