Introducing Postpartum Family Planning in Maternal Health Services in Low-Performing Areas of Bangladesh

Bangladesh has a high total fertility rate (TFR) of 2.3 lifetime births per woman and a contraceptive prevalence rate (CPR) of 61%. The most popular modern contraceptive methods used by married women are the pill and the injectable, with only 8% of currently married couples using a long-acting or permanent method of contraception (LA/PM). The unmet need for family planning (FP) was 14% in 2011, with 68% of women receiving at least one antenatal care check-up from any type of healthcare provider. The government sector remains the major provider of contraceptive methods, providing services to more than half of all users (52%). Public-sector facilities are the main source for sterilizations, intrauterine devices (IUDs), hormonal implants, and injectables. The private sector supplies contraceptives to 43% of all users, with pharmacies contributing 33%. Postpartum women are less likely to use an FP method than all women, with exclusive breastfeeding sharply declining and sexual activity increasing in the first 3-6 months postpartum. The World Health Organization recommends that women wait at least 24 months before attempting another pregnancy to reduce the risk of maternal and newborn complications. The Mayer Hashi project applied EngenderHealth's comprehensive Supply-Enabling Environment-Demand (SEED) programming model to introduce PPFP services. The project focused on the district headquarters and Sadar upazilas of the 21 disadvantaged Mayer Hashi project districts, where facilities with the highest delivery case-loads are located. Between June 2009 and September 2013, a total of 111 facilities introduced PPFP services where they were previously not available. Interventions to improve the enabling environment for PPFP included advocacy for policy change, enhancing local coordination, and improving monitoring. Advocacy efforts led to the approval of a proposal to allow trained nurses of the Directorate General of Health Services (DGHS) and the private sector to provide IUDs. A second policy approved by the DGFP and DGHS in 2011 states that DGHS-registered facilities, both private and NGO, do not require separate registration and acknowledgment from the DGFP to receive FP commodities and funds. District-level coordination meetings were organized to improve local cooperation between the DGFP, the DGHS, and the private sector, and to ensure a flow of FP commodities and funds. To ensure consistent monitoring of PPFP service uptake in the national management information system (MIS), PPFP was included as a separate indicator in revised DGFP MIS forms circulated in January 2013. The DGHS MIS Unit has committed to doing the same in the next revision of their MIS. Interventions to strengthen provider capacity and ensure quality PPFP services included curriculum development, capacity building, and provision of instruments. A PPFP training curriculum was developed for various levels of facility-based service providers and was approved by the DGFP and DGHS. Central-level training of trainers was conducted with 81 trainers of the DGFP, the DGHS, and the private sector. These individuals trained 249 physicians, 144 family welfare visitors (FWVs), and 80 nurses. After the training, the providers were given coaching, while facilitative supervision was strengthened. Facility-wide orientations were conducted to ensure that all staff at the new PPFP facilities were aware of PPFP and could refer clients. Local-level behavior change communication (BCC) campaigns were implemented in the 21 Sadar upazilas where the facility-based interventions were conducted. The campaigns aimed to ensure that potential clients and their families were informed about PPFP. The project also monitored the uptake of long-acting and permanent methods of contraception (LA/PMs) among women in the extended postpartum period. At the end of the intervention, uptake of LA/PMs increased slightly, from 5.1% at baseline to 5.7%, while overall uptake of modern contraceptives increased from 47.8% to 60.4%.