The Challenges of Integrating Family Planning and Maternal/Child Health Services
by Mia Foreman
(June 2011) For years, family planning (FP) has been integrated with maternal and child health services (MCH) in countries such as Colombia, Indonesia, Mexico, the Philippines, and Thailand. Birth rates have fallen in these countries as more women have been able to avoid unintended pregnancies. As a result, population growth has slowed and the countries have been able to speed economic progress and lift more people out of poverty. But in many countries, women who are pregnant or have recently given birth are still not informed about FP or offered a contraceptive method to prevent another pregnancy as part of their MCH services, even though the majority of them do not want another birth within two years. Integrating FP and MCH services can better meet the needs of these women, while also offering opportunities to strengthen health systems.
MCH services are a logical and strategic entry point for FP because they reach a "captive audience" of women who are at high risk of a subsequent pregnancy and strongly motivated to prevent another immediate pregnancy. Integration of FP and MCH has been shown to increase women's use of contraception, which leads to better birth spacing and improves the health of women and their infants. Integration is also cost-effective, can save the health system money, and responds to the multiple demands on women's time that often leads them to neglect their own health.
But there are challenges, including resistance within the often separate government health units responsible for FP and MCH services, weak health systems, and clinic- or community-based workers who are not trained to provide both services.1 While the challenges can be daunting, many programs have successfully addressed barriers to integration.
Integrating Services in a Health System Resistant to Change: John Snow Inc. (JSI), Russia
Integrating services requires political, administrative, and technical changes that may generate resistance among health workers and managers, or prompt fears of losing prioritization and resources.2 In Russia, FP is a highly sensitive political issue because of population decline in recent decades and religious opposition. In the early to mid-1990s, international evidence-based standards for contraception were not widely known or practiced, hormonal methods were viewed as harmful to health, and frequent unintended pregnancies led women to have repeat abortions.
In 1999, recognizing the need to integrate FP into maternal and child health services, USAID/Russia supported JSI in implementing a new pilot project—the Women and Infant's Health (WIN) project—in two regions. The project was designed to integrate FP as a key element of improved MCH services. A variety of stakeholders collaborated in designing and implementing the program, building commitment and shared ownership. A technical working group of policymakers from various sectors willing to implement innovative practices reviewed the evidence on contraceptive safety and the benefits of offering FP within a MCH continuum of care. The group also included health personnel and medical school faculty who were trained to provide new contraceptive methods according to international standards for client-centered care, and the pharmaceutical industry who were engaged to expand the limited method mix.
The new client-focused system addressed a broad spectrum of reproductive health services including antenatal, maternity, and newborn care; exclusive breastfeeding support; and FP counseling and services, especially for postpartum and post-abortion clients. The WIN project's national media campaign promoted the new services through television and radio spots, brochures, posters, and local promotional activities.
From 2003 to 2006, with JSI's continued technical assistance, WIN was further scaled up through the Maternal and Child Health Initiative (MCHI). WIN/MCHI's innovative design helped regional and municipal government-supported health facilities adopt internationally recognized, client-centered, evidence-based MCH standards and practices. By 2006, the new protocols had been embraced and activities scaled up in 16 of Russia's 89 regions. In the last two years of the project alone, contraceptive prevalence for reversible methods increased from 41 percent to nearly 58 percent, and the abortion rate fell from 49 to 43 per 1,000 women ages 15 to 44.3
These successes were instrumental in enabling JSI's project office in Russia to become an autonomous NGO, the Institute for Family Health, in 2007. The institute continues to implement the MCHI project and others with USAID support, fostering the sustainability and further scale-up of integration activities, including in rural regions with high abortion rates. By 2009, for the 10 regions involved in the MCHI project, official statistics showed that abortions had further fallen to 31 per 1,000.4
Integrating Services in a Post-Conflict Setting: Health Alliance International, Timor-Leste
After decades of conflict that extensively damaged the health system, Timor-Leste became an independent nation in 2002. As in other post-conflict environments, there was an urgent need for reproductive health and FP services. Health Alliance International (HAI), a Ministry of Health partner providing maternal and newborn care, began to integrate FP services into its existing program in 2006. First, HAI clarified for the government the link between closely spaced births and high mortality and morbidity among infants and mothers. HAI then encouraged Ministry of Health officials and health workers to integrate education about child spacing and FP into basic maternal care. It also built the capacity of the Ministry of Health's midwives to deliver FP information and services. Offering FP services during MCH home and facility visits contributed to an increase in the contraceptive prevalence rate from 8 percent in 2003 to 26 percent in 2008.5
Providing Integrated FP and MCH Services Where Demand Is Low: ACCESS/Nigeria
In predominately Muslim northern Nigeria, religious and cultural resistance contributes to low use of FP. In addition, a poor public-sector health system deters clients from seeking reproductive health services. In 2006, as part of its mandate to broaden access to FP for postpartum women, ACCESS/Nigeria initiated a program in Kano State that aimed to increase the use of emergency obstetric and newborn care services and FP. The first six months of the project focused on emergency obstetric and newborn care training in facilities. Providers were then trained in postpartum family planning with an emphasis on birth spacing. FP messages were integrated into care during pregnancy, after delivery, and during postnatal care. In 2008, providers were trained to insert contraceptive implants and IUDs. All trainings have been followed up by supportive supervision activities. At the community level, selected female community counselors were trained to provide basic maternal and newborn health messages for pregnant women and those who had recently given birth, including FP information.
ACCESS FP discovered that providing FP did not negatively affect the use of MCH services. In fact, client satisfaction with both services increased. Providers considered integrating FP with MCH in this conservative society a good approach, especially through educating women and couples about the importance of birth spacing for child health. One provider noted: "In our setting here, most of the time they don't come for FP. So only when we catch them during antenatal care or labor and delivery, we can use the opportunity to talk with them."
While the program had positive results, challenges included provider and community attitudes, and inadequate staff time to address both MNCH and FP needs. The following elements were considered important to the success of this program:
- Training providers to give FP messages beginning in the antenatal period and continuing to reinforce these messages throughout the postpartum period and beyond.
- Attending to community linkages and contextual considerations, such as the role of husbands.
- Providing support materials such as job aids at the facility and posters in the community.
Despite challenges, organizations and partners are finding solutions to integrate FP and MCH services. It takes creativity, political, financial, and managerial commitment and the willingness to address barriers from the national to community level to make sure that women receive the health care they demand and need to live healthy and productive lives. These programs have shown it is worth the effort.
Mia Foreman is a policy analyst at the Population Reference Bureau.
References
- Kate J. Kerber et al., "Continuum of Care For Maternal, Newborn, and Child Health: From Slogan to Service Delivery,"The Lancet 370, no. 9595 (2007): 1358-69.
- WHO, "Integrated Health Services—What and Why?"Technical Brief no. 1 (Geneva: WHO, 2008).
- Laurel Cappa and Natalia Varapetova,TASC Russia Maternal and Child Health Initiative (MCHI), Final Technical Report (Arlington, VA: JSI, 2007).
- JSI, personal communication, 2011.
- Susan Thompson and Mary Anne Mercer, "Integrating Child Spacing and Maternal Care in Timor-Leste," Health Alliance International Flexible Fund Case Study, accessed at www.flexfund.org, on May 2, 2011.