It's about time: WHO and partners release programming strategies for postpartum family planning

POSTPARTUM WOMEN NEED FAMILY PLANNING, TOO

Although the postpartum period is clinically defined as the first 6 weeks following childbirth, PPFP is the initiation of family planning services within the first 12 months following childbirth to prevent closely spaced and unintended pregnancies. Pregnancies within the first 12 months after a birth—in other words, a birth-to-pregnancy interval of less than 12 months—are at highest risk for adverse health outcomes to the mother and child⁴; are much more likely to end in potentially unsafe induced abortion⁵; and are at elevated risk for stillbirth, preterm birth, low birth weight, and small size for gestational age.⁴ Closely spaced births are also correlated with increased likelihood of chronic undernourishment, stunted growth, and infant mortality.⁶ Because of these serious health risks, spacing pregnancies at least 2 years apart can avert an estimated 10% of infant deaths and 21% of deaths in children ages 1 to 4 globally.⁴

As a group, postpartum women have high unmet need for family planning, defined as the percentage of fecund and sexually active women who report not wanting any more children or wanting to delay the birth of their next child but are not using any method of contraception.⁷ One analysis of 27 low- and middle-income countries estimated that 65% of postpartum women had unmet need.¹ A more recent analysis of data from 17 low- and middle-income countries found even higher unmet need estimates when women were asked about prospective need—that is, to express their fertility preferences looking into the future, instead of at the time of their previous pregnancy.⁸

HOW POSTPARTUM WOMEN ARE DIFFERENT

Family planning services for postpartum women require unique physiological considerations. Postpartum women experience amenorrhea, or the absence of menses, for varying lengths of time, and their fertility can return before menses resumes, even when breastfeeding.⁹ PPFP programs also must understand the clinical safety standards applied to different contraceptive methods across the 12-month period following birth, taking the mother's breastfeeding status into special consideration.³ The Programming Strategies resource includes a tool for determining the appropriate method options throughout the first year postpartum, following the WHO Medical Eligibility Criteria for Contraceptive Use¹⁰ (Figure). These criteria are periodically reviewed to ensure that they are consistent with the latest evidence.

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FIGURE.

Use of Contraceptive Methods in the Postpartum Period, According to WHO's Medical Eligibility Criteria

Source: World Health Organization³

MITIGATING MISSED OPPORTUNITIES

Integrating PPFP services into antenatal care (ANC), labor and delivery, postnatal care (PNC), and well-child health visits allows programs to deliver family planning counseling and services during the points at which couples have the most frequent contact with the health care system, without substantial increases in staff or infrastructure.^2,9 Effective PPFP use, however, relies on adaptation to established or developing health systems within each country, particularly in terms of the services that can be offered immediately after delivery, such as insertion of postpartum intrauterine devices (IUDs) post-delivery versus post-discharge. As a result, it can be difficult to effectively transfer models, even when they are employed successfully in other contexts. Nevertheless, careful planning and learning from challenges faced by PPFP programs in similar settings can overcome these obstacles.

Qualitative analysis on perceptions of effective access to and provision of PPFP services in Ethiopia and Kenya identified certain consistent programmatic requirements:

• Tracking of postpartum contraceptive use allows health workers, governments, and organizations to ensure the steady supply and distribution of contraceptive commodities, especially in rural areas.

• Availability of high-quality, easy-to-understand informational materials about PPFP and contraceptive options can help women and their families make informed choices.

• Consistent health worker training and use of global PPFP best practices ensure that service delivery is consistent with global standards for care.¹¹

Government support is also a critical component of PPFP programming and can help ensure that voluntary family planning services are well-funded; are delivered consistently, safely, and effectively; and are technically and clinically sound. In cases where the government relies on or collaborates with funding sources from nongovernmental or private-sector partners, program managers may be able to advocate increased PPFP attention and support by leveraging these relationships.³

APPLYING PROGRAMMING STRATEGIES FOR POSTPARTUM FAMILY PLANNING

The new resource, “Programming Strategies for Postpartum Family Planning,”³ adapts the assessment questions identified by WHO's health systems framework,¹² and it includes an additional element for determining community and sociocultural obstacles. It helps readers identify programmatic weaknesses related to the essential elements of any health system and provides examples of evidence-based interventions that program managers can adopt, depending on the findings in their assessments (Box). Although not intended to be exhaustive, these approaches should help direct attention toward interventions that strengthen service delivery, human resources, or financing. For example, if high rates of breastfeeding are noted, program planners can ensure that the Lactational Amenorrhea Method (LAM), and counseling on the transition from LAM to other effective contraceptive methods, are part of routine PNC and infant health care.

Irrespective of the policy and programmatic choices made to capitalize on entry points across the continuum of care—ANC, labor and delivery, PNC, or infant health and immunization services—the document provides ample references to potential program goals, outcomes, strategies, activities, and indicators for each contact point. Of particular note, the document cites WHO's recently updated recommendations that women receive PNC for at least 24 hours after birth and additional PNC contacts on day 3, between days 7–14, and at 6 weeks after birth.¹³

To support programming decisions, several examples of programs with targeted PPFP components that have been implemented in multiple cultural contexts are provided in the resource. Brief descriptions of program efforts and observed results are included, and supplemental information on program indicators for monitoring and evaluation purposes is also outlined.

TIME FOR ACTION ON PPFP

In July 2012, bold global goals were announced during the London Summit on Family Planning, where 32 countries and numerous donors, foundations, and organizations, including WHO, made global political commitments to expand access to voluntary family planning for 120 million more women and girls around the world by 2020 (the “FP2020 goals”). The momentum of the Summit and the commitments that followed have not only renewed global attention on family planning as a key element in achieving development targets but also underscored the importance of coordinated action among various ministries and government entities, private and public sectors, stakeholders, and donors. The development of strong programs that can effectively meet the family planning needs of postpartum women while maintaining high-quality counseling and service delivery requires multisector collaboration among stakeholders at a variety of programmatic levels—ranging from facility directors, community health workers, and national program managers to private donors and international nongovernmental organizations. The careful coordination of these entities advances program practices that are based on sound sexual and reproductive health policies and standards of care and establishes robust, sustainable programs that have the ability to withstand and adjust to contextual changes. “Programming Strategies for Postpartum Family Planning” makes it easier to develop family planning programs by providing practical assessment tools for each step of the process, helping countries to identify the right solutions for their problems and employ the best strategies in their unique situations.

CONCLUSION

Given the few short years for us to reach FP2020 goals, we must take immediate action to encourage country programs to offer the family planning services that postpartum women want and deserve. The release of “Programming Strategies for Postpartum Family Planning” will help propel these programs in the right direction and enable the international community to reach this large and important population.