Important Needs Follow Pregnancy

Coordinating family planning with other health services during and after pregnancy can help improve reproductive health. A chart on When to Begin Methods after Pregnancy is included. Training: An Essential Step offers examples of recent training programs.

Network: Summer 1997, Vol. 17, No. 4

After a woman gives birth, she faces caring for a newborn -- an especially challenging task for first-time mothers -- and ensuring her own recovery from pregnancy and delivery. Many postpartum women also want to space or limit their childbearing in order to protect their own health and that of their infants.

Despite these special needs, health services often pay little attention to postpartum care, including the need to begin contraception when fertility returns. In Ecuador, for example, three-quarters of women go for prenatal visits, but only one-third get postpartum care.1 In a study in two Kenya hospitals, 92 percent of postpartum women reported that they wanted to use family planning, but only 2 percent left the hospital with a method after delivery.2 Worldwide, about a third of women with an unmet need for family planning are pregnant or have recently given birth.3

What is the best way to serve postpartum women? The International Planned Parenthood Federation (IPPF) encourages its affiliates to integrate family planning with other services, says Dr. Pramilla Senanayake, the organization's assistant secretary general. "We have said to them: 'For the women you are serving, the comprehensive approach is far better, so try to coordinate and collaborate with other groups providing postpartum care,' " she says. This approach prevents duplication of services and expertise, reduces costs, and responds to the call of the 1994 International Conference on Population and Development in Cairo for integrated services.

The World Health Organization (WHO) is moving in a similar direction. In May, WHO convened a panel of experts to determine how to address the needs of postpartum women and their infants. The group's report, expected later this year, will recommend appropriate postpartum care for mother and baby, including nutrition, social support and HIV prevention, in addition to family planning.

"Integration of family planning into maternal and child health services is essential," says Dr. Roberto Rivera, FHI's corporate director for international medical affairs. "It is the best way to meet growing reproductive health needs in the postpartum period." Offering a variety of services -- including but not limited to family planning -- protects the health of women and their children, prevents coercive use of contraceptives, and improves the quality of care, he says.

Providers in Mexico, Chile, Zambia, the Philippines and elsewhere are developing integrated postpartum services that include family planning. Many link maternal and child care with contraceptive provision; others emphasize breastfeeding to enhance mother and infant health while offering contraceptive protection; and still others link prenatal services and family planning to postpartum follow-up.

Limited resources

Offering a variety of services can seem overwhelming to providers who are short on resources, time or training. But the results may include more satisfied clients, good follow-up and improved health care, says Dr. Enrique Suárez, director of the Federación Mexicana de Asociaciones Privadas de Salud y Desarrollo Comunitario (FEMAP), a nongovernmental organization in Mexico that began offering integrated perinatal services in the early 1980s. "You have to see the person as a whole person with other needs" than family planning, says Dr. Suárez. "Otherwise, you are not able to get through to them."

Currently, FEMAP's perinatal services work like this: About 10,000 community promoters refer pregnant women to FEMAP clinics throughout Mexico for prenatal care. During the checkups, doctors or nurses give them information on nutrition, fetal development and breastfeeding. Women are also screened for reproductive cancer and sexually transmitted diseases and counseled on family planning. When it comes time for delivery, women enter one of FEMAP's seven hospitals or a hospital linked to the organization, where health workers offer medical care and reinforce messages given during prenatal visits.

After returning home, women are again contacted by promoters, who provide more information on family planning methods, if needed, and remind them to return to a FEMAP clinic for regular postpartum checkups. These visits combine mother and infant care, including immunizations, breastfeeding support, health checkups and other services. Many providers report that linking child care to postpartum checkups for women is important, because many women will return for their children, but not for themselves.

Nearly 40 percent of FEMAP's clients now return for postpartum checkups, compared to less than 5 percent in 1981 when the program began. The rate for prenatal services is even better -- about 80 percent of FEMAP's pregnant clients receive them. Educating women about preventive health care, especially prenatally, is one key to the program's success, Dr. Suárez says.

During perinatal family planning consultations, women choose from a variety of available contraceptive methods, including pills, condoms, voluntary surgical sterilization and intrauterine devices (IUDs). The continuation rate for contraceptives is high -- about 72 percent after five years. Because FEMAP has the capacity for excellent follow-up, the organization can offer a variety of short-term and long-term methods with confidence that women's needs will be met, Dr. Suárez says.

Having a contraceptive option available after delivery is important, because longer intervals between births improve both the infant's and mother's health. A baby born less than two years after a sibling's birth faces more than twice the risk of dying in infancy than a baby born after a longer interval, and there is a greater chance that a baby born very soon after a previous delivery will be premature.4

The Instituto Chileno de Medicina Reproductiva (ICMER) also offers an integrated postpartum health program, which began in a research-based setting and was then established at the Consultorio San Luis de Huechuraba, a clinic in a poor Santiago neighborhood. Through the program, women are invited to come in with their babies for postpartum health checkups over many months. Among the program's components are counseling tailored to each client; management of breastfeeding, contraception, and maternal and child health; and teamwork among providers.

Participants say they appreciate the information and respectful treatment by staff, says Dr. Soledad Díaz, program director. Participants had levels of contraceptive continuation of greater than 95 percent if they reached the end of a year in the program, and they had higher rates of breastfeeding than comparable Santiago women who did not participate.

"Nursing behavior associated with lactational amenorrhea is quite demanding on women, and they may require support from the system to keep it up for a long time," Díaz says. "If such support is given, it may contribute to a positive interaction between the health team and the clients, particularly if the mothers perceive the benefits for infant growth and health." Such interactions can make contraceptives and health interventions more acceptable, she says.

Postpartum contraception

Postpartum women have particular health needs, including specific contraceptive requirements. IUDs, barrier methods and hormonal contraceptives are all appropriate for the postpartum period, but advice about their use may be different than for regular use, especially for breastfeeding women. Providers must be aware of restrictions and inform clients of them in order to ensure effective contraceptive coverage and protect the breastfeeding infant.

For example, the IUD is a good option for most woman after pregnancy, including those who are breastfeeding. However, IUDs should be inserted within 48 hours or delayed six weeks to reduce the risk of expulsion (during the 48 hours after delivery, risk of explusion is lowest for immediate insertions, those done within 10 minutes of delivery). Barrier methods that require fitting, such as the diaphragm, should be delayed six weeks. While sterilization can be performed any time, some experts believe it is preferable to delay sterilization until at least four weeks postpartum to reduce the risk of infection.

Progestin-only hormonal methods (injectables, Norplant and progestin-only pills) may be started immediately postpartum by women who are not breastfeeding, but should be delayed six weeks by breastfeeding mothers, since hormones are transferred through milk from mother to infant. Although no adverse effects have been reported among children exposed to synthetic hormones during breastfeeding, most experts recommend delaying use as a precaution against theoretical concerns.

Combined hormonal methods (those that contain estrogen), including oral contraceptives and certain injectables, should normally be delayed six months for breastfeeding women, but if lactation is well-established and other contraceptive options are not available or acceptable they may begin after six weeks. In general, combined hormonal methods are not recommended for breastfeeding mothers unless other acceptable choices are not available, since estrogen can diminish the amount of breastmilk. Some experts recommend that nonbreastfeeding women delay combined hormonal methods three weeks after delivery, although there is no known risk from immediate use other than a very slight risk of blood clotting problems.

An excellent contraceptive option for postpartum women is the lactational amenorrhea method (LAM), which if used correctly is at least 98 percent effective. Correct use means that a woman's menses have not resumed, that she is fully or nearly fully breastfeeding, and that her baby is less than six months old.

Establishing LAM education and promotion can be an ideal way to provide integrated postpartum care. By promoting full breastfeeding for six months, LAM education leads to other health benefits for both the mother and baby. Infants who are breastfed get immune protection from gut infections, and they receive excellent nutrition as well. Breastfeeding also speeds involution of the uterus after delivery, decreases postpartum bleeding and may protect against breast cancer. Providers trained in LAM and other postpartum care can ensure that breastfeeding is going well and that the baby and mother are healthy.

Women using LAM should be prepared to use a different contraceptive method when conditions for LAM no longer apply. Integrated services with a LAM component can ensure that new mothers get the family planning methods they choose when they need them. Also, like other contraceptive methods except the condom, LAM does not block HIV, the virus that causes AIDS.

Health and family planning services in Ecuador, the Philippines, Zambia and other countries have begun promoting LAM to improve health and contraception. In Zambia, for example, women who have prenatal or postpartum checkups at government health clinics can see counselors from the Family Life Movement, a nongovernmental organization, for advice on proper breastfeeding techniques and LAM.

"Women find it convenient to move around the clinic and get what they need," says Kristin Cooney, director of breastfeeding and maternal and child health at the Institute for Reproductive Health at Georgetown University in Washington. Some providers worry that women who use LAM will not move on to other effective family planning methods. But in Zambia, as in other countries, Cooney says, LAM encouraged women to begin using other contraceptives.

Prenatal services

Many experts say family planning counseling for postpartum contraception should take place several months before the birth, as well as after. Prenatal counseling for postpartum contraception -- especially for long-term methods such as surgical sterilization and IUDs -- allows the woman to make a more informed choice without time pressure. Prenatal counseling can also help educate women about their fertility. Throughout the world, for example, many women use the return of their menstrual periods, not the end of pregnancy, as a signal to begin using contraception. Yet the return of menses may indicate that fertility returned weeks before.

Women's needs and sense of timing may differ from that of providers, research shows. For example, a study by the Institute of Child Health in Istanbul, Turkey found that a majority of the 184 postpartum women interviewed had wanted to receive family planning information during prenatal visits, while other women preferred the period immediately after delivery, or 40 days postpartum. They also wanted information on infant care. Many women who wanted contraceptive information did not receive it at all. Providers, on the other hand, thought that family planning information should be given primarily after delivery, to women at high risk of difficult pregnancies.5

Programs that "offer only a limited range of contraceptives and push women to accept them immediately after delivery, may be open to criticism and described as using coercive tactics," says Dr. Beverly Winikoff, reproductive health program director at the Population Council. "You have to have a much broader perspective about what people want. We think it makes more sense for women and providers to have more flexibility" to offer a variety of method choices and timing of initiation, for example.

Paying attention to women's needs allows providers to target the best moments for introducing information. In the Maternal and Neonatal Hospital of Sfax, Tunisia, which began offering integrated postpartum services more than a decade ago, women were encouraged to come in for a 40-day postpartum checkup for themselves and their infants. The visit included family planning. The 40-day mark has cultural and religious significance for Muslims, so Tunisian women remembered the event and were eager to participate. More than 83 percent returned for follow-up visits.6

Elsewhere in Africa, providers are sensing the demand for integrated quality services, says Dr. Karen Stein, a Population Council program associate. "Often women discontinue methods not only because they receive incorrect or insufficient information about the advantages, disadvantages and side effects of the method, but because their other reproductive health needs are not being met, and they tend to blame the method" for reproductive tract infections or other problems, she says. "Providers are beginning to address that." Women in the perinatal period need information on many important topics, she says, including the process of recovery, what to eat, symptoms of infections, when to resume sex, how much postpartum bleeding is too much, recognizing infant illnesses and dealing with the stages of infant growth and development.

However, many family planning services are still offered in different locations by systems separate from maternal and child health care services. In such cases, coordinating services and offering them in the same location is a first step toward integration, says Dr. Rivera of FHI. Coordinated services are more convenient and less expensive for clients and provide better quality care. In places where few services exist, training maternal and child health providers to offer family planning is another important step.

Family planning providers often resist integration because they fear losing clients, reducing their effectiveness or running out of resources. But integration of services improves client care and pays for itself in some cases.

About 70 percent of FEMAP's clients, primarily low-income families, pay for their services, allowing the organization to be self-sufficient. "Our strategy is to have large volume, high quality and low prices," Dr. Suárez says. "We have very efficient procedures and cost reduction. It is a delicate balance."

Some IPPF affiliates have responded to the call for integrated care with concern that the approach will dilute family planning. "When you have been good at doing something for 40 years, then to enlarge and diversify is always challenging and threatening," says Dr. Senanayake of IPPF. "But we do not want to make family planning less important. We do not want to undermine it, but to expand and enrich it by making linkages and working in the broader areas of sexual and reproductive health."

-- Carol Lynn Blaney

Carol Lynn Blaney, a former Network staff writer, is a science writer based in San Jose, CA, USA.

References

1. Pan American Health Organization/Family Health International. Postpartum and Postabortion Family Planning in Latin America: Interviews with Health Providers, Policy-makers and Women's Advocates in Ecuador, Honduras and Mexico WP97-02. (Research Triangle Park: Family Health International, 1997) 13.
2. Bradley J, Lynam P, Gachara M, et al. Unmet family planning demand: evidence from two sites in Kenya. Jour Obst Gyn East Cent Afr 1993; 11:20-23.
3. Robey B, Ross J, Bhushan I. Meeting unmet need: new strategies. Population Reports 1996; Series J, No. 43:18.
4. Potts M, Thapa S. Child Survival: The Role of Family Planning. (Research Triangle Park, NC: Family Health International, 1991) 8.
5. Bulut A. Postpartum service delivery, Istanbul, Turkey. In Rethinking Postpartum Health Care, Proceedings of a Seminar, December 10-11, 1992. (New York: Population Council, 1993) 8-10.
6. Coeytaux F, Winikoff B. Celebrating mother and child on the fortieth day: The Sfax, Tunisia postpartum program. Quality/Calidad/Qualite 1989; 1:1-24.
   

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