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

ENRIQUITO LU, MD, MPH Jhpiego XX FIGO CONGRESS

Fiera di Roma, Italy 10 October 2012

GLOBAL: BURDEN/NEED
ALL DEVELOPING COUNTRIES
Women Wanting to Avoid Pregnancy Women Having Unintended Pregnancies
18%

26%

74%

Using Modern FP Methods No Method or Traditional Method

82%

818 MILLION

75 MILLION

Darroch et al., Contraceptive Technologies : Responding to Womens Needs, Guttmacher Institute, 2011

GLOBAL: BURDEN/NEED
Disproportionate Burden
Other Developing Regions South Central Asia 13 31 30
11 13 45

South East Asia Sub Saharan Africa

23
57

31
34 5 7

Women 15 - 49

Unintended Pregnancy

Maternal Deaths

Darroch et al., Contraceptive Technologies : Responding to Womens Needs, Guttmacher Institute, 2011

Reasons for Not Using FP

Darroch et al., Contraceptive Technologies : Responding to Womens Needs, Guttmacher Institute, 2011

OPPORTUNITY FOR FP
Family Planning Use Among All Postpartum Women Across Postpartum Periods 1% 100% 3% 3% 4% 100% 2% 4% 5% 6% 13%
18%

80%
Uttrakhand, India

39%

34% 44%

80%
Kenya

32% 38%

31%

60% 40% 20% 0%

0-5.9 Mos N=127 6-11.9 Mos 12-23.9 Mos Total 0-23.9 N=158 N=209 Mos N=494
IDHS 2005-2006 (Zhuzi Moore, MCHIP)
87% 56% 63% 53%

Trad/Folk Modern No method

60% 40% 20% 0%

0-5.9 Mos 6-11.9 Mos 12-23.9 Mos Total 0-23.9 N=545 N=625 N=1,094 Mos N=2,264
KDHS 2008-2009 (Zhuzi Moore, MCHIP)

Trad/Folk
81% 64% 56% 64%

Modern No method

POSTPARTUM FP UNMET NEED

Unmet PPFP Need (Kenya, 2008 )
1%

Unmet PPFP Need (Philippines, 2008)

13%

30%

Unmet need

11% 1%

2% 22%

Unmet need Using FP Desire birth <2 yrs. Infecund

Using FP

Desire birth <2 yrs.

20%

No sex/Wants to wait Infecund

20%

No sex/Wants to wait Spacing/Limiting failure

36%

44%

N=2,264

N=3,208

PPFP/PPIUD Country Program Experience

ASIA
Afghanistan India1 Pakistan Philippines2

AFRICA
Ethiopia Guinea Kenya Mozambique Rwanda

Europe
Albania

LAC
Paraguay

1 Scaled up in 19 states 2 Started in 3 island groups

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

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 Womens 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

PPIUD acceptors by type of insertions per state: February 2010 to July 2012
25000
Intracesarean 21%

N=56,590
Postplacental (within 10 min) 44%

20000

19174

15000
Postpartum (within 48 hrs) 35% 7188

10000

5000

5329 4177 3146 2708

Source: PPIUCD Monthly reports, India

2184 2082 1939 1782 1417 1363 1188 810 746 696 548 75 38

Adapted from Bulbul, PPIUD India, FIGO 2012

PPIUD Service Standards Improvement

Improved PPIUD Service Standards compliance
Baseline - 32% Midline - 56%

Source: Das et al., PPIUD India, FIGO 2012

PROGRAM INTERVENTIONS/ACTIVITIES (1)

HEALTH SYSTEM LEVEL

FACILITY LEVEL Regular engagement with All staff orientation national and state level Reorganizing services
officials Engaging national professional bodies Advocacy through orientation meetings Adapting and consensus building for standards Program assessment
1.

2.

3.

Instrument kits match to expected case loads Counselors and education/counseling at ANC, Labor and Postpartum areas 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 antenatal clinics, and for early labor, postpartum women

Post insertion instructions and followup by mobile calls

Source: Das et al., PPIUD India, FIGO 2012

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
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PPIUD PROGRAM LESSONS LEARNED: Developing Confident Providers (2)

Training and Performance Support

Competency based

Qualified Trainers
Transfer of Learning Supportive supervision

32

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
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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
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Thank You - Grazie

Ricky Lu +1.410.537.1824 rlu@jhpiego.net 1615 Thames St Ste 200, Baltimore, Md 21231