PAC FP - X-CD System Conference Management
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Breaking the Cycle of Unintended Pregnancy in Postpartum and Postabortion Women Carolyn Curtis, CNM, MSN, FACNM Office of Population & Reproductive Health US Agency for International Development 2013 International Conference on Family Planning Addis Ababa, November 15, 2013
Overview Barriers Postpartum Women Postabortion Women
How to overcome “missed opportunities”
Barriers to FP services for postpartum and postabortion (PAC) clients Outcomes when barriers are overcome:
Barriers Structure of services Exaggerated provider concerns (re STI, PID, infertility, expulsion)
Provider bias Lack of knowledge re: return to fertility Lack of skills Source: RESPOND Project, 2012.
Myths and misperceptions Inappropriate eligibility criteria Stigma Where births occur Poor CPI
↑ ↑ Access ↑ ↑ Quality of services
↑ ↑ Choice and use ↓ ↓ Rapid repeat pregnancy ↓ ↓ Abortion
Family planning programs: What has worked? Ten Essential Elements of Successful FP Programs
1. Supportive Policies 2. Evidence Based Programming 3. Strong Leadership and Good Management
Selected, High-Impact Practices (HIPs)
• Community-based services & task-shifting / task-sharing • Postpartum FP
4. Effective Communication Strategies
• Postabortion FP (PAC)
5. Contraceptive Security
• Mobile outreach services
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.
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
Reproductive intentions of postpartum women – 12 months following a birth 100%
95%
80% 65% 60%
40% 30% 20% 5% 0% Want to give Want to space birth in 2 years or limit
Using FP method
Not using a method
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
Unmet need, contraceptive use & reproductive intention in women 0-12 months postpartum 100 90 80 70
74 65
62
60
54
52
50
44
42
40 30
32
29 18
20 10
5
8 4
4
3
0 Global % Unmet Need
Sub-Saharan Africa
Middle East
% Using Method - Modern & Traditional
Asia
Latin America
% Desiring birth within 2 years
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 100 90 80 70
62
60 50
92
87
87
83
78
77
77
76
40
30 20 10 0
Permanent method
LARCs
Short-acting resupply
Source: RESPOND Project, secondary analysis of respective DHS, 2010.
Traditional method
Not using
PAC FP: background
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: How we fail women 100
80 77% 60
60%
40 20
32% 20%
0 Using FP before pregnancy (method failure) Desire to space or limit next pregnancy Desired a FP method before leaving facility Left facility with FP method Source: Situation Analyses in Haiti, Dominican Republic, & Nicaragua. Population Council, 2008
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
PAC Clients
17,262
Counseled on FP
14,737
FP counseling and services in 224 sites Accepted
Source: ACQUIRE Tanzania Project
12,106
0
5,000
10,000
15,000
Number of PAC clients
20,000
Integration of FP with immunization – seems a good idea, but not much solid evidence yet FP Acceptors
Vaccines Administered
600
16000 14000
500 12000 400
10000 307
300
FP -Post FP- Pre 167
200
7525
8000 5839
6000 4000 5839
100
2000
200
4185
144
0 0
Test Group Test Group
Control
Control Group
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
Imm - Post Imm - Pre
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
Facility Level
Make FP & LA/PMs available and at reduced cost or free
Ensure the latest WHO FP service delivery guidelines are in place – and model following them in practice
Support proven policy changes for midlevel providers
Reorganize services to ensure FP services at same location (PP, PAC, EMOC).
Include FP in pre-service curricula & certifying exams
Become a visible “champion” in your facility for increasing FP availability and access.
Ensure contraceptive supply
Change in the WHO MEC for postpartum women
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.
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