Guest post by Holly Blanchard, Senior Reproductive Health/Family Planning Advisor, Maternal and Child Health Integrated Program (MCHIP)
Access to a wide range of safe and effective contraceptive options is every woman’s human right, including those who have just given birth. Access to family planning (FP) not only enables a woman to achieve her and her partner’s desired family size, but also contributes to improved health outcomes for both women and children. However, in many low resource settings, postpartum women are offered a limited range of FP methods, if they are counseled on postpartum FP (PPFP) at all. With increasing numbers of women delivering in health facilities, the opportunity to offer the option of immediate postpartum intrauterine device (PPIUD) services should be maximized.
A woman who has voluntarily chosen a PPIUD can leave the maternity ward with a reversible, highly effective method of contraception. She will not be at risk of becoming pregnant too soon and can breastfeed her baby up to the second year of life and beyond as is recommended by both the World Health Organization (WHO) and UNICEF. Many women experience unplanned pregnancies within the first 24 months after giving birth because they rely solely on breastfeeding. When lactational amenorrhea method (LAM), (exclusive breastfeeding and no return to menses), is used, it is highly effective, but temporary—for up to six months postpartum. To meet the nutritional needs of infants, they must start eating other foods at six months.
Studies have also shown that FP reduces child and maternal mortality. “By preventing high-risk pregnancies, especially in women of high parities[ more than four children] and those that would have ended in unsafe abortion, increased contraceptive use has reduced the maternal mortality ratio—the risk of maternal death per 100,000 live births—by about 26% in little more than a decade. A further 30% of maternal deaths could be avoided by fulfillment of unmet need for contraception.”
The U.S. Agency for International Development’s (USAID) flagship Maternal and Child Health Integrated Program (MCHIP) and Population Services International (PSI) have initiated PPIUD services through integration into maternity services around the world, collectively reaching more than 160,000 postpartum women globally. Despite these efforts, PPIUDs still represent a small proportion of contraceptive service delivery in Sub‑Saharan Africa, and more must be done to make this option widely available to all women who deliver in a facility.
With this in mind, MCHIP and PSI’s Support for International Family Planning Organizations (SIFPO) project—with funding from USAID—are increasing awareness of the PPIUD and its role in expanding contraceptive method choice through regional meetings in Africa. The one in West Africa was held in Ouagadougou, Burkina Faso last February and attended by 48 participants representing 11 low-resource countries, including representatives of the Burkina Faso Ministry of Health (MOH) and international partner organizations.
The three-day workshop allowed for south-to-south learning among experts, health providers, programmers, and policy makers to establish and scale up PPIUD services. Expanding the contraceptive method mix in West African countries to include the highly effective PPIUD depends on support from global and regional actors—including the WHO, West African Health Organization (WAHO), USAID, and United Nations Population Fund (UNFPA), as well as national decision makers including MOH staff.
The engagement of MOH officials is especially critical for fostering successful south-to-south learning. One of the most effective ways to encourage governments to incorporate the PPIUD into its basket of available contraceptive methods is through learning from neighboring countries about their experiences in PPIUD services. In his closing remarks, Guy Ahialegbedzi of UNFPA/Togo reflected on the importance of and participant enthusiasm regarding regional knowledge sharing with respect to the PPIUD: “The sharing of experiences has been very rich, with many practical lessons learned. The best testimonial we can make for this workshop will be our mobilization for a rapid implementation of our action plan.”
 Burkina Faso, Cameroon, Cote d’Ivoire, Democratic Republic of Congo, Guinea, Haiti, Madagascar, Mali, Mauritania, Niger, and Togo.
The task of translating the International Conference on Population and Development’s (ICPD) Programme of Action (PoA) into meaningful change for women and girls globally includes some important detail work. Several years ago, my organization – the Center for Health and Gender Equity (CHANGE) – set out to better define the meaning of key PoA terms. Our guiding question was: “What constitutes comprehensive, rights-based sexual and reproductive health (SRH) care?” We found some useful literature and human rights documents to point us in the right direction, but most importantly, we wanted to make sure our answer was grounded in the lived experiences of women and girls.
Through fact-finding trips to Ethiopia, Botswana, and the Dominican Republic, CHANGE uncovered daunting obstacles to comprehensive care grounded in human rights. We learned of a peer mother program for women living with HIV that expelled volunteers for becoming pregnant. Clinic conditions for birthing women were appalling, with rampant overcrowding, poor quality care, and limited access to postpartum family planning (FP). We met young people without access to the information and tools they need to prevent pregnancy and HIV. And too often we encountered programs that claimed to offer a comprehensive constellation of reproductive health services, including family planning, maternal health, and HIV; however, each service was administratively and geographically separated, making it difficult for women and girls to fulfill their comprehensive sexual and reproductive healthcare needs and achieve continuity of care.
In the midst of these obstacles, we found evidence of the positive impact of comprehensive, rights-based care:
Supported by an extensive review of the literature, three key lessons emerged from our field research and shaped the development of our framework defining comprehensive, rights-based SRH care. First, comprehensive, rights-based care must be defined from the user perspective, which implies not just that services are linked at the national government or clinic level, but most importantly at the level of the individual. Second, people know comprehensive when they encounter its antithesis – when they have to wait in multiple lines, endure the time-consuming burden of visiting multiple providers, or encounter providers who do not connect their HIV risk and their pregnancy risk. Lastly, people know rights-based when they have a voice in their care, and when they’re treated with respect and dignity.
As we reach ICPD’s 20th anniversary, we can only fulfill its legacy by paying thorough attention to details. A global community of advocates and implementing organizations has contributed to the growing consensus on what these details should be. In particular, the framework spearheaded by Futures Group and EngenderHealth offers invaluable guidance on how to design and implement FP programs with full attention to human rights. While CHANGE uses both frameworks as touchstones for our advocacy work, we also hope that they prompt further critical thinking about how we advance and protect rights throughout the range of SRH services women and girls need over the course of their lives.
Guest post by Shannon Harris
Given the many challenges that countries face in providing family planning (FP) services, how can a client-centered, rights-based approach to programming help governments meet their obligations to respect, protect, and fulfill clients’ rights to meet their reproductive needs and desires? This question framed two recent country consultations in India and Kenya to explore the feasibility and desirability of applying the voluntary, rights-based FP (VRBFP) conceptual framework. Were country-level FP stakeholders—program managers, policymakers, and providers—even interested in such an approach?
With funding from the Bill & Melinda Gates Foundation, the Futures Group and EngenderHealth partnered with the Population Foundation of India and the National Council for Population and Development in Kenya to host national and regional stakeholder consultations, as well as conduct FP site visits to explore these questions. Despite diverse cultural, policy and program environments, stakeholders in both countries expressed tremendous interest in using a rights-based approach. Stakeholders found the program vision described in the VRBFP framework appealing and relevant to their programs because of its emphasis on the individuals and communities served by the FP program, while simultaneously acknowledging the importance of the policy environment and supply-side factors.
In India, stakeholders offered insights into how a rights-based approach might help address some of their concerns about contraceptive method choice and quality of care. For example, the public sector in India primarily provides sterilization services and intrauterine devices (IUDs); injectables and implants are unavailable in the public sector altogether, which limits method choice for women who depend on public-sector services. A rights-based approach calls for the widest possible range of methods to be made available and accessible to all clients. National stakeholders in Delhi spoke about the opposition to hormonal methods by some activists, an unfortunate irony given concerns about the dominance of sterilization and IUDs in the method mix. Stakeholders in India’s Bihar State spoke about the community and cultural factors that impede access to FP and expressed their belief that an approach that teaches women about their right to quality FP services would help generate demand.
People often assume that women who’ve undergone an obstetric fistula repair are not interested in using family planning (FP). After all, most lost a baby during the obstructed labor that led to their injury. However, recent studies (see here and here) indicate that fistula clients are often interested in using FP if they learn about available methods and services during their post-repair recovery period. When fistula surgeons and counselors make assumptions about women’s desires, they miss the opportunity to provide needed services and to offer reproductive choices to women who may have been disadvantaged and marginalized as a result of their injury.
Access to high-quality FP services and a wide range of methods supports a woman’s right to have the number of children she wants (if possible) and to space births to protect the health of the mother and her infant(s). FP is also uniquely important for women who have had a fistula. Access to contraception helps to protect a repaired fistula and prevent breakdown and recurrence by delaying pregnancy. FP counseling can also help women who want to achieve a successful pregnancy to increase their fertility awareness and to delay a future pregnancy until they are fully healed.
This week, the Center for Reproductive Rights (CRR) published Substantive Equality and Reproductive Rights: A Briefing Paper on Aligning Development Goals with Human Rights Obligations, a new resource offering guidance on how governments can ensure that principles of substantive equality, including human rights principles and obligations, are reflected in the post-2015 development agenda.
Substantive equality calls for states to respect, protect, and fulfill human rights, ensure equality for all, and promote accountability for rights violations. The paper contends that violations of reproductive rights are primarily manifestations of discrimination, poverty, and violence. Therefore, where women’s rights to equality and nondiscrimination are not fulfilled, their ability to access reproductive health services and make meaningful choices about their reproductive lives is limited.
Human rights–based family planning (FP) programming—what does it mean? Where do you start to translate it into practice? How comprehensive do you need to be? It is easy to become daunted by a long list of inputs and activities, such as those listed in the voluntary, rights-based family planning framework developed by a team led by Futures Group and EngenderHealth. The recent 2020 Vision newsletter refers to the overwhelming nature of existing guidance documents for ensuring that FP programs are rights-based and offers a simplified starting point. But will simplification of a complex set of challenges lead to the transformation in FP programming that our field needs?
We welcome the dialogue started by Population Action International (PAI) about how to move forward to protect and fulfill human rights within FP programs. This conversation is needed; multiple voices and views add richness to the discussion. PAI suggests starting with three priorities: voluntarism, informed choice, and achieving a diverse method mix. Certainly, we have to start somewhere, and these three elements are essential to rights-based FP— programs must be vigilant in preventing instances of coercion and in ensuring full, free, and informed contraceptive choice.
However, these program elements are not sufficient to ensure equitable access to services for all nor to ensure that the services are of high quality. They also do not address community factors that impede access to and use of FP. And they do not address the issue of accountability. These are critical considerations for reaching and fulfilling the human rights of the 220 million women with an unmet need for FP.
Guest Post by Shannon Harris
There is greater interest and investment in family planning (FP) programs now than in the last 20 years. With this increased attention and funding, programs are also benefiting from an increased commitment to ensuring that vulnerable and hard-to-reach populations are being better served and that women are receiving high-quality services and expanded contraceptive choice. As FP reemerges as a global priority, there is more attention to the human rights that underlie providing contraceptive services to all individuals. The recently published Family Planning 2020 (FP2020) first annual progress report highlights the new Conceptual Framework for Voluntary, Rights-Based Family Planning, a tool designed to ensure that public health programs oriented toward increasing voluntary FP access and use respect, protect, and fulfill human rights in the way they are designed, implemented, and evaluated.
Guest post by Molly Tumusiime, Program Associate (Community Engagement), EngenderHealth/Uganda
The Right to Health asserts that people are entitled to access reproductive health services, including family planning (FP), that are acceptable to them and of the highest possible quality. However, there are many barriers to individuals’ realizing this right at many levels. While policy change and provider training can support increased FP access and use and better ensure contraceptive choice, interventions at the policy and service delivery levels alone are insufficient. Community-level barriers also impede service utilization and should be addressed in participatory and cooperative ways.
In 2010, EngenderHealth began piloting site walk-throughs (SWTs) in Bangladesh, Ethiopia, Ghana, Tanzania, and Uganda. This promising approach—rooted in the core human rights principles of participation, empowerment, and accountability—catalyzes community participation in health and strengthens the accountability of service providers to communities. In addition, SWTs foster linkages and collaborative partnerships between health providers and community members in addressing barriers to informed choice and service access and in improving the quality and acceptability of services.
Guest post by Lauren VanEnk, Program Officer, Institute for Reproductive Health at Georgetown University (IRH)
For decades, India’s national family planning (FP) program has emphasized female sterilization, resulting in limited contraceptive method options for those with an unmet need for FP, especially for spacing pregnancies. However, following the 1994 International Conference on Population and Development (ICPD), which recommended high-quality services and a range of methods, the Government of India adopted a national population policy in 2000 that shifted its FP program’s focus from achieving target-driven demographic goals to ensuring reproductive health and rights, including voluntary and informed choice.
From November 12–15, an estimated 4,000 government officials, policymakers, program managers, researchers, academics, and youth advocates will gather in Addis Ababa, Ethiopia for the 3rd Annual International Conference on Family Planning (ICFP).
The theme of this year’s conference—cohosted by The Bill and Melinda Gates Institute for Population and Reproductive Health and Ethiopia’s Ministry of Health—is “Full Access, Full Choice,” echoing the Family Planning 2020 (FP2020) initiative's call to ensure that rights and contraceptive choice are central to meeting the commitment made at the London Summit on Family Planning to reach an additional 120 million women with access to contraception by 2020.