Integrating Family Planning within a CommunityBased Maternal and Neonatal Health Program in Sylhet, Bangladesh

Salahuddin Ahmed1 & 2, Nazmul Kabir 4, Jaime Mungia2, Catharine McKaig2, Saifuddin Ahmed1, Amnesty LeFevre1, Peter Winch1, Ahmed Al-Kabir3, and Abdullah Baqui1 1Johns Hopkins School of Public Health; 2 Jhpiego; 3Shimantik, 4 Save the Children
Asia Regional Meeting on Interventions for impact in Essential Obstetric and Newborn Care

May 4-6, 2012, Dhaka, Bangladesh

Study Context
TFR by Divisions, Bangladesh, 2004 Selected FP indicators in Sylhet, BDHS 2007

Indicators
2.6 2.9 4.2 Unmet FP need CPR (any method) TFR Birth intervals 2.8 <24 months

BGD
17% 56% 2.7

Sylhet
26% 31% 3.7

15% 37%

26% 57%

2.9
3.7

<36 months

Integrated Model of PPFP & MNH

Evolution of MNH packages
Designed and evaluated a community-based maternal and newborn care intervention package A home care package which involved CHW antenatal and postnatal home visits and management of sick newborn reduced NMR by 34% (Baqui et al., Lancet, 2008)

Newborn care

Postpartum FP counseling and contraceptive distribution

Study Objectives
To develop and test an integrated FP/MNH service delivery approach To assess: strengths and limitations of integrating FP into an ongoing community-based MNH care program
impact of the intervention package on

contraceptive knowledge and practices

impact of the intervention package on

pregnancy spacing
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Study Design
Study sites: eight unions in two sub-districts in Sylhet district, Bangladesh
Non-Random Allocation Intervention unions: four Enrolled women: 2247 Comparison unions: four Enrolled women: 2257

Enrollment of women during <8 months of pregnancy Intervention clusters: MNH plus FP during ANC and Postpartum visit Comparison clusters: MNH ONLY during ANC and Postpartum visit

Follow the cohort through pregnancy to 36 months postpartum

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Integrated Maternal, Newborn Care, Child Health and Family Planning Package
PP maternal care, Vit A and management of Management/refer complications of newborn complications Essential newborn care Clean delivery and immediate newborn care Birth preparedness CHW counseling IFA Supplementation TT ANC1 ANC2 TT ANC3 ANC4 ARI, CDD, EPI Refer sick mother and child, Supply and refer for FP methods

Pregnancy identification

Postnatal session promotion LAM, and transition, spacing, PPFP, Immunization

p1

p2

p3

p4

p5

p6

Exclusive breastfeeding and promotion of LAM/PPFP and transition

Intervention Delivery Strategy

Service Delivery Home visits by CHWs
Counsel in antepartum and postpartum periods Pregnancy surveillance and contraceptives dispensing

Messages on LAM and transition, return to fertility, optimum birth spacing, and contraceptive methods

Household visits every two months to identify new MWRA and pregnant women

Pills, condoms, and injectables Refer for other methods

Community mobilization: Conduct meetings with women, husbands, mothers, mothers-in-law and community leaders including religious leaders to raise awareness about PPFP messages LAM Ambassadors: Local champions providing peer support, counseling and advocacy for LAM
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Results

Starts in a Low Performance Area

Ever Used Contraceptive Method

Intervention

18.0

Control

21.1

10

20

30

40

50

60

70

80

90

100

Percent

CPR Trend During 18 Months Postpartum

*P <0.001

Contraceptive method mix among intervention area users

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Contraceptive method mix among intervention area users

Overall high adoption of LAM 23% at 3 months and 12% at 6 months Shift in method preference from LAM to pills, condoms, and injectables

12

Contraceptive method mix among intervention area users

Slight increases in

injectables and long-acting methods Rise in sterilization from 1.9% to 3.1% in intervention area Oral contraceptives are the preferred contraceptive at 12 and 18 months

13

Contraceptive Method Mix Among Control Area Users

14

Self Reported Pregnancy Incidence

0.25 0.00 0.05 0.10 0.15 0.20

7 8 9 10 11 12 13 14 15 16 17 18 Months since delivery Intervention Control

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The difference is statistically significant (P = 0.013)

Does integration of FP adversely affect MNH program?

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Effect of Integration on MNH Care: Selected Newborn Care practices

Intervention Comparison (%) (%)

P value

Drying and wrapping of newborn within 10 minutes of delivery Initiation of Breastfeeding within 30 minutes of delivery

50.4

44.1

<0.001

56.6

46.8

<0.001

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Duration of Exclusive Breastfeeding by Study Arm

1.00

Duration of exclusive breastfeeding by study arm

0.00

0.25

0.50

0.75

3 analysis time Intervention 18 Control

*P <0.001

Lessons Learned
HFS demonstrates: 1. Feasibility of integration of FP within a community-based MNH program 2. Effectiveness of the model in increasing modern method use 3. No notable negative effect on the delivery of MNH services 4. Positive effect of LAM promotion on the duration of exclusive breastfeeding
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Best Practices, Research Gaps

Best practices: CHW antenatal and postnatal home visits to counsel on HTSP, emphasis on LAM and transition, integration of FP with MNH Return to fertility messages Community meetings targeting husbands and mothers-in-law Provision of pills, condoms and injectables through CHW at home Research Gaps 20 Cost, cost-effectiveness studies being planned

Scaling up through ACCESS and MCHIP (MaMoni)

Major MaMoni Interventions:
Capacity building for both GO and NGO staff

Gap management through CHW deployment

Counseling and CBD of pills, condoms and

injectables Referral for LAPM

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CPR in Sylhet - Modern Method

100

75

50.8
% 50

34.0
25

24.7

0 DHS 2007 Baseline 2010 7 months after baseline

Source:

BDHS, 2007 Baseline survey, Sep10 Progress Assessment April11

Unmet Need for Family Planning at Sylhet in MaMoni Working Areas

45 40 35 30 25

42

29
25 19

20
15 10 5 0

13 5
Unmet need for spacing Unmet need for limiting Total unmet need

Base line Sep'10

After 7 months of base line

Source: Baseline survey, Sep10

Progress Assessment April11

THANK YOU
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