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

The ABC’s of

Postpartum Family

PlanningRobin Anthony Kouyaté, BCC AdvisorCORE Elluminate Session14 October 2008

Photo by Emmanuel Otolurin

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Objectives

At the end of the session, participants will be able to discuss:

Overview of PPFP Barriers to PPFP services and method use Key PPFP messages: HTSP, return to fertility, LAM

and the transition, couples communication Integration of PPFP into MNCH programs: facility

level services and the community Referral systems Resources

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Definitions

Postpartum Family Planning: The initiation and use of FP during the first year after delivery

Postpartum period: traditionally 6 weeks after birth

Extended postpartum period: For ACCESS FP, extend the postpartum period to include 1st

year after birth to increase programmatic opportunities to reach families

Photo by Angela Nash-Mercado

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Rationale for including postpartum family planning in MNCH and FP programs

To achieve healthy maternal, perinatal, newborn, infant and child health outcomes, including reduction of maternal & neonatal mortality

To address unmet need for FP among postpartum women

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PPFP can contribute to reductions in maternal and child mortality

Maternal Mortality 32% “In the year 2000, family

planning could have averted 90% of abortion related and 20% of obstetric related

mortality and morbidity”Child Mortality

“1 million of the 11 million deaths in children <5 could be averted by elimination of interbirth intervals of less than 2 years. Effective use of postpartum family planning is the most obvious way in which progress should be achieved.”

Cleland et al. 2006 Lancet Series, Sexual and Reproductive Health Volume 368, Number 9549, 18 November 2006

9%

14%

37%

40% <18 months

18-23 months

24-35 months

36+ months

Kenya- 23% of births are less than 2 years apart.

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Barriers to PPFP service and method useLack of informationLack of awareness of health benefits of spacingShifts in traditions that protected from pregnancy –postpartum abstinenceLack of knowledge about fertility return

Social supportSpousal permission/clandestine useCo-wife competitionLack of support from MIL

MisconceptionsMisconceptions about BF as a method of FP (LAM)Misconceptions about FP for BF women

Access to servicesLow mobility particularly for low parity women – 40 day period after a birth Mothers’ busy schedules influences accessReferrals

Supportive environmentReligious beliefs

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Key content for PPFP messages

1. Healthy spacing of pregnancies2. Mother’s risk for unintended pregnancy after a

birth3. LAM and the transition4. Methods for BF postpartum women 5. Discussing and choosing a family planning

method within the first month postpartum (couples communication)

6. Importance of postpartum care services - referral

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HTSP: 2006 Technical Consultation Experts’ Recommendations to WHOWait at least 24 months after a live birth before attempting the next pregnancy in order to reduce the risk of adverse maternal, perinatal and infant outcomes.

Wait at least 6 months after a miscarriage or induced abortion before attempting the next pregnancy in order to reduce risks of adverse maternal and perinatal outcomes.Source: World Health Organization, 2006 Report of a WHO Technical Consultation on Birth Spacing

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A woman’s risk of pregnancy after childbirth

YOU CAN BECOME PREGNANT EVEN IF YOUR MENSES HAS NOT

RETURNED!!

Your risk of pregnancy increases as breastfeeding decreases and as time passes

Delivery

6 monthspostpartum

(sooner if your menses has returned)

If you are ONLY Breastfeeding

6 weeks Postpartum

If you are PARTIALLY Breastfeeding

3 weekspostpartum

If you areNOT breastfeeding

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Lactational Amenorrhea Method (LAM): 3 criteria and the transition

Three criteria for a PP women to practice LAM

Only breastfeeding No menstrual bleeding Infant is 6 months or less

Transition to another method should occur when ANY 1 of the 3 criteria changes

Draft LAM Client Brochure: Georgetown University/IRH

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Postpartum contraceptive options

Adapted from the MAQ Exchange: Contraceptive Technology Update

Message: There are many FP methods with no affect on breastfeeding.

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Discuss & choose a PPFP method within the 1st month postpartum

Key barrier:

Fear of discussion about family planning with husbands, yet husband is key decision-maker

Key Facilitator: Male support for spacing for economic reasons

Message: “Couples, discuss a family planning method before your baby is 1 month old and obtain more information from your health provider. An understanding between couples early on, can help prevent unplanned pregnancies.”

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Importance of postpartum visits

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Opportunities for Integration of PPFP messages into MNCH programs at the facility

and in the community

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FAMILY PLANNING

ANC-FP messages-

Immediate Post Partum FamilyPlanning

0-48 hours

Postpartum FP6 wk visit

Extended postpartum FP

6 weeks to 12 months

Birth Preparedness

ANC

Delivery care

3-6 days

6 weeks

POSTPARTUMImmunization EBF 6wks

Immunization EBF 10 wks

Immunization EBF 14 wks

Infant feeding 6 mo

Immunization-Measles

9 mo

TT Immunization

Immediate Neonatal care 6-12 hrs

Later postnatal3-6 days

Immediate postpartum

6-12 hrs

MATERNAL HEALTH NEONATAL & INFANT HEALTH

PMTCT

PED

CARE

PROGRAMMATIC FRAMEWORK: PPFP IN AN INTEGRATED CONTEXT

HIV

Opportunities?

MNH and PPFP Behavior Change Communication Strategy and Channels of Communication

3 pronged approach:1. Influence individual level behaviors through

household counseling: Channel: Counsel mothers, husbands and mothers-in-law

during antenatal and postpartum period

2. Create a supportive environment: Channel: Community based activities with religious and

community leaders

3. Reinforce with print materials and existing mass media programs

Reaching postpartum women through household counseling

Messages 1st 5 months – pregnancy

7-8 months pregnancy

24 hrs Postpartum

5-7 days postpartum

4 months postpartum

Birth plan X X

Refer for ANC visit X X

Refer for PNC X X X

Danger signs & referral X X X X

Immediate newborn care X

Immediate BF/ EBF for 6 months

X XX

(EBF only)X

(EBF only)

Healthy spacing X X X XReturn to fertility X X X X

LAM & transition X (LAM only) X (LAM Only) X X

Modifications to ACCESS-Nigeria MNH HH counseling schedule to integrate PPFP

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World Vision – “Timed and targeted counseling” Pragati Child Survival Project in India

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Male involvement

Decision-making at the household level Creating a supportive environment through community –level advocacy activities

Photos by Angela Nash-Mercado

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Creating a supportive environment for PPFP through community advocacy

Photo by Berengere de Negri Photo by Angela Nash-Mercado

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CHW referrals for FP at the facility

CHW screening & referral system:LAM screening & referral during HH visits (NC- 28, month 2-3 and 4-5 visits)

CHWs ask women if they are still practicing LAM and if they would like to transition to another method.

If the mother would like to use another method, CHW provides a referral slip for a facility convenient to her home.

Photo by Robin Anthony Kouyate

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Postpartum Family Planning provides

ABetter

Chance and choice forMothers’, infants’ and children’s health and survival!

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Selected resources

PPFP Overview: Cleland, J., Bernstein, S., Ezeh, A., Faundes, A., Glasier, A., Innis, J. (2006.) Family planning: The unfinished agenda.

The Lancet, 368(9549), 1810-1827. Ross, J. A. and Winfrey, W. L. (2001.) Contraceptive use, intention to use and unmet needs during the extended

postpartum period. International Family Planning Perspectives, 27, 20–27. Ross, J Winfrey W (2002) Unmet Need for Contraception in the Developing World and the Former Soviet Union: An

Updated Estimate International Family Planning Perspectives, 28(3):138–143Healthy Timing and Spacing of Pregnancies : Norton, M. (2005.) New evidence on birth spacing: Promising findings for improving newborn, infant, child, and maternal

health. International Journal of Gynecology and Obstetrics, 89: 1-6. Report of a WHO Technical Consultation on Birth Spacing Geneva, Switzerland, 13–15 June 2005. Healthy Timing and Spacing of Pregnancies: A pocket guide for health practitioners, program managers, and community

leaders. Extending Services Delivery Project. http://www.esdproj.orgReturn to fertility: Gray, R.H., Campbell, O.M., Apelo, R., Eslami, S.S., Zacur, H., Ramos, R.M., et al. (1990.) Risk of ovulation during

lactation. The Lancet, 335(8680): 25-29. Becker & Ahmed. (2001). Dynamics of Contraceptive Use and Breastfeeding during the Post-Partum Period in Peru and

Indonesia. Population Studies, 55 (2), pp. 165-179.Resumption of sexual activity: Gebreselassie, T., Rutstein, S. and Mishra, V. (2008). Contraceptive use, BF, Amenorrhea and Abstinence during the

Postpartum Period: An analysis of four countries. DHS Analytical Studies No.14. Calverton, MD: Macro International Inc.

Desgrees-du-Lou & Brou. (2005). Resumption of sexual relations following childbirth: Norms, practices and reproductive health issues in Abidjan Cote d’Ivoire. RHM. 13 (25):155-163.

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Selected resources

LAM: Hight-Laukaran, V., Labbok, M. H., Peterson, A. E., Fletcher, V., von Hertzen, H., and Van Look, P. F. (1997.)

Multicenter study of the Lactational Amenorrhea Method (LAM): II. Acceptability, utility, and policy implications.Contraception, 55(6), 337–346.

Hardy, E., Santos, L. C., Osis, M. J., Carvalho, G., Cecatti, J. G., and Faundes, A. (1998.) Contraceptive use and pregnancy before and after introducing lactational amenorrhea (LAM) in a postpartum program. Advances in Contraception, 14(1), 59–68.

Lopez-Martinez, M.G., Romero-Gutierrez, G., Ponce-Ponce De Leon, A.L. (2006.) Acceptance of lactational amenorrhoea for family planning after postpartum counseling. The European Journal of Contraception and Reproductive Health Care, 11(4), 297-301.

Spousal agreement on birth spacing: Gebreselassie, T., Rutstein, S. and Mishra, V. (2007). DHS Working Paper No. 35: Spousal Agreement on Waiting Time

to Next Birth in Sub-Saharan Africa. Polygamy and contraceptive use: Audu et al. (2007). Polygamy and the use of contraceptives. International Journal of Gynecology and Obstetrics, 101,

pp. 88-92.BCC for FP: Population reports: Communication for Better Health (Jan 2008). Series J, Number 56.

Please visit the PPFP publications page on the ACCESS website for more resources: http://www.accesstohealth.org/toolres/pubs.htm