Conference Agenda

ABSTRACT:

Providing reproductive health services, including family planning, to women and their newborn during the first six weeks and beyond can substantially reduce maternal and infant mortality and morbidity. To ensure that postpartum women have the opportunity to achieve their fertility intentions (whether through spacing or limiting subsequent pregnancies), service delivery protocols must include the application of appropriate medical eligibility criteria on contraceptive use, combined with quality counselling. Despite the availability of clinical guidance and a selection of contraceptive methods, analyses of population-based data from 27 developing countries show that approximately 2/3 of women who had a birth in the past 12 months have an unmet need for family planning. Moreover, studies illustrate that uptake of contraception during the first 12 months postpartum averages only 55%. Limited access to a continuum of postpartum care through one year following delivery, coupled with poor understanding of the timing of return to fertility and inadequate support for the value of family planning, are just a few of the factors that contribute towards this indicator of reproductive health. Maximizing occasions for women to access family planning services, during the immediate postpartum period and thereafter, offer promise towards improving the health of women and their newborns'. This session begins with a presentation of updated evidence-based recommendations on contraceptive medical eligibility for postpartum women, which take into consideration the mother's breastfeeding status. Subsequent presentations feature programmatic activities and approaches aimed towards achieving family planning goals and the needs of postpartum women. Selected examples of innovative approaches to promote and integrate family planning messages and services into health systems are highlighted. A strategy to strengthen family planning services through the development of programmatic guidance for this important population group is proposed for discussion.

The session includes the following presentations:

• Medical eligibility criteria for post-partum women: new recommendations from the World Health Organization.

Maria Rodriguez, World Health Organization, Geneva, Switzerland

• Importance of postpartum family planning.

Nuriye Ortayli, United Nations Population Fund, New York City, USA

• Addressing serve delivery issues of family planning to postpartum women: a proposal for programmatic guidance.

Mary Lyn Gaffield, World Health Organization, Geneva, Switzerland

Medical eligibility criteria for post-partum women: new recommendations from the World Health Organization.

Maria Rodriguez, World Health Organization, Geneva, Switzerland

During 2008 and 2010, the World Health Organization (WHO) convened two technical consultations in Geneva, Switzerland to revise the third edition of the Medical eligibility criteria for contraceptive use (MEC), to ensure that recommendations in this evidence-based guideline reflect the most up-to-date published evidence. Together, these meetings brought together 50 participants from 25 countries, including nine agency representatives. Consultation participants included a globally-representative body of: international family planning experts, including clinicians, epidemiologists, policy makers, programme managers; experts in evidence identification and synthesis; experts in pharmacology; and users of the guideline. In preparation, WHO identified recommendations for which new evidence was available using a system that identifies new evidence on an on-going basis, the Continuous Identification of Research Evidence, or CIRE system. Through CIRE, new evidence was identified regarding the safety of initiating combined hormonal contraceptive methods for non-breastfeeding postpartum women (< 21 days, ≥21-42 days, and >42 days), and insertion of the copper-bearing intrauterine device (IUD) or levonorgestrel-releasing intrauterine device (LNG-IUD) immediately (<48 hours) after delivery. Systematic reviews were prepared which summarized and appraised the methodological quality of published evidence on the safety of using contraceptives among postpartum women. Reviews were sent to experts prior to each consultation and served as the basis for the deliberations during each meeting. Recommendations were developed following a consensus-driven process. Medical eligibility was classified according to four categories: 1 = no restriction for use; 2 = advantages of use generally outweigh the theoretical or proven risks; 3 = theoretical or proven risks usually outweigh the advantages of using the method; 4 = unacceptable health risk. Where resources for clinical judgement are limited, the four-category classification framework can be simplified into two categories. Categories 1 or 2 indicate medical eligible, and category 3 or 4 conditions indicate that a woman is not medically eligible. Based upon the evidence, recommendations for immediate insertion (<48 hours after delivery) of the copper-bearing IUD and LNG-IUD (among non-breastfeeding mothers) are less restrictive. In contrast, eligibility for combined hormonal methods among non-breastfeeding mothers (<42 days postpartum) are more restrictive. In particular, eligibility is more restrictive for non-breastfeeding women who are at elevated risk for venous thromboembolism. Lactational amenorrhoea method recommendations were updated to reflect recent WHO advice for women who are HIV-infected. Evidence supporting these new recommendations and clarifications on their interpretation for providers and programme managers are presented.

Importance of postpartum family planning.

Nuriye Ortayli, United Nations Population Fund, New York City, USA

BACKGROUND

According to a WHO Technical Consultation on Birth Spacing to ensure the healthiest outcome for mother and baby, couples should wait at least two years after the birth of their last infant before they try to conceive again, to reduce risks of adverse maternal, perinatal and infant outcomes. Provision of quality family planning services in the postpartum period contributes significantly to reducing maternal and child mortality and morbidity, as well as to preventing future abortions. Studies show that a large proportion of women interviewed in the postpartum period wish to regulate their fertility, either by spacing or preventing future pregnancies. Therefore, provision of FP counseling and services during the postpartum period is not only necessary, but highly likely to be well-accepted by women and their families.

METHODOLOGY

Emergency Obstetric and Newborn Care Assessments conducted in three countries (Ethiopia, Madagascar and Malawi) during 2009-2010 by AMDD and national teams with support from UNFPA, were reviewed to examine the availability of FP services at facilities where EmONC is delivered. The number of facilities sampled included 797 in Ethiopia (109 hospitals, 5 specialized maternity clinics, and 683 health centers), 303 in Madagascar, and 309 in Malawi (92 hospitals and 217 health centers.

RESULTS

In Ethiopia about 90% of all facilities had at least 3 contraceptive methods in stock and reported that they had provided them during the last three months (no data have been collected on the percentage of postpartum women who had left the facility with a method). The same facilities provided contraception to 73% of cases, following a safe abortion or treatment of an abortion complication (induced or spontaneous). In Madagascar; 83% of facilities offered temporary methods of FP and 25.5% provided permanent methods of FP during the last three months. In Malawi, 77% of hospitals and 85% of health centers had at least three methods of FP in stock and 49% of hospitals and 53% of health centres had FP guidelines at the maternity wards. 85% of all facilities provide FP methods (nearly all government facilities, but 50% of hospitals and 20% of rural hospitals run by Christian Health Association of Malawi).

CONCLUSION

Ethiopia, Madagascar and Malawi are among countries in Sub-Saharan Africa with relatively strong FP programmes. Nevertheless, EmONC assessments indicate that there is need to pursue in detail, issues around integration of FP into maternity services.

Addressing serve delivery issues of family planning to postpartum women: a proposal for programmatic guidance.

Mary Lyn Gaffield, World Health Organization, Geneva, Switzerland

Attention from the global family planning community towards addressing the family planning needs of postpartum women, including women during the 24-month period following childbirth, continues to increase. Recognizing the importance of providing family planning services to this vulnerable group at high risk for unintended pregnancy, WHO Member States and partners have encouraged the development of programmatic guidance that focuses on how programmes can promote the delivery of family planning services to women who have recently given birth. To initiate this area of work, two brainstorming consultations were convened at WHO during 2010 to review past and current activities, present evidence from selected projects, and identify remaining gaps. Suggestions from these meetings include: mapping currently available guidance on the topic; soliciting input from key family planning officials working in countries with the highest need; ensuring that such guidance accommodates settings with varying levels of resources and constraints; and that the product adheres to WHO requirements for guideline development. Interview questions focused on family planning in relation to WHO's six primary building blocks of health systems. Results from the guideline mapping exercise and principle themes emerging from family planning official telephone interviews are summarized. An expansion of the programmatic guidance chapter within the WHO's Selected practice recommendations for contraceptive use (SPR) is proposed. Examples of potential, additional SPR questions include: expanding family planning services within other settings, proposing strategies to promote service delivery health facilities, and increasing uptake of long-acting reversible contraceptive methods.

Session participants will be encouraged to comment on the proposed SPR questions, and offered opportunities to propose questions.