Family Planning Contribution to Health and How It Works

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Dr. Anne Peterson, MD, MPH explains how using family planning to safely time and space births improves maternal and child health and survival and reduces abortion rates. Dr. Peterson also explains how recent research has shown previous beliefs that some contraceptive methods were abortifacients to be inaccurate.

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Family Planning Contribution to Health and How It Works

  1. 1. Family Planning: Contribution to Health & How it Works Epidemiology Disease of Major Importance Fall Trimester
  2. 2. WHO definition    Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy. ◦ Decreases mother, infant & child death rates ◦ Can reduce abortion rates ◦ Assists in prevention of AIDS
  3. 3. Better Birth Spacing Saves the Lives of Children
  4. 4. Maternal Factors Associated with High Infant Mortality  Age of mother at birth ◦ too young or too old       Preceding birth interval: too short Birth order: too high Birth size: small/below average Availability of care Access to care Education
  5. 5. Risk of death among under-five children with a preceding birth interval of 36-41 months compared to risk of death at other birth intervals 317% 316% 300% Relative risk (percent) 281% 200% 151% 143% 140% 126% 137% 116% 105% 100% 105% 100% 82% 0% <18 18-23 24-29 30-35 36-41 42-47 48-53 54-59 60+ Duration of preceding birth interval (months) Neonatal Mortality Infant Mortality Under-Five Mortality Perinatal Mortality Source: United States Agency for International Development (USAID), Bureau for Global Health, Office of Population and Reproductive Health, Washington, D.C. 20523-3600. December 2002. (WWW.USAID.GOV)
  6. 6. Positive Outcomes When Pregnancies well timed Children born 3 but less than 5 years apart compared to children born less than 2 years apart are:     1.5 2.2 2.3 2.4 times times times times more more more more likely likely likely likely to to to to survive survive survive survive first 7 days first 28 days first year to age 5  After A Miscarriage: spacing < 6 months more than 2x as likely to have low birth weight or preterm delivery compared to spacing of 18- 23  Closely spaced births or births to very young mothers increases the risk of death 2 ½ to 3 fold compared to births spaced 3-5 years apart for the mothers, their newborn children and the previously born child.
  7. 7. Percent of Birth Intervals that are Short 76 70 69 68 67 66 64 64 64 <36 months <24 months 62 61 61 61 60 59 58 58 55 48 45 36 36 28 27 24 20 Nepal India Bolivia Egypt Zambia Morocco Nigeria Uttar Pradesh Guatemala Madhya Pradesh Uganda Jordan 0 Philippines 19 24 23 17 16 18 15 Indonesia 20 27 26 Ghana 28 Peru 27 28 Tanzania 34 33 Kenya 40 Cote d'Ivoire Percent 49 Bangladesh 80 Source: United States Agency for International Development (USAID), Bureau for Global Health, Office of Population and Reproductive Health, Washington, D.C. 20523-3600. December 2002. (WWW.USAID.GOV)
  8. 8. Increased Contraceptive use impact on mortality
  9. 9. Deaths averted with Family Planning If there had been no change in contraceptive prevalence there would have been 3.8m additional maternal deaths in the two decades between 1985 and 2005 Source: John Stover, The Policy Project, The Futures Group, 2006
  10. 10. Family Planning as a priority in high HIV prevalence areas? For:  Will reduce pregnancies in known HIV+ women > decreased AIDS transmission  Will reduce pregnancies in HIV+ women who have not yet been diagnosed (90% still undiagnosed)  Ongoing and regular Family planning – will reduce pregnancy occurring during the first weeks of AIDS when viral load is highest  Birth Spacing allows HIV+ women to recover from previous pregnancies, maximizing her health before the challenge of another pregnancy Against:  Mixed evidence on increased HIV transmission to men when on long acting hormone contraception. Conclusion:  Recent WHO technical consultation concluded proven benefits of FP outweighed the inconsistent potential
  11. 11. Family Planning Use: Impact on Abortion Rates    Classic relationship in post-Soviet countries Mixed in places with falling fertility where there is very high unmet need for fertility control Reaffirms need for additional FP access Increased access to FP estimated to reduce induced abortions in the developing world by 70% (from 35 million to 11 million), also reducing deaths and post-abortion costs due to unsafe abortions. International Family Planning Perspectives, 2003, 29(1):6-13
  12. 12. CPR  Coverage globally in 2010 ~28%
  13. 13. Comparing effectiveness of methods More effective How to make your method most effective Less than 1 pregnancy per 100 women in one year After procedure, little or nothing to do or remember Implants Female Sterilization Vasectomy Vasectomy: Use another method for first 3 months IUD Injections: Get repeat injections on time LAM (for 6 months): Breastfeed often, day and night Injectables LAM Pills Patch Ring Pills: Take a pill each day Patch, ring: Keep in place, change on time Condoms, diaphragm: Use correctly every time you have sex Male Condoms Female Condoms Withdrawal Less effective About 30 pregnancies per 100 women in one year Diaphragm Fertility-Awareness Based Methods Spermicide Fertility-awareness based methods: Abstain or use condoms on fertile days. Newest methods (Standard Days Method and TwoDay Method) may be easier to use. Withdrawal, spermicide: Use correctly every time you have sex
  14. 14. Side Effects & Obstacles         Oral Contraceptives – Take every day IUDs – Medical procedure to insert Sterilization – Permanent Injectable – Menstrual disturbance Norplant – Cost Condom – Use every time Diaphragm – Use every time Natural family planning – precision in timing Myth: Family Planning methods are abortifacients IN THE PAST, there was an incorrect understanding of the mechanisms of action that limited unified faith-based support for family planning. TRUTH: Family Planning methods prevent conception  Most methods accepted by people of faith as contraceptive  But incorrect understanding of EC & IUD mechanism limited acceptance
  15. 15. How DO EC and IUDs work? Emergency contraception: prevent pregnancy  Effective only in the first few days following intercourse  before the ovum is released from the ovary and before the sperm fertilizes the ovum.  Prevent ovulation, change cervical mucous to inhibits entry of sperm to uterus, disrupt sperm binding to the egg.  Emergency contraceptive pills cannot interrupt an established pregnancy or harm a developing embryo. Hormonal & Copper IUD: prevent pregnancy by  Chemical change that damages sperm and egg before they can meet.  Cervical mucous change that inhibits entry of sperm to uterus
  16. 16. Economic Benefits too: Costs & net health effects of contraceptive methods. Compared with use of no contraception,  Cost savings over 2 years, ◦ US$5907/woman for tubal sterilization ◦ US$9936 for vasectomy  Health gains ◦ 0.088 QALYs for diaphragm ◦ 0.147 QALYs for depot medroxyprogesterone acetate.  Even modest increases in the use of the most effective methods result in financial savings and health gains. Sonnenberg FA, Burkman RT, Hagerty CG, Speroff L, Speroff T. Contraception. 2004 Jun;69(6):447-59.
  17. 17. Conclusion Family planning is one of the most effective life saving interventions we have to reduce maternal and child mortality.  Increased use of family planning can significantly reduce abortion rates  Unmet need for contraceptives is still at about 24% for Sub-Saharan Africa.  Effective, non-abortifacient methods, including natural family planning methods, exist that are acceptable to people of all faiths 
  18. 18. Take Action Get the word out  We promote family planning because we value women and children  Use the growing & compelling evidence  Debunk the myths  People of all faiths can now unify in support of family planning to improve health and well-being of millions.
  19. 19. Thank you
  20. 20. Unmet Family Planning Need 1st Year Postpartum (blue) & All Women (purple) 80 70 60 50 1st Year PP 40 All Women 30 20 10 0 B-desh Haiti Kenya Nigeria Source: Borda, M. and W. Winfrey. Family Planning Needs during the First Year Postpartum. ACCESS-FP.
  21. 21. Non-users: 55% intend to use--Their preferred methods for future (Kenya DHS 08-09)          Injectables Unsure Pill Female sterilization Implants Male condom IUD Periodic abstinence Female condom 52% 13 12 8 8 2 2 2 0.3
  22. 22. Contraceptive use in USA among women at risk of unintended pregnancy* by religious affiliation (Natl Surv Fam Grwth 2006-08; n=7,356 women) Protestant Catholic Mainline Evangelical No Relig Contraceptive Method All Women Affil Highly Effective 69% 68% 73% 74% 62% Sterilization 33 32 34 41 26 Pill & other hormonal 31 31 35 28 30 Intrauterine device 5 5 4 4 6 Condom 14 15 13 10 17 Natural FP 1 2 1 1 1 Other 5 4 4 6 7 None 11 11 10 9 14 * % of women sexually active but not pregnant, post-partum or trying to become pregnant. Christian Connections for International Health, at Center for Bioethics & Human Dignity, 13 July 2012
  23. 23. The 2 classic female hormones (progesterone and estrogen) vary throughout the cycle Cervical mucus is amenable to sperm penetration only mid-cycle, when estrogen peaks and before progesterone rises. Any contraceptive that has progestin in it will make cervical mucus hostile to sperm.
  24. 24. IUDS  Hormonal IUDs - progestin levonorgestrel. Prevention of pregnancy due to subsequent thickening of cervical mucus, which prevents the passage of sperm, inhibition of sperm mobility and inhibition of endometrial growth.  Copper IUD – endometrium releases white blood cells, enzymes and prostaglandins; and these reactions of the endometrium appear to prevent sperm from reaching the fallopian tubes. In addition, release copper ions into the the uterus, enhancing the debilitating effect on sperm.
  25. 25. Hormonal contraceptive methods have at least 2 major mechanisms of action:  Inhibiting/disrupting  Thickening  Other? ovulation cervical mucus
  26. 26. Population growth
  27. 27. RH bulge to come
  28. 28. Health in Afghanistan Maternal Mortality Rates:  VA is 7/100,000  Puerto Rico 18/100,000  2001 was 1600/100,000  NE Corner Badakshan province 6400,100,000  Now (2010) 337/100,000 Key Findings • Fewer Women die during Pregnancy and Childbirth. • More Children survive to their Fifth Birthday. • Women are having fewer children. • More Women Use Life Saving Care.
  29. 29. USAID and State Family Planning and Reproductive Health Budgets - FY2009 - FY 2011 FY 2009 Enacted FY 2010 653(a) Initial FY 2011 Request Congressional Earmark/Direc tive $545,000 $648,457 - Family Planning and Reproductive Health $572,401 $666,590 $715,740 $27,401 $18,133 - Delta Earmark/Direc tive vs. Programmed FY09 included $50m as a USG contribution to UNFPA. FY10 includes $55m as a USG contribution to UNFPA. FY11 includes $50m as a USG contribution to UNFPA.
  30. 30. Funding comparisons
  31. 31. Equity for the Moms and Babies! We cannot be complacent!!!
  32. 32. Impact of FP on abortion rates   Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly.
  33. 33. Resources   Jim Shelton: FP Myths Mary Ellen Stanton: MH  National Family Planning and Reproductive Health Association – http://www.nfprha.org/main/index.cfm WHO Family Planning Site http://www.who.int/topics/family_planning/en/ K4Health (knowledge for Health)project: Hopkins,   ◦ Family Planning Guidebook for providers & Wall chart    CEDPA: women’s empowerment & RH PATH: new technology & coverage expansion FHI:http://www.fhi.org/en/index.htm

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