A life saving
intervention within our
grasp: Postpartum
Family Planning
Catharine McKaig
31 August 2001
CHW and Mother, Healthy Fertility Study ,Bangladesh
Photo Credit: Salahuddin Ahmed
Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development,
The American College of Nurse-Midwives and IMA World Health
PPFP context
 Progress in maternal health- increased
emphasis on FANC, facility deliveries,
immediate postpartum
 New efforts in newborn carecommunity 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.
Father and Infant at Well baby Visit, Albania
Photo Credit: Galina Stolarsky
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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
100%
90%
Sexually active
Return to menses
Exclusively breastfdg
80%
70%
60%
50%
40%
30%
20%
10%
0%
0-3
4-6
7-9
10-12
Winfrey and Borda. 2007: Addressing the Family Planning
Needs of Women in the First Year Postpartum: Bangladesh.
ACCESS-FP
3
High levels of unmet need - potential for
addressing maternal and child health
Ethiopia 2005
Rw anda 2005
Ghana 2003
Uganda 2006
Madagascar 2003-2004
Tanzania 2004-2005
Kenya 2003
Pakistan 2006-2007
India 2005-2006
Nigeria 2003
Zam bia 2007
Bangladesh 2007
0
20
40
60
80
100
Percent unmet need
Winfrey and Borda. 2010. Postpartum fertility and contraception:
An analysis of findings from 17 countries. ACCESS-FP
4
FP use in the first year postpartum
LAM use 3-6 months
FP use 9-12 months
Zambia 2007
Bangladesh 2007
Madagascar 2003-2004
Zambia 2007
Haiti 2005-2006
Malawi 2004
Guinea 2005
India 2005-2006
Nigeria 2003
Kenya 2003
Mali 2006
Pakistan 2006-2007
Ghana 2003
Tanzania 2004-2005
Rwanda 2005
Haiti 2005-2006
Tanzania 2004-2005
Ghana 2003
Ethiopia 2005
Nigeria 2003
Uganda 2006
Madagascar 2003-2004
Pakistan 2006-2007
Uganda 2006
Malawi 2004
Congo, DRC 2007
Kenya 2003
Rwanda 2005
India 2005-2006
Ethiopia 2005
Congo, DRC 2007
Mali 2006
Bangladesh 2007
Guinea 2005
0
15
30
0
15
30
45
Winfrey and Borda. 2010. Postpartum fertility and contraception:
An analysis of findings from 17 countries. ACCESS-FP
5
LAM transition- barrier analysis
Compared 40 transitioners and 40
non-transitioners
 Higher education for transitioners
(5 yrs) than non (3 yrs)
CHW counseling woman 30 day visit, Sylhet Bangladesh
(Credit: C. McKaig)
 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
R. Anthony-Kouyate et al. Barrier Analysis LAM and Transition in
Sylhet, Bangladesh, ACCESS-FP, Report Forthcoming
6
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
Mohamed, Med Princ Pract 2003;12: 170-175
Foreit et al. 1993. International FP Perspectives. 19(1),19-24,33.
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
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
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PROGRAMMATIC FRAMEWORK: PPFP IN
AN INTEGRATED CONTEXT
FAMILY PLANNING
MATERNAL HEALTH
HIV
NEONATAL & CHILD
HEALTH
Birth Preparedness
ANC
ANC-FP messagesDelivery care
Immediate Post Partum Family
Planning
P
M
T
C
T
TT Immunization
Immediate postpartum
Neonatal care 6-12 hrs
6-12 hrs
Later postnatal
3-6 days
3-6 days
0-48 hours
POSTPARTUM
Postpartum FP
6 wk visit
6 weeks
Extended postpartum FP
6 weeks to 12 months
Opportunities?
Immunization EBF 6 wks
P
E
D
Immunization EBF 10 wks
C
A
R
E
Immunization EBF 14 wks
Complementary Feeding
6 mo
Immunization-Measles
9 mo
Integrated services to prevent
unintended pregnancies
 Early community level contacts- LAM and
effective transition through provision of
other modern methods
 Increased skilled birth assistanceprovision 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
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
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