Re-envisioning approaches to improve postpartum family planning (PPFP) and

maternal, infant and young child nutrition (MIYCN) in Tanzania

Presenter: Dr. Justine Kavle, MCSP/PATH, Nutrition

Ms. Chelsea Cooper MCSP/Jhpiego, Family Planning

Dr. Joyce Nyoni, University of Dar es Salaam, Social Science Dr. Gloria Shirima and Mary Drake, MCSP Tanzania Country office

Ministry of Health, Tanzania

Birth to Pregnancy Spacing Among All Women Aged 15-49, All Non-first Births in the Last 5 Years, Tanzania, DHS 2010

2% 6%

39%

25%

12%

6%

10%

<6 months

6-11 months

12-23 months

24-35 months

36-47 months

48-59 months

60+ monthsN of Non-First Births=6,472 47 % space birth to next

pregnancy too soon!

Early Childhood Mortality Rates According to Birth-to-Pregnancy Intervals Tanzania, 2010

136

8074 7486

50 4844

36

1822 19

60

2821

39

0

50

100

150

<15 Mos 15-26 Mos 27-38 Mos 39+ Mos

U5MR

IMR

NNMR

PMR

NNMR = Neonatal Mortality Rate

PMR = Perinatal Mortality Rate

IMR = Infant Mortality Rate

U5MR = Under-5 Mortality Rate

Tanzania DHS, 2010

Children conceived after longer durations were less likely to be stunted and underweight

1.25 1.301.23

1.161.11

1.07

0.98

0.89 0.82

1.221.29

1.191.13 1.11 1.06

0.98 0.95

0.82

0.4

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

<6 6-11 12-17 18-23 24-29 30-35 36-47ref.

48-59 60-95 96+

Adj. R

elat

ive R

isk

Interval in months

Child Malnutrition by Birth to Conception Interval

StuntedUnderweight

265,144 children

Source: Rutstein 2008

Significant Health Benefits of Birth Spacing, for Maternal, Child Health and Nutrition

For Children • Lower risk for:

• Stunted and underweight child

• Small for gestational age • Low birth weight • Preterm birth • Lower rates of newborn,

infant, and child mortality

Rutstein SO, 2008, Conde-Agudelo A, 2006, Zhu BP, 2005, King JC 2003

For Mothers • More time to breastfeed,

improving infant health • More time for women to

recover physically and nutritionally between births

• Lower risk of maternal death

Lactational Amenorrhea Method (LAM)

LAM is a modern and effective method of family planning (FP) based on the natural effect of breastfeeding on fertility.

Menstruation has not returned Mother is only breastfeeding Baby is less than 6 months

LAM: Efficacy established in clinical research studies

Trial Multi-center

Ecuador Chile Philippines Pakistan

N 519 330 422 485 391

# of Pregnancies

5 1 1 2 1

Efficacy 98.5 99.9 99.6 99.0 99.4

Labbok et al, 1997, Perez et al 1992, FHI 1994a, FHI 1994 b, Wade, Sevilla and Labbok, 1994

Early initiation of LAM or other FP method is important if couple doesn’t not want to become

pregnant right away

Fertility May Return Soon after Delivery • If not breastfeeding, ovulation will occur at 45 days

postpartum on average and as early as 21 days

• Breastfeeding women not practicing LAM are likely to ovulate before return of menstrual period - Between 8% and 10% of women conceive within the first year postpartum

Need to Re-envision LAM

• Confusion that breastfeeding = LAM

- Local term for LAM = breastfeeding for family planning

• Confusion regarding LAM effectiveness and the 3 criteria for use – so few women using are using correctly (only 26%).

• LAM transition to other modern method has been a gap

• LAM is an underutilized method despite effectiveness

- Providers’ knowledge and training are low - Few programs offer LAM

Integration; Maximizing routine contact points

Pre-pregnancy adolescent

s

Antenatal Care

(ANC) visits 1-4+

Birth • home • facility

PNC visits • home • facility

Immunization visits

Introduction of complementary foods, return to

fertility

Measles immuniz.

Pharmacy/ drug shop

visits

Pregnancy Neonatal period

Post-neonatal → 2nd year

FP and Nutrition Linkages

Lactational amenorrhea Fertility return Maternal nutrition

• Spacing Maternal survival

Exclusive breastfeeding Complementary feeding Infant and young child nutrition Infant survival

Overall aim of formative research to inform on program design

• To inform development of updated

approach for promoting PPFP, MIYCN, and optimal practice of LAM and timely transition to another modern contraceptive method in Mara and Kagera, Tanzania

Study Objectives

• This study aims to:

• Explore sociocultural and environmental cues to birth spacing and MIYCN practices

• Identify barriers and facilitating factors for optimal FP and MIYCN practices

• Develop innovative communication approaches for influencing nutrition and FP perceptions and practices among women, their family members, village leaders, and health providers in Mara and Kagera regions of Tanzania.

Methods Methodologies utilized and type of study participant

Number of respondents

IDIs with mothers of children under age 1, three consecutive visits

24

IDIs with Grandmothers 12 IDIs with Influential Women / traditional birth attendants (TBAs)

12

IDIs with facility-based reproductive and child health providers

6

FGDs with CHWs 24-32 = four FGDs

FGDs with Fathers of children <1 year 36-48 = four FGDs

FGDs with Community leaders

24-32 = four FGDs

Topics Explored

• PPFP & MIYCN perceptions, knowledge, practices

• Barriers & motivating factors for optimal practices

• Cues for introduction of complementary foods and starting PPFP

• Care-seeking practices for FP, maternal, newborn and child health services and nutrition

• Service provider beliefs, counseling practices, and service delivery processes

• Couple/family communication & roles in decision-making

• Use of mobile phone services

Preliminary Findings – Nutrition

• Delayed initiation of breastfeeding • Perception of not having enough

breastmilk led mothers to introduce foods as early as 2-3 months of age (“light” versus “heavy” milk)

• First foods for children: bananas, or maize porridge and liquids such as cow milk, tea, soda, and juice with sugar

• Women work long hours outside the home –farming. Some leave child at home –impedes exclusive breastfeeding

Mothers’ perspective: breastmilk insufficiency

“ I started feeding her on porridge after one month because I had no breastmilk and decided to initiate porridge ….usually after I deliver I don’t have enough breastmilk and I don’t know where the breastmilk goes. Therefore I usually decide to initiate foods.” – Mother of 2 month old child

“ There are those who give them porridge, milk or even tea, especially those who go to work, and have to leave their children at home, so when the children are hungry, they are fed on porridge or tea….when children cry most of the time and they [identify] the problem is [the child] being hungry, because the mothers’ breastmilk is not enough.” – 18 year old mother of 2 month old child

Mothers’ perspective: breastmilk insufficiency

Nutrition Findings Continued

• Nutritional needs of mothers considered during pregnancy but limited attention given during lactation

• Numerous influencers on nutrition practices: grandmothers, TBAs, fathers, providers, CHWs,

• Women link what they eat and quantity of their breastmilk • Use of traditional medicines to increase quantity of breastmilk • Women recognize that their work affects how long and how

frequent they breastfeed • Gaps in counseling on nutrition given by health workers

Preliminary Findings – FP

• Couples return to sexual activity as early as 1-2 weeks postpartum but often do not start using FP until much later

• Return of menses – cue to start FP • Breastfeeding associated with lack of

menses; perceptions varied on when return to fertility occurs

• Common for men and women to have multiple sexual partners / may be associated with distrust, desire for control, closely spaced pregnancies

FP Findings Continued

• Some know of breastfeeding for FP, but don’t know the LAM criteria (mother, father, health provider)

• Father as primary decision-maker for FP; health worker also influences

• Secret use of FP in some cases

• Unclear guidance given by health workers about recommended timing for starting to use FP after childbirth

Health provider perspective: return to fertility

“ I used to tell them that they have to expect getting pregnant at any time, because this [ LAM] is not an assured family planning method, so they do not have to100 percent rely on it. That is because of the body changes and food we consume may lead them to get pregnant, also the environment may make their menstrual cycle change and that may cause them to get pregnant while they are breastfeeding.” Health provider

FP Findings Continued

• Concerns about FP methods and side effects • Experiences shared with other women; influences

decision-making • Lack of opportunities in the community to learn about

FP; women are interested in learning more • Women know benefits of FP, birth spacing, and

understand value

Preliminary Findings – Cross Cutting

• Women and spouses rarely discuss FP, reproductive intentions, and MIYCN together as a couple.

• Men expressed interest in learning more about FP and nutrition, but said outreach and community activities have been primarily designed for women.

• Main sources of information on MIYCN and FP: health center, informational brochures CHWs, radio

• People own cell phones, but are not receiving health messages / people would be interested to receive health messages

Next steps

• Complete analyses and write up of these findings • Utilize the findings to design interventions to address PPFP

and MIYCN integration through the MCSP program

For more information, please visit www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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