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Nutrition and Family
Planning Integration:
Developing programmatic
approaches to addressing
infant and young child
feeding & LAM
Presenter:
Dr. Justine Kavle
Senior Technical Officer, MCSP/PATH
2
Birth-to-Pregnancy Spacing Among All Women Aged 15-
49, All Non-first Births in the Last 5 years, 2008-09
DHS, Kenya
4%
11%
35% 22%
11%
6% 11%
<6 months
6-11 months
12-23 months
24-35 months
36-47 months
48-59 months
60+ months
N of Non-First
Births=4,531
3
54
21 16
35
83
36
18
42
91
48
31
60
130
73
53
78
0
50
100
150
<15 Mos 15-26 Mos 27-38 Mos 39+ Mos
NNMRPMRIMRU5MR
Early Childhood Mortality Rates According to
Birth-to-Pregnancy Intervals, 2008-09 DHS, Kenya
NMR = Neonatal
Mortality Rate
PMR = Perinatal
Mortality Rate
IMR = Infant Mortality
Rate
U5MR = Under-5
Mortality Rate
Children conceived after longer durations were
less likely to be stunted and underweight
1.251.30
1.23
1.16
1.111.07
0.98
0.89 0.82
1.22
1.29
1.191.13
1.111.06
0.98 0.95
0.82
0.4
0.5
0.6
0.7
0.8
0.9
1
1.1
1.2
1.3
1.4
<6 6-11 12-17 18-23 24-29 30-35 36-47ref.
48-59 60-95 96+
Ad
j. R
ela
tiv
e R
isk
Interval in months
Child Malnutrition by Birth to Conception Interval
Stunted
Underweight
265,144 children
Source: Rutstein 2008
Significant Health Benefits of Birth Spacing,
for Maternal, Child Health and Nutrition
For Children
• Lower risk for:
• Stunted and underweight
child
• Small for gestational age
• Low birth weight
• Preterm birth
• Lower rates of newborn,
infant, and child mortality
Rutstein SO, 2008, Conde-Agudelo A, 2006, Zhu BP, 2005, King JC 2003
For Mothers
• More time to breastfeed,
improving infant health
• More time for women to
recover physically and
nutritionally between births
• Lower risk of maternal death
Lactational Amenorrhea Method (LAM)
LAM is a modern and effective method of family planning
(FP) based on the natural effect of breastfeeding on
fertility.
Menstruation has not returned
Mother is only breastfeeding
Baby is less than 6 months
LAM: Efficacy established in clinical research studies
Trial Multi-
center
Ecuador Chile Philippines Pakistan
N 519 330 422 485 391
# of
Pregnancies
5 1 1 2 1
Efficacy 98.5 99.9 99.6 99.0 99.4
Labbok et al, 1997, Perez et al 1992, FHI 1994a, FHI 1994 b, Wade, Sevilla and Labbok, 1994
Exclusive Breastfeeding and LAM:
Dual benefits for mother and baby
1. Prevents neonatal and infant illness
2. Prevents neonatal and infant mortality
3. Supports growth and development
4. Stimulates uterine contraction- reduce postpartum blood
loss
5. LAM promotion increased exclusive breastfeeding
- 58% intervention vs 47% in control group (p <0.01) in
Healthy Fertility Study
Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP, 2010
Early initiation of LAM or other FP method is
important if couple doesn’t not want to become
pregnant right away
Fertility May Return Soon after Delivery
• If not breastfeeding, ovulation will occur at 45 days
postpartum on average and as early as 21 days
• Breastfeeding women not practicing LAM are likely to
ovulate before return of menstrual period
- Between 8% and 10% of women conceive within the
first year postpartum
Integration;
Maximizing routine contact points
Pre-pregnancy adolescent
s
Antenatal Care
(ANC) visits 1-4+
Birth
• home
• facility
PNC visits
• home
• facility
Immunization visits
Introduction of complementary foods, return to
fertility
Measles immuniz.
Pharmacy/ drug shop
visits
Pregnancy Neonatal
period
Post-neonatal → 2nd year
Birth Spacing and Maternal, Infant and Young Child
Nutrition (MIYCN) Linkages
Lactational amenorrhea
Fertility return
Maternal nutrition
Maternal survival
Exclusive breastfeeding
Complementary feeding
Infant and young child
nutrition
Infant survival
Approach to MIYCN-FP Integrated
Service Delivery in Kenya
12
• Designed collaboratively with national and district
Reproductive Health (RH) and Nutrition stakeholders
• Informed by findings from formative assessment
• Implemented in 6 health facilities and adjacent
community units in Bondo, Kenya
• Implementation ran for ~ 1 year
Health Facility Approach
13
• A “One Stop Shop” model where
both FP and nutrition services are
accessed in the same room at various
service delivery points:
• ANC
• Intrapartum
• Postnatal Care (PNC)
• Well-child
• Family planning (FP)
counseling visits
• MIYCN/FP job aids, poster, brochure
used to support integration efforts
14
Community Approach
• Inclusion of MIYCN-FP messages within
routine community outreach activities
• Counseling cards, brochure, poster used
to support integration efforts, and serve
as complement to existing community-
level reproductive health (RH) and
nutrition materials
Greater Integration of Counseling and Services at Health Center
Versus Hospital Level, Bondo District
Bondo Sub-County Hospital Bondo Health Centers (x2)
# of
Clients
Total
Clients
Percentage
of total
Number
of clients
Total
clients
Percentage of
total
ANC
Nutrition 32 57 56.1% 21 23 91.3%
FP 1 57 1.8% 13 23 56.5%
LAM
counseling
0 57 0.0% 9 23 39.1%
Nutrition &
FP
1 57 1.8% 13 23 56.5%
Bondo Sub-County Hospital Bondo Health Centers (x2)
# of
Clients
Total
Clients
Percentage
of total
Number
of clients
Total
clients
Percentage of
total
PNC
Nutrition 19 29 65.5% 22 25 88.0%
FP 10 29 34.5% 21 25 84.0%
LAM
counseling
2 29 6.9%
15 25 60.0%
Nutrition &
FP
counseling
7 29 24.1%
21 25 84.0%
Nutrition &
FP services
21 228 9.2% 68 152 44.7%
Greater Integration of Counseling and Services at Health Center Versus Hospital Level, Bondo District
Exclusive Breastfeeding
0
10
20
30
40
50
60
70
80
90
Jul-Sept 12 Oct-Dec 12 Jan-Mar 13 April-June 13
% of Children Under 6 Months
Exclusively Breastfed,
Bondo District Hospital
(Source: CHIS)
“I have 3 exclusively
breastfeeding mothers and
one has a child who is
already 6 months. Some
know that when they are
breastfeeding exclusively
they cannot get pregnant...”
-- CHV, Bondo
Findings • Health workers saw benefits for infant health, noted client
willingness to transition to other FP methods.
• Majority of health workers demonstrated knowledge of
MIYCN-FP, however refresher training offered on return to
fecundity, LAM criteria and transition to address gaps.
• Challenges completing MIYCN-FP supplemental registers,
however providers reported marked increases in number of FP
clients.
• Greater integration of counseling and services at the health
center versus the hospital level. “One stop shop” approach
worked most effectively in the dispensary and health centers.
Factors Enhancing Success
• Buy-in from national and district nutrition + RH stakeholders
• Strategically designed social and behavior change communication
(SBCC) materials & working tools
• Supervisor buy-in, leadership, and on-the-job mentoring
• Involvement of community and religious leaders, male partners,
mothers/mothers-in-law
• Human resource availability and continuity
• Availability of FP methods and equipment
• Whole site trainings, especially at facilities where staff rotations
routinely occur
Recommendations for expanding
MIYCN-FP integration
• Involve sub-county health management team (SCHMT) and
hospital management teams to build buy-in and enhance
sustainability
• Pair facility-based integration with community maternal,
newborn, child health (MNCH) efforts – building health
provider capacity
• Build support among facility supervisors, health workers, and
community and religious leaders
• Encourage family members’ support of exclusive breastfeeding
• Engage champions
• Focus first on health centers with high client loads
For more information, please visit
www.mcsprogram.org
This presentation was made possible by the generous support of the American people through the
United States Agency for International Development (USAID), under the terms of the Cooperative
Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarily reflect the views of USAID or the United States Government.
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