In many countries, postpartum family planning services are not well integrated into existing health services, and most health delivery services do not address women's needs after abortion1 -- i.e., treatment for complications of incomplete or septic abortions and the provision of family planning counseling and contraception.
Inability to obtain effective contraception exposes women to the risk of poorly timed or unwanted pregnancies. Closely spaced pregnancies pose greater health risks for mothers and their infants, while unwanted pregnancies often result in unsafe abortions. Although much progress has been made in family planning programs, unmet needs for postpartum and postabortion information and services remain, especially among adolescents and rural residents.
Strategies to improve reproductive health care for women after pregnancy should become a higher priority. The provision of quality family planning services in the postpartum and postabortion 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. However, many of these women do not have access to the contraceptive options that would enable them to do so.
Important opportunities
Many women who deliver in medical settings do not receive contraceptive counseling while they are there. In many cultures, women typically do not return to the hospital for a postnatal checkup unless they are feeling ill or have complications. This suggests that family planning counseling during the initial hospital visit is an important opportunity, one that should be fully used.
In countries where a low proportion of births occurs in institutional settings, proven strategies of community education -- such as the use of traditional birth attendants to provide postpartum and postabortion contraception -- should also be utilized.
Even where postpartum and postabortion family planning programs are available, many factors can limit their success. Primary among them are a lack of institutional or official support and poor integration of these programs into existing maternal and child health services. Other factors include cultural barriers to family planning among both providers and clients, provider biases against women seeking postabortion care, a lack of adequately trained personnel and updated service delivery guidelines, legal barriers, and inadequate attention to the development of client-centered services. Inadequate facilities, equipment and commodities are major limiting factors to family planning services for women after pregnancy. Counseling on family planning is a crucial component in the range of services women need after pregnancy, yet is often neglected.
The lactational amenorrhea method (LAM) is an effective, natural method of family planning for postpartum women. Especially in countries where there is a strong bias on the part of both providers and women against contraceptive technologies, the introduction of LAM into existing family planning services could fill an important need.
The 1990 International Conference on Postpartum Contraception in Mexico and the 1993 International Workshop on Postpartum and Postabortion Family Planning in Ecuador listed numerous recommendations for improving family planning options after pregnancy, including the need to integrate reproductive health services.2 Other recommendations called for evaluating contraceptive methods used in the postpartum and postabortion period; giving more attention to clients' perspectives, expectations and needs; and extending postpartum services to non-hospital and non-urban settings.
Improving the choice of methods available; evaluating the effectiveness of postpartum and postabortion counseling and family planning services, as well as providers' attitudes and training needs; and identifying barriers, both medical and non-medical, to postpartum and postabortion family planning were among other important recommendations from these conferences.
Provider training
Key steps to better services include training providers to counsel clients effectively and training program managers to adopt a more gender-sensitive approach to service delivery. All types of health providers need training. Training programs also need to be country-specific, in order to address priority areas such as program management, logistics, technical skills, contraceptive technology updates, quality of care and counseling.
Postpartum and postabortion family planning should be included in medical and nursing school curricula, especially where medical services emphasize curative rather than preventive care. Training for residents in contraceptive technology and IUD insertion should be institutionalized.
In some countries, family planning is not included in nursing and medical school curricula, or the information presented is inadequate. In other countries, training needs may lie in specific areas, such as a need for better counseling techniques to ensure adequate method choice and informed consent. The contraceptive options available to many women after pregnancy are often limited. Unfortunately, many program managers equate postpartum contraception only with postpartum IUD insertion or voluntary surgical sterilization, and may not have considered or do not provide other appropriate method choices. National service delivery guidelines may need to be reviewed and revised to include the most recent scientific information on both clinical and programmatic aspects of care.
Ideally, providers should offer services designed for the specific groups they are trying to reach. For example, postpartum and postabortion women's needs may be quite different. Specific strategies may be needed to serve high-risk groups, such as adolescents or rural clients. Providers should also challenge themselves to consider ways to include men in postpartum family planning counseling.
In conclusion, it should be remembered that building community and institutional support for better services begins with identifying both needs and opportunities. Clearly, many women will seek health care services when they are pregnant, offering an ideal opportunity to provide a range of quality services, including family planning counseling. Better training is another key step to better services, as is the integration of family planning with other postpartum services. Finally, a client-centered approach to the development and implementation of policies and programs is essential and will improve family planning services for women after pregnancy.
Editor's note: This commentary is based on an executive summary by Drs. Solís and Rivera in their recent working paper, Postpartum and Postabortion Family Planning in Latin America: Interviews with Health Providers, Policy-makers and Women's Advocates in Ecuador, Honduras and Mexico.
References
- McLaurin KE, Senanayake P, Toubia N, et al., eds. Meeting women's needs for post-abortion family planning: report of a Bellagio technical working group. Int J Gynaecol Obstet, 1994; 45:S1-33.
- Rivera R, Kennedy K, Rosman A, et al. Identification of Clinical and Programmatic Research Needs in Postpartum Contraception. Report on the International Conference on Postpartum Contraception, Mexico City, 17-19 September 1990. Research Triangle Park, NC: Family Health International, 1991. Organización Panamericana de la Salud. Taller International sobre la Planificación Familiar Postparto y Postaborto: Relato final, 12-15 Julio, Quito, Ecuador. Unpublished report, July 1993.
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