breaking the cycle of unintended pregnancy in postpartum and postabortion women carolyn curtis, cnm,...
TRANSCRIPT
Breaking the Cycle of Unintended Pregnancy in Postpartum and Postabortion Women
Carolyn Curtis, CNM, MSN, FACNM
Office of Population & Reproductive HealthUS Agency for International Development
2013 International Conference on Family PlanningAddis Ababa, November 15, 2013
Overview
Barriers
Postpartum Women
Postabortion Women
How to overcome “missed opportunities”
Where births occur
Exaggerated provider concerns
(re STI, PID, infertility, expulsion)
Poor CPI
Provider bias
Lack of knowledge re:
return to fertility
Lack of skills
Myths and misperceptions
Structure of services
Inappropriate eligibility criteria
Barriers
Stigma
Source: RESPOND Project, 2012.
↑ ↑ Access
↑ ↑ Quality of services
↑ ↑ Choice and use
↓ ↓ Rapid repeat pregnancy
↓ ↓ Abortion
Outcomes when barriers are overcome:
Barriers to FP services for postpartum and postabortion (PAC) clients
Ten Essential Elements of Successful FP Programs Selected, High-Impact Practices (HIPs)
1. Supportive Policies
2. Evidence Based Programming
3. Strong Leadership and Good Management
4. Effective Communication Strategies
5. Contraceptive Security
6. High Performing Staff
7. Client-Centered Care
8. Easy Access To Services
9. Affordable Services
10. Appropriate Integration of Services
Source: Population Reports 2008, JHU.
• Community-based services & task-shifting / task-sharing
• Postpartum FP
• Postabortion FP (PAC)
• Mobile outreach services
Family planning programs: What has worked?
Who are the women?
1 in 4 women in developing countries have an unmet need for FP = 222 MILLION women with unmet need!
Each year: 210 million pregnancies 80 million unintended
pregnancies 44 million abortions 31 million stillbirths Approximately 130 million
births = 130 million postpartum women
Source: Ross and Winfrey “Contraceptive use, Intention to use, and unmet need during the extended postpartum period, Intl FP Perspectives, 2001. Analysis of DHS data from 27 countries
Reproductive intentions of postpartum women – 12 months following a birth
Want to give birth in 2
years
Want to space or limit
Using FP method
Not using a method
0%
20%
40%
60%
80%
100%
5%
95%
30%
65%
Global Sub-Saharan Africa
Middle East Asia Latin America0
10
20
30
40
50
60
70
80
90
100
65
74
52
62
54
29
18
44
32
42
58
4 4 3
% Unmet Need % Using Method - Modern & Traditional
Unmet need, contraceptive use & reproductive intention in women 0-12 months postpartum
Source: Ross, J, Winfrey, W, Contraceptive Use, Intention to Use and Unmet Need During the Extended Postpartum Period, International Family Planning Perspectives, 2001 27(1) 20-27.
Postpartum FP use and method mix among women giving birth in previous 12 months
9287 87 83
78 77 77 76
62
0
10
20
30
40
50
60
70
80
90
100
Permanent method LARCs Short-acting resupply Traditional method Not using
Source: RESPOND Project, secondary analysis of respective DHS, 2010.
26% of the world’s 7 billion people are aged 10-24
FP demand in young and unmarried women is high, but access is constrained:
50-80% demand among married women age 15-24; 20-40% unmet need
~ 90% of unmarried women 15-24 in all regions of the world do not want to become pregnant, but their unmet need is very high, approaching 50% in some sub-Saharan African countries
Complications of unsafe abortion are a main cause of death in 15-19 year-old women in low-resource countries
A considerable problem in the U.S. too:
The American College of Obstetricians and Gynecologists recommends that its members “encourage adolescents age 15-19 to consider implants and IUDs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.”
--ACOG Committee Opinion #539, Obstet. Gynecol., 2012; 120(4):983-988
PAC FP: background
Series10
20
40
60
80
100
32%
77%
60%
20%
Using FP before pregnancy (method failure) Desire to space or limit next pregnancyDesired a FP method before leaving facility Left facility with FP method
Source: Situation Analyses in Haiti, Dominican Republic, & Nicaragua. Population Council, 2008
PAC FP: How we fail women
Preventing missed opportunities: What can we do?
Reorganize services to integrate/strengthen FP services with: Postpartum (including EMOC), Postabortion, MCH, HIV/AIDS
Task-sharing / task-shifting (proven; widely endorsed) Mid-level providers
• Clinical Officers, Midwives, Nurses• injectables, implants, IUDs, permanent methods
Community Health Workers• Injectables, implants (e.g., Ethiopia)
Use mobile outreach Dedicated providers, free services, wide method choice:
leads to greater access and use
Decentralize services
Impact of decentralizing PAC services to lower-level fixed sites
PAC Clients, 21 Districts in Tanzania (October 1, 2007 - September 30, 2010)
Results: Decentralized
PAC services in 21 districts
293 health care workers trained
FP counseling and services in 224 sites
Accepted
Counseled on FP
PAC Clients
02,
000
4,00
06,
000
8,00
0
10,0
00
12,0
00
14,0
00
16,0
00
18,0
00
20,0
00
12,106
14,737
17,262
Number of PAC clients
Source: ACQUIRE Tanzania Project
Integration of FP with immunization – seems a good idea, but not much solid evidence yet
Test Group Control0
100
200
300
400
500
600
200144
307
167
FP -PostFP- Pre
Huntington, D. and Aplogan, A., The Integration of Family Planning and Childhood Immunisation Services in Togo Studies in Family Planning, Vol 25, No.3, 1994
Test Group Control Group
0
2000
4000
6000
8000
10000
12000
14000
16000
58394185
7525
5839Imm - PostImm - Pre
FP Acceptors Vaccines Administered
Joint Statements by: FIGO ICM ICN DFID Gates White Ribbon
Alliance Others
to advance postpartum and postabortion FP
What is needed to ensure “No missed opportunity”?
National Level
Ensure contraceptive supply
Make FP & LA/PMs available and at reduced cost or free
Support proven policy changes for midlevel providers
Include FP in pre-service curricula & certifying exams
Change in the WHO MEC for postpartum women
Facility Level
Ensure the latest WHO FP service delivery guidelines are in place – and model following them in practice
Reorganize services to ensure FP services at same location (PP, PAC, EMOC).
Become a visible “champion” in your facility for increasing FP availability and access.
Thank You!!!
Photo credits: Slide 1 (left to right), A. Jackson/EngenderHealth; A. Fiorente/EngenderHealth; C. Svingen/EngenderHealth. Slide 5 (top to bottom), M. Tuschman/EngenderHealth; C. Svingen/EngenderHealth; M. Tuschman/EngenderHealth; E. Uphoff/EngenderHealth.