1. 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 Planning Robin Anthony Kouyaté, BCC Advisor CORE Elluminate Session 14 October 2008 Photo by Emmanuel Otolurin

2. 2 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

3. 3 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 1 st year after birth to increase programmatic opportunities to reach families Photo by Angela Nash-Mercado

4. 4 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

5. 5 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.

6. 6 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 Misconceptions  Misconceptions about BF as a method of FP (LAM)  Misconceptions about FP for BF women Access to services  Low mobility particularly for low parity women – 40 day period after a birth  Mothers’ busy schedules influences access  Referrals Supportive environment  Religious beliefs

7. 7 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

8. 8 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 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

10. 10 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 months postpartum (sooner if your menses has returned) If you are ONLY Breastfeeding 6 weeks Postpartum If you are PARTIALLY Breastfeeding 3 weeks postpartum If you are NOT breastfeeding

11. 11 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

12. 12 Postpartum contraceptive options Adapted from the MAQ Exchange: Contraceptive Technology Update Message: There are many FP methods with no affect on breastfeeding.

13. 13 Discuss & choose a PPFP method within the 1 st 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.”

14. 14 Importance of postpartum visits

15. 15 Opportunities for Integration of PPFP messages into MNCH programs at the facility and in the community

16. 16 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 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 postnatal 3-6 days Immediate postpartum 6-12 hrs MATERNAL HEALTH NEONATAL & INFANT HEALTH PMTCTPMTCT PEDCAREPEDCARE PROGRAMMATIC FRAMEWORK: PPFP IN AN INTEGRATED CONTEXT HIV Opportunities?

17. 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

18. Reaching postpartum women through household counseling Messages1 st 5 months – pregnancy 7-8 months pregnancy 24 hrs Postpartum 5-7 days postpartum 4 months postpartum Birth plan XX Refer for ANC visit XX Refer for PNC XXX Danger signs & referral XXXX Immediate newborn care X Immediate BF/ EBF for 6 months XX X (EBF only) X (EBF only) Healthy spacing XXXX Return to fertility XXXX LAM & transition X (LAM only)X (LAM Only)XX Modifications to ACCESS-Nigeria MNH HH counseling schedule to integrate PPFP

19. 19 World Vision – “Timed and targeted counseling” Pragati Child Survival Project in India

20. 20 Male involvement  Decision-making at the household level  Creating a supportive environment through community –level advocacy activities Photos by Angela Nash-Mercado

21. 21 Creating a supportive environment for PPFP through community advocacy Photo by Berengere de NegriPhoto by Angela Nash-Mercado

22. 22 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

23. 23 Postpartum Family Planning provides  A  B etter  C hance and choice for Mothers’, infants’ and children’s health and survival!

24. 24 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.orghttp://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.

25. 25 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.htmhttp://www.accesstohealth.org/toolres/pubs.htm