We are delighted to have this opportunity to talk with you about family planning’s role in maternal and child health and its contribution to Ending Preventable Child and Maternal Deaths: USAID’s contribution to A PROMISE RENEWED , a country-led endeavor with leadership and support from UNICEF and USAID.
Family planning contributes to child and maternal health by enabling women to choose if and when to become pregnant and thus: -- preventing unintended pregnancies and reducing unmet need for contraception -- helps couples achieve their desired family size -- helping women to use family planning to ensure that pregnancies occur at the healthiest times of women’s lives -- that is: After age 18 and before age 34 At least 24 months after a live birth (about three years between births) Six months after a miscarriage or induced abortion And by preventing many children per woman. (this is awkward. I would use the family size language above)
Sexually active women of reproductive age in developing countries experience high rates of unintended pregnancy. Nearly 90 percent of the estimated 208 million pregnancies in 2008 occurred in the developing world, according to the Guttmacher Institute. Globally, 86 million pregnancies were unintended; of these, 41 million ended in abortions 33 million in unplanned birth and 11 million in miscarriage. Roughly as many women with unintended pregnancies obtain induced abortions as give birth to a child they had not planned for. The majority of these induced abortions take place in non-medical settings under unsafe conditions. 222 million women in the developing world have an unmet need for FP Meeting this need would prevent 54 million unintended pregnancies 26,000,000 fewer abortions ~ 80,000 fewer maternal deaths 2,400,000 fewer serious morbidities 1,100,000 fewer infant deaths >300,000 fewer children lose mother 208 million pregnancies 86 m unintended pregnancies 41-44 m abortions 33m unplanned births 11m miscarriages ~50% ~38% ~13%
This graph shows that maternal mortality is lower among women who become pregnant before age 34. It is important to keep in mind that APR now includes a focus on maternal mortality. The analysis presented in the graph is still underway, and will be shared with us when it is completed. The findings strengthen the rationale for countries to invest in LARCs and LAPMs in the context of a broad method mix to help prevent maternal deaths in the higher age groups, and for programs to help this group of women understand the advantages of LARCs and LAPMs. As far as we know, this is the first comprehensive analysis of advanced maternal age and maternal mortality. This graph shows that maternal mortality is lower when women have fewer children. As far was we know, this is the first comprehensive analysis of the relationship between the number of children and maternal death. These findings also strengthen the rationale for countries investing in LARCs and LAPMs to save women’s lives. This analysis is still underway and will be shared when it is completed. Maternal mortality ratio (maternal deaths per 100,000 live births). FP prevents unintended pregnancy, one of the underlying causes of maternal mortality. [Insert % of pregnancies that are unplanned worldwide?] Postpartum FP and postabortion FP offer important opportunities for more effective linkages with other efforts to end preventable maternal deaths. Challenges to cohesive prioritization of efforts include: insufficient funding and staffing, plus organizational divisions between maternal health and family planning – both in USAID and in the healty facilities and health systems we support What is within our manageable interest to overcome? Within USAID, we can build on our current efforts to become better integrated in our approach to strengthen postpartum FP and postabortion FP
This graph shows that the risk of under-five mortality is lower among children born about three years after a preceding birth. The graph clearly shows almost three times the risk of child mortality when the pregnancy occurs after a short interval of 6 months or less (see the far left side of the horizontal axis) compared to longer and healthier intervals of about three years or more. SPEAKER CAN STOP HERE Additional information if needed: This slide presents pooled data from 52 Demographic and Health Surveys. The vertical axis presents the adjusted relative risk (adjusted for about 16 socio-economic variables and relative to the risk at 36-47 months) of under-five mortality. The horizontal axis presents birth to pregnancy intervals in months. The analysis was prepared by Shea Rutstein, Technical Director at IFC Macro. The under-five mortality rate is defined as: the number of children who die by the age of five, per 1000 live births per year.
Family planning contributes to child and maternal health by enabling women to choose if and when to become pregnant and thus: -- preventing unintended pregnancies and reducing unmet need for contraception -- helps couples achieve their desired family size -- helping women to use family planning to ensure that pregnancies occur at the healthiest times of women’s lives -- that is: After age 18 and before age 34 At least 24 months after a live birth (about three years between births) Six months after a miscarriage or induced abortion Shea Rutstein, Technical Director at IFC Macro, analyzed 52 Demographic and Health Surveys. He estimated that if all birth to pregnancy intervals were increased to three years, approximately 1.6 million under-five deaths could be prevented annually . Finally, researchers at Johns Hopkins and the Gates Foundation (Saiffudin Ahmed and Amy Tsui) presented their findings on family planning’s contribution to maternal health in The Lancet in June of 2012. They concluded that, in one year, family planning prevented more than 272,000 maternal deaths, a 44 percent reduction. And if all FP needs were met, an additional 104,000 maternal deaths could be prevented annually. In the next few slides we present some data that show that pregnancies occurring at healthy times of women’s lives contribute to healthier outcomes for the woman and her children. Family planning use can help ensure that pregnancies occur at the healthiest times. In this slide, we present data gathered by WHO that show that perinatal mortality is lower among babies born when the woman is between the ages of 20-29, compared to when she is an adolescent* Family planning can help ensure that women’s pregnancies occur after age 20 and in this way it helps prevent perinatal mortality. SPEAKER CAN STOP HERE. (Additional information if needed is included below.) The slide shows perintatal mortality rates at ages 20-29 and under age 20 in six countries. Data from additional countries are available. The horizontal axis presents perinatal mortality rates – the number of perinatal deaths per 1000 live births.* In each country, as shown on the vertical axis, perinatal mortality is higher when the woman is under age 20, compared to when she is ages 20-29. *The perinatal mortality rate is defined as the number of fetal and infant deaths, including stillbirth, from 28 weeks of gestation to the end of the neonatal period of 4 weeks after the birth, per 1000 live births, in a given period and a specific geographic region. This graph shows that the risk of undernutrition -- meaning child stunting and underweight -- is lower among children born about three years after a preceding birth. The World Food Programme defines underweight as being dangerously thin, and stunting as being too short for one’s age (moved from below). The graph clearly shows significantly higher risk when the pregnancy occurs after a short interval of 6 months or less (see the far left side of the horizontal axis) compared to intervals of about three years or longer. SPEAKER CAN STOP HERE Additional information if needed: This slide presents pooled data from 52 Demographic and Health Surveys. The vertical axis presents the adjusted relative risk (adjusted for about 16 socio-economic variables) of stunting and underweight. The horizontal axis presents birth to pregnancy intervals in months. The analysis was prepared by Shea Rutstein, Technical Director at --.
FP/MNCH: The goal of FP/MNCH is to meet the need of postpartum and postabortion women by integrating FP into the services that they use and reaching them at every point of contact. Focused Antenatal Care (FANC) + FP counseling Emergency Obstetric Care (EmOC) for PAC + FP counseling and methods Birth and Essential Newborn Care (0-48 hours) + LAM, PPIUD, male/female sterilization, and any methods for non-breastfeeding women Postnatal Care, Immunization & Nutrition (through 1 st year) + LAM & transition, all FP methods after 6 weeks Child health services & Nutrition (through 2-5 years) + all FP methods with a focus on continuation
Avant de commencer la discussion sur les Résultats de la Recherche, nous devons nous demander pourquoi la planification familiale est tellement importante dans les soins après avortement ? C’est le Counseling et les services de planification familiale qui distinguent les soins après avortement des services obstétricaux d’urgence. Evacuation utérine + planification familiale = soins après avortement Evacuation utérine sans planification familiale= uniquement soins obstétricaux d’urgence. La planification familiale est nécessaire quelle que soit la méthode d’évacuation utérine utilisée, D&C ou AMIU
This slide portrays the programming streams as they exist. Dotted lines indicate that services are more theoretical than existing. In FP emphasis is placed on integrating FP messages in ANC, then immediate PPFP for long acting and permanent methods as available, with the greatest emphasis on the six week postpartum visit. In maternal health, more emphasis is placed on skilled delivery care and the immediate postpartum period. In neonatal and child health, emphasis is placed on immediate and later postnatal as well as the immunization schedule.
Family Planning's Role in Improving Maternal and Child Health_Patricia MacDonald_4.23.13
Family Planning’s Rolein Improving Maternal & ChildHealth and Well-BeingPatricia MacDonald RN, MPHCore Group Spring ConferenceApril 22-25, 2013Baltimore, MD
Family Planning Improves Maternal and ChildHealth and Well-being by: Preventing unintended pregnancy and abortion Helping couples achieve their desired family size Reducing unmet need for contraceptionAnd by helping ensure that pregnancy occurs at thehealthiest times of a woman’s life: After age 18 and before age 34 At least 24 months after a live birth About 6 months after an abortion or miscarriage At birth orders below 5Desired FP Outcomes forImproved Maternal and Child Health
208 million pregnancies86 m unintended pregnancies41-44 m abortions33m unplanned births11m miscarriages~49%~38%~13%Of These…MaternaldeathsOf These…~9-13%Unintended Pregnancies Lead To:
Maternal Mortality isLower among Womenwho Become PregnantBefore Age 34Maternal Mortality isLower among Women whoHave Fewer ChildrenFamily Planning SupportsImproved Maternal Health
Proportion of Births That Are Fifth Orderor Higher in Sub-Saharan AfricaThe proportion of births of fifth order or higher in SSAranges from 22.8 percent in Ghana to 43.3 percent in Uganda.
Risk of Under-Five Mortality is Lower Among ChildrenBorn about Three Years After a Preceding Birth
Perinatal Mortality is Loweramong Babies Born to WomenAges 20-29 vs Those Born toAdolescentsRisk of Undernutrition isLower Among Children Bornabout Three Years After aPreceding BirthHealthy Pregnancy Timing and SpacingContributes to Improved Child Survival
Percentage of Births by Number of MonthsSince Preceding Birth - Sub-Saharan AfricaSource: Demographic and Health Surveys for given years.Between 40 to 65 percent of births are spaced less than 36 months apart.Between 4 to 14 percent of births are spaced more than 68 months apart.
Percentage of Births by Number of MonthsSince Preceding Birth - Asia and HaitiSource: Demographic and Health Surveys for given years. Pakistan is ever-married only. Data are unavailable for Afghanistan and Yemen.Between 35 and 57 percent of births are spaced less than 36 months apart.Between 5 to 15 percent of births are spaced more than 68 months apart.
Percentage of Women Aged 15–19 Who AreMothers or Pregnant With Their First Child-Sub-Saharan Africa-Source: STATcompiler – most recent Demographic and Health Surveys, Malawi 2010.Between 5.7 percent of 15-19 year olds in Rwanda to 41 percent in Mozambique aremothers or pregnant with their first child.
Percentage of Adolescents Aged 15–19 Who AreMothers or Pregnant With Their First Childin Asia and HaitiSource: STATcompiler – most recent Demographic and Health Surveys. Information is not available for Afghanistan, Yemen and India (UP). Note: Bangladesh sample isever-married women.Between 9.1 percent of 15-19 year olds in Pakistan to 32.7 percent in Bangladeshare mothers or are pregnant with their first child.
Percentage of Births by Number of MonthsSince Preceding Birth Among Young WomenAged 15–19 Sub-Saharan AfricaSource: Demographic and Health Surveys for given years.The majority of young women aged 15-19 space their births fewer than 36 months apart,from 72.1 percent in Malawi to 90.7 percent in Kenya.
Percentage of Births by Number of MonthsSince Preceding Birth Among Young WomenAged 15–19 Asia and HaitiSource: Demographic and Health Surveys for given years. Pakistan is ever-married only. Data are unavailable for Afghanistan and Yemen.The majority of young women aged 15-19 space their births less than 36months apart, from 71.7 percent in Nepal to 93 percent in Pakistan.
Adolescents have more very closelyspaced pregnancies than other age groupsNigeriaMozambiqueMalawiSource: Demographic and Health Surveys
Source: Most recent DHS; data for all women. Secondary analysisby EngenderHealth & Futures Institute (The RESPOND Project), 2012Total demand, unmet need and method useamong all women with demand to space70%60%50%40%30%20%10%0%Traditional method use to spaceNo method use, or Unmet need to spaceHeight of bar = Total demand for FP to spaceOther modern method use (resupply method) to spaceLong-acting reversible method (IUD or implant) to space+ = Unmet need for modern FP to space
70%60%50%40%30%20%10%0%Total demand, unmet need and method useamong all women with demand to limitSource: Most recent DHS; data for all women. Secondary analysis byEngenderHealth & Futures Institute (The RESPOND Project), 2012.Using traditional method to limitUsing no method to limitHeight of bar = Total demand for FP to limitOther modern method use (resupply method) to limitUsing one of the four LAPMs to limit+ = Unmet need for modern FP to limit
Programming interventionsto help women achieve healthymaternal and child outcomes
Reaching Girls and Young Women –Before they Become Pregnant• Keeping Girls in School – helps delay the age of firstpregnancy• Providing Youth –Friendly Care, integrated into arange of existing community services, reaches youthwith FP/RH information and services• Expanding access to emergency contraception –helps prevent unintended pregnancy and abortion• Promoting good nutrition – helps improve maternaland newborn health when pregnancy does occur
FP/MNCH: “Smart” Integrationof FP with MNCH/N ServicesFANC•FP CounselingEmOCPAC•All FPMethodsDelivery & NB Care(0-48 hours)•LAM•PPIUD•Female Sterilization•Vasectomy•Hormonal methods fornon-breastfeedingwomenPNC, Immunization& Nutrition(through 1 year)•LAM & Transition•All FP Methods(after 6 weeks)Child HealthServices& Nutrition(through 2-5 years)•All FP MethodsInitiationContinuationReaching women with FP counseling and services:PPFP/PA-FP Indicators, Documentation, Evaluation of Integration
First Time Parents activities addressRH goals and FP needs1. Fertility intentions of young married women around secondand subsequent pregnancies and their ability to act on theirintentions through the lens of the individual,couple/extended family, and community at large2. Quality of FP/RH care offered to the young marriedwomen/couple when they seek FP services and counseling3. Interventions targeting spacing for second and subsequentpregnancies among young married women– REPRODUCTIVE LIFE PLAN –
Determinants of Spacing Second and SubsequentPregnancies among First Time ParentsDemand Side•Individual Factors-Cognitive abilities-Autonomy-Mobility-Education•Household Factors-Relationship with spouse-Relationship with in-laws•Community-Culture and gender norms•State-National laws, policies andregulationsSupply Side•FP/RH service deliverysystem-Accessibility, availabilityand coverage-High performing healthworkers and quality ofcounseling and services-Supportive policies andsystemsIncreasebirth topregnancyinterval >24 months
First Time Parents activities also addressintegrated maternal, newborn and child care1. Maternal care, hygiene and nutrition during pregnancy,childbirth, postpartum and between pregnancies2. Knowledge and skills to breastfeed and care for thenewborn through infancy and early childhood, includingfeeding practices, immunizations, stimulation for learning3. Prevention of gender based violence, utilization of healthservices for prevention services and treatment of illnesses
Postabortion Carecompared with EmOC• Uterine evacuation • Uterine evacuation• Family Planning• Family PlanningPostabortion Care Emergency ObstetricCare only
FAMILY PLANNINGANC-FP messages-Immediate Post Partum FamilyPlanning0-48 hoursPostpartum FP6 wk visitExtended Postpartum FP6 weeks to 12 monthsInter-partum FPUp to 24 months or longerBirth PreparednessANCDelivery care3-6 days1-6 weeksPOSTPARTUMImmunization EBF 4-6wksImmunization EBF 8 wksImmunization EBF 12 wksChild feeding 6 moImmunization-Measles9 moTT ImmunizationNeonatal care 6-12 hrsLater postnatal3-6 daysImmediate postpartum6-12 hrsMATERNAL HEALTH NEONATAL & CHILDHEALTHPMTCTPEDIATRICCAREPPFP integrated with MNCH servicesHIVOpportunities?
Continuum of Points of Contactfor Postpartum Family Planning (PPFP)
Postpartum Contraceptive OptionsTiming of Method Initiation and Breastfeeding Considerations
International Support for PPFPhttp://www.mchip.net/ppfphttp://www.k4health.org/toolkits/ppfp
• 222 million women in the developingworld have an unmet need for FP• Meeting this need would prevent 54million unintended pregnancies– 26,000,000 fewer abortions– ~ 80,000 fewer maternal deaths– 2,400,000 fewer serious morbidities– 1,100,000 fewer infant deaths– >300,000 fewer children lose mother• Many other family, societal andnational benefits.PhotobyR.Mowli/EngenderHealthPhotobyStaff/EngenderHealthHere’s the “health payoff”if FP choice and access are increased!