The integration of family planning (FP) and maternal and child health (MCH) programs and services provides multiple opportunities to streamline and improve care at favorable and critical times for maximizing women’s reproductive health (RH) and the health of their children. The benefits associated with combining FP and MCH services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health. Through collaboration with a number of international partners, the USAID ACCESS-FP program has been working to expand the integration of FP with MCH programs in these priority areas: (1) policies and strategies to include FP in national maternal and newborn essential care packages; (2) postpartum (PP) information on return to fertility, pregnancy spacing and FP methods in curricula, standards, and guidelines for training and service delivery; (3) behavior change communication strategies promoting pregnancy spacing and FP; and (4) facility- and community-based approaches for integrating antenatal care (ANC), safe delivery, essential newborn care, and PP care for mothers and newborns (USAID, 2008a).  ACCESS-FP is integrating women’s needs for RH care and postpartum family planning (PPFP) with newborn and child health services, including prevention of mother-to-child transmission of HIV, during the extended PP period (i.e., through the first year after delivery).

FP use during the first year PP has the potential to significantly reduce the number of unplanned pregnancies and research has shown a large unmet need among women in the extended PP period.  Meeting these needs could substantially increase contraceptive prevalence, reduce the percentage of birth intervals that are dangerously close, and reduce maternal and child mortality (Cleland et al., 2006).  In 2005, a WHO technical consultation recommended the minimum interval of 24 months after a live birth before attempting the next pregnancy in order to reduce risk of adverse maternal, perinatal, and infant outcomes (WHO 2006). Greater FP use during the extended PP period, fully breastfeeding, and slower return to sexual activity can combine to lengthen birth intervals.

From a programmatic standpoint, women who use maternal health services are more likely to use FP services during the extended PP period (Borda and Winfrey, 2010). ACCESS-FP focuses on four PP fertility reducing factors: (1) return of menses; (2) return to sexual activity; (3) breastfeeding and the lactational amenorrhea method (LAM); and (4) use of maternal health services, and has developed a programmatic framework for integrating PPFP with maternal, newborn, and child health (USAID, 2008b).  For FP, emphasis is placed first on integrating FP messages during ANC and then on immediate PPFP, highlighting the importance of the six-week PP visit given the crucial timing for PPFP acceptance. In maternal health, the focus is placed on skilled delivery care and the immediate PP period, again with corresponding reference to the six-week PP visit.  For newborn and child health, emphasis is placed on immediate and postnatal care and the immunization schedule. For women with HIV, counseling on exclusive breastfeeding, and the impact of abrupt weaning on women’s return to fertility are stressed. The framework lays out the multiple overlapping opportunities to promote spacing of pregnancies and to provide FP information within the context of maternal and infant health services.

Integrating and scaling up PPFP services necessitates putting systems in place for monitoring and evaluating (M&E) levels and trends of PPFP use, training and service delivery, and the impact on various measures of MCH.  The six core indicators selected for this database cover the programmatic areas recommended by ACCESS-FP, focusing specifically on clients’ use of PPFP services, the quality of these services and the unmet need for PP contraception. (Note: See Mwangi et al. (2008) for a list of 16 postnatal care M&E indicators used in the USAID collaborative ACCESS-FP and Frontiers ‘Postnatal care – family planning’ project in Kenya). In addition to the database indicator for LAM counseling, an indicator for the percent of women using LAM for FP can be found in the technical area on Breastfeeding.  More birth spacing indicators can be found under Healthy Timing and Spacing of Pregnancy.  Where sufficient data are available, the indicator for PP unmet need may be disaggregated from the corresponding unmet need indicator in the technical area on Family Planning.

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References:

Borda M and Winfrey W, 2010, Postpartum fertility and contraception: An analysis of findings from 17 countries, Washington, DC: USAID/ACCESS-FP.

Cleland J, Bernstein S, Ezah A, et al., 2006, Family Planning: the unfinished agenda, Lancet Series, Sexual and Reproductive Health:368.

Mwangi A, Warren C. Koskei N, Blanchard H., 2008, Strengthening Postnatal Care Services Including Postpartum Family Planning in Kenya, Washington, DC: USAID/ACCESS-FP/Frontiers (Indicators on page 10). http://reprolineplus.org/system/files/resources/accessfp_kenyappfp.pdf

USAID, 2008a, Addressing unmet need for postpartum family planning: The ACCESS-FP Program, Newsbrief Apr, Washington, DC, USAID.

USAID, 2008b, ACCESS-FP Programmatic Framework: Postpartum Family Planning in an Integrated Context, Washington, DC: USAID. http://www.accesstohealth.org/toolres/pdfs/ACCESSFP_pgmframework.pdf

USAID, 2008c, Postpartum Family Planning: A review of programmatic approaches through the first year of postpartum-report, 15 May, Washington, DC, USAID.

WHO, 2006, Report of a WHO Technical Consultation on Birth Spacing, Geneva: 13-15 June 2005, WHO.