Seeking Synchrony Between Family Planning and Immunization: A Week-10 DMPA Start Option for Breastfeeding Mothers

SYNCHRONIZED SERVICES

This last advantage, better synchrony, may be the most important, but the benefits of synchronized visits have never been promoted or evaluated, in spite of much recent attention focused on the benefits of integrating family planning with other health services such as immunization.⁹ Intuitively, initiating contraception during the 6-week visit makes good sense. Throughout the developing world, maternal and child health programs have made enormous investments to ensure that mothers come to clinics at this time for their infants' immunizations and growth monitoring, so it is no surprise that family planning programs have tried to “piggyback” onto this all-important visit.

However, given the 3-month (13-week) cycle of DMPA, subsequent resupply visits after a week-6 initiation do not align well with scheduled immunization visits, resulting in a total of 6 scheduled family planning and immunization revisits in the following 10 months (Figure 1).

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FIGURE 1

Standard Week-6 DMPA Initiation Schedule With 7 Immunization and DMPA Visits Through 11 Months Postpartum

Abbreviations: DMPA, depot-medroxyprogesterone acetate; FP, family planning; Imz, immunization.

In contrast, if new mothers are counseled about family planning at week 6 and choose DMPA, they can be offered the option of a more “mother-friendly” schedule if they delay their first injection until their baby's second immunization visit at week 10. This voluntary alternative schedule (Figure 2), which takes modest advantage of the 1-month “grace period” for DMPA resupply, decreases the number of follow-up visits (after the initial 6-week visit) over the next 10 months by a full third—from 6 visits to 4 visits. (If the full 12 months postpartum period is considered, a final family planning visit would be due at week 52.) Furthermore, it is possible that women will better adhere to a reduced schedule of dual-purpose visits than to more numerous single-purpose visits. This could improve contraceptive continuation if scheduled immunization visits help overcome any hesitation to seek DMPA reinjection. Similarly, a synchronized schedule could boost immunization timeliness and coverage if the family planning appointment provides an extra cue to action for the 10-week booster or the often-neglected measles vaccination at 39 weeks. Finally, a scheduled mid-year family planning visit at around 6 months (25 weeks) (Figure 2) coincides with the baby's recommended first dose of vitamin A, and also presents a good opportunity for growth monitoring and counseling on complementary feeding at the World Health Organization's recommended timing for weaning.

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FIGURE 2

Optional Week-10 DMPA Initiation Schedule With 5 Immunization and DMPA Visits Through 11 Months Postpartum

Abbreviations: DMPA, depot-medroxyprogesterone acetate; FP, family planning; Imz, immunization.

Of course, there are several potential arguments against the 10-week start for DMPA. The first, that mothers may become pregnant between 6 and 10 weeks postpartum, should be negligible if providers are careful to offer this option only to fully (or nearly fully) breastfeeding mothers who plan to continue breastfeeding for several months. A more serious argument is that a mother who presents at 6 weeks postpartum might never return. This is certainly possible, but drop-out between the first and third visits in the primary immunization series is already low—an average of 6% in Gavi-supported countries¹⁰—and having 2 reasons to return at 10 weeks, instead of only 1 reason, could further reduce that drop-out rate.

It is much more likely that some mothers will be late for the 10-week visit. Indeed, a 2009 Lancet review of the timing of children's vaccinations in 45 low- and middle-income countries, while not explicitly addressing the 10-week visit, found that tardiness was common.¹¹ However, such delays might actually be reduced by virtue of the dual-purpose nature of the visit—mothers not sufficiently motivated to be on time for their baby's vaccination boosters may be more motivated by their own contraceptive needs. Furthermore, even if mothers are late, fully or nearly fully breastfeeding should protect them from pregnancy for at least 6 months, if they experience no bleeding episodes.

A CALL FOR RESEARCH

Compelling practical and theoretical arguments exist for giving breastfeeding mothers the option of delaying DMPA initiation from 6 weeks to 10 weeks postpartum. Research should be undertaken to test hypotheses related to the potential benefits of “synchronizing” the DMPA schedule with that for infant immunizations. Will new mothers accept a 1-month delay in initiating DMPA use? Will providers offer women this option, given the modest extra effort required? And, most importantly, will the benefits of synchronized, dual-purpose visits translate into better contraceptive continuation, immunization coverage, and other outcomes, compared with possible risks, such as unintended pregnancies among mothers who stop breastfeeding or fail to return?

Synchronized scheduling for new mothers, with fewer, more integrated revisits, not only reflects the tenets of integrated services and patient-centered, mother-friendly care, but could also improve important outcomes in vulnerable populations.