Ccih 2014-fp-immunization-integration-anne-pfitzer

Family Planning Integration within Maternal, Newborn and Child Health and Nutrition

CCIH conference; Integrating Family Planning into other health programs

Anne Pfitzer, MCHIP Family Planning Team Leader

Family Planning and Immunization Integration Rebecca Fields, MCHIP Sr. Immunization Advisor

Presenter

Presentation Notes

Two presentations in one as immunization colleagues are out of the country…

Why integrate?

Short birth intervals result in: 51% more LBW, 58% more preterm If <18 months → 83% more infant deaths If <24 months → 61% more newborn deaths

→ 48% deaths in children <5 Sources: Kozuki, Lee, et al, 2013, BMC Public Health, 13(Suppl 3) Kozuki & Walker, 2013, BMC Public Health, 13(Suppl 3)

→ Children 25% more stunted and 25% more underweight

Source: Rutstein, 2008, DHS Working paper 41

Presenter

Presentation Notes

The Child Health Epidemiology Reference Group (CHERG) did a number of important analyses on the life-saving impact of family planning and birth spacing, published in a supplement last year.

Short intervals are very common

Source: Moore, Z et al, An Analysis of Birth-to-Pregnancy Intervals, Contraceptive Method Use, and Pregnancy Risk Among Postpartum Women in 21 Low- and Middle-Income Countries (forthcoming)

Percentage of Postpartum Women with Short, Ideal and Long Birth-to-Pregnancy Intervals

Presenter

Presentation Notes

If we could reduce the incidence of short birth intervals, we would thus be able to avert many, many child deaths.

Pakistan Return to Fertility and Pregnancy Risk (DHS 2006-07) Factors influencing return to fertility among all women 0–24 months postpartum

Risk of pregnancy among sexually active women 0–24 months postpartum

Postpartum Women: N = 3,375 Return to Menses: N = 2,304 Sexually Active: N = 2,741 Exclusive Breastfeeding: N = 430 Predominant Breastfeeding: N = 755

Sexually Active: N = 2,741 Using Modern FP: N = 571 Predominant Breastfeeding: N = 456

Note: the women predominantly breastfeeding from 6-11.9 months have increasing risk of return to fertility, especially if their menses have returned

Presenter

Presentation Notes

0-5.9 months postpartum: not at risk for pregnancy includes women who are (1) exclusively breastfeeding, OR (2) fully breastfeeding (breastmilk and plain water only), OR (3) using a modern method of family planning. 6-11.9 months postpartum: not at risk for pregnancy includes women who are (1) exclusively breastfeeding AND menses have not returned, OR (2) fully breastfeeding (breastmilk and plain water only) AND menses have not returned, OR (3) using a modern method of family planning. 12-23.9 months postpartum: not at risk for pregnancy includes women who are (1) using a modern method of family planning. PM: Are the lines in the second graph (R) labeled correctly? It seems that the green line should be orange – indicating modern FP use going up over time, and the orange line should be green, with predominant BF decreasing over time. AP: YOU ARE RIGHT – I think I accidentally clicked a “switch columns” button when I was reformatting this for powerpoint… Now corrected. The second part of your question I think is no longer applicable. I looked at it again and we assume that the predominant BF meets the LAM definition. Should the blue shaded area on the left side of the graph between the orange and green lines be not at risk, or perhaps a ‘moderate risk’, or simply ‘at risk’. The period between 6-12 months, if she has been using EBF/LAM, could be protective, but not 100%, so there could be some risk for those not using FP. There are some women

PPFP: High Unmet Need, Low Use

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Source: Ross and Winfrey “Contraceptive use, Intention to use, and unmet need during the extended postpartum period, Intl FP Perspectives, 2001.

Want to space or limit, 95%

Using a FP method, 38%

Not using a FP method, 62%

0-12 Months Postpartum Women

Other, 5%

Presenter

Presentation Notes

This analysis by John Ross and Bill Winfrey was of 27 DHS surveys. We have just done it with 22 more recent surveys and we still get 61% postpartum unmet need.

Family Planning; Every Woman, Every Time

Presenter

Presentation Notes

At every point of contact from pregnancy until after child is two, we should be asking women:�- will you want more children after this one? have you decided how long you want to wait before getting pregnant? (and if she says less than 2 years, health benefits of waiting) How are you making sure you don’t get pregnant before that time?

Lactational Amenorrhea Method (LAM)

Presenter

Presentation Notes

Leaflet from MCHIP program in Egypt that was implemented through community development agencies. A major focus of the Egypt work was nutrition, but we were able to advocate for adding FP

MIYCN-FP integration

Kenya model demonstration

Facility: Multiple integration points ANC, L&D/PNC and

child health Community through

CHVs Home visits,

breastfeeding support groups, community mobilization

Presenter

Presentation Notes

Family planning and nutrition programs have a lot of synergies. Already spoke of relationship between birth interval and stunting. But the timing of guidance for EBF and LAM, introduction of complementary foods and transition to another modern method also need to be synchronized. More programs should truly integrate these two interventions. We are currently evaluating a small program in Kenya.

Postpartum IUDs

13 countries supported by MCHIP

Low complication rates: Expulsion, infection,

perforation Acceptable Cramping and

bleeding masked

Liberia: FP/Immunization Integration

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Presenter

Presentation Notes

More on this with Rebecca’s slides, but MCHIP worked in Liberia on a model that had vaccinators ask questions such as those mentioned above and then give a referral to the FP unit.

FAMILY PLANNING AND IMMUNIZATION

DTP3 stagnant and lower, at 73-75%, in poorest

countries for past 5 years

Presenter

Presentation Notes

A quick look at WHO/UNICEF estimates for immunization indicates that immunization reaches the majority of children in their first year of life, as shown here by DTP3 – that is, the 3rd dose of vaccine protecting against diphtheria, whooping cough, and tetanus. So in principle, it is a good platform for offering FP services and in many places this is true. But the global estimates shown with the yellow bars mask disparities across regions, countries, and districts. In most countries, immunization continues to miss the poorest and most vulnerable populations.

Integration: a guiding principle in the Global Vaccine Action Plan for the Decade of Vaccines,

2010-2020

On integration, GVAP says: “Strong immunization systems, as part of health systems and closely coordinated with other primary health care delivery programmes, are essential for achieving immunization goals.”

Higher priority on integration of health interventions to address a common condition, e.g., vaccines + case management to reduce pneumonia or diarrheal disease

Presenter

Presentation Notes

Integration of immunization and other services has long been mentioned in global immunization strategy documents. The current strategy document is the Global Vaccine Action Plan, which is a blueprint to operationalize the global Decade of Vaccines. In the G-VAP, integration is one of 6 guiding principles. In the previous global strategy document for immunization, it had been one of four aims. In the highly consultative process that led to the creation of the GVAP, immunization program managers backed away from a commitment to full integration of immunization with other health interventions – whether family planning or otherwise - because they were concerned about taking on responsibility for the management and delivery of non-immunization services. Read 2nd bullet.

Possible effects on immunization of integrating services with family planning

Positive: - Secure support for EPI by using it as platform to serve another program - By increasing convenience to caregivers through “one stop shopping” increase utilization of services and vaccination coverage

Negative: - Deter mothers who accept EPI but not FP - Create confusion that EPI is really FP and a masked attempt to sterilize women or children

Presenter

Presentation Notes

In the past, efforts to integrate child vaccination and family planning services have been driven by FP interests and therefore the focus has been on improving the outcome for FP services. If we consider the potential effect of FP/immunization integration specifically on immunization, there are some potential positive and negative effects to consider. Potential positive effects for immunization include: read from slide Potential negative effects on immunization include: read from slide

Precedent: experiences with negative consequences

Cameroon (early 1990s) – death threats to vaccinators; halted immunization efforts for 2-3 years

Philippines (early 1990s) – halt in immunization services, lingering damage; efforts to engage Church did not succeed

Madagascar (2004/05) – MCH Weeks with FP and tetanus toxoid for women confusion, distrust, ineffective campaign

Northern Nigeria (2004-2006) – allegations that polio vaccine is sterilizing agent the failure of polio campaigns led to re-introduction of polio virus to countries as distant as Indonesia; massive, multi-country setback to Polio Eradication Initiative that lasted years

Pakistan (2012-present) – targeted murders of >75 vaccinators and escorts for polio campaigns due to allegations that campaigns sterilize children and are related to spying

Presenter

Presentation Notes

Unfortunately, the potential negative effects on immunization are not just hypothetical. Over the past 20 years, there have been several instances of lasting or severe negative consequences for immunization when the suspicion arises that immunization is really FP or “sterilization” of certain populations in disguise. Several of these situations are described here, with the most severe examples being the most recent ones, which are still taking place. A major point to note is that these negative effects arise mostly during mass immunization campaigns. These are highly visible and well-funded events that are heavily backed by national governments. That same high visibility, evident funding, and political dimension usually are part of a recipe for success but on occasion give rise to distrust and rumors and political rifts that can lead to the failure of campaign, at a high financial and public health cost. Because of the need to avoid such rumors – as well as the fact that the crowded, chaotic environment of a campaign provides no privacy for FP counseling – FP/immunization integration should be carried out during routine immunization services – NOT mass campaigns.

For engaging the immunization community

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Reduce risks

• Design approaches that minimize hazards. DO NOT INTEGRATE FP and EPI DURING IMMUNIZATION MASS CAMPAIGNS.

• Design win/win approaches intended to benefit EPI and FP

Show benefits

• Actively measure effects on EPI using MOH EPI data • Share data that demonstrate gains, if documented

Share experience

• Engage country level immunization staff in both designing and sharing FP/Imm experiences

• Disseminate the how-to approach so it can be replicated

Presenter

Presentation Notes

Because of these experiences, the key players in the immunization community, such as WHO and UNICEF, are not very supportive of FP/immunization integration. At country level, they may be unenthusiastic or resistant to proposals of work in this area. A few ways of actively addressing their concerns are: Reduce risks by developing a strong design for integration based on routine immunization. NOT DURING CAMPAIGNS. Approaches for FP/imm integration during routine immunization should take into account how both services are typically organized, i.e., patient flow, typical vaccinator capabilities, how to assure privacy for FP messages or counseling during immunization services, which themselves do not afford privacy. Design a win/win approach that aims to benefit both services. Actively measure the effect of integration on both services. Use routine, monthly MOH immunization data on doses administered and drop out rates, which are a crude indication of satisfaction with services. At this point, there are no data from FP/imm integration experiences that indicate an actual benefit to immunization of FP/Imm integration. Make sure to involve people from the immunization program and other local partners in immunization (such as the local WHO or UNICEF immunization focal points) in designing the approach and the M&E plan. Ask them to participate in implementation and evaluation. Share both the results and the implementation approach. If they are amenable, ask them to be the ones who share the findings with others.

Useful resources: mchip.net/ppfp

Toolkits on K4Health PPFP MIYCN-FP FP-Immunization

Join Communities of practice

https://knowledge-gateway.org/ppfp

Endorse Statement for Collective Action!

http://www.mchip.net/actionppfp/

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https://knowledge-gateway.org/ppfp

THANK YOU!

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Ccih 2014-fp-immunization-integration-anne-pfitzer

Healthcare

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