Studies on Postpartum Family Planning Services

Family planning has gained a massive amount of audience due to the recent rapid increase in the populations. Ever since, it has been recognized as one of the pillars in the Sexual and Reproductive Health (SRH) (1). Family planning, as a whole, is an aspect that plans the reproduction, ranging from individual method use to community based awareness campaigns and country policies (2,3). Throughout the years, different countries have tried implementing different strategies and policies to tackle the issue of population growth; however, there is no clear policy that offers an efficient and effective solution (3).

In the 1970s, family planning services were carried out within a vertical delivery system by community health workers. However, they underwent an evolution, and they were integrated into the formal health delivery system due to the success of earlier programs, decrease in the budget of family planning, and the need to increase in the efficiency of their management. Extensive research has been made in the area of postpartum family planning, which is a group of services done within the 1st year post delivery (2). Thus, in this report, family planning will be examined from different aspects, hoping it gets the appropriate funding and attention that it needs. The purpose behind implementing family planning programs had been cut clear since the 1960s, when developing countries began conducting social programs to deliver family planning services (3). These services gave families the control of having their desired number of pregnancies, while there is proper spacing between which, preventing short-interval pregnancies (1,4). The World Health Organization (WHO) recommends applying an interval of 24 months before any attempt of pregnancy (5). Therefore, family planning is a cost-effective method that aims to prevent the occurrence of unintended pregnancies, which might negatively affect the maternal and infant health; thus, decreasing the maternal and infant mortality rates (1,6).

Based on studies made in Mali, Indonesia, Kenya, and Ukraine, the application of family planning services has resulted in the decrease of the annual increases in pregnancies and births in countries with high fertility. When births are avoided, maternal deaths, stillbirths, and children exposed to death decrease in number. However, when it is applied on countries with low fertility rates, it decreased the rate of abortion due to unintended pregnancies. Thus, depending on the country’s status, pregnancies, abortions, and maternal and infant mortality tend to increase if there are no family planning services delivered (7). Moreover, a study, conducted in Uganda, supports such assertion, claiming that if all the women in Uganda effectively used contraceptive methods, maternal deaths would decrease by 40% (8).

The timing of introducing the family planning services is crucial. Since “women’s demand for contraception fluctuates over [their] lifetimes,” the service delivery has to be precise. Barber claimed that the best timing for introducing the family planning services advice and education is antenatal because it’s a good opportunity to reach out women (2). However, Mahamed et al. stated that the best timing for the services education is either during puberty or before marriage (4).

The style of the services, also, has to be considered. One study, conducted in Iran, examined the different effects between implementing either the traditional method or the interventional method. The traditional one was just a short course on sexual and reproductive health, conducted in 1 lecture. However, the interventional one was 4 designated educational sessions (4). Thus, multiple sessions have better effects than 1 session does (4,6). Moreover, Blazer and Prata examined it from another aspect; they concluded that home visits by skilled clinicians might be applicable, but would use a lot of resources. Such approach is compared to home visits conducted by community workers, which is both available and cost-effective (6).

Studies also highlighted the importance of implementing contraception methods. Based on the goals of the services, the most suitable time is postpartum, as it allows birth spacing, and prevents unintended pregnancies (2). Such timing is supported by the fact that 88% of women want to avoid pregnancy during their postpartum period (9). There are various methods that people can choose from, based on their needs. Condoms and oral contraceptives are popular in Edinburgh, for example, as it is more flexible and temporary (3). Other methods include injectable, Intra-uterine devices, and natural contraception (which is avoiding intercourse during the days with high fertility). Moreover, sterilization is done depending on the quality of the healthcare system, since it is permanent and invasive. However, pills are not significantly used, as they require a lot of effort to remember them (2).

The types of services provided under the umbrella of family planning vary greatly among countries; they even vary within countries (3). The main determinant of the difference between which services provided is money. Blazer and Prata mentioned that women living in global south countries have unmet needs. They shed some light on the United Kingdom, South Africa, and China. Each of which is implementing different types of family planning services. The United Kingdom, for example, carries out postpartum family planning education after delivery with 6 weeks. In South Africa, though, women are referred to their local family planning clinics 1 week postpartum. However, China had put a strict policy, which is the “One Child Policy” in 1977. This policy is the most effective, yet the most dangerous, as women turn to unreliable family planning methods, placing them in danger; results showed only 40% use condoms, while 20% carry out natural family planning (3). On a similar note, a study, done in west and central Africa, assessed the implemented “immediate postpartum IUD” policy. The policy showed promising results, although it requires a lot of resources, not found in such areas (10).

In order to tailor an effective method that is used effective and efficient, all the barriers should be identified. Although these issues might be modifiable or non-modifiable, if most of them are tackled, an improvement might take place. Firstly, there was a consensus among the studies conducted that lack of knowledge and education has been “the prime influencing factor”. Lack of education is negatively correlated to contraceptive use. One study added that adolescent females don’t receive adequate health education on the right time, while other studies show that women might have incomplete knowledge, and they don’t use contraceptive methods postpartum, as the risk of pregnancy is very low when they have Lactational amenorrhea (4,11). In fact, women tend to adopt contraceptive methods only after the return of menses or sexual activity (12).

Religion, society, and culture were also stated as barriers for people to use contraception (1,4). Due to cultural norms, some people fear the social stigma that is going to accompany. Also, sometimes, male resistance, due to unequal power dynamics in relationships, accounts for a huge barrier to contraceptive use (1). Results from Central and West Africa show that 1 in 5 women face opposition from male partners over the topic of family planning (13). Other studies highlighted other factors. They explained that the content of the counseling sessions was not as effective. Other factors, such as poverty and socio-economic deprivation are also correlated with low contraceptive use (3).

Side effects were a main concern; women feared the hormonal changes that happen after contraceptive use, to the extent that 18-52% of people discontinue hormonal methods and IUD (1,4). Due to the nature of the postpartum period, women are more probably fatigued and distracted which might be reason for not attending postpartum family clinics (14). Lastly, Smith et al. found a negative correlation between being young, being unmarried and not attending to post-natal clinic and the use of contraception (3).

One main aspect that should be considered is breastfeeding. “Breastfeeding is [considered] the most important influencing factor” (15). Women who don’t exclusively breastfeed have a probability of recurring pregnancy within 45 days postpartum, even before menses (12). Moreover, it was shown that irregular breastfeeding and the introduction of complementary breastfeeding, before 6 months, decrease the power of breastfeeding as a natural contraception method, limiting the phase of contraception (15).

Based on the barriers that were identified, solutions should be tailored based on the communities to accommodate them, considering that each country would benefit using different sets of solutions. Concerning education, one study concludes that education should be long-term not only once to have a sustained effect. In fact, educational films might be used as useful resources for implementing the effects (4). Also, counseling programs should be designed in a “low dose, high frequency” style, which is better than the regularly used “high dose, low frequency style” for better results (12).

Moreover, Mahamad et al. concluded that antenatal care, lactational amenorrhea promotion and post –partum IUD are tentative improvements of postnatal care (6). Most studies stressed on the value of male integration in family planning services. In 1994, the International conference of population and development put the spotlight on the critical need to engage men in family planning services. An efficient way to help support couple through their decision-making, method initiation, and follow up is using mobile health, which is used in Harrington et al.’s study (1).

In order to get a wider audience, improvement in the public health’s quality is important as it helps in making family planning services more universal (2). Finally, we should engage stakeholders such as adolescents, women, men, public figures, policy makers, and researchers in order to have a well-rounded approach (12). In conclusion, family planning is a field that is gaining popularity recently, since it holds great hope in solving the uncontrollable growth in populations. There are various barriers that stop the success of such methods, however, researches held are paving the way for policy makers to create tailored solution depending on the country’s cultural and socioeconomic status.