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Postpartum family planning (FP) could prevent more than 30% of maternal deaths by effectively spacing births; this is particularly relevant in humanitarian contexts given that disproportionate maternal death occurs in countries affected by crises. In humanitarian settings, where accessing functional facilities is challenging with security risks that constrain movement, many women are unable to return for their 6-week postpartum visits and thus unable to receive FP counseling and adopt a method that suits their fertility intentions. Thus, immediate postpartum family planning (IPPFP) interventions, focused on long-acting reversible contraception (LARC) and tailored toward humanitarian contexts, could contribute to healthy timing and spacing of pregnancy, particularly among postpartum women, and improve maternal and newborn health. In 2014, Save the Children integrated postpartum intrauterine device (IUD) services into its FP package in emergency settings. In 2017, this expanded to include postpartum implant uptake as well, given updated World Health Organization guidelines. Three countries (Democratic Republic of Congo, Somalia, and Pakistan) opted for higher-intensity programming for IPPFP with a specific focus on LARC. This involved training delivery-room providers on counseling and provision of IPPFP, as well as training antenatal care nurses in counseling pregnant women on IPPFP options. Three countries (Rwanda, Syria, and Yemen) did not implement notable IPPFP interventions, although they provided the standard of care and monitored provision via monthly service delivery data. Using data from 2016 to 2019, we examined trends in immediate postpartum LARC (IPP LARC) uptake and compared countries with higher-intensity IPP LARC interventions to countries providing standard care. Tests of association were performed to assess the significance of these differences. In the country programs with higher-intensity IPPFP interventions, IPP LARC as a percentage of all deliveries was much higher overall during the July 2016–December 2019 period. The IPP LARC intervention had a significant impact on the overall proportion of women and girls who adopted an IUD or implant within the first 48 h of delivery, F(1, 250) = 523.16, p < 0.001. The mean percentage of IPP LARC among all deliveries in intervention country programs was 10.01% as compared to 0.77% in countries providing standard care. Results suggest that there is demand for IPP LARC in humanitarian contexts and that uptake increases when multipronged solutions focusing on provider training, community outreach, and service integration are applied.
Keywords: humanitarian settings, immediate postpartum contraception, intrauterime device, implant, acute crisis, protracted emergencies, Long acting reversible contraception (LARC), healthy timing and spacing of pregnancy
Postpartum family planning (PPFP) could prevent more than 30% of maternal deaths by effectively spacing births (1). Given that more than 60% of maternal deaths occur in countries affected by humanitarian crises, it is necessary to understand the drivers for and barriers to increasing demand and use of PPFP in countries affected by conflict and natural disaster (2).
Humanitarian settings, also referred to as conflict-affected or emergency settings, can be a direct result of human-induced conflicts, such as war and economic insecurity, or environmental conflicts, such as cyclones, droughts, and famine. These crises can also be further described as a protracted crisis, which is characterized by recurrent or long-lasting conflict or persistent emergency, or acute crisis, which is characterized as an active conflict or natural disaster. Displacement, exposure to environmental toxins, persecution, and gender-based violence are just some of the many devastating conditions experienced by communities in these settings. In some cases, protection of marginalized groups by a national government is not guaranteed, often culminating in human rights violations.
As of 2017, at least 129 million people around the globe live in humanitarian settings, with nearly one-fourth being women and adolescent girls of reproductive age (3). The structural instability and limited resources in humanitarian settings can make it particularly difficult to obtain adequate FP services, much less PPFP services. A mere 16% of sexual and reproductive health (SRH) services in conflict-affected settings in sub-Saharan Africa are able to provide comprehensive FP services (4). And although more than 95% of postpartum women in resource-limited countries did not want another pregnancy within a year, nearly half had an unmet need for FP services (5). These gaps in services can be problematic as it suggests high rates of unplanned pregnancies, complicated births, unsafe abortions, and even higher mortality rates in humanitarian settings (3, 6).
Family Planning High Impact Practices, guidance used for FP delivery primarily in development settings, recommends offering contraceptive counseling and immediate postpartum family planning (IPPFP) services as part of facility-based childbirth care prior to discharge from the health facility (7). In humanitarian settings, where accessing functional facilities is challenging with security risks that constrain movement, many women are unable to return for their 6-week postpartum visits and thus unable to receive FP counseling and adopt a method that suits their fertility intentions. Thus, IPPFP interventions tailored toward humanitarian contexts could contribute to improvements in FP uptake, particularly among postpartum women, and reduce maternal mortality in crisis settings (8, 9).
Family planning, inclusive of the postpartum period, allows women to exercise their human right to contraceptive access so they may choose when to conceive as well as prevent unintended pregnancies if they choose not to conceive (10). By practicing this rights-based approach, women can ensure the healthy timing and spacing of pregnancy (HTSP), which is a notable benefit of PPFP (11). HTSP reduces the risks of adverse maternal and perinatal outcomes by giving the mother enough time to recuperate after her delivery and provide care for her child. Contrarily, short intervals between pregnancies increase the likelihood of maternal mortality, subsequent premature and low-birth-weight babies, congenital disorders, and other birth-related complications (12–14). Nonetheless, the unmet need for contraception among postpartum women remains high in many resource-limited settings (15).
Integrating high-impact practices such as immediate postpartum IPPFP counselling services and services into FP programs is key in addressing gaps in unmet FP needs (7). The World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC) provides guidance on the safety of contraceptive methods for use given specific characteristics and health contexts using numerical categories ranging from one (a condition for which there is no restriction for the use of the contraceptive method) to four (a condition that represents an unacceptable health risk if the contraceptive method is used) (16). Contraceptive methods that can be performed or used immediately after childbirth (i.e., within 48 h of delivery) and are appropriate for women who are breastfeeding have MEC categories of 1 and 2. These include the intrauterine device (IUD) within 48 h of delivery (copper-bearing is MEC category 1, levonorgestrel is MEC category 2); implants (MEC category 2), progestin-only pills (MEC category 2), lactational amenorrhea method (LAM), condoms, and voluntary surgical contraception (VSC) (16).
Progestin-only pills, condoms, and LAM are highly effective methods when used adherently and consistently. VSC is a permanent method that requires highly skilled healthcare personnel and explicit service provision when implemented into practice (11), given the uncertainty that often exists within humanitarian contexts that challenges contraceptive adherence along with the common shortage of health providers with the skills and qualifications needed to perform VSC. Both IUDs and contraceptive implants are long-acting reversible contraceptive (LARC) methods that are effective for anywhere between 3 and 10 years, depending on the type of LARC inserted. The IPP period has several potential benefits for LARC use as women know they are not pregnant and are motivated to avoid short-interval pregnancy. In the case of an IUD, given that the uterus is often lax during the IPP period, insertion can be much easier, and less painful after childbirth (17). The discomfort related to standard insertion can also be masked by the lochia, vaginal bleeding, and discharge, which occurs during and shortly after childbirth (17). An additional benefit of IPP LARC use is that clients are already under the care of a medical provider when giving birth, so it proves to be more cost-effective and provides a level of convenience to the client when inserted after childbirth (18, 19). The efficacy of LARC methods combined with the immediacy of insertion allows for HTSP and ultimately improves maternal, newborn, and child health (15). With the assumption of free and informed choice, LARCs have been shown to be a safe, effective, and feasible IPPFP intervention for HTSP (20).
Immediate LARC insertion can be beneficial to clients who face access barriers or are unable to follow up with postpartum care visits as recommended, which can be especially relevant in humanitarian settings because of the structural instability and a woman's desire to delay pregnancy because of conditions of conflict and uncertainty (12, 14, 21). With that said, IPPFP can negligently be viewed as low priority when providing humanitarian aid in these contexts despite a continued need and desire for HTSP (22, 23).
While the topic of IPPFP has become an emerging interest among FP initiatives and humanitarian workers, there remain gaps in understanding its application in conflict settings. The benefits of IPPFP are contingent on its effective implementation, which requires quality clinical training, availability of supplies and commodities, community sensitization, and the installation of monitoring systems.
To address the issue of high maternal morbidity and mortality among women and girls living in humanitarian settings, Save the Children began implementing a SRH program focused on FP and postabortion care (PAC) in 2012. Working in collaboration with the Ministries of Health, governments, and other relevant stakeholders, Save the Children applied a four-pronged approach to ensure voluntary, high-quality FP and PAC services in humanitarian settings; this included capacity building, assurance of supplies and infrastructure, community collaboration and mobilization, and consistent data management for ongoing monitoring, evaluation, and data use ( Figure 1 ).