Recommendations Related to Integrating Postabortion and Postpartum Family Planning for Diverse Categories of Womena

PopulationWhat PPFP or PAFP Service Is Relevant Here?How Might This Service Be Affected by COVID-19 Mitigation?bHow Might You Modify the PPFP or PAFP Services in Context of COVID-19?Key Resources
Women seeking ANC servicesPPFP counseling at every ANC contact (whether in person or virtual) and messages reinforced at each subsequent contact to help women formulate a plan for voluntary PPFP.ANC schedules and visits may be modified to allow for screening, triage, scheduling, social distancing, shifting some visits to virtual platforms or tele-consultations, providing ANC through CHWs, and/or by combining ANC contacts.All Women: PPFP counseling at each of these ANC contacts remains paramount, particularly as disruptions to ANC may result in inconsistent models of care and providers throughout the pregnancy and beyond. Staff and clients follow local guidelines for wearing masks, especially when social distancing cannot be observed.COVID-19 Technical Brief for Maternity Services (UNFPA)26
WHO recommendations on antenatal care for a positive pregnancy experience (includes PPFP ANC counseling)27
WHO Advice on the use of masks in the context of COVID-1928
Additional recommendations for women with positive COVID-19 test or symptoms: As infrastructure allows and operating within local guidance, ensure that symptomatic women do not share the same space used by other women and that any shared spaces are cleaned between uses, offer telementoring of symptoms, and establish referral pathways for pregnant women requiring EmONC or treatment for severe COVID-19 disease.
Women presenting for PACPAFP counseling to include all contraceptive methods and information on return to fertility. Voluntary FP service provision of all eligible methods.Due to supply and/or service limitations, possible shifts to teleconsultations for medical management of abortion complications; the ability to provide a full range of FP options during PAC could be limited.All Women: Where provision of a woman’s desired contraceptive method is not immediately possible, counsel about alternatives and plan for obtaining their preferred method once services and supply stabilize.
When providing methods, observe all infection prevention and control protocols. For long-acting reversible methods, ensure client has a plan for managing side effects and for obtaining removal services. For short-acting methods, provide advance prescriptions and refills for several months depending on stock availability.
Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected29
Family Planning: A Global Handbook for Providers (2018 Update)11
A guide to preventing and addressing social stigma associated with COVID-1930
Additional for women with positive COVID-19 test or symptoms: Place FP products (including self-administered methods and ECPs) at pharmacies for caregivers or trusted relatives of clients to access on their behalf and provide telehealth support.
Women seeking maternity servicesPPFP counseling to include all contraceptive methods and information on return to fertility, relative to exclusive breast-feeding practices. Voluntary service provision of all eligible methods.After uncomplicated vaginal delivery, and where the home setting is suitable for recovery, health systems may consider early discharge with frequent telehealth monitoring for routine postnatal care and referrals for postpartum or newborn emergency care.All Women: In these instances, continue offering PPFP counseling prior to discharge, emphasizing return to fertility and how and where to access PPFP during later postnatal or immunization visits.
When providing FP methods, observe all infection prevention and control protocols. For long-acting reversible methods, ensure client has a plan for managing side effects and for obtaining removal services. For short-acting methods, consider advance dispensing ECPs and/or condoms for LAM users, or POPs or progesterone vaginal rings for those who will breastfeed, but not exclusively.
COVID-19 Technical Brief for Maternity Services (UNFPA)26
Advice on the use of point-of-care immunodiagnostic tests for COVID-19: scientific brief31
Additional recommendations for women with positive COVID-19 test or symptoms: Ensure respectful care and companionship even if a woman delivers in area separate from asymptomatic women. Initiate breastfeeding promptly, with COVID-19 specific protective equipment for the mother. Plan for COVID-19related support post-discharge.
Woman presenting for postnatal care and infant immunization services in facilitiesPPFP counseling at PNC and immunization contacts. Voluntary FP service provision of all eligible methods.Return postnatal care visits had low coverage in normal times and may be further compromised by COVID-19. Immunization coverage, while typically higher in normal times, is also affected by COVID-19.All Women: Strengthen counseling during return postnatal care (PNC), and where appropriate, within immunization services. If privacy does not allow FP counseling during immunization/well baby clinic and staffing adequate, provide intra-facility linkage for FP for the mother. Consider utilizing lay counselors where clinical staff are overburdened or there are no staff providing FP services concurrently to immunization. In group education sessions, keep clients seated 2 meters apart; staff and clients follow local guidelines for wearing masks.Guiding principles for immunization activities during the COVID-1932
Family Planning and Immunization Integration33
Additional for women with positive COVID-19 test or symptoms: Same as with ANC, maintain adequate separation from asymptomatic women. Provide or reiterate mother with COVID-19 specific guidance for safe breastfeeding. Plan for additional COVID-19 related support.
Pregnant, delivering and postpartum women not accessing facility-based servicesPPFP and PAFP counseling at every community-based contact (whether in person or virtual), information on return to fertility, support for exclusive breastfeeding practices where applicable. Voluntary FP service provision and/or referral of all eligible methods.Community- and home-based services may be utilized in greater magnitude due to limitations on facility-based care.All Women: Emphasize PPFP and PAFP counseling and information on how to access services as part of CHW-led and other community-based initiatives, observing privacy and confidentiality. Health education platforms can also enhance education on PPFP and PAFP and educate women on how to use fertility awareness (with caution for women who have yet to see regular menstrual cycles return) and self-administered methods, such as LAM, POPs, and where available, progesterone vaginal rings. Various community stakeholders (women’s groups, community leaders, faith community) can also encourage essential services including PAC and PPFP, and provide support for finding these services.
For in-person community-based care of pregnant, delivering, and postpartum women, services should be modified per local and international guidance to ensure safety, continuity, and protection of individuals and health workers.
To provide FP methods, consider doorstep delivery of contraceptives, placing FP products at pharmacies, use of mobile outreach, deployment of digital applications that support self-administered and fertility awareness method use, referral to safe facility-based care where applicable.
Where medical records allow, health workers may consider contacting women via phone to offer telehealth pregnancy and postnatal care, and to schedule safe facility-based visits.
Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response34
Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic35
Additional for women with positive COVID-19 test or symptoms: Support through hotlines (or other remote means) for monitoring severity of symptoms and need for specialized care. Women with symptoms should be advised to stay away from community health events.
  • aGeneral principles for all women:

    • Promote respectful, stigma-free care, with cautious communication to blame the virus, not the person. This applies to women experiencing abortion complications as well.30

    • Promote task-sharing where CHWs already exist, including to encourage referrals to facility services and build trust through risk communication and community engagement.

    • In the immediate postpartum or postabortion periods, women are, by default, nonusers after pregnancy. After method adoption, women may also need support to manage side effects and/or removal. Refer to contraception and COVID-19 guidance in such cases.21

    • Be on the lookout for signs of gender-based violence and support victims, as incidence of violence is expected to increase.36

    • Post or adapt WHO infographics on gender-based violence for displaying in health facilities and consider providing training to health workers who work with women on the 2016 WHO ANC recommendation which suggest clinical inquiry and referrals for GBV.b Factors that may influence implementation of PAC and PPFP services during the COVID-19 pandemic:

    • COVID-19 testing availability

    • Country-specific laws, clinical guidelines and practice standards

    • Task-sharing practices

    • Pervasiveness of mobile phones and other communication technologies to facilitate “telehealth”

    • Availability of IPC supplies (hand hygiene resources, personal protective equipment including masks for all HCWs and clients), environmental cleaning, and waste management)

    • Stay-at-home orders and/or curfews

    • Modifications to ANC, PAC, childbirth, PNC and immunization services

    • Religious or cultural practices

  • Abbreviations: ANC, antenatal care; CHWs, community health workers; ECPs, emergency contraceptive pills; EmONC, emergency obstetric and newborn care; FP, family planning; GBV, gender-based violence; HCW, health care workers; LAM, Lactational Amenorrhea Method; LARC, long-acting reversible contraception; PAC, postabortion care; PAFP, postabortion family planning; PPFP, postpartum family planning; PNC, postnatal care; POPs, progestin-only pills; Q&A, question and answer; RH, reproductive health; UNFPA, United Nations Population Fund; WHO, World Health Organization.