Benefits, Impacts and Requirement of Meeting National MNCH Targets in Nigeria

Session: Impact of Family Planning on Maternal Newborn Health

Presenter: Chukwuemeka Nwachukwu, Futures Group International
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Background: Nigeria’s poor reproductive health indices have persisted over the past decade with high maternal mortality ratio (500 maternal deaths per 100,000 live births), contraceptive prevalence rate (CPR) stagnating at 15% and minimal improvement in unmet need for family planning. To improve this condition, the Federal Ministry of Health set an ambitious goal of increasing the CPR 36% and saving 1 million lives by 2018 through other MNCH interventions.  This study evaluated the resources needed to meet this goal as well as its population level impact.

Methodology:  Spectrum® policy modelling software was used to project the resource implication and impact of the national family planning goal. The projections were based on reproductive, maternal, newborn and child health targets set by the National Strategic Health Development Plan, and national health initiatives including the saving one million lives and SURE-P project. Data used were derived from population level health surveys such as National Demographic Health Survey (NDHS), National Population Census figures and Multi-Cluster Indicator Surveys.

Results:  The projection showed that to achieve a contraceptive prevalence rate of 36% by 2018, and additional NGN 4.1 Billion will be invested on commodity procurement and distribution. The quantity of additional contraceptive commodities needed to meet this goal include; 1.2 million condoms, 8.6 million 3-monthly injectable contraceptives, 14,000 IUCD, 83,000 implants and 14 million combined oral pills with impact on number of new users. This additional investment alone will save the lives of an estimated 19,000 WRA and 292,300 under-five.

Conclusion:  This policy analysis will guide the Federal Ministry of Health and other relevant stakeholders in planning and rolling out future family planning programs that are aimed at meeting the national family planning goal. It also identifies the resource needs by methods mix, presents funding gaps and show impacts of family planning investments in Nigeria.

Using Family Planning to Address Drivers of Mortality – Reaching Women Who Experience High Parity and Advanced Maternal Age Pregnancies

Session: Impact of Family Planning on Maternal Newborn Health

Presenter: Maureen Norton, USAID
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Background: High parity and advanced maternal age pregnancies are associated with increased risk of maternal death, as well as other adverse outcomes. Most of these pregnancies are unintended reflecting high unmet need. Postpartum family planning offers an opportune time to reach these women, yet there are few counseling tools or other guidance materials to help providers, clients, and their partners discuss these risks and consider effective contraceptive methods to prevent these high-risk pregnancies.

Methodology: Global data on the association of high parity pregnancies and advanced maternal age pregnancies with maternal mortality/morbidity will be presented. Prevalence data will also be presented. A literature search for counseling tools or guidance materials for high parity and/or advanced maternal age clients, undertaken as part of the 2013 USAID Behavior Change Evidence Summit, will be described, along with preliminary findings from message development and testing for this population group.

Results: Effective family planning methods to prevent unintended high parity and advanced maternal age pregnancies, along with newly developed counseling tools for advanced maternal age and high parity women, will be presented. Integrated birthing and postpartum family planning approaches are making these methods accessible to women who wish to limit future pregnancies, during the immediate postpartum period.

Conclusion: Reaching women of high parity or advanced maternal age with guidance and counseling to advance their understanding of the risks of these types of pregnancies, while helping them make a voluntary and informed decision about use of contraception to prevent these risks, and making these methods available in the postpartum period, should be a high priority in all reproductive health service delivery programs. This will contribute to the achievement of global goals.

Reducing Maternal Mortality in Romania by Increasing Equitable Access and Use of Family Planning: An Update After Donors’ Withdrawal

Session: Impact of Family Planning on Maternal Newborn Health

Presenter: Merce Gasco, JSI Research & Training Institute
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Background: Before 1990, modern contraception methods and abortion were illegal in Romania while over 80% of maternal deaths were reportedly caused by illegal abortion. In 1990, both modern contraception and abortion were legalized, but access to contraceptives was limited especially in rural areas keeping maternal mortality ratio 170/100.000. In rural areas, Romania’s Ministry of Health (MOH) used a unique multi-tiered, stepwise strategy to integrate FP services into primary health care services with USAID and other donors support during 1999-2007.

Methodology: The 2008-2012 trends of key project indicators (public expenditures on FP commodities, contraceptive use, abortion & maternal mortality rates) plus fertility rate were investigated through publicly available data/reports. Data on contraceptive use are from DHS surveys 1999 & 2004 and later sub-national survey 2010.

Results:  By the end of 2007, the national FP program ensured a “safety net” by addressing women’s FP needs at all main entry points to the health system, and counseling on FP a was a routine in all client-provider interactions; not only at the PHC level, but also at the secondary and tertiary levels. Seven years after donors’ withdrawal, changes remain. Statistics demonstrate a sustainable decline of maternal mortality ratio from 52 per 100,000 death/live births in 2000 to 21.1 during 2008-2012, decline of abortion ratio from 1.11 abortions/live birth (1999), 0.88 abortions/live birth (2004), and eventually to 0.55 abortions/live birth in 2011, while fertility rate remained constant since 1999 (1.3 children/woman). Recent evidence suggests modern contraception use continues to increase among rural women.

Conclusions: Increase equitable access to FP had a high impact on reducing maternal mortality in Romania and the results of the programs persist after donors’ withdrawal. Maternal Health remains a priority under the National Health Strategy 2014-2020.

Adapting the Reaching Every District (RED) Strategy in Reducing Unmet Need for Family Planning Among Disadvantaged Women in Mongolia

Session: Impact of Family Planning on Maternal Newborn Health

Presenter: Shinetugs Bayanbileg, United Nations Population Fund
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The RED strategy, originally introduced in Mongolia by WHO and UNICEF to improve immunization coverage was adapted for meeting sexual and reproductive health needs of the disadvantaged women: poor, living in remote pastoral areas, unregistered, young girls at risk, disabled or subject of gender-based violence. The intervention covered Zavkhan, Gobi-Altai and Bayankhongor aimags, and selected sub-districts of Chingeltei District of Ulaanbaatar City starting October 2012. By the end of 2013, 17,019 women were reached out ranging from 17 to 31 percent of reproductive age women in the target areas. The unmet need was calculated for the intervention and non-intervention areas from national household surveys: the MICS 2010 and Social Indicators Sample Survey (SISS) 2013 among poorest and second poorest quintiles and residents of pastoral areas. The data collection of SISS was done during October – December 2013. The MICS 2010 data serving as the baseline did not show any significant difference between the intervention and non-intervention sites. However, more significant reduction from 19.8 to 11.0 was observed in the areas where the RED strategy was implemented among the targeted poorest two quintiles and residents of rural pastoral areas in intervention sites (p<0.01), compared to women with the same characteristics in non-intervention sites, where the unmet reduced from 20.6 to 15.8. At the same time at the project sites, the contraceptive prevalence rate for modern methods among poorest two quintiles and residents of rural pastoral areas has increased from 59.1 to 61.0, while that in the non-project sites reduced from 54.1 to 53.1. The data clearly show that the application of the RED strategy in reproductive health was effective in reducing the unmet need and increasing modern contraceptive use among the disadvantaged population groups.

Integration of Postpartum Family Planning in to a Community-Based Maternal and Newborn Health Program in Bangladesh: Evidence on Impact on Contraceptive Use and Optimal Birth Spacing

Session: Impact of Family Planning on Maternal Newborn Health

Presenter: Saifuddin Ahmed, Department of Family and Reproductive Health/International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health
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Background: Promoting contraceptive use immediately after birth is considered an important family planning (FP) programmatic strategy. The integration of FP and maternal and newborn health (MNH) services is expected to provide a “gateway” for reaching women during antenatal care and soon after birth for FP counseling and services. However, few studies examined the effects of MNH-FP program integration in resource-poor settings and the results are mixed.

Methodology: Using a quasi-experimental trial design, this study examined the effect of MNH-FP integration on improvement of postpartum contraceptive use and reduction of short birth intervals < 24 months in 4,504 pregnant women in a rural district of Bangladesh.  Intervention women received a package of integrated MNH and FP interventions and control women received MNH interventions only. Locally recruited CHWs counselled on risks of closely spaced births, timing of return to fertility, benefits of longer birth intervals, promoted use of LAM and modern methods, and distributed oral pills and condoms. Standard FP services from the Ministry of Health and Family Welfare (MOHFW) were available in both the intervention and comparison areas. A team of data collectors, independent of the CHWs, conducted surveys 8 times over a three year period.

Results: Integration of FP with MNH program was not associated with any negative impact on MNH services; rather there was a synergy. There was a 20% increased cumulative probability of modern contraceptive method adoption through 36 months postpartum period, preventing pregnancies that had the highest risk for the women and newborn health. The intervention women experienced a 21% lower probability of shorter birth intervals (95% CI: 11.7% – 30.4%) and 20% lower risk of preterm birth.

Conclusion: MNH programs should consider systematically integrating FP as it would offer women benefits from early and sustained use of FP and reduced risk of short birth intervals.

Exploring Women’s Experiences with Modern Contraceptives Prior to Induced Abortions: A Qualitative Study in Southern Ethiopia

Session: Impact of Family Planning on Maternal Newborn Health

Presenter: Mahlet Atakilt Woldetsadik, Pardee RAND Graduate School and RAND Corporation

Background: Although Ethiopia has one of Africa’s most progressive abortion laws, unsafe abortions are estimated to account for 32% of maternal deaths in Ethiopia, and the context under which they occur is not fully understood. This study explores women’s experiences with modern contraceptives prior to termination of pregnancy, and aims to identify barriers to accessing and using sexual and reproductive health services.

Methodology: We conducted in-depth interviews with thirty-four women between April and July 2013. Women aged 14 – 44 years with a history of at least one induced abortion within the past twelve months were invited to participate. Participants were recruited from sexual and reproductive health clinics, governmental health posts, and public hospitals in Hawassa, and neighboring rural districts. We used a grounded theory approach to code interview transcripts and identify themes in the data.

Results: Although all of the interviewed women had some knowledge of contraceptive methods, there was a prevailing belief that modern contraceptives cause infertility, abnormalities in subsequent pregnancies, and other side effects. Most of the women suggested that medical or unsafe abortions were a better alternative for terminating unplanned pregnancies. Predominant reasons for not accessing safe abortion services included high costs of services, lack of privacy, and fear of judgment from providers. Women who had multiple experiences with accessing safe abortion care said they did not receive proper counseling after getting services, and were reluctant to return to health facilities. Women who had negative experiences with abortion care providers were more likely to seek unsafe abortion the second time around.

Conclusion: Providers need to address women’s concerns about using modern contraceptives, and educate their clients about the best ways to prevent unwanted pregnancies. In addition, comprehensive counseling services that include contraceptive counseling must be made available to women before, during, and after comprehensive abortion care.

Community Health Workers Champion Postnatal Home Visits in Rwanda

Session: Postnatal Care: Reaching Newborn Infants and Mothers with Preventative and Curative Care

Presenter: Catherine Mugeni, Ministry of Health, Rwanda
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Background: Rwanda DHS 2010 showed that the maternal mortality ratio is high at 476/100,000 live births, while neonatal mortality is 27/1000 live births. The post-natal period is a critical time for the survival of both mother and newborn.  Studies have shown that post-natal home visits (PNHVs) by community health workers (CHWs) contribute to the reduction of neonatal mortality. Rwanda has incorporated PNHV by maternal and newborn CHWs, Agent de Santé Maternelle (ASMs), into its strong CHW system. ASMs visit women during the antenatal period and support them to seek antenatal care (ANC) and delivery at a health facility. They also visit the mother and newborn during the postnatal visits. Women who deliver at home are visited immediately and supported to seek postnatal care (PNC) from the health facility.

Methodology: ASMs record all data related to their antenatal and postnatal home visits in their assigned registers. This is then entered into the Community Health Management Information System (CHMIS).  Data from the 2014 CHMIS was analyzed to assess the progress of the PNHVs.

Results: Approximately, 64% of all home deliveries, both mother and baby, were accompanied by ASMs to a health center for PNC. Over two thousand children less than 2 months of age were identified as sick based on observed danger signs and referred to health centers by ASMs.  Among 136,294 women who gave birth during the year 2014, 39% of couple mothers/new born received PNHV 1 and 36% received PNHV 2 by ASMs.

Conclusion: Rwanda has made significant progress to provide support to mothers and newborns during the critical postnatal period.  ASMs conducts PNHVs as part of a broader continuum of MCH services.  Key lessons learned would improve the current services and also assist other countries as they seek to introduce or expand their PNHV programs.