Family Planning and Maternal and Child Health

 

Welcome to the programmatic area on family planning (FP) and maternal and child health (MCH) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the family planning section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. The integration of FP and MCH programs and services provides multiple opportunities to streamline and improve care, both for the woman and her children. The indicators included in the database relate to postpartum FP counseling and service provision. Key indicators to monitor and evaluate FP and MCH can be found in the links at left.    Full Text The integration of family planning (FP) and maternal and child health (MCH) programs and services provides multiple opportunities to streamline and improve care at favorable and critical times for maximizing women’s reproductive health (RH) and the health of their children. The benefits associated with combining FP and MCH services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health. Through collaboration with a number of international partners, the USAID ACCESS-FP program has been working to expand the integration of FP with MCH programs in these priority areas: (1) policies and strategies to include FP in national maternal and newborn essential care packages; (2) postpartum (PP) information on return to fertility, pregnancy spacing and FP methods in curricula, standards, and guidelines for training and service delivery; (3) behavior change communication strategies promoting pregnancy spacing and FP; and (4) facility- and community-based approaches for integrating antenatal care (ANC), safe delivery, essential newborn care, and PP care for mothers and newborns (USAID, 2008a).  ACCESS-FP is integrating women’s needs for RH care and postpartum family planning (PPFP) with newborn and child health services, including prevention of mother-to-child transmission of HIV, during the extended PP period (i.e., through the first year after delivery). FP use during the first year PP has the potential to significantly reduce the number of unplanned pregnancies and research has shown a large unmet need among women in the extended PP period.  Meeting these needs could substantially increase contraceptive prevalence, reduce the percentage of birth intervals that are dangerously close, and reduce maternal and child mortality (Cleland et al., 2006).  In 2005, a WHO technical consultation recommended the minimum interval of 24 months after a live birth before attempting the next pregnancy in order to reduce risk of adverse maternal, perinatal, and infant outcomes (WHO 2006). Greater FP use during the extended PP period, fully breastfeeding, and slower return to sexual activity can combine to lengthen birth intervals.    From a programmatic standpoint, women who use maternal health services are more likely to use FP services during the extended PP period (Borda and Winfrey, 2010). ACCESS-FP focuses on four PP fertility reducing factors: (1) return of menses; (2) return to sexual activity; (3) breastfeeding and the lactational amenorrhea method (LAM); and (4) use of maternal health services, and has developed a programmatic framework for integrating PPFP with maternal, newborn, and child health (USAID, 2008b).  For FP, emphasis is placed first on integrating FP messages during ANC and then on immediate PPFP, highlighting the importance of the six-week PP visit given the crucial timing for PPFP acceptance. In maternal health, the focus is placed on skilled delivery care and the immediate PP period, again with corresponding reference to the six-week PP visit.  For newborn and child health, emphasis is placed on immediate and postnatal care and the immunization schedule. For women with HIV, counseling on exclusive breastfeeding, and the impact of abrupt weaning on women’s return to fertility are stressed. The framework lays out the multiple overlapping opportunities to promote spacing of pregnancies and to provide FP information within the context of maternal and infant health services. Integrating and scaling up PPFP services necessitates putting systems in place for monitoring and evaluating (ME) levels and trends of PPFP use, training and service delivery, and the impact on various measures of MCH.  The six core indicators selected for this database cover the programmatic areas recommended by ACCESS-FP, focusing specifically on clients’ use of PPFP services, the quality of these services and the unmet need for PP contraception. (Note: See Mwangi et al. (2008) for a list of 16 postnatal care ME indicators used in the USAID collaborative ACCESS-FP and Frontiers ‘Postnatal care – family planning’ project in Kenya). In addition to the database indicator for LAM counseling, an indicator for the percent of women using LAM for FP can be found in the technical area on Breastfeeding.  More birth spacing indicators can be found under Healthy Timing and Spacing of Pregnancy.  Where sufficient data are available, the indicator for PP unmet need may be disaggregated from the corresponding unmet need indicator in the technical area on Family Planning.    ____________  References: Borda M and Winfrey W, 2010, Postpartum fertility and contraception: An analysis of findings from 17 countries, Washington, DC: USAID/ACCESS-FP. Cleland J, Bernstein S, Ezah A, et al., 2006, Family Planning: the unfinished agenda, Lancet Series, Sexual and Reproductive Health:368. Mwangi A, Warren C. Koskei N, Blanchard H., 2008, Strengthening Postnatal Care Services Including Postpartum Family Planning in Kenya, Washington, DC: USAID/ACCESS-FP/Frontiers (Indicators on page 10). http://www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Kenya_PPFP.pdf USAID, 2008a, Addressing unmet need for postpartum family planning: The ACCESS-FP Program, Newsbrief Apr, Washington, DC, USAID. USAID, 2008b, ACCESS-FP Programmatic Framework: Postpartum Family Planning in an Integrated Context, Washington, DC: USAID. http://www.accesstohealth.org/toolres/pdfs/ACCESSFP_pgmframework.pdf USAID, 2008c, Postpartum Family Planning: A review of programmatic approaches through the first year of postpartum-report, 15 May, Washington, DC, USAID. WHO, 2006, Report of a WHO Technical Consultation on Birth Spacing, Geneva: 13-15 June 2005, WHO. 

Number or percent of maternal and child health services clients who received counseling about LAM

Definition:

 

The number or percent of women attending maternal and child health (MCH) services (i.e., antenatal care, labor and delivery, postpartum visit, and/or infant and child health/immunization visits) during a specified time period, who received counseling about the lactational amenorrhea method (LAM) as a postpartum family planning (FP) method.

For women delivering at a facility, counseling should be conducted prior to discharge.  It should consist of an evaluation for LAM use, instruction on the method including information that LAM is 98 percent effective in preventing pregnancy when used correctly, and the need for immediate transition to another modern method when any of the LAM criteria are no longer being met.  The three criteria for correct LAM use are:

  1. The mother’s period has not returned.
  2. The infant is fully or nearly fully breastfed and is fed often, day and night.
  3. The infant is less than six months old.

For more background on LAM counseling, see the K4Health LAM Toolkit.

This indicator is calculated as:

(Number of women attending MCH services who received LAM counseling / Total number of women who attended MCH services during a specified time period) x 100

For closely related indicators in this database, see the Percent of women receiving postpartum/ postabortion family planning counseling under Safe Motherhood; the Percent of eligible women who use the lactational amenorrhea method as their method of FP under Breastfeeding; and the Percent of women who received family planning information for pregnancy spacing during a postpartum/postabortion visit, by type of visit under Healthy Timing and Spacing of Pregnancy.

Data Requirements:

Data can be used from facility records, health information systems (HIS), client interviews, and specialized surveys. The data can be disaggregated by the type of MCH services (e.g., antenatal, labor and delivery, or postpartum), the type of facility or program (public, private, non-governmental, community-based), and where data are available by other relevant factors, such as women’s age, parity, and urban/rural location.

Data Sources:

Facility records; HIS; client interviews; specialized surveys

Purpose:

This indicator provides information on the level of access women have to information and counseling on LAM and can be used to compare and track trends in the integration of LAM counseling with MCH services. Because LAM is 98 percent effective when used correctly, encourages the best breastfeeding patterns with health benefits for both mother and baby, and is a good option before transitioning to another postpartum contraceptive method, it is often promoted by health providers, particularly in low resource settings. FP use during the first year postpartum has the potential to significantly reduce the number of unplanned pregnancies leading to fewer closely spaced pregnancy intervals and decreases in maternal and child morbidity and mortality. The integration of LAM counseling, as well as other FP methods, with MCH programs and services provides opportunities to streamline and improve care at the most favorable and critical times for maximizing women’s reproductive health and the health of their children. Multiple contacts with MCH services during the antenatal and the postpartum periods have been shown to increase women’s use of FP methods by six months postpartum and decrease unmet need for FP (USAID, ACCESS-FP, Frontiers, 2008). The benefits associated with combining FP and MCH services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health.

Issue(s):

 

This indicator does not  capture the quality of the LAM counseling services, if LAM was accepted as a FP method, or whether the facility makes referrals or follows up with women on the adoption, correct use, or continuation of LAM. Where the indicator is primarily based on self-report, clients may not remember or know for certain whether they received counseling on LAM, especially if there is a long time lag between receiving services and the interview.

References:

 

K4Health LAM Toolkit: http://www.k4health.org/toolkits/lam

JHPIEGO/ ACCESS-FP, 2009, LAM Counseling Checklist for MNCH Service Providers, Baltimore MD: K4Health, Johns Hopkins Bloomberg School of Public Health.  https://www.k4health.org/toolkits/lam/lam-counseling-checklist-mnch-service-providers

USAID/ ACCESS-FP/ Frontiers, 2008, Strengthening Postnatal Care Services Including Postpartum Family Planning in Kenya, New York: The Population Council. http://pdf.usaid.gov/pdf_docs/Pnadn570.pdf

Number or percent of service delivery points which offer a range of appropriate contraceptive options for postpartum women

Definition:

 

The number or percent of maternal and child health (MCH) service delivery points (SDPs) which offer a range of appropriate contraceptive method options for postpartum women, assessed during a specified time period (e.g., one year). In order to be counted for the indicator, the SDP should be providing contraceptive services onsite rather than as client referrals

The recommended contraceptive options for postpartum women include the lactational amenorrhea method (LAM) for the first six months and methods that do not interfere with breastfeeding and are safe to use any time after birth including: condoms; IUD (non-hormonal); diaphragm; vasectomy; and tubal ligation.  The full range of postpartum contraceptive options are presented below.

ACCESS-FP, 2007

For more background on the full range of postpartum contraceptive options, see  USAID/ACCESS-FP (2007).

SDPs include all public, private, non-governmental and community-based health facilities and outlets in which MCH services are offered, including antenatal care, labor and delivery, postpartum and/or infant and child care.

This indicator is calculated as:

(Number of SDPs that offer a range of appropriate postpartum contraceptive methods / Total number of SDPs in a designated area) x 100

This indicator is closely related to the recommended USAID/CORE Group’s postpartum care indicator for Health facilities providing a range of contraceptive methods (USAID/CORE Group, 2004). For further information on assessing availability of contraceptive methods and services, see the sections in this database on Commodities, Securities and Logistics; Service Delivery; and Health Systems Strengthening.

Data Requirements:

 

Data on which contraceptives are available at SDPs, subset by those types appropriate for postpartum women. Ideally method availability should include commodities, as well as service provision and counseling for the methods, such as on the use of LAM. A comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, including availability of FP methods and postpartum care (MEASURE DHS, 2011). The data can be disaggregated by the type of facility or program (public, private, non-governmental, community-based, etc.), by the specific types of methods available, and by other relevant factors such as districts, urban/rural location, and target populations.

Data Sources:

Facility registers on services provided; inventory records; specialized surveys, such as SPA; and information management systems. In countries where available, DELIVER Project data can be used to assess supplies for a range of modern contraceptive methods that will include methods appropriate for postpartum women (DELIVER, 2006; DELIVER, 2011).

Purpose:

This indicator measures the availability of contraceptive methods appropriate for women during the postpartum period and can be used to compare and track trends in the integration of postpartum FP with MCH services.  Optimally, MCH programs and services can provide a range of methods to meet the needs of postpartum women for limiting and spacing pregnancies. FP use during the first year postpartum has the potential to significantly reduce the number of unplanned pregnancies leading to fewer closely spaced pregnancy intervals, and decreases in maternal and child morbidity and mortality. The integration of the range of contraceptive methods for postpartum women with MCH programs and services provides opportunities to streamline and improve care at the most favorable and critical times for maximizing women’s reproductive health and the health of their children. Multiple contacts with MCH services during the antenatal and the postpartum periods have been shown to increase women’s use of FP methods by six months postpartum and decrease unmet need for FP (USAID/ACCESS-FP/ Frontiers, 2008). The benefits associated with combining FP and MCH services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health.

Issue(s):

 

This indicator measures availability of postpartum contraceptive methods and services, but the overall access to, distribution of, and quality of services can best be measured using a range of indicators that provide data on method procurement, storage, affordability, travel time to facilities, staffing, delivery of method services and follow-up, and client utilization and satisfaction (WHO, 2010).

It is important to note the distinction between whether a site offers a given contraceptive option (in other words that the method is defined to be part of the site’s postpartum method mix) and whether a site has the resources it needs to actually provide the FP service at an adequate level of quality. A relatively large proportion of interviewees or facility registers may report that several postpartum FP options are offered, however a significant proportion of these sites may not be currently offering the FP services because they do not have a provider who has been trained in the provision of that service in the past three years or the site may not have all the appropriate supplies and instruments.

References:

 

DELIVER, 2006, Contraceptive Security index 2006 a tool for priority Setting and planning, Arlington, VA: John Snow, Inc., USAID DELIVER Project.  http://www.healthpolicyplus.com/archive/ns/pubs/hpi/667_1_Contraceptive_Security_Index_2006.pdf 

DELIVER, 2011, Family Planning Tools Website, Arlington VA: John Snow, Inc., USAID Deliver Project. 

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website. http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

USAID, 2005, Family Planning for Postpartum Women: Seizing a Missed Opportunity, Washington, DC: USAID. https://www.k4health.org/sites/default/files/FP%20for%20PP_eng.pdf

USAID/ACCESS-FP, 2007, Postpartum Contraceptive Options, Washington, DC: USAID. http://www.accesstohealth.org/toolres/pdfs/ACCESSFP_ContOptionsGraphEN.pdf

USAID/Core Group, 2004, Maternal and Newborn Standards and Indicators Compendium, Washington DC: USAID/CORE Group. http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

Number or percent of providers at service delivery points who know the contraceptive options for postpartum women up to six months postpartum

Definition:

The number and percent of providers at maternal and child health (MCH) service delivery points (SDPs) who know the range of contraceptive options that do not interfere with breastfeeding.

SDPs include all public, private, non-governmental and community-based health facilities and outlets in which MCH services are offered, including antenatal care, labor and delivery, postpartum and/or infant and child care.

The recommended contraceptive options for postpartum women include the lactational amenorrhea method (LAM) for the first six months and methods that do not interfere with breastfeeding and are safe to use any time after birth including: condoms; IUD (non-hormonal); diaphragm; vasectomy; and tubal ligation. The full range of postpartum contraceptive options are presented below.

ACCESS-FP, 2007

The Family Planning Global Handbook for Providers ( WHO/JHU-CCP, 2011) notes that breastfeeding women can also take progestin-only pills (as soon as six weeks postpartum) and combined oral contraceptives. If the woman is partially breastfeeding, she can start combined oral contraceptives as soon as six weeks postpartum. If she is fully or nearly fully breastfeeding, she can start the pills six months postpartum or when breast milk is no longer the baby’s main food, whichever comes first. For more background on the full range of postpartum contraceptive options, seeUSAID/ACCESS-FP (2007). The questionnaire used by USAID/ACCESS/Frontiers (2008) asks providers which methods they would normally offer to breastfeeding women within 48 hours, at two weeks, and at six weeks postpartum.

This indicator is calculated as:

(Number of providers at SDPs who know contraceptive options during breastfeeding / Total number of providers at SDPs in a designated area during a specified time period) x100

Data Requirements:

Data from surveys and interviews with facility staff about which contraceptive methods are recommended for use while women are breastfeeding. Questions need to be standardized in advance and used consistently over time in order to compare programs, locations, and trends. The data can be disaggregated by the type of provider, by the type of facility (public, private, non-governmental, community based) and by other relevant factors such as districts and urban/rural location.

Data Sources:

Health worker interviews; specialized surveys

Purpose:

This indicator measures the knowledge of MCH service providers about contraceptive options for women who are breastfeeding and can serve as a proxy for the coverage and quality of service provider training in postpartum family planning (FP).  Additionally, the indicator can be used to compare and track the level of women’s access to this information through MCH services. Providers who have been trained in and are knowledgeable about contraceptive options for breastfeeding women report being more confident in the care they give postpartum women and their clients are more likely to start contraceptive methods earlier and at increased rates (USAID/ ACCESS/Frontiers, 2008). FP use during the first year postpartum has the potential to significantly reduce the number of unplanned pregnancies leading to fewer closely spaced pregnancy intervals and decreases in maternal and child morbidity and mortality. The integration of counseling and provision of methods for postpartum women with MCH programs and services provides opportunities to streamline and improve care at the most favorable and critical times for maximizing women’s reproductive health and the health of their children. Multiple contacts with MCH services during the antenatal and the postpartum periods have been shown to increase women’s use of FP methods by six months postpartum and decrease unmet need for FP (USAID/ACCESS/ Frontiers, 2008). The benefits associated with combining FP and MCH services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health.

Issue(s):

The providers’ knowledge of methods compatible with breastfeeding does not indicate that they are effective or consistent in communicating this information or in providing related contraceptive services or referrals.

References:

WHO and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (JHU-CCP), 2011, Family Planning: A Global Handbook for Providers, Baltimore, MD: Johns Hopkins University.  http://www.globalhandbook.org/

USAID, 2011, Family Planning for Postpartum Women: Seizing a Missed Opportunity, Washington, DC: USAID. http://www.usaid.gov/our_work/global_health/mch/mh/techareas/missed_opportunity_brief.html

USAID/ACCESS-FP, 2007, Postpartum contraceptive Options, Washington, DC: USAID. http://www.accesstohealth.org/toolres/pdfs/ACCESSFP_ContOptionsGraphEN.pdf

USAID/ ACCESS-FP/ Frontiers, 2008, Strengthening Postnatal Care Services Including Postpartum Family Planning in Kenya, New York: The Population Council. http://www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Kenya_PPFP.pdf

Number or percent of service delivery points that offer postpartum family planning integrated with other services, by type of service

Definition:

 

The number or percent of maternal and child health (MCH service delivery points (SDPs) in a designated area that offer postpartum family planning (FP) integrated with other services subset by the type of service.  Postpartum FP includes counseling and, if applicable, provision of method and/or referral.

SDPs include all public, private, non-governmental and community-based health facilities and outlets in which MCH services are offered, including antenatal care, labor and delivery, postpartum visits, and/or infant and child health/immunization visits.

The recommended contraceptive options for postpartum women include the lactational amenorrhea method (LAM) for the first six months and methods that do not interfere with breastfeeding and are safe to use any time after birth including: condoms; IUD (non-hormonal);diaphragm; vasectomy; and tubal ligation. The full range of postpartum contraceptive options are presented below.

ACCESS-FP, 2007

The Family Planning Global Handbook for Providers (WHO/JHU-CCP, 2011) notes that breastfeeding women can also take progestin-only pills (as soon as six weeks postpartum) and combined oral contraceptives. If the woman is partially breastfeeding, she can start combined oral contraceptives as soon as six weeks postpartum. If she is fully or nearly fully breastfeeding, she can start the pills six months postpartum or when breast milk is no longer the baby’s main food, whichever comes first. For more background on the full range of postpartum contraceptive options, see USAID/ACCESS-FP (2007).

This indicator is calculated as:

(Number of SDPs that offer postpartum FP integrated with other services / Total number of SDPs in a designated area) x 100

Data Requirements:

Data on integration of provision of postpartum FP services with MCH services by the types of service. A comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, including availability of FP methods as part of labor and delivery, postpartum, and/or child health care (MEASURE DHS, 2011). The data can be further disaggregated by the type of facility or program (public, private, non-governmental, community-based, etc.), by the specific types of methods available, and by other relevant factors such as districts, urban/rural location, and target populations.

Data Sources:

Facility registers on services provided; surveys, such as SPA; WHO's Service Availability and Readiness Assessment (SARA); and information management systems.

Purpose:

This indicator can be used to compare and track trends in the level of integration of FP with MCH services and can serve as a proxy for women’s access to postpartum FP services.  When subset by type of service, the indicator can help policy and program planners identify where scaling up of integrated FP and MCH services is taking place and where there are gaps. Optimally, MCH programs and services can provide a range of methods to meet the needs of postpartum woman for limiting and spacing pregnancies. FP use during the first year postpartum has the potential to significantly reduce the number of unplanned pregnancies leading to fewer closely spaced pregnancy intervals and decreases in maternal and child morbidity and mortality. The integration of the range of contraceptive methods for postpartum women with MCH programs and services provides opportunities to streamline and improve care at the most favorable and critical times for maximizing women’s reproductive health and the health of their children. Multiple contacts with MCH services during the antenatal and the postpartum periods have been shown to increase women’s use of FP methods by six months postpartum and decrease unmet need for FP (USAID/ACCESS-FP/ Frontiers, 2008). The benefits associated with combining FP and MCH services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health.

Issue(s):

This indicator measures integration of and increased access to postpartum FP through MCH services, but the overall access to, distribution of, and quality of services can best be measured using a range of indicators that provide data on method procurement, storage, affordability, travel time to facilities, staffing, delivery of method services and follow-up, and client utilization and satisfaction (WHO, 2010).

References:

 

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website. http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

USAID, 2011, Family Planning for Postpartum Women: Seizing a Missed Opportunity, Washington, DC: USAID. https://www.k4health.org/toolkits/info-publications/family-planning-postpartum-women-seizing-missed-opportunity

USAID/ACCESS-FP, 2007, Postpartum contraceptive Options, Washington, DC: USAID. http://www.accesstohealth.org/toolres/pdfs/ACCESSFP_ContOptionsGraphEN.pdf

USAID/ ACCESS-FP/ Frontiers, 2008, Strengthening Postnatal Care Services Including Postpartum Family Planning in Kenya, New York: The Population Council. http://pdf.usaid.gov/pdf_docs/Pnadn570.pdf 

WHO and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (JHU-CCP), 2011, Family Planning: A Global Handbook for Providers, Baltimore, MD: Johns Hopkins University.  http://www.globalhandbook.org/

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Evidence that preservice and/or inservice curricula includes postpartum care and pregnancy spacing/limiting components as part of postpartum family planning

Definition:

 

Documented evidence exists that training curricula used for preservice or inservice training of maternal and child health (MCH) care providers, as well as postabortion care (PAC) providers, includes components on postpartum care and pregnancy spacing and limiting.

Preservice and inservice training can take place through hospitals, clinics, professional schools and certification programs, in addition to inservice training at public, private, non-governmental and community-based health facilities in which MCH services are offered.  MCH services include antenatal care, labor and delivery, postpartum and/or infant and child care.

Recommended components of postpartum care include (USAID/ ACCESS-FP/ Frontiers, 2008): 

For more background and example PPFP training modules, see USAID/ ACCESS-FP/ Frontiers (2008); ACCESS-FP (2006); and Pathfinder International (2001).

Data Requirements:

Reviews of curricula used in a country or designated area by programs and facilities for preservice and inservice training of MCH and PAC service providers

Data Sources:

Copies of training curricula for MCH and PAC service providers, including any curricula recommended by the respective ministry of health

Purpose:

This indicator measures whether training programs for MCH and PAC service providers contain the recommended components on postpartum family planning (FP) and can serve as a proxy for the level of integration of postpartum FP into MCH and PAC training and services.  Training of service providers in relevant postpartum FP counseling and delivery of methods should be part of basic MCH and postabortion care. Providers who have been trained in and are knowledgeable about postpartum FP options report being more confident in the care they give women and their clients are more likely to start FP methods earlier and at increased rates (USAID/ACCESS-FP/Frontiers, 2008). FP use during the first year postpartum has the potential to significantly reduce the number of unplanned pregnancies leading to fewer closely pregnancy intervals, and decreases in maternal and child morbidity and mortality. The integration of training on counseling and provision of methods for postpartum women with MCH and PAC programs and services provides opportunities to streamline and improve care at the most favorable and critical times for maximizing women’s reproductive health and the health of their children. Multiple contacts with MCH services during the antenatal and the postpartum periods have been shown to increase women’s use of FP methods by six months postpartum and decrease unmet need for FP (USAID/ACCESS-FP/ Frontiers, 2008). The benefits associated with combining FP and MCH and PAC services are directly related to achieving Millennium Development Goals #4 reduce child mortality and #5 improve maternal health.

Issue(s):

The inclusion of postpartum FP components in preservice and inservice training curricula for MCH and PAC does not provide information about the quality of the training or the quality of services provided by those who have been trained. In order to assess mastery of knowledge and skills, evaluators should also measure whether providers are knowledgeable and effective in communicating this information and in providing postpartum FP services.  An example of a complimentary indicator would be “Number or percent of service providers trained in postpartum FP who have mastered relevant knowledge”.

Also, evaluators or program managers may want to track preservice and inservice separately, as well as look into the inclusion of postpartum FP components in policies or guidelines, in which case suggested indicators would be:

Evidence that preservice curricula includes postpartum care and pregnancy spacing/limiting components as part of family planning

Evidence that inservice curricula includes postpartum care and pregnancy spacing/limiting components as part of family planning

Evidence that policies, standards of practice, or other national service delivery guidelines include postpartum care and pregnancy spacing/limiting components as part of family planning

References:

 

Pathfinder International, 2001, Comprehensive Reproductive Health and Family Planning Training Curriculum, Module 13: Postpartum and postabortion contraception, Waterton, Ma: Pathfinder International. http://www.pathfinder.org/publications/module-13-postpartum-postabortion-contraception/

USAID/Core Group, 2004, Maternal and Newborn Standards and Indicators Compendium, Washington DC: USAID/CORE Group. http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

USAID/ACCESS-FP, 2006, Postpartum contraception: Family planning methods and birth spacing after childbirth.  
https://www.globalhealthlearning.org/sites/default/files/page-files/ACCESSFP_ppcontraceptionPPT2.pdf

USAID/ ACCESS-FP/ Frontiers, 2008, Strengthening Postnatal Care Services Including Postpartum Family Planning in Kenya, New York: The Population Council. http://pdf.usaid.gov/pdf_docs/Pnadn570.pdf

Percent of postpartum women with unmet need for contraception

Definition:

The percent of women (ages 15 to 49) within the first year following the birth of their most recent child who desire to either stop or postpone childbearing who are at risk or have returned to fertility, but are not currently using a contraceptive method. 

In its definition of unmet need, the Demographic Health Survey (DHS) includes women who are currently married who say they prefer not to have another child either within the next two years or ever again, as well as women who are pregnant or less than six months postpartum who did not intend to become pregnant at the time they conceived and were not using a contraceptive method. The definition excludes women who declare that they are infecund, have had a hysterectomy, or are in menopause (MEASURE DHS, 2007).

Based on the ACCESS-FP program's reanalysis of the DHS data on family planning (FP) need among postpartum women undertaken in 17 countries, the recommendation is to calculate prospective unmet need, or fertility preferences looking forward, because it is most likely to correlate with the need for FP in the extended postpartum period. The reanalysis report states, "Since women’s return to fertility varies and it is difficult to predict that return, all women who are postpartum and not using a method could be considered to have an unmet need for FP" (Borda and Winfrey, 2010).  The calculation is based on women who are currently pregnant or in the postpartum period without the resumption of menses, and have or will have an unmet need for FP in the first year following birth.  Thus, the prospective definition of unmet need produces a two- to three-fold increase relative to the usual unmet need definition.

In response to the question, "Would you like your next child within the next two years or would you like no more children?", this indicator is calculated as:

(Number of women who respond that they do not want a child within the next two years or do not want more children / Total number of women surveyed who are up to one year postpartum)

Note: The actual calculation of unmet need is fairly complex, as depicted in the United Nations Population Division's 2009 Metadata on Unmet Need and MEASURE DHS (2007).

Data Requirements:

Data from responses to the following survey questions used to calculate unmet need, disaggregated for women with an interval of one year or less since their most recent birth:

Data can be further disaggregated by duration postpartum, breastfeeding status, age, parity, education, and type of contraceptive method used.

Data Sources:

Population-based surveys, such as DHS and Reproductive Health Surveys

Purpose: