Postpartum Family Planning: What to Expect When You‟re No Longer Expecting... Holly Blanchard & Angela Nash-Mercado 12 September 2008 Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health Session Objectives By the end of the session participants will be able to: – Discuss the rationale for family planning during the extended postpartum period – Explain benefits of healthy pregnancy spacing – Describe return to fertility for postpartum women both lactating and non-lactating – Describe contraceptive methods appropriate for lactating women – Describe programmatic considerations related to PPFP pre-discharge counseling – Describe programmatic considerations for postpartum long-acting and permanent methods Graphs Healthy Fertility Family Potpourri and Charts Spacing Planning 10 10 10 10 10 20 20 20 20 20 30 30 30 30 30 40 40 40 40 40 50 50 50 50 50 Source: FHI 2000 How can postpartum family planning save infants lives? Analysis of postpartum family planning needs in Kenya Source: ACCESS-FP DHS reanalysis on postpartum women in Kenya, 2006 What are the postpartum family planning needs of Kenyan women? Factors that influence fertility: Nigeria 90 Sexually active 80 % of postpartum women Menses 70 Insert Text for Question returned 60 50 Category 1 – 50 points Predom. brstfeeding 40 30 20 10 Triangle of Exposure 0 0-3 4-6 7-9 10-12 Postpartum months • What are the factors that influence return to fertility? What are Postpartum Contraceptive Options and Timeline? Adapted from the MAQ Exchange: Contraceptive Technology Update Bangladesh: Birth-to-birth Intervals 7% <17 mo 10% 18-23 mo 24-35 mo 36% 36-47 mo 48 + 26% 21% What is the graphic representation of birth spacing among women in Bangladesh? (Note % women who space births <24 months and <35 months apart) The recommended interval before attempting the next pregnancy after a live birth, is at least 24 months. This interval reduces the risk of adverse: •Maternal •Perinatal and •Infant outcomes What is the recommendation from the expert committee to WHO on birth spacing (2005)? oThis interval is consistent with the WHO and UNICEF recommendation on breastfeeding AND oThis interval is associated with the lowest risk of adverse maternal, perinatal and infant outcome • What is the birth-to- pregnancy interval of at least 24 months? Women who conceive within 6 months of delivering their last infant are 7.5 times more likely to terminate the pregnancy (and to be at risk for an unsafe abortion) DeVanzo 2007 • What are the odds that a woman will terminate a pregnancy if conceived too soon? Prematurity Fetal death Low birth weight Small for gestational age Neonatal and infant mortality Conde-Agudelo (2006) Rutstein (2005) • What are the perinatal and infant risks when birth to pregnancy spacing is less than 24 months? “1 million of the 11 million deaths in children <5 could be averted by elimination of interbirth intervals of less than 2 years. Effective use of postpartum family planning is the most obvious way in which progress should be achieved.” (Cleland 2006) • What is one of the benefits of postpartum family planning in regards to averting <5 child mortality? •Return to sexual activity •Reduction in breastfeeding •Resumption of menses • What are the behaviors and characteristics that increase the postpartum woman‟s risk for an unintended pregnancy? For fully lactating, amenorrheic mothers with infants less than 6 months-- <2% will conceive. What is the risk of pregnancy for women practicing LAM? In some countries, it is common for women to practice “postpartum abstinence” while breastfeeding. Degrées-du-Loû, A and Brou, H. (2005). • What is a traditional practice that may affect perception of pregnancy risk in the extended postpartum period? The risk of pregnancy occurs prior to onset of menses. According to studies 6- 10% of women may conceive prior to menses returning. Becker & Ahmed, 2001 • What is the percentage of women who conceive prior to menses return? A study that provides insight into when ovulation and the required hormonal levels are right to support fertility which occurs-as early as 30-37 days post delivery in non-breastfeeding women Gray, R.H., Campbell, O.M., Apelo, R., Eslami, S.S., Zacur, H., Ramos, R.M., et al. (1990.) Risk of ovulation during lactation. The Lancet, 335(8680): 25-29. • When is a non-breastfeeding postpartum woman potentially at risk for an unintended pregnancy? Revitalization of lactational amenorrheic method of contraception (LAM) and transition to other modern methods increased contraceptive uptake in nine facilities in Ouagadougou. ACCESS-FP and IRH 2007 • What are the benefits of LAM revitalization particularly transition to other modern methods? • LAM is a GATEWAY to other methods LAM, Progestin-only methods (POP, DMPA, Noristerate, implants) IUDs and Sterilization • What are contraceptive methods that breastfeeding women can initiate before 6 months? Non-breastfeeding women can start progestin-only methods when they are discharged from the facility or within the first few days postpartum. They can start combined oral contraception at 3 weeks postpartum WHO MEC 2004 • When can non- breastfeeding women start hormonal contraception? HIV-positive women, who are unable to use supplemental feeding because it is not acceptable, feasible affordable, safe and sustainable, may use this method of contraception and their infants will have increased chances of survival. • What is LAM? While the repeat DMPA injection can be given up to 4 weeks late without requiring additional contraceptive protection, this does not mean that the regular DMPA injection interval can be extended by 4 weeks. • What is the newest recommendation by WHO MEC regarding the „grace‟ period for women late for their next DMPA? When FP materials were provided on the postpartum ward in Pakistan significantly increased client uptake of modern contraceptive methods controlled by women. When these materials were not available clients more likely to be using traditional methods controlled by men. Saeed (2008) • What can the systematic provision of PPFP materials do to influence uptake of modern contraception? Benefits Risks • Post-insertion symptoms • Increased risk for are masked by the spontaneous expulsion normal postpartum cramping and lochia • Risk of poor counseling • Cost-effective for the • Need to initiate client and facility counseling in ANC • Client leaves the facility with an effective method • Training provides a review to providers on IP, counseling and AMTSL • Insertion is done when there is no risk of pregnancy • What are some of the risks and benefits of providing postpartum IUD‟s (within 48 hours)? Dominican Republic: Cumulative probability of starting contraceptive use by postpartum month, by timing of family planning information 1 No info 0.9 0.8 0.7 Only in ANC 0.6 0.5 Only in hospital stay for delivery 0.4 0.3 Only in PNC visits 0.2 0.1 At more than one 0 moment 0.067 1 2 3 4 5 6 Months since childbirth Vernon R, et al 2008 • How does the timing of information on contraception affect the probability of postpartum women initiating contraception in the Dominican Republic? Unmet Need 1st Year Postpartum and 80 All Women 70 60 50 Category 5 – 40 points 1st Year 40 All Wome 30 20 10 0 B-desh Haiti Kenya Nigeria Source: Borda, M. and W. Winfrey. Family Planning Needs during the First Year Postpartum. ACCESS-FP. • How does unmet need among postpartum women compare to that of all women? Mexico 2006 Current Contraceptive users according to the time that they started the method Percentage 100 22.5 80 41.6 60 90.2 40 77.5 58.4 20 9.8 0 Sterilization IUD Other Pospartum Other time Vernon et al. 2008 • What is the impact of offering LAPMs to postpartum women? Summary and Reference Slides Rationale for family planning during the extended postpartum period – Postpartum women express a desire to prevent pregnancy during first two years after delivery but the majority are not using contraception (UNMET NEED) – Antenatal, postnatal and immunization visits are opportunities for PPFP messages to women who accessing health facilities multiple times Benefits of PPFP – 9-10% Reduction in infant mortality rate – Reduction in exposure to unsafe abortion (responsible for 13% of MMR) – Family planning in general can reduce MMR by 32% Return to fertility – Fertility returns prior to onset of menses – 6-10 % conceive prior to menses. – Fully lactating amenorrheic mothers of infants less than 6 months ---<2% conceive Contraceptive methods for lactating women – Progestin-only methods—updates from WHO – LAM, transition, and AFASS – PPIUCD – sterilization Programmatic implications related to PPFP pre-discharge counseling – Systematic provision of PPFP at time of discharge – Counseling and information can increase contraceptive use – LAM is a gateway method to other family planning – Increase in contraceptive methods (method mix) increases uptake and effective use Rationale for long-acting and permanent methods – Demand for limiting among postpartum women – At time of delivery opportune moment – ANC counseling! KEY POSTPARTUM FAMILY PLANNING MESSAGES Antenatal period Immediate and exclusive breastfeeding Fertility intentions and return to fertility LAM or other methods as fertility intentions indicate Pregnancy spacing Importance of a skilled attendant Immediate postpartum (1 week) Exclusive breastfeeding Fertility intentions and return to fertility Pregnancy spacing LAM or other methods as fertility intentions indicate Importance of postnatal care Danger signs for mother and newborn Postnatal care contact (6 weeks) Exclusive breastfeeding Fertility intentions and return to fertility Return to sexual activity Pregnancy spacing LAM or other methods as fertility intentions indicate Contraceptive choices that have no affect on breastfeeding Importance of postnatal care Photo by A. Nash-Mercado Child health contacts during the first year Exclusive breastfeeding through first six months, then complementary feeding Fertility intentions and return to fertility Pregnancy spacing LAM and transition to other methods as fertility intentions Contraceptive choices that have no affect on breastfeeding Importance of well baby care Resource list • Marston C, Cleland J (2004) The effects of contraception on obstetric outcomes WHO Library Cataloguing-in-Publication • Cleland, J., Bernstein, S., Ezeh, A., Faundes, A., Glasier, A., Innis, J. (2006.) Family planning: The unfinished agenda. The Lancet, 368(9549), 1810-1827. • Ross, J. A. and Winfrey, W. L. (2001.) Contraceptive use, intention to use and unmet needs during the extended postpartum period. International Family Planning Perspectives, 27, 20–27. • Ross, J Winfrey W (2002) Unmet Need for Contraception in the Developing World and the Former Soviet Union: An Updated Estimate International Family Planning Perspectives, 28(3):138–143 • DaVanzo J, L Hale, A Razzaque, M Rahman (2006) Effects of interpregnancy interval and outcome of the preceding pregnancy on pregnancy outcomes in Matlab, Bangladesh www.blackwellpublishing.com/bjog • Senarath, U., Fernando, D.N., and Rodrigo, I. (2006.) Factors determining client satisfaction with hospital-based perinatal care in Sri Lanka. Tropical Medicine and International Health, 11(9), 1442-1451. • Gulshan Ara Saeeda,⁎, Shazia Fakhara, Faisal Rahimb, Sabir Tabassum (2008) Change in trend of contraceptive uptake —effect of educational leaflets and counseling, Contraception • Gray, R.H., Campbell, O.M., Apelo, R., Eslami, S.S., Zacur, H., Ramos, R.M., et al. (1990.) Risk of ovulation during lactation. 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Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. Contraception, 74(5), 376-381 • Grimes, D., Schulz, K., Van Vliet, H., and Stanwood, N. (2003.) Immediate post-partum insertion of intrauterine devices. The Cochrane Database of Systematic Reviews, Issue 1. Art. No: CD003036. DOI: 10.1002/14651858.CD003036.