Breaking the Cycle of Unintended Pregnancy in
Postpartum and Postabortion Women
Carolyn Curtis, CNM, MSN, FACNM
Office of Population & Reproductive Health
US Agency for International Development
2013 International Conference on Family Planning
Addis Ababa, November 15, 2013

 Barriers
 Postpartum Women
 Postabortion Women
 How to overcome “missed opportunities ”

Barriers to FP services for postpartum and postabortion (PAC) clients
Barriers
Structure of services Myths and misperceptions
Exaggerated provider concerns
Inappropriate
(re STI, PID, infertility, expulsion) eligibility criteria
Provider bias
Stigma
Lack of knowledge re: return to fertility
Where births occur
Poor CPI
Lack of skills
Source: RESPOND Project, 2012.
Outcomes when barriers are overcome:
↑ ↑
Access
↑ ↑
Quality of services
↑ ↑
Choice and use
↓ ↓
Rapid repeat pregnancy
↓ ↓
Abortion

Family planning programs:
What has worked?
Ten Essential Elements of Successful FP Programs
1. Supportive Policies
2. Evidence Based Programming
3. Strong Leadership and Good
Management
4. Effective Communication Strategies
5. Contraceptive Security
6. High Performing Staff
7. Client-Centered Care
8. Easy Access To Services
9. Affordable Services
10. Appropriate Integration of Services
Source: Population Reports 2008, JHU.
Selected, High-Impact Practices (HIPs)
• Community-based services & task-shifting / task-sharing
•
Postpartum FP
• Postabortion FP (PAC)
•
Mobile outreach services

Who are the women?
1 in 4 women in developing countries have an unmet need for FP = 222 MILLION women with unmet need!
Each year:
 210 million pregnancies
 80 million unintended pregnancies
 44 million abortions
 31 million stillbirths
 Approximately 130 million births = 130 million postpartum women

Reproductive intentions of postpartum women – 12 months following a birth
100%
95%
80%
60%
40%
30%
20%
5%
0%
Want to give birth in 2 years
Want to space or limit
Using FP method
65%
Not using a method
Source: Ross and Winfrey “Contraceptive use, Intention to use, and unmet need during the extended postpartum period, Intl FP Perspectives, 2001. Analysis of DHS data from 27 countries

Unmet need, contraceptive use & reproductive intention in women 0-12 months postpartum
100
90
80
70
60
50
40
30
20
10
0
65
29
74
52
44
62
32
54
42
Global
5
18
8
4
Sub-Saharan
Africa
Middle East
% Using Method - Modern & Traditional
Asia
4
3
Latin America
% Unmet Need % Desiring birth within 2 years
Source: Ross, J, Winfrey, W, Contraceptive Use, Intention to Use and Unmet Need During the Extended Postpartum Period,
International Family Planning Perspectives, 2001 27(1) 20-27.

Postpartum FP use and method mix among women giving birth in previous 12 months
70
60
50
40
30
20
10
0
100
90
80
92
87 87
83
78 77 77 76
62
Permanent method LARCs Short-acting resupply
Source: RESPOND Project, secondary analysis of respective DHS, 2010.
Traditional method Not using

PAC FP: background
 26% of the world’s 7 billion people are aged 10-24
 FP demand in young and unmarried women is high, but access is constrained:
 50-80% demand among married women age 15-24; 20-40% unmet need

~ 90% of unmarried women 15-24 in all regions of the world do not want to become pregnant, but their unmet need is very high, approaching 50% in some sub-Saharan African countries
 Complications of unsafe abortion are a main cause of death in 15-19 year-old women in low-resource countries
 A considerable problem in the U.S. too:
The American College of Obstetricians and Gynecologists recommends that its members “ encourage adolescents age 15-19 to consider implants and
IUDs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.”
ACOG Committee Opinion #539, Obstet. Gynecol., 2012; 120(4):983-988

PAC FP: How we fail women
100
80
60
40
20
0
32%
77%
60%
Using FP before pregnancy (method failure)
Desire to space or limit next pregnancy
Desired a FP method before leaving facility
Left facility with FP method
Source: Situation Analyses in Haiti, Dominican Republic, & Nicaragua. Population Council, 2008
20%

Preventing missed opportunities:
What can we do?
 Reorganize services to integrate/strengthen FP services with:
 Postpartum (including EMOC), Postabortion, MCH, HIV/AIDS
 Task-sharing / task-shifting (proven; widely endorsed)
 Mid-level providers
• Clinical Officers, Midwives, Nurses
• injectables, implants, IUDs, permanent methods
 Community Health Workers
• Injectables, implants (e.g., Ethiopia)
 Use mobile outreach
 Dedicated providers, free services, wide method choice: leads to greater access and use
 Decentralize services

Impact of decentralizing PAC services to lower-level fixed sites
Results:
 Decentralized
PAC services in 21 districts
 293 health care workers trained
 FP counseling and services in
224 sites
PAC Clients
Counseled on FP
PAC Clients, 21 Districts in Tanzania
(October 1, 2007 - September 30, 2010)
14 737
17 262
Accepted 12 106
Source: ACQUIRE Tanzania Project 0 5 000 10 000 15 000
Number of PAC clients
20 000

Integration of FP with immunization
– seems a good idea, but not much solid evidence yet
600
500
400
300
200
FP Acceptors
307
167
100 200
144
0
Test Group Control
FP -Post
FP- Pre
Vaccines Administered
16000
14000
12000
10000
8000
6000
7525
5839
4000
2000
5839
4185
0
Test Group Control
Group
Imm - Post
Imm - Pre
Huntington, D. and Aplogan, A., The Integration of Family Planning and Childhood Immunisation
Services in Togo Studies in Family Planning, Vol 25, No.3, 1994

Joint Statements by:
 FIGO
 ICM
 ICN
 DFID
 Gates
 White Ribbon
Alliance
 Others to advance postpartum and postabortion FP

What is needed to ensure
“No missed opportunity”?
National Level
 Ensure contraceptive supply
 Make FP & LA/PMs available and at reduced cost or free
 Support proven policy changes for midlevel providers
 Include FP in pre-service curricula & certifying exams
 Change in the WHO MEC for postpartum women
Facility Level
 Ensure the latest WHO FP service delivery guidelines are in place – and model following them in practice
 Reorganize services to ensure FP services at same location (PP, PAC, EMOC).
 Become a visible “champion” in your facility for increasing
FP availability and access.

Photo credits: Slide 1 (left to right), A. Jackson/EngenderHealth; A. Fiorente/EngenderHealth; C. Svingen/EngenderHealth. Slide 5 (top to bottom), M.
Tuschman/EngenderHealth; C. Svingen/EngenderHealth; M. Tuschman/EngenderHealth; E. Uphoff/EngenderHealth.