Written by Siti Nurul Qomariyah, Research and Evaluation Director, Jhpiego Indonesia and Michael Muthamia, Senior Technical Officer, Jhpiego Kenya
A woman’s right to use family planning throughout her reproductive years should be valued, protected, and secured—especially in the period of time right after giving birth or losing a baby.
This right is enshrined in numerous global frameworks. For example, the World Health Organization explicitly recognizes the potential of postpartum family planning to transform individual and family health and well-being. Still, a majority (61%) of women who want to space or prevent pregnancy within the first year postpartum are not using family planning. Further, more than half of patients post abortion express interest in using contraception, yet 74% leave the facility without a method.
Health policy makers, programmers, and practitioners are missing a vital opportunity to ensure that women and adolescent girls can decide when to get pregnant depending on their own desires and needs.
Following an unprecedented five-year study, we have a promising path forward to address this need for post-pregnancy family planning, or PPFP, that is grounded in evidence. As technical leads in our respective countries, we are confident that the study has illuminated a strategic blueprint to accelerate PPFP and save lives. While our lessons were many, two dominant findings have emerged: strengthening our efforts around counseling is key, and we must engage more effectively with private facilities and providers.
Unprecedented study and implementation program
One of the largest studies of its kind, Post-Pregnancy Family Planning Choices (PPFP Choices), gathered quantitative and qualitative data from health care providers, facility managers, community leaders, policy makers, and more than 9,000 clients in Kenya and Indonesia.
Based on these inputs, this initiative also implemented a series of robust activities with an ambitious scope. Our in-country teams raised awareness and advocated for a more supportive environment for health workers, women, and adolescents at the facility and community levels. We provided knowledge and skills to health workers so they could more effectively counsel women and families about their options regarding PPFP. We helped address regulatory barriers around a lack of equipment, supplies, and business management skills, particularly in the private sector. We also convened a quality improvement team to address systemic barriers and ensure continuity at the district level.
In short, we sought to unearth and begin to address a range of complex barriers to PPFP access and use—a daunting but deeply rewarding undertaking.
Based on our findings, it is abundantly clear that counseling prior to discharge is a transformational opportunity. Counseling—whether during antenatal visits or facility delivery visits—was found to be a key determinant to whether a client ended up using PPFP. That held true in both countries—Kenya and Indonesia each saw 24% higher uptake of postpartum contraception immediately after delivery in intervention sites compared to control sites.
However, significant barriers remain. The study reinforced that reluctance to use family planning methods can be influenced heavily by one’s cultural and religious backgrounds. In Kenya, for example, some women believe one must heal from childbirth before using a family planning method. There is also a tendency to undervalue the effectiveness of long-acting, reversible contraceptives while overvaluing injectables, a perception that can limit individuals’ openness to the range of PPFP methods that suit their life stage and lifestyle. Reaching adolescents, who have high discontinuation rates, is another challenge revealed by PPFP Choices. Consistent, person-centered, and well-informed counseling can mitigate all of these challenges.
New insights into engaging with the private sector
In Kenya, nearly 25% of facility deliveries are taking place in private facilities, and in Indonesia that number is close to 73%. This motivated us to focus on how best to engage the private sector in providing immediate postpartum family planning. We learned that while use of family planning is increasing overall, it remains low during the immediate postpartum period in private facilities in both countries.
Our findings reveal that clients who choose to access care in private facilities value personal connection and continuity with their health care provider more than the depth and breadth of services offered by those facilities—a factor that may limit private providers’ interest in expanding into PPFP despite it being a natural extension of maternal health services.
But we also encountered deeper, systematic barriers. Factors including lagging financial reimbursements, shortages of contraceptive equipment and supplies, and burdensome certification processes all inhibit private facilities from providing family planning post-pregnancy.
The expectations and value around providing PPFP should be better articulated and speak directly to what influences service delivery within the private sector, and to the interests of women and families who access maternal health care in those settings. These facilities must be linked to government health office oversight for support to make the case for a stronger continuum of care of services that will retain clients, build trust between clients and providers, and establish continuity. Most importantly, we cannot sit back and wait to make PPFP a more common offering—solutions must be developed, tested, and finalized with private sector providers’ own goals and challenges in mind.
A call to action
Building on these learnings and more, health leaders, programmers, and practitioners have indispensable new tools to grow global, national, and local PPFP efforts.
Our hope is that every advocate, practitioner, and policymaker will have renewed confidence to urgently leverage their trusted positions and influence to make PPFP available to every woman or girl who wants and needs it. As the evidence mounts, we must not remain idle. We have the knowledge—it is now imperative that we translate and adopt these findings to other contexts as broadly as possible.
Photo credit: Jhpiego
Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.