Impact of Integrating Family Planning within a
Community-Based Maternal and Neonatal Health
Program in Rural Bangladesh
Salahuddin Ahmed1 & 2, Jaime Mungia2, Catharine McKaig2, Saifuddin
Ahmed1, Amnesty LeFevre1, Peter Winch1, Ahmed Al-Kabir3, and Abdullah
Baqui1
1Johns Hopkins School of Public Health; 2 Jhpiego; 3Shimantik
1
Study Context
Selected FP indicators in Sylhet, BDHS
2007
TFR by Divisions, Bangladesh, 2004
2.6
2.9
4.2
Indicators
Sylhet
Unmet FP need
26%
CPR (any method)
31%
TFR
3.7
Birth intervals
2.8
2.9
3.7
<24 months
26%
<36 months
57%
Integrated model of PPFP & MNH
Evolution of MNCH packages
Designed a community-based maternal and newborn care intervention
package and evaluated the effectiveness of the package using a cluster
randomized design
A home care package which involved CHW antenatal and postnatal home
visits and management of sick newborn reduced NMR by 34% (Baqui et al.,
Lancet, 2008)
Newborn care
3
Postpartum FP counseling and
contraceptive distribution
Study Objectives
1. To develop and test an integrated Family Planning,
Maternal and Neonatal Health (FP/MNH) service
delivery approach
2. To assess the strengths and limitations of integrating
FP into an ongoing community-based MNH care
program
3. To assess the impact of the intervention package on
contraceptive knowledge and practices including
LAM during the extended postpartum period
4. To assess the impact of the intervention package on
pregnancy spacing
4
Study Design
Study sites: eight unions in two sub-districts in Sylhet district, Bangladesh
Non-Random Allocation
Comparison unions: four
Enrolled women: 2257
Intervention unions: four
Enrolled women: 2247
Enrollment of women during <8 months of pregnancy
Comparison clusters:
MNH ONLY during ANC
and Postpartum visit
Intervention clusters:
MNH plus FP during ANC
and Postpartum visit
Follow the cohort through pregnancy to 36 months postpartum
5
Intervention Delivery Strategy
Service Delivery: Home visits by
CHWs
Conduct pregnancy
surveillance and provide
contraceptives
•
Conduct visits to all
households every two
months to identify new
MWRA and pregnant
women
•
•
Pills, condoms, and follow
up doses of injectables
Refer for other methods
Counsel in antenatal and
postpartum periods
•
Messages on LAM and
transition, return to
fertility, healthy spacing,
contraceptive methods
Community mobilization: Conduct meetings with husbands, mothers-in-law and community
leaders to raise awareness
6 about PPFP messages
Results
7
Starts in a Low Performance Area
Ever Used Contraceptive Method
Intervention
18.0
Control
21.1
0
10
20
30
40
50
Percent
60
70
80
90
100
Contraceptive Use Rate at 3, 6,
12, and 18 Months Postpartum by
Study Arm
50%
47%
45%
40%
42%
36%
37%
34%
35%
30%
27%
25%
18%
20%
15%
11%
10%
5%
0%
3 months 6 months 12 months 18 months 3 months 6 months 12 months 18 months
Intervention
Comparison
9
Contraceptive Use Rate at 3, 6,
12, and 18 Months Postpartum by
Study Arm
50%
45%
47%
42%
40%
37%
36%
34%
• Statistically significant improvement in the contraceptive use rate in the intervention area
35%
during the high risk period of first 18 months after delivery
30%
27%
-- 18% ever user before the index pregnancy to 47% at 18 months postpartum
25% -- 21% ever user before the index pregnancy to 34% at 18 months postpartum
18%
20%
• High number of new users and a trend towards increased early adoption
15%
11%
10%
5%
0%
3 months 6 months 12 months 18 months 3 months 6 months 12 months 18 months
Intervention
Comparison
10
Probability of Contraceptive
Adoption by Study Arm
1.00
Contraceptive adoption during PP period
0.00
0.25
0.50
0.75
P<.001
1
2
3
4
5
6
7 8 9 10 11 12 13 14 15 16 17 18
Months since delivery
Intervention
11
Control
Probabilities of Pregnancy Incidence
during 18 months of postpartum follow-up period
0.00
0.05
0.10
0.15
Self Reported Pregnancy
Incidence
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18
Months since delivery
Intervention
Control
The difference is statistically significant (P = 0.03)
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Does integration of FP adversely affect
MNH program?
13
CHW Home Visit Coverage
Pregnancy counseling- 1
Pregnancy counseling- 2*
Newborn-1 counseling
Newborn-3 counseling
Newborn-6 counseling*
Newborn-9 counseling
Newborn-15 counseling
Intervention
Comparison
(n=1889)
(n=1838)
92%
86%
74%
72%
73%
73%
51%
97%
90%
80%
76%
75%
77%
50%
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*Integrated counseling
Effect of Integration on MNH Care:
Selected Newborn Care practices by
Study Arm
Drying and wrapping of
newborn within 10
minutes of delivery
Initiation of
Breastfeeding within 30
minutes
Intervention
(%)
50.4
Comparison (%)
56.6
46.8
44.1
15
Duration of exclusive breastfeeding by study arm
0.00
0.25
0.50
0.75
1.00
Duration of Exclusive
Breastfeeding by Study Arm
1
3
analysis time
Intervention
16
6
Control
Lessons Learned
HFS demonstrates
1. The feasibility of integration of FP within a
community-based MNH program.
2. The effectiveness of the model in increasing
modern method use.
3. No notable negative effect on the delivery of
MNH services.
4. The promotion of LAM had a positive effect
on the duration of exclusive breastfeeding.
17
Study Partners
Funded by USAID
Shimantik and
CDPA
Government
of Bangladesh
JHSPH
ACCESS-FP
/MCHIP
18
THANK YOU
19