By Roberto Rivera, MD, Corporate Director for International Medical Affairs,
Family Health International and José Antonio Solís, MD, Coordinator, Family Health and
Population, Pan American Health Organization
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 healthcare 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 healthcare 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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