Breaking the Cycle of Unintended Pregnancy in Postpartum and Postabortion Women

Carolyn Curtis, CNM, MSN, FACNMOffice of Population & Reproductive HealthUS Agency for International Development

2013 International Conference on Family PlanningAddis Ababa, November 15, 2013

Overview

Barriers

Postpartum Women

Postabortion Women

How to overcome “missed opportunities”

Where births occur

Exaggerated provider concerns

(re STI, PID, infertility, expulsion)

Poor CPI

Provider biasLack of

knowledge re: return to fertility

Lack of skills

Myths and misperceptions

Structure of services

Inappropriate eligibility criteria

Barriers

Stigma

Source: RESPOND Project, 2012.

↑ ↑ Access

↑ ↑ Quality of services

↑ ↑ Choice and use

↓ ↓ Rapid repeat pregnancy

↓ ↓ Abortion

Outcomes when barriers are overcome:

Barriers to FP services for postpartum and postabortion (PAC) clients

Ten Essential Elements of Successful FP Programs Selected, High-Impact Practices (HIPs)

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.

• Community-based services & task-shifting / task-sharing

• Postpartum FP

• Postabortion FP (PAC)

• Mobile outreach services

Family planning programs: What has worked?

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

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

Reproductive intentions of postpartum women – 12 months following a birth

Want to give birth in 2

years

Want to space or limit

Using FP method

Not using a method

0%

20%

40%

60%

80%

100%

5%

95%

30%

65%

Global Sub-Saharan Africa

Middle East Asia Latin America0

102030405060708090

100

65

74

52

62

54

29

18

44

32

42

5 84 4 3

% Unmet Need % Using Method - Modern & Traditional

Unmet need, contraceptive use & reproductive intention in women 0-12 months postpartum

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

92 87 87 8378 77 77 76

62

0

10

20

30

40

50

60

70

80

90

100

Permanent method LARCs Short-acting resupply Traditional method Not using

Source: RESPOND Project, secondary analysis of respective DHS, 2010.

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: background

Series10

20

40

60

80

100

32%

77%

60%

20%

Using FP before pregnancy (method failure) Desire to space or limit next pregnancyDesired a FP method before leaving facility Left facility with FP method

Source: Situation Analyses in Haiti, Dominican Republic, & Nicaragua. Population Council, 2008

PAC FP: How we fail women

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

PAC Clients, 21 Districts in Tanzania (October 1, 2007 - September 30, 2010)

Results: Decentralized

PAC services in 21 districts

293 health care workers trained

FP counseling and services in 224 sites

Accepted

Counseled on FP

PAC Clients

02,0

004,0

006,0

008,0

0010

,000

12,00

014

,000

16,00

018

,000

20,00

0

12,106

14,737

17,262

Number of PAC clientsSource: ACQUIRE Tanzania Project

Integration of FP with immunization – seems a good idea, but not much solid evidence yet

Test Group Control0

100

200

300

400

500

600

200144

307

167

FP -PostFP- 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

Test Group Control Group

0

2000

4000

6000

8000

10000

12000

14000

16000

58394185

7525

5839 Imm - PostImm - Pre

FP Acceptors Vaccines Administered

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.

Thank You!!!

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.