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.