Postpartum IUD Expansion and Scale-up: Challenges, Opportunities and Essential Program Practices

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1 Postpartum IUD Expansion and Scale-up: Challenges, Opportunities and Essential Program Practices ENRIQUITO LU, MD, MPH Jhpiego XX FIGO WORLD CONGRESS Fiera di Roma, Italy 10 October 2012

2 GLOBAL: BURDEN/NEED ALL DEVELOPING COUNTRIES Women Wanting to Avoid Pregnancy Women Having Unintended Pregnancies 26% 74% Using Modern FP Methods No Method or Traditional Method 82% 18% 818 MILLION 75 MILLION Darroch et al., Contraceptive Technologies : Responding to Women s Needs, Guttmacher Institute, 2011

3 GLOBAL: BURDEN/NEED Disproportionate Burden Other Developing Regions South East Asia South Central Asia Sub Saharan Africa Women Unintended Pregnancy Maternal Deaths Darroch et al., Contraceptive Technologies : Responding to Women s Needs, Guttmacher Institute, 2011

4 Reasons for Not Using FP Darroch et al., Contraceptive Technologies : Responding to Women s Needs, Guttmacher Institute, 2011

5 Uttrakhand, India Family Planning Use Among All Postpartum Women Across Postpartum Periods 100% 1% 4% 3% 3% 100% 80% 60% 40% 20% 13% OPPORTUNITY FOR FP 34% 39% 44% 87% 63% 56% 53% Trad/Folk Modern No method Kenya 80% 60% 40% 20% 2% 4% 6% 5% 18% 32% 31% 38% 81% 64% 64% 56% Trad/Folk Modern No method 0% Mos N= Mos N= Mos N=209 Total Mos N=494 IDHS (Zhuzi Moore, MCHIP) 0% Mos N= Mos N= Mos N=1,094 Total Mos N=2,264 KDHS (Zhuzi Moore, MCHIP)

6 POSTPARTUM FP UNMET NEED Unmet PPFP Need (Kenya, 2008 ) Unmet PPFP Need (Philippines, 2008) 13% 1% 30% Unmet need Using FP 1% 11% 2% Unmet need 22% Using FP Desire birth <2 yrs. Desire birth <2 yrs. 20% No sex/wants to wait Infecund 20% Infecund No sex/wants to wait 36% 44% Spacing/Limiting failure N=2,264 N=3,208

7 PPFP/PPIUD Country Program Experience ASIA Afghanistan India 1 Pakistan Philippines 2 Europe Albania LAC Paraguay AFRICA Ethiopia Guinea Kenya Mozambique Rwanda 1 Scaled up in 19 states 2 Started in 3 Major Regions

PPIUD INSERTION APPROACHES Insertion Period:

During cesarean section Insertion Techniques:

8 PPIUD INSERTION APPROACHES Insertion Period: Post placental: 10(- 30) minutes after delivery of placenta Immediate post partum within 48 hours after delivery Intracesarean During cesarean section Insertion Techniques: Instrumental : Long Kelly Placental Forceps Bulbul, FIGO 2012

9 Country Experience: Rapid expansion of PPFP/PPIUD Services in India Start of PPFP/PPIUCD program in U.P. in 2009 Queen Mary Hospital, Lucknow District Women s Hospitals - Allahabad and Jhansi Scaled up to 19 states (2012) UP Uttarakhand Jharkhand Delhi Haryana Punjab Rajasthan Bihar Madhya Pradesh Assam Meghalaya Chattisgarh Orissa West Bengal Gujarat Maharashtra Tamil Nadu Karnataka Andhra Pradesh Supported by both national GOI and State level government Multiple donor support Adapted from Bulbul, PPIUD India, FIGO 2012

10 PPIUD acceptors by type of insertions per state: February 2010 to July Intracesarean 21% Postpartum (within 48 hrs) 35% Postplacental (within 10 min) 44% N=56, Source: PPIUCD Monthly reports, India Adapted from Bulbul, PPIUD India, FIGO 2012

11 PPIUD Service Standards Improvement Improved PPIUD Service Standards compliance Baseline - 32% Midline - 56% Source: Das et al., PPIUD India, FIGO 2012

12 PROGRAM INTERVENTIONS/ACTIVITIES (1) HEALTH SYSTEM LEVEL Regular engagement with national and state level officials Engaging national professional bodies Advocacy through orientation meetings Adapting and consensus building for standards Program assessment FACILITY LEVEL All staff orientation Reorganizing services 1. Instrument kits match to expected case loads 2. Counselors and education/counseling at ANC, Labor and Postpartum areas 3. Performance Standards setting Timely supportive supervision Source: Das et al., PPIUD India, FIGO 2012

PROGRAM INTERVENTIONS/ACTIVITIES (2) CLIENTS/FAMILIES IEC materials provided to facilities for clients Implementing educational activities and counseling at

13 PROGRAM INTERVENTIONS/ACTIVITIES (2) CLIENTS/FAMILIES IEC materials provided to facilities for clients Implementing educational activities and counseling at antenatal clinics, and for early labor, postpartum women Post insertion instructions and followup by mobile calls Source: Das et al., PPIUD India, FIGO 2012

14 PPIUD PROGRAM LESSONS LEARNED: Starting Right (1) Systemic Effort Identify and nurture CHAMPIONS Cultivate Political Will Work with professional organizations and other groups Adapt Service Delivery Guideline/Clinical Practice Guidelines 32

15 PPIUD PROGRAM LESSONS LEARNED: Developing Confident Providers (2) Training and Performance Support Competency based Qualified Trainers Transfer of Learning Supportive supervision 32

Delivery Reorganization IUD Logistics and Supply

16 PPIUD PROGRAM LESSONS LEARNED: Seamless Service Access (3) Service Strengthening Adapt Clinical Protocols Service Delivery Reorganization IUD Logistics and Supply Effectiveness Monitoring and Assessment Institutionalize to assure availability 32

evaluation POINT OF CARE LEVEL Standardization of Services Maintaining

17 PPIUD PROGRAM CHALLENGES: Sustaining Success PROGRAM LEVEL Scale up Training and Supervision Cost effective quality assurance Monitoring and evaluation POINT OF CARE LEVEL Standardization of Services Maintaining commodity availability Functioning internal quality improvement Task Shifting and Sharing 32

18 Thank You - Grazie Ricky Lu rlu@jhpiego.net 1615 Thames St Ste 200, Baltimore, Md 21231

Revitalization of PPFP/PPIUCD Services in India Dr Bulbul Sood Country Director Jhpiego/India

Revitalization of PPFP/PPIUCD Services in India Dr Bulbul Sood Country Director Jhpiego/India Family Planning Technical Meeting Women Deliver Conference, Kuala Lumpur, Malaysia 27 May 2013 India Most Populous