is a lactational amenorrhea method ( ) c ff (lam) user card an...
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Is a Lactational Amenorrhea Method ( ) C ff (LAM) User Card an effective strategy for improving LAM uptake and facilitating the transition to other FP methods? methods? Justine A. Kavle, Donald Cruz, Miriam Betancourt, Rebecka LundgrenGeorgetown University, IRH and MOH, Guatemala
Presenter: Rebecka Lundgren2011 International Conference on Family Planning Dakar Senegal2011 International Conference on Family Planning Dakar, Senegal
E X P A N D I N G F A M I L Y P L A N N I N G O P T I O N S
What is LAM
• Modern and effective method of family planning (FP), Modern and effective method of family planning (FP), based on natural effect of breastfeeding on fertility
• LAM criteria1. Menstruation has not returned2. Mother is only breastfeeding 3 Baby is less than 6 months3. Baby is less than 6 months
LAM Efficacy LAM Efficacy 6m Post-partum
90%
100%99.6% 99.5% 99.4% 99.0% 98.8% 98.5%
LAM Efficacy
70%
80%
90%
50%
60%
(Rwanda measured LAM effectiveness at 9-months post-partum)
LAM supports exclusive breastfeeding: Dual benefits for mother and babyDual benefits for mother and baby
Supports growth and developmentSupports growth and development
Stimulates oxytocinrelease causing
Stimulates oxytocinrelease causing
Prevents neonatal and infant mortalityPrevents neonatal
and infant mortality
guterine contraction
to reduce postpartum blood
loss
guterine contraction
to reduce postpartum blood
losslossloss
LAM ti LAM ti Prevents neonatal and infant illness
(diarrhea, respiratory
Prevents neonatal and infant illness
(diarrhea, respiratory
LAM promotion increased
percentage of women that
l l
LAM promotion increased
percentage of women that
l l
Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP, 2010
respiratory infection)
respiratory infection) exclusively
breastfeed exclusively breastfeed
LAM users were more likely to use contraceptives at 12 months postpartum Jordanat 12 months postpartum, Jordan
*Multicenter: ~ 68% use FP at 9 and 12 months
8090100 *Brazil: After LAM introduction, at 12 months, lower % women
not using FP (pre-post) p<0.0001.
4140506070
2313 14
10203040
0LAM BFFP Traditional No FP Use
Bongiovanni et. al 2005, Hardy et al, 1998, Hight-Laukaran et al, 1997BFFP = Breastfeeding for family planning
Challenges in Recording LAM UseChallenges in Recording LAM Use
Zambia 2007Mali 2006
Full Breastfeeding Rates v. LAM use
M li 2006
Nigeria 2003
Guinea 2005
Haiti 2005-2006
Madagascar…
India 2005-2006
Ghana 2003
Madagascar 2003-2004
Guinea 2005
Rwanda 2005
Ethiopia 2005
Tanzania 2004-…
Rwanda 2005
Ghana 2003
Mali 2006
Uganda 2006
Ethiopia 2005
Malawi 2004
Nigeria 2003
India 2005-2006
Kenya 2003
Malawi 2004
Pakistan 2006-…
Uganda 2006
p
Tanzania 2004-2005
Bangladesh 2007
DR Congo of 2007
Pakistan 2006-2007
Zambia 2007
0 20 40 60 80 100
Bangladesh 2007
Congo, DRC 2007
India 2005-2006
0 20 40 60 80 100
Kenya 2003
Haiti 2005-2006
Tanzania 2004-2005
Percent of women 3.0 to 5.9 months postpartum who are full breastfeedingDHS Analysis, 2003-2007
Percent of women using LAMDHS Analysis, 2003-2007
Challenges for integrating LAM into g g gFP and MCH programs
Demographic Health Survey (DHS) analysis ACCESS‐FPDemographic Health Survey (DHS) analysis, ACCESS‐FP‐ High levels full breastfeeding, yet low LAM use‐ Poor breastfeeding practices require reinforcement for LAM use
Confusion that breastfeeding = LAM‐ Women believe breastfeeding protects them from pregnancy
L l t f LAM b tf di f f il l i‐ Local term for LAM = breastfeeding for family planning
LAM is an underutilized method despite effectiveness‐ Providers’ knowledge and training are lowProviders knowledge and training are low‐Women and health workers believe LAM is not effective‐ Few programs offer LAM
Winfrey and Borda, 2010, Tilley et al. 2009
Study Background
• LAM is offered in Guatemala, but health LAM is offered in Guatemala, but health providers and users often mistakenly believe breastfeeding = LAM.
• Confusion exists among providers and • Confusion exists among providers and users regarding LAM effectiveness and the 3 criteria for use.
P d l f h LAM • Providers rarely confirm that LAM users know and meet the criteria.
• LAM users may not use LAM correctly or do not transition to another FP method when any of the criteria change.
• Postpartum, breastfeeding women are p glikely misreported as LAM users.
Study PurposeStudy PurposeTo examine if introducing a LAM user card can improveimprove…• LAM users’ and providers’ knowledge of the three
criteria and when to transition another FP method• uptake of LAM• recording of LAM users by providers• stakeholder perceptions stakeholder perceptions
regarding LAM
Study Design
Training of MOH P id
Counseling and recording LAM users Providers recording LAM users
MaterialsIntervention:
LAM user cardMOH LAM brochure
Control:MOH LAM brochure
LAM knowledge, use, LAM knowledge, use,
Outcomes:User, provider, stakeholder
LAM knowledge, use, timely transition
Provider knowledge, counseling, recording
LAM knowledge, use, timely transition
Provider knowledge, counseling, recordingstakeholder
Stakeholder perceptions Stakeholder perceptions
Family planning user card
• LAM assigned a separate code in 2008• LAM assigned a separate code in 2008 • Card frequently out-of-stock
LAM User Card – Intervention Group
Standard card given to both groupsMOH LAM BrochureInside page Front page
Study Implementation: Intervention challenges2011 2012
April July Sept. March
LAM provider training (some cards distributed)
X
Refresher training XRefresher training (revised card distributed)
X
Fidelity check X
Service statistics (April 2010 through March 2012)
X
March 2012)
Interviews with providers, users, stakeholders
X
stakeholders
Data collected to check intervention fidelity
In-Depth Structured Interviews Focus
y
interviews Stakeholders
(#)
Groups with LAM
users(#)
LAM Users
HealthProviders (#)Users
(#) Providers
(#)
Control 10 30 1Control Group
10 30 1
InterventionGroup
26 44 1Group
Total 6 36 74 2
Perceptions of LAM and user card
P i l P i l
In-depth interviews with stakeholders (N=6) Potential
to integrate
LAM
Potential to
integrate LAM
Many women breastfeed and are likely to adopt another FP method later.
stakeholders (N 6)
Barriers to
i l
Barriers to
i l
Even with training providers may still not understand the 3 criteria.
Provider bias – “Depo Provera is most implemen-ting LAM
implemen-ting LAM
pused and most discreet.”
Time for counseling – “easier to give injection.”
Different forms are used, which
Difficulties recording
LAM
Difficulties recording
LAM
can be lost.Quality and timeliness of data reporting is lacking for all FP.Tendency to record all post-
t LAM partum women as LAM users
+ and – of LAM user + and – of LAM user
Visual resonates with women, most (5) thought would improve recording, monitoring is possible
i h ki i f LAM user card
LAM user card
with tracking appointments of userPrinting is expensive and getting providers
to use it would be challenging
Provider interviewsKnowledge of conditions for LAM use and transition
96
Intervention Group N = 44 Control Group N = 30
93
89
93 93
83
Period not returned Fully / nearly fully BF Baby less than 6 months
**When a woman no longer meets LAM criteria, all providers, in both groups, gave advice to “immediately use another method”
Provider interviews
Intervention Group = 44 Control Group = 30
Provider interviewsOffering LAM – when and how
7786 91
667080
8777
p p
66
15.9
Offer LAM-last 3 months
Offer LAM antenatal care
Offer LAM postpartum
MOH Brochure to
talk about LAM
LAM user card to talk about
LAM
Provider interviewsImpact on counseling and recording
Use of LAM card to counsel • 27% of providers had LAM cards in stock
Impact on counseling and recording
27% of providers had LAM cards in stock at time of interview
• < ½ showed the card during counseling and most of these providers gave women cards to take homewomen cards to take home
Reasons for not using LAM card to counsel • Had stock-out of LAM cards• Had no time to counsel• No directive from the health authorities.• Were not present for the training
Recording of LAM users weak, though better in intervention group• ‘Ever recorded’ a LAM user (18 % vs. 13%)
R d d LAM i d il i (30% 20%) • Recorded LAM users in daily register (30% vs 20%)
When women received LAM messages
LAM user interviewsg
• Most received LAM messages during prenatal care • 63% - intervention
75% l• 75% - control
• About half received LAM messages during postnatal care • 50% - intervention• 60% - in control
LAM user interviews
(n=36)
Knowledge of conditions for LAM use and transition
60
70
25
11
Breastmilk only Until 6 months Until menses returns New method at 6 months
Fidelity Testing: I l d Intervention not implemented
LAM d di ib d • LAM user cards not distributed to providers
• FP user cards out of stock• Providers report lack of time to
record FP users• Few LAM users reported (although Few LAM users reported (although
improved)• Providers report no official guidance
received regarding user cardreceived regarding user card• Not all staff trained (rotation,
vacation)
Next steps
• Provide feedback to MOH authorities
• Share results with providers
• Monitoring visit facilities to ensure stock of reporting forms and user cardp g
• Continue collecting service statistics from gcontrol and experimental health centers
• At 6 months conduct interviews with stakeholders, providers and users
Lessons LearnedLessons Learned
• Measuring intervention fidelity is critical
• Health system weaknesses trump stakeholder buy-in and best intentions
• Challenges of relying on print materials (design, stock-outs, distribution)( g )
• Key factor in associated with correct reporting is strong MOH leadershipp g g p
• Knowledge of LAM criteria, including transition high among providerstransition high among providers
Thank youThank you
For more information
www.irh.org