Philippines Toolkit: AYSRH Service Delivery
Postpartum Family Planning
Health worker provides postpartum counseling to a young mother who just gave birth. (Photo Source: ZFF).
Postpartum family planning (PPFP) is defined as the prevention of unintended pregnancies and closely spaced pregnancies through the first 12 months after childbirth, but it can apply to an “extended” postpartum period up to two years following childbirth (WHO 2018).
Providing family planning counseling as part of childbirth care raises awareness of the importance of birth spacing and postpartum contraceptive options. Family planning may be provided:
- Immediately postpartum (IPPFP) – within 48 hours
- During early postpartum (EPPFP) – 48 hours up to 6 weeks
- Including extended postpartum (EPPFP) – 6 weeks to one year after delivery
This proven intervention is intended to help programs implement PPFP at the facility and community level.
What are the benefits of PPFP?
- Research has demonstrated that more than 90% of women including adolescents during their first-year postpartum want to either delay the next pregnancy for at least two years or avoid future pregnancies all together.
- Increased contraceptive uptake if women/adolescents have made a decision before going into labor.
- Reduced risks of adverse health outcomes for women/adolescents and infants in the postpartum period.
- Reduced risks of adverse health outcomes for women/adolescents and infants within six months following fetal loss.
How to implement
Step 1: Determine which contact points will integrate PPFP based on country-level data
Consider both hospitals and public health facilities in coming up with the list of contact points and prioritize hospitals with a Program for Young Parents.
| Key question/data point | Implication |
| What is the number and percentage of women and adolescents who are pregnant? | This indicates the potential group to be reached through integration of PPFP with MNCH-related service settings. |
| What is the number and percentage of women and adolescents with miscarriage or abortion? | Among adolescents, abortions could mean that they are sexually active and probably had unwanted pregnancies |
| What is the percentage of pregnancies spaced less than 18, 24 and 36 months apart among women and adolescents? | If the majority of pregnancies are spaced less than 2 years apart, this could indicate that most women/adolescents are unaware of pregnancy risk and/or are unable to access FP services during the extended postpartum period. |
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What are the levels of unmet need for:
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Levels of unmet need above 10% indicate a need to review the reach and effectiveness of the overall FP effort.
NOTE: Since the levels of unmet need are not available at the city level and only through NDHS for ICC/ HUC city/province, the city may use “Total demand for family planning versus those served”. |
| What is the total contraceptive use and what is the percentage of use by method (i.e. the method mix)? Is LAM part of the contraceptive method mix? | This indicates what options are currently available and used and what needs to be done to improve choices. For example, does the method mix include at least three options for breastfeeding women at 6 weeks? Are there already some levels of IUD and postpartum sterilization use to suggest that strengthening immediate postpartum provision of these methods has potential for impact? How are the male partners influencing the method mix? |
| What percentage of women/adolescents receive ANC? | If the majority of women/adolescents receive ANC, this indicates high potential to reach pregnant women if a PPFP intervention is systematically implemented. |
| What is the percentage of mothers adolescent first time mothers practicing and the median duration of exclusive breastfeeding (EBF)? | Indicates potential for introducing EBF and LAM as a ‘win-win’ strategy for mothers and babies. |
| What percentage of deliveries are in health facilities? What is the breakdown of deliveries in facilities by age group, residence and wealth quintile? | If the percentage of facility-based births is significant, there is high potential for reaching women/adolescents through pre-discharge counseling, as well as for referral back to primary and community-based services for both follow-up and access to other contraceptive methods. There may be potential for offering postpartum IUD (PPIUD) insertion and postpartum Bilateral Tubal Ligation (PPBTL). Breakdown by age, residence, and socioeconomic status will help to identify underserved groups. |
| What percentage of postpartum women receive PNC for either mothers or infants? | If a substantial percentage of women receive PNC, there is good potential for reaching postpartum women with PPFP information and services. If this is not the case, exploring routine immunization services may be another option. |
| What are the immunization rates for children less than 1 year of age (bacille Calmette–Guérin (BCG), DPT and Pentavalent 1, 2, 3, or measles vaccines)? |
If there is robust routine immunization coverage through facility-based or outreach services, there is good potential for integrating PPFP information, counseling, and referrals.
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| What is the percentage of first births in women under 18 years of age? | If there is a significant percentage of first births for women age 18 years and under, there is an opportunity to promote healthy timing and spacing to delay second and subsequent births. |
Antenatal care, Labor and delivery/pre-discharge, Postnatal care, Post-pregnancy loss care
Births to adolescents and youth under 19-years-old are considered high-risk in the Philippines. As a result, pregnant adolescents and youth must deliver in the hospital, which presents an opportunity to seek parental permission for contraceptive services. This same opportunity exists during antenatal, delivery and postpartum care visits in which the young women is often occupied by her mother or guardian.
In the Philippines, the law mandates that care, including family planning counseling, must be provided to all patients following pregnancy loss whether it was spontaneous or induced (Republic Act No. 10354). In addition to counseling the woman/adolescent, the law also provides that the male partner should be counseled on family planning as the responsibility of preventing another unplanned/early pregnancy is the responsibility of both partners. Ovulation could resume as early as 11 days after treatment hence the need to start the use of a contraceptive as soon as possible following the pregnancy loss. Uptake of a family planning method is also better when offered to the woman/adolescent within 48 hours of giving them post-pregnancy loss care.
Infant health and immunization services
If a young woman does not adopt PPFP from the hospital, it is critical that this is documented in her paperwork that is shared with the health center at the local government unit (LGU), which should follow-up when the adolescent parent goes back for postpartum check-ups or newborn child checkups, including immunization appointments.
| Ensuring Family Planning Services in the Time of COVID-19 |
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FP services shall continually be provided along with other essential health services such as but not limited to: maternal care, immunization services, women and child protection services, among others (e.g. birth plans of all pregnant women/adolescents shall continue to include FP counseling and choices of postpartum FP methods). All hospitals shall continue to provide FP services including long-acting reversible (PSI and postpartum and interval IUD) and permanent methods (BTL and NSV) for postpartum clients following their own hospital protocol. All hospitals and other facilities shall set-up a referral arrangement to RHUs or any lower level health facilities for the continued FP use of clients as they return to their community. |
Step 2: Prepare the facility by carrying out a facility assessment for provision of PPFP and Post-Pregnancy FP
The assessment should focus on skills, equipment, and space to offer FP services, ensuring commodity availability and proper documentation.
Public and private service providers attending to deliveries in birthing units of hospitals, lying-ins, RHUs or CHOs should be familiar with what methods are available for mothers in the birthing facility, start counseling during the antenatal visits and focus on the health and economic benefits of birth spacing or limiting for the woman/adolescent and her family.
The methods available for postpartum women/adolescent are:
- Lactational amenorrhea method (LAM)
- Progestin-only pills
- Progestin-only injectable
- Single rod subdermal implant
- Intrauterine device (IUD)
The following methods are available for post-pregnancy family planning and may be started immediately:
- Combined oral contraceptive pills
- Progestin-only pills
- Progestin-only Injectables (e.g. depot-medroxyprogesterone acetate or DMPA and Norethisterone Enanthate or Net-En)
- Single rod subdermal implant
- Intrauterine device (IUD), only after infection and injury have been ruled out or resolved
- Condoms and other barrier methods, once sexual activity resumes
Supplying facilities with sufficient instruments for service delivery and ensuring that they have a regular source of commodities, positioned in maternity, is a basic minimum for continued service delivery. Integration of counseling at every possible contact with a client, whether prenatal, at birth, in the immediate postpartum period, or during post-pregnancy loss care means integration at multiple points and by multiple providers to ensure consistent access.
Step 3: Enhance capacity through whole site orientation (WSO) for all staff within facility on PPFP
Train/mentor health care providers from antenatal care, maternity, postnatal care and post-pregnancy care on clinical skills. See the supplemental to the Philippine Clinical Standards Manual, which discusses different contraceptive methods that can be used in the postpartum period including timing of initiation, attributes, and risks and benefits of the available choices.
In the Philippines, capacitating providers as trainers has helped to ensure that more providers, including residents, are involved in service delivery, and that the program is prepared to expand from the 10 centers of excellence outward, including reaching out to private sector midwives. Post-training support to facilities, either through transfer-of-learning follow-up visits, supportive supervision visits, or other strategies for assistance has been crucial to address quality gaps in the medium term.
Ensuring that all staff in a given facility are aware of and understand the messages around the introduction of PPFP and PPIUDs has been essential, particularly during expansion to new sites.
Ensuring that all staff in a given facility are aware of and understand the messages around the introduction of PPFP, PPIUDs, and post-pregnancy FP has been essential, particularly during expansion to new sites.
| Tip: For integration of PPFP/PPIUD services to be effective, the target of training and mentoring must be different than it is for traditional family planning programs: the focus must be on prenatal care and maternity staff, those assisting women/adolescents at the time of birth. |
Step 4: Conduct home visits to identify pregnant adolescents and first-time, young parents
Sensitize Barangay Health Workers (BHWs) and population volunteers on the benefits and barriers to PPFP and providing them with job aids/informational booklets. In addition, make sure that they are coached on how to complete the Target Client List (TCL) for Family Planning to include Postpartum Family Planning and Post-Pregnancy Family Planning. The TCL is filled out by health workers when providing services and is updated every time a client comes back for a follow-up visit. It has the following purposes:
- It helps the health worker plan and carry outpatient care and service delivery
- It facilitates the monitoring and supervision of service delivery activities
- It facilitates the preparation of reports,
- it provides clinic-level data that can be accessed for further studies.
| Ensuring Family Planning Services in the Time of COVID-19 |
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All FP service providers in primary care facilities e.g. birthing clinics, rural health units, urban health centers, barangay health stations, free-standing FP clinics, among others, shall review the TCL for FP to identify current users who are due for resupply of commodities. Clients who are due for resupply shall be informed through text message, phone call, or through the Barangay Health Emergency Response Team (BHERTs)or Barangay Health Workers (BHWs) to visit the primary care facility to get their supply and bring with them the FP client card. Clients who are using oral contraceptive pills such as Combined Oral Contraceptive (COC), Progestin-Only Pill (POP), or male condom shall be provided with 3 months’ worth of supplies. If client visit to the primary care facility is not feasible, BHERTs/BHWs shall be allowed to deliver the re-supply to the clients. |
Step 5: Document Immediate PPFP uptake data
Provide a family planning register in all service delivery points. Ensure that women/adolescents who received post-pregnancy loss care and started using a family planning method are included. See Annex on recording postpartum family planning data.
Step 6: Identify a facility PPFP champion
Recognize this person and encourage them to ensure routine provision of immediate PPFP and post-pregnancy family planning as well as supportive supervision of other health care providers in the unit providing PPFP and post-pregnancy family planning.
Step 7: Conduct monthly facility review meetings
Monthly review meeting looking at the data on immediate PPFP will help to strengthen the quality of services.
Indicators for success
| Indicator | Disaggregation | Data Source(s) | ||
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Number of health personnel trained in providing adolescent and youth-friendly health services
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Type of health personnel (doctor, nurse, midwife, peer educator) | Regional AHDP reports | ||
| Number of health facilities completing AYSRH whole site orientation | Facility/project report | |||
| Number/percent of women who delivered in a facility and received counseling on family planning prior to discharge |
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Hospital data/facility register | ||
| Number/percent of women who delivered in a facility and initiated or left with a modern contraceptive method prior to discharge |
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Hospital data/facility register | ||
| Number/percent of women/adolescents who received post-pregnancy loss care and received counseling on family planning prior to discharge |
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Hospital data/facility register | ||
| Number/percent of women/adolescent who received post-pregnancy loss care and initiated or left with a modern contraceptive method prior to discharge |
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Hospital data/facility register |
Resources needed
- Venue space for trainings and WSO, if necessary, because space inside or immediately outside the facility should be used if possible
- Whole site orientation and training material printing costs
- Information, education and communication (IEC) materials Job aids, tools and guideline material printing
What’s the evidence?
- Offering modern contraception services as part of care provided during childbirth increases postpartum contraceptive use and is likely to reduce both unintended pregnancies and pregnancies that are too closely spaced (Cleland et al., 2012; Kozuki et al., 2013).
- Adolescent mothers who received immediate postpartum counseling in Thailand were 3.67 times more likely to use LARC than those who received conventional (4-6 weeks) postpartum counseling (Kaewkiattikun, 2017).
- In India, women who had received family planning counseling during their time of delivery at a health facility were more than twice as likely to use a method postpartum than those who had not received family planning counseling (Achyut et al., 2016).
- There is a significant missed opportunity for family planning in the postpartum period in the Philippines, according to an analysis of 2008 DHIS data: “The majority of pregnancies occur between 12 and 23 months after a birth and the percentages of very short (< 6 months) intervals are less than 5%, except in certain surveys from Asian countries: Pakistan (10%), Philippines (8%) and Bihar and Uttarakhand (7% each). These four surveys also have the highest percentages of interpregnancy intervals shorter than 1 year, with approximately one in five (19–24%) of second or higher-order live births conceived within 1 year of the previous birth” (Moore et al., 2015).
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Helpful Tips
- During ANC counseling, health care providers should counsel clients on family planning options.
- Provide IEC materials on PFFP messages posted in maternity, labor and delivery and gynecology wards.
- Make sure that Department of Health’s family planning forms are available at all service delivery points and used.
- Consider holding dedicated PPFP days during the extended 6 weeks for immunization visits at adolescent-friendly health service facilities.
Challenges
- Documentation on whether or not FP counseling in antenatal care and delivery and adoption of method or referral back to health centers for follow-up care and management needs to be strengthened. Consider incentives or other innovations to improve back referral. For example, 2000 for vaccine for baby or client does not have to wait for contraceptive method (i.e., they receive priority for services) if you show the referral slip. The use of electronic medical records, might help in improving tracking of PPFP uptake.
External Resources
- High Impact Practices in Family Planning (HIP) Brief on Immediate Postpartum Family Planning
- HIP Brief on Family Planning and Immunization Integration
- USAID Global Health Learning Center course on Postpartum FP
