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The ABC’s of Postpartum Family Planning. Robin Anthony Kouyaté, BCC Advisor CORE Elluminate Session 14 October 2008. Photo by Emmanuel Otolurin. Objectives. At the end of the session, participants will be able to discuss: Overview of PPFP Barriers to PPFP services and method use

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the abc s of postpartum family planning

The ABC’s of Postpartum Family Planning

Robin Anthony Kouyaté, BCC Advisor

CORE Elluminate Session

14 October 2008

Photo by Emmanuel Otolurin

objectives
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
definitions
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

rationale for including postpartum family planning in mnch and fp programs
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
ppfp can contribute to reductions in maternal and child mortality
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

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

barriers to ppfp service and method use
Lack of information

Lack of awareness of health benefits of spacing

Shifts in traditions that protected from pregnancy – postpartum abstinence

Lack of knowledge about fertility return

Social support

Spousal permission/clandestine use

Co-wife competition

Lack of support from MIL

Barriers to PPFP service and method use

Access to services

  • Low mobility particularly for low parity women – 40 day period after a birth
  • Mothers’ busy schedules influences access
  • Referrals

Misconceptions

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

Supportive environment

  • Religious beliefs
key content for ppfp messages
Key content for PPFP messages
  • Healthy spacing of pregnancies
  • Mother’s risk for unintended pregnancy after a birth
  • LAM and the transition
  • Methods for BF postpartum women
  • Discussing and choosing a family planning method within the first month postpartum (couples communication)
  • Importance of postpartum care services - referral
htsp 2006 technical consultation experts recommendations to who
HTSP: 2006 Technical Consultation Experts’ Recommendations to WHO

Wait 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 abortionbefore 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

a woman s risk of pregnancy after childbirth

6 weeks

Postpartum

If you are

PARTIALLY

Breastfeeding

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

Delivery

3 weeks

postpartum

If you are

NOT breastfeeding

A woman’s risk of pregnancy after childbirth

YOU CAN BECOME PREGNANT EVEN IF YOUR MENSES HAS NOT RETURNED!!

6 months

postpartum

(sooner if

your menses

has returned)

If you are

ONLY

Breastfeeding

lactational amenorrhea method lam 3 criteria and the transition
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

postpartum contraceptive options
Postpartum contraceptive options

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

Adapted from the MAQ Exchange: Contraceptive Technology Update

discuss choose a ppfp method within the 1 st month postpartum
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.”

slide15
Opportunities for Integration of PPFP messages into MNCH programs at the facility and in the community
slide16

PROGRAMMATIC FRAMEWORK: PPFP IN AN INTEGRATED CONTEXT

NEONATAL & INFANT HEALTH

HIV

MATERNAL HEALTH

FAMILY PLANNING

Birth Preparedness

ANC

PMTCT

TT Immunization

ANC-FP messages-

Delivery care

Immediate Neonatal care 6-12 hrs

Immediate postpartum

6-12 hrs

Immediate Post Partum FamilyPlanning

0-48 hours

Later postnatal

3-6 days

3-6 days

POSTPARTUM

Postpartum FP

6 wk visit

6 weeks

Immunization EBF 6wks

PED

CARE

Immunization EBF 10 wks

Extended postpartum FP

6 weeks to 12 months

Immunization EBF 14 wks

Opportunities?

Infant feeding 6 mo

Immunization-Measles

9 mo

mnh and ppfp behavior change communication strategy and channels of communication
MNH and PPFP Behavior Change Communication Strategy and Channels of Communication

3 pronged approach:

  • Influence individual level behaviors through household counseling:
    • Channel: Counsel mothers, husbands and mothers-in-law during antenatal and postpartum period
  • Create a supportive environment:
    • Channel: Community based activities with religious and community leaders
  • Reinforce with print materials and existing mass media programs
reaching postpartum women through household counseling
Reaching postpartum women through household counseling

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

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

Photos by Angela Nash-Mercado

creating a supportive environment for ppfp through community advocacy
Creating a supportive environment for PPFP through community advocacy

Photo by Berengere de Negri

Photo by Angela Nash-Mercado

chw referrals for fp at the facility
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

slide23
Postpartum Family Planning provides

A

Better

Chance and choice for

Mothers’, infants’ and children’s health and survival!

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):138–143

Healthy 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.org

Return 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.

Selected resources
selected resources25
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

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