PAC FP - X-CD System Conference Management

Report
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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