1. FP Options for Extended Postpartum Dr. Bernabe Marinduque 20 March 2014

2. Objectives  At the end of this presentation:  Learners should be able to define extended postpartum period  Define unmet need in the extended postpartum period  Understand the WHO recommendation on birth spacing  Enumerate FP options during extended postpartum period  Understand the importance of integrating FP into maternal care

3. Postpartum Period  Traditional postpartum period: 0–6 months post delivery  Extended postpartum period: 0–23 months post delivery

4. 2011 Family Health Survey 19.3 unmet need  8.8 spacing  10.5 limiting

5. Prospective Unmet Need Across Postpartum Periods

6. 2006 WHO Recommendation for Birth Spacing  Birth-to-pregnancy (BTP) interval: two years  Birth-to-birth (BTB) interval: three years  Miscarriage-to-pregnancy interval: 6 months Defer pregnancy until 18 years of age Birth spacing prevents 30% of maternal mortality and 10% of child mortality

7. FP Options During 0–6 Months Post Delivery  LAM  POP  Progesterone-only injectable  IUD  Implant  COC  Condoms  NFP

8. FP Options: Mechanisms of Action FP optionsMechanism of Action LAMInhibition of ovulation POPThickens cervical mucus IUDAlters sperm and egg motility PO injectableThickens cervical mucus ImplantThickens cervical mucus and inhibition of ovulation COCinhibition of ovulation and thickens cervical mucus

9. FP Options: 0–6 Months Post Delivery Postpartum SituationsFP optionsWhen to start Fully Breastfeeding LAM Progestin-only Pills (POP) Progestin-only Injectables Intrauterine Contraceptive Device (IUD) Implant Combined Oral Contraceptive (COC) Condom Natural Family Planning Within an hour post delivery 6 weeks post delivery Within 10 minutes of placental expulsion Within 48 hours post delivery 6 weeks post delivery (manufacturer’s recommendation: 3 weeks) 6 months post delivery When sexually active Not applicable

10. FP Options: 0–6 Months Post Delivery Postpartum SituationsFP optionsWhen to start Partially Breastfeeding POP Progestin-only Injectables IUD Implant COC Condom NFP 3 weeks post delivery Within 10 minutes of placental expulsion Within 48 hours post delivery 3 weeks post delivery When sexually active With onset of period

11. FP Options: 0–6 Months Post Delivery Postpartum SituationsFP optionsWhen to start Non Breastfeeding POP Progestin-only injectables IUD Implants COC Condom NFP Prior to discharge 3 weeks post delivery Within 10 minutes of placental expulsion Within 48 hours post delivery Prior to discharge 3 weeks post delivery When sexually active With onset of period

12. Extended Postpartum Period Rationale  Based on the WHO recommendation on birth spacing:  Women are most vulnerable for unintended pregnancy during the extended postpartum period

13. FP Options During 7–23 Months Post Delivery Long Acting Reversible Contraceptives  IUD  Implant Short Acting contraceptives  Progesterone-only injectable  COC  Condoms  NFP Permanent Method  Non scalpel Vasectomy  Bilateral tubal ligation

14. FP Options Extended Postpartum Period When to Start?  Hormonal contraceptives: First five days of the menstrual cycle or QUICK START  IUD: First five days of the menstrual cycle or QUICK START  Vasectomy: Anytime  BTL: Follicular phase of the menstrual cycle or anytime that the client is reasonably sure not to be pregnant

15. What is Quick Start?  Starting the contraceptives on the first clinic visit  Assessment using the WHO pregnancy checklist to rule out pregnancy  Follow up after three weeks for re-assessment of undetected pregnancy in the first visit

17. Method Effectiveness and Continuation Method Failure Rates (unintended pregnancy) Continuation at 1 year Typical UsePerfect Use No method85% Withdrawal27%4%43% “Standard Days Method”25%5%51% Male condom15%2%53% COCs/Progestin-only methods8%0.3%68% DMPA (injections)3%0.3%56% Copper T 380A (IUD)0.8%0.6%78% Implants0.05% 84% Female sterilization0.5% 100% Male sterilization0.15%0.10%100%

18. The Need to Integrate FP Into Maternal Care A successful integration of FP services in the maternal and child care entails:  Integrate FP counseling in the antenatal care, early labor and immediate postpartum  Come up with a standardized protocol for postpartum FP service delivery  Make sure that there different methods available for the mothers in the birthing facility

19. Summary  Extended postpartum period is 0–23 months post delivery when the woman is at risk unintended pregnancy and unmet need for FP is high.  Birth spacing prevents pregnancy complications and child morbidity and mortality.  There are several FP options for postpartum women depending on their reproductive intentions.  Key to successful integration of postpartum family planning in MCH is to offer the service including counseling while the mother is still under the care of the provider.

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