International FP Conference 2013 Lynn Bakamjian , Consultant

1. Presentation, International FP Conference 2013 Addis Ababa, Ethiopia Postpartum Family Planning: Opportunities for Integration International FP Conference 2013 Lynn Bakamjian, Consultant Lynn Bakamjian, MPH Consultant

2. Acknowledgements • PPFP Programming Strategies document team • Synthesis of PPFP Program literature, Barbara Deller, Jhpiego, 2012 (unpublished) • The many stakeholders at consultations held from 2010 to 2012

3. General Principles of PPFP • PPFP is the systematic provision of family planning to women during the 1st year postpartum – when unmet need is high • Promote PPFP as a standard of care • Promote immediate and exclusive breastfeeding; and LAM – a “win-win” for mothers and infants • Expand contraceptive choice and options to meet women’s needs • No missed opportunities across continuum of care

4. General Principles of PPFP Understanding the PPFP “Continuum of Care” … to assist policy makers and leaders to: • Identify opportunities for integrating PPFP within Maternal and Child Health services • Support decisions about program design and investment : • For introducing or strengthening existing services • For comprehensive or discrete programming

5. PPFP Continuum of care Contact Points Pregnancy Labor, Delivery, Pre Discharge Postnatal (including PMTCT) Infant Care 0-48 hours 48 hours – 6 weeks 4-6 weeks – 12 months

6. PPFP Continuum of care • Service Delivery at Contact Points Pregnancy Labor, Delivery, Pre Discharge Postnatal (including PMTCT) Infant Care • Facility-based antenatal care (ANC) • Community-based pregnancy screening • Facility-based or home-based with skilled birth attendant • Facility or household visits • Birth @ home, w/in 24 hours • Birth @ facility, prior to discharge • Day 3 (48-72 hours) • Between 7 and 14 days • 6 weeks • Facility, home, or community-based visits: • Immunizations (DPT or Pentavalent 1, 2, 3; measles; rota-virus; boosters; etc.) • Well child visits • Nutrition/growth monitoring, event days (e.g., Vitamin A) • Illness visits (e.g., iCCM/IMNCI) • PMTCT/antiretroviral (ARV) care and treatment 0-48 hours 48 hours – 6 weeks 4-6 weeks – 12 months

7. Unique Program Considerations for PPFP • Medical eligibility criteria: Initiation of method and timing of method are dependent on # of hours/days/weeks post-delivery, lactation status, and a woman’s choice. • Other contextual issues: • Integration requires coordination among health services • Socio-cultural norms and beliefs surrounding childbirth, the newborn and lactating mother

8. Timing of method and Breastfeeding Considerations • Postpartum Contraceptive Options 48 hours 3 weeks 4 weeks 6 weeks 6 months 12 months + All Women IUD Female Sterilization Male Sterilization Condoms/Spermicides Emergency Contraception Diaphragm/Cervical Cap Breast Feeding Women Lactactional Amenorrhea Method Progestin Only Comb. Estrogen/Progestin Non-Breast Feeding Women Progestin-Only Methods Combined Estrogen-Progestin

9. PPFP Programming Strategies • Illustrative Goals, Strategies, Activities and Indicators for each contact point • Menu of options – not intended as a “How-To”but to illustrate possibilities ……Due to time limitations, will provide one illustrative goal/strategy for each contact point Pregnancy (Antenatal Care) Labor, Delivery, Pre Discharge Postnatal (including PMTCT) Infant Care 0-48 hours 48 hours – 6 weeks 4-6 weeks – 12 months

10. PPFP Programming Strategies Pregnancy (Antenatal Care) • Women discuss reproductive intentions and choose a method during ANC GOAL Strengthen awareness of and demand for PPFP during ANC STRATEGY • Integrate PPFP info and counseling into ANC services • Promote inclusion of husbands and other family members in ANC education and counseling • Assign health workers to routinely provide group education on PPFP • Make PPFP IEC materials available at facilities or for home visits

11. PPFP Programming Strategies Labor, Delivery, Pre Discharge • Women who chose a method during ANC receive high quality service GOAL PPFP info, counseling, and services are provided at maternal service delivery points STRATEGY • Conduct skills training (pre- and in-service) • Support providers with supervision, job aids • Establish protocols for informed consent • Ensure exclusive breastfeeding and LAM are routine components of pre-discharge counseling

12. PPFP Programming Strategies Postnatal Care • Postpartum women who are not exclusively breastfeeding and who wish to avoid a closely spaced pregnancy choose a FP method GOAL Home-based maternal and newborn care includes PPFP counseling and service referral STRATEGY • CHWs conduct community education activities that engage men, families and communities to support PPFP • Health care provides provide PPFP messages and referrals CHWs are trained in counseling skills and equipped with job aids, commodities • Community health workers provide short-term methods

13. PPFP Programming Strategies Infant Health and Immunization Services • Postpartum women who practice EBF and LAM until infant is 6 months, transition to another modern method GOAL STRATEGY • Integrate PPFP with routine immunization services • Community-based workers mobilize mothers for immunization days and assist with group FP sessions and follow-up • Conduct group talks (HTSP, return to fertility, FP) during routine immunization sessions • Dedicated FP providers provide co-located, same-day FP counseling and services • Immunization providers screen women about FP needs and provide vouchers or referrals for services

14. Lessons from the Program Evidence • Program attention at any contact point to increase accurate information, upgrade skills and capacities of health care workers to provide quality counseling and services will generally result in increased FP use by postpartum women • However, longer programs with multiple contact across the continuum of care may have more effect on PPFP utilization than short programs with few contacts.

15. Final Words Start wherever you can along the PPFP continuum of care – you can make a difference!