Anne Pfitzer, Family Planning Technical Team Leader, MCHIP, discusses post-partem family planning and the importance of integrating family planning services with immunization services.

1. 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

2. 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

3. 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

4. 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

5. 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%

6. Family Planning; Every Woman, Every Time

7. Lactational Amenorrhea Method (LAM)

8. 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

9. Postpartum IUDs
 13 countries
supported by MCHIP
 Low complication
rates:
 Expulsion, infection,
perforation
 Acceptable
 Cramping and
bleeding masked

10. Liberia: FP/Immunization Integration
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11. FAMILY PLANNING AND
IMMUNIZATION

12. DTP3 stagnant and lower,
at 73-75%, in poorest
countries for past 5 years

13. 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

14. 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

15. 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

16. 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

17. 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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18. THANK YOU!
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