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.
When to Begin Methods
after Pregnancy
Breastfeeding
Mothers |
Nonbreastfeeding
Mothers |
Immediately
- LAM (up to six months protection)
- Condoms (male or female)
- Spermicides
- Sterilization
Immediately or Delay
- IUD insertion within 48 hours1 or after six weeks
Delay Six Weeks
- Diaphragm
- Cervical cap
- Sponge
- Progestin-only methods (POPs, Norplant, DMPA)
Delay Six Months
- Combined hormonal contraceptives (pills or injectables)2
|
Immediately
- Condoms (male or female)
- Spermicides
- Sterilization
- Progestin-only methods (POPs, Norplant, DMPA)
Immediately or Delay
- IUD insertion within 48 hours1 or after six weeks
Delay Three Weeks
- Combined hormonal contraceptives (pills or injectables)
Delay Six Weeks
- Diaphragm
- Cervical cap
- Sponge
|
Postabortion
Women
(First Trimester) |
Men |
| Immediately
|
Vasectomy (male sterilization) may be used
immediately after pregnancy by any couple. |
Postabortion
Women
(Second Trimester) |
Notes:
- Risk of expulsion may be greater after 10 minutes but within 48 hours, compared with
immediate insertions.
-
- May begin use after six weeks only if lactation is well-established and other options
are not available or acceptable. In general, combined hormonal contraceptives are not
recommended for breastfeeding mothers.
|
Immediately
- Condoms (male or female)
- Spermicides
- Progestin-only methods (POPs, Norplant, DMPA)
- Sterilization
- Combined hormonal contraceptives (pills or injectables)
Immediately or Delay
- IUD insertion within 48 hours1 or after six weeks
Delay Six Weeks
- Diaphragm
- Cervical cap
- Sponge
|
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 healthcare, 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 healthcare, 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.
Training: An Essential Step
An essential step to improve or establish postpartum services is training, both on
postpartum use of contraceptive methods and on linking women's healthcare to infant care
and family planning. Training can be designed to meet specific needs:
- In rural regions of the Central Asian Republics women often make the long trek to a
hospital only to give birth. In 1996, FHI conducted a series of training workshops on
family planning, including postpartum topics, for more than 100 general practitioners,
obstetrician-gynecologists, pediatricians and midwives in the region. "It is very
important to use this one hospital visit as an opportunity to counsel women and help them
consider their contraceptive options," says Dr. Irina Yacobson, an FHI clinical
training associate who participated in the workshops. "Women are interested in
reducing the number of pregnancies or spacing their children, especially since the
region's economy is so bad. But they are not aware of the contraceptive choices available
to them."
Training a variety of specialists was important because women see different physicians
depending on whether they are pregnant or in the postpartum period, she says. Workshops
covered appropriate methods of postpartum contraception, including IUDs, condoms,
injectables and the lactational amenorrhea method (LAM).
- In regions where women are more accustomed to seeking healthcare, training can be used
to improve postpartum services. In recent years, FHI conducted a series of postpartum
family planning workshops in Latin America. These conferences examined the existing state
of postpartum care in the region, explored options for improving care, described
postpartum use of contraceptive methods, and encouraged participants to integrate
postpartum services into existing programs or create new ones.
-
- Some countries use training to reach underserved women in the postpregnancy period, and
to improve access and the quality of care. In Egypt, AVSC International (AVSC) is training
providers to offer tubal ligations to women who face the possibility of a high-risk
pregnancy. It is also training health-care workers to reach women in the immediate
postpartum and postabortion periods with family planning information, and the option of
predischarge IUD insertion. The Safe Reproductive Health program has been developed in
five hospitals, which will be used as training centers for a broader expansion of services
into the public sector.
"Family planning is traditionally an outpatient service and is not integrated into
inpatient postpartum care in Egypt," says Georgeanne Neamatalla Kumar, an AVSC senior
program manager who oversees the project, which aims to strengthen and link family
planning and other services throughout the perinatal and postabortion periods.
AVSC assists providers in developing standards of practice, client record and
information systems, and better infection-prevention practices, Kumar says. AVSC also
orients all levels of staff -- including administrators, cleaning staff and health-care
workers -- to recognize and refer high-risk women for counseling on preventing pregnancy.
-- Carol Lynn Blaney |
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 healthcare 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
- 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.
- 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.
- Robey B, Ross J, Bhushan I. Meeting unmet need: new
strategies. Population Reports 1996; Series J, No. 43:18.
- Potts M, Thapa S. Child Survival: The Role of Family
Planning. (Research Triangle Park, NC: Family Health International, 1991) 8.
- 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.
- Coeytaux F, Winikoff B. Celebrating mother and child on
the fortieth day: The Sfax, Tunisia postpartum program. Quality/Calidad/Qualite
1989; 1:1-24.
For more information, visit Family Health International's Website at www.fhi.org
Go to FHI's Network |
Copyright