ahmed_integration of family planning and mnh programs

8/2/2019 Ahmed_Integration of Family Planning and MNH Programs

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Integrating Family Planning within a Community-

Based Maternal and Neonatal Health Program in

Sylhet, Bangladesh

Salahuddin Ahmed1 & 2, Nazmul Kabir 4, Jaime Mungia2, Catharine McKaig2,

Saifuddin Ahmed1, Amnesty LeFevre1, Peter Winch1, Ahmed Al-Kabir3, and

Abdullah Baqui1

1

Johns Hopkins School of Public Health;2

Jhpiego;3

Shimantik,4

Save theChildren

Asia Regional Meeting on Interventions for impact in Essential Obstetric and Newborn Care

May 4-6, 2012, Dhaka, Bangladesh



Study Context

TFR by Divisions, Bangladesh, 2004 Selected FP indicators in Sylhet, BDHS

2007

2.9

4.22.9

2.8

2.6

3.7

Indicators BGD Sylhet

Unmet FP need 17% 26%

CPR (any method) 56% 31%

TFR 2.7 3.7

Birth intervals

<24 months 15% 26%

<36 months 37% 57%



Integrated Model of PPFP & MNH

3Newborn care

Postpartum FP counseling and

contraceptive distribution

Evolution of MNH packages • Designed and evaluated a community-based maternal and

newborn care intervention package

• A home care package which involved CHW antenatal andpostnatal home visits and management of sick newbornreduced NMR by 34% (Baqui et al., Lancet, 2008)



Study Objectives

• To develop and test an integrated FP/MNHservice delivery approach

• To assess: –

strengths and limitations of integrating FP intoan ongoing community-based MNH careprogram

– impact of the intervention package oncontraceptive knowledge and practices

– impact of the intervention package onpregnancy spacing

4



5

Study Design

Study sites: eight unions in two sub-districts in Sylhet district, Bangladesh

Non-Random Allocation

Intervention unions: four

Enrolled women: 2247

Comparison unions: four

Enrolled women: 2257

Enrollment of women during <8 months of pregnancy

Intervention clusters:

MNH plus FP during ANC

and Postpartum visit

Comparison clusters:

MNH ONLY during ANC

and Postpartum visit

Follow the cohort through pregnancy to 36 months postpartum



1 2 3 4 5 6 7 8 9 p1 p2 p3 p4 p5 p6D

IFASupplementation

ANC1

TT

ANC2 ANC4

TT

ANC3

Pregnancyidentification

Clean delivery andimmediate

newborn care

PP maternal care, Vit A andmanagement of

complications

Essential newborncare

Management/referof newborn

complications

Immunization

Postnatal sessionpromotion LAM, andtransition, spacing, PPFP,

ARI, CDD, EPI

Refer sick mother andchild, Supply and refer for

FP methods

Integrated Maternal, NewbornCare, Child Health and Family

Planning Package

Birth preparedness

CHW counseling

Exclusive breastfeeding and

promotion of LAM/PPFP andtransition



Intervention Delivery Strategy

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Service DeliveryHome visits by CHWs

Counsel in antepartumand postpartum periods

Pregnancy surveillance andcontraceptives dispensing

Household visitsevery two months toidentify new MWRA

and pregnant women

Messages on LAM andtransition, return to fertility,optimum birth spacing, and

contraceptive methods

• Pills, condoms, andinjectables

• Refer for other

methods

Community mobilization: Conduct meetings with women, husbands, mothers, mothers-in-law

and community leaders including religious leaders to raise awareness about PPFP messages

LAM Ambassadors: Local champions providing peer support, counseling and advocacy for LAM



Results

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Starts in a Low Performance Area

21.1

18.0

0 10 20 30 40 50 60 70 80 90 100

Percent

Control

Intervention

Ever Used Contraceptive Method



CPR Trend During 18Months Postpartum

*P <0.001



Contraceptive method mix among

intervention area users’

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• Overall high adoption of

LAM 23% at 3 months

and 12% at 6 months

• Shift in method preferencefrom LAM to pills, condoms,

and injectables

12

C i i





13

• Slight increases in

injectables and long-acting

methods

• Rise in sterilizationfrom 1.9% to 3.1% in

intervention area

• Oral contraceptives are

the preferred contraceptiveat 12 and 18 months

C i M h d Mi



Contraceptive Method Mix

Among Control Area Users’

14



Self Reported Pregnancy

Incidence

15

0 . 0

0

0 . 0

5

0 . 1

0

0 . 1 5

0 . 2

0

0 . 2

5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18Months since delivery

Intervention Control

The difference is statistically significant (P = 0.013)



Does integration of FP adversely affect

MNH program?

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Effect of Integration on MNH Care:

Selected Newborn Care practices

Intervention

(%)

Comparison

(%)

P value

Drying andwrapping of

newborn within 10

minutes of delivery

50.4 44.1 <0.001

Initiation of

Breastfeeding

within 30 minutes

of delivery

56.6 46.8 <0.001

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.

0 . 2

5

.

0 . 7

5

.

1 3 6analysis time

Intervention Control

Duration of exclusive breastfeeding by study arm

18

Duration of Exclusive

Breastfeeding by Study Arm

*P <0.001



Lessons Learned

HFS demonstrates:

1. Feasibility of integration of FP within acommunity-based MNH program

2. Effectiveness of the model in increasingmodern method use

3. No notable negative effect on the delivery of

MNH services4. Positive effect of LAM promotion on the

duration of exclusive breastfeeding

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Best Practices, Research Gaps

Best practices:

CHW antenatal and postnatal home visits tocounsel on HTSP, emphasis on LAM and

transition, integration of FP with MNH Return to fertility messages

Community meetings targeting husbands andmothers-in-law

Provision of pills, condoms and injectablesthrough CHW at home

Research Gaps

Cost, cost-effectiveness studies being planned20



Scaling up through ACCESS and

MCHIP (MaMoni)

Major MaMoni Interventions:

Capacity building for both GO and NGO staff

Gap management through CHW deployment

Counseling and CBD of pills, condoms andinjectables

Referral for LAPM

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24.7

34.0

50.8

0

25

50

75

100

DHS 2007 Baseline 2010 7 months after baseline

%

Source: BDHS, 2007

Baseline survey, Sep’10 Progress Assessment’ April’11

CPR in Sylhet - Modern Method



Unmet Need for Family Planning at

Sylhet in MaMoni Working Areas

Source: Baseline survey, Sep’10 Progress Assessment’ April’11

13

29

42

5

19

25

0

5

10

15

20

25

30

35

40

45

Unmet need forspacing

Unmet need forlimiting

Total unmet need

Base line Sep'10 After 7 months of base line



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ahmed_integration of family planning and mnh programs

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