Postpartum contraception the experience and findings from the Leading Safe Choices programme in Tanzania and South Africa
Each day, 830 women lose their lives from complications of pregnancy and childbirth, most occurring in lowand middle income countries. Cleland et al. estimate that over the past 20 years, 40% of the reduction in maternal mortality in low income countries is attributable to increased uptake of contraception, with resultant lowered fertility. Globally, an estimated 40% of pregnancies are unintended. Access to contraception reduces unintended pregnancy, including high risk pregnancies in highly parous women and those that may have ended in unsafe abortion, while increasing birth spacing. Cleland has shown that adverse perinatal outcomes (preterm birth, low birthweight or small for gestational age) are associated with pregnancy intervals <6 months and >50 months. Rutstein observed an increase in child mortality where birth intervals are <2 years; the shorter the birth interval, the higher the risk. If couples space children more than 2 years apart, 30% of maternal deaths and 1 in 10 child deaths could be avoided. Healthy birth spacing can be achieved through increased access to postpartum contraception. With rising proportions of births occurring in health facilities, postpartum family planning (PPFP) may increase access among poorer women from rural areas, with positive effects on women's autonomy and decision making in reproductive health, economic development, and outcomes for existing children. However, in 2016 one in five women in Tanzania and almost one in seven in South Africa had an unmet need for contraception. Immediate postpartum contraception is recognised practice by the UK Medical Eligibility Criteria for Contraception (MEC) and USA and effectiveness has been demonstrated in India and elsewhere. The immediate postpartum period provides an opportunity to offer contraception to women motivated to avoid another pregnancy too soon but is frequently missed. A cross sectional study in rural Tanzania found 35% of women received no postnatal care. Singh et al. estimate that across sub Saharan Africa only 9% of women receive postpartum family planning counselling within a year of giving birth. Furthermore, the likelihood of receiving postpartum family planning counselling is highest in wealthy, educated women living in urban environments. Contraceptive prevalence increases when a greater choice of contraceptive methods is offered to meet individual needs. We describe below the experience of implementing training for immediate postpartum family planning in a lowand middle income country. The RCOG Leading Safe Choices (LSC) programme ran from 2015 to 2018 in 20 health facilities in Dar es Salaam and Kilimanjaro regions in Tanzania and in the Western Cape, South Africa. The aim of the programme was to increase access and choice in immediate postpartum family planning through education and training of midwives, nurses, and non specialist doctors (healthcare providers [HCP] Training was based on most recent evidence of effectiveness, and Best Practice Papers were published and made openly accessible as part of the programme. The project was funded by an anonymous donor, who assisted in the selection of the two countries, both with high unmet need for PPFP.
BJOG an international journal of obstetrics and gynaecology