1. Breaking the Cycle of Unintended Pregnancy in Postpartum and Postabortion Women Carolyn Curtis, CNM, MSN, FACNM Office of Population & Reproductive Health US Agency for International Development 2013 International Conference on Family Planning Addis Ababa, November 15, 2013

2. Overview  Barriers  Postpartum Women  Postabortion Women  How to overcome “missed opportunities”

3. Where births occur Exaggerated provider concerns (re STI, PID, infertility, expulsion) Poor CPI Provider bias Lack of knowledge re: return to fertility Lack of skills Myths and misperceptions Structure of services Inappropriate eligibility criteria Barriers Stigma Source: RESPOND Project, 2012. ↑ ↑ Access ↑ ↑ Quality of services ↑ ↑ Choice and use ↓ ↓ Rapid repeat pregnancy ↓ ↓ Abortion Outcomes when barriers are overcome: Barriers to FP services for postpartum and postabortion (PAC) clients

4. Ten Essential Elements of Successful FP Programs Selected, High-Impact Practices (HIPs) 1.Supportive Policies 2.Evidence Based Programming 3.Strong Leadership and Good Management 4.Effective Communication Strategies 5.Contraceptive Security 6.High Performing Staff 7.Client-Centered Care 8.Easy Access To Services 9.Affordable Services 10.Appropriate Integration of Services Source: Population Reports 2008, JHU. Community-based services & task-shifting / task-sharing Postpartum FP Postabortion FP (PAC) Mobile outreach services Family planning programs: What has worked?

5. Who are the women? 1 in 4 women in developing countries have an unmet need for FP = 222 MILLION women with unmet need! Each year:  210 million pregnancies  80 million unintended pregnancies  44 million abortions  31 million stillbirths  Approximately 130 million births = 130 million postpartum women

6. Source: Ross and Winfrey “Contraceptive use, Intention to use, and unmet need during the extended postpartum period, Intl FP Perspectives, 2001. Analysis of DHS data from 27 countries Reproductive intentions of postpartum women – 12 months following a birth

7. Unmet need, contraceptive use & reproductive intention in women 0-12 months postpartum Source: Ross, J, Winfrey, W, Contraceptive Use, Intention to Use and Unmet Need During the Extended Postpartum Period, International Family Planning Perspectives, 2001 27(1) 20-27.

8. Postpartum FP use and method mix among women giving birth in previous 12 months Source: RESPOND Project, secondary analysis of respective DHS, 2010.

9.  26% of the world’s 7 billion people are aged 10-24  FP demand in young and unmarried women is high, but access is constrained:  50-80% demand among married women age 15-24; 20-40% unmet need  ~ 90% of unmarried women 15-24 in all regions of the world do not want to become pregnant, but their unmet need is very high, approaching 50% in some sub-Saharan African countries  Complications of unsafe abortion are a main cause of death in 15-19 year-old women in low-resource countries  A considerable problem in the U.S. too: The American College of Obstetricians and Gynecologists recommends that its members “encourage adolescents age 15-19 to consider implants and IUDs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.” - -ACOG Committee Opinion #539, Obstet. Gynecol., 2012; 120(4):983-988 The American College of Obstetricians and Gynecologists recommends that its members “encourage adolescents age 15-19 to consider implants and IUDs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.” - -ACOG Committee Opinion #539, Obstet. Gynecol., 2012; 120(4):983-988 PAC FP: background

10. Source: Situation Analyses in Haiti, Dominican Republic, & Nicaragua. Population Council, 2008 PAC FP: How we fail women

11. Preventing missed opportunities: What can we do?  Reorganize services to integrate/strengthen FP services with:  Postpartum (including EMOC), Postabortion, MCH, HIV/AIDS  Task-sharing / task-shifting (proven; widely endorsed)  Mid-level providers Clinical Officers, Midwives, Nurses injectables, implants, IUDs, permanent methods  Community Health Workers Injectables, implants (e.g., Ethiopia)  Use mobile outreach  Dedicated providers, free services, wide method choice: leads to greater access and use  Decentralize services

12. Impact of decentralizing PAC services to lower-level fixed sites PAC Clients, 21 Districts in Tanzania (October 1, 2007 - September 30, 2010) Results:  Decentralized PAC services in 21 districts  293 health care workers trained  FP counseling and services in 224 sites Number of PAC clients Source: ACQUIRE Tanzania Project

13. Integration of FP with immunization – seems a good idea, but not much solid evidence yet Huntington, D. and Aplogan, A., The Integration of Family Planning and Childhood Immunisation Services in Togo Studies in Family Planning, Vol 25, No.3, 1994 FP AcceptorsVaccines Administered

14. Joint Statements by:  FIGO  ICM  ICN  DFID  Gates  White Ribbon Alliance  Others to advance postpartum and postabortion FP

15. What is needed to ensure “No missed opportunity”? National Level  Ensure contraceptive supply  Make FP & LA/PMs available and at reduced cost or free  Support proven policy changes for midlevel providers  Include FP in pre-service curricula & certifying exams  Change in the WHO MEC for postpartum women Facility Level  Ensure the latest WHO FP service delivery guidelines are in place – and model following them in practice  Reorganize services to ensure FP services at same location (PP, PAC, EMOC).  Become a visible “champion” in your facility for increasing FP availability and access.

16. Thank You!!! Photo credits: Slide 1 (left to right), A. Jackson/EngenderHealth; A. Fiorente/EngenderHealth; C. Svingen/EngenderHealth. Slide 5 (top to bottom), M. Tuschman/EngenderHealth; C. Svingen/EngenderHealth; M. Tuschman/EngenderHealth; E. Uphoff/EngenderHealth.