Integrating postnatal care, family planning, and HIV services

By Dr James Kimani, Senior Analyst (Population Council, Nairobi, Kenya)

Addressing the postpartum needs of new mothers, including new mothers who are living with HIV, and new mothers living in settings with a high HIV prevalence, is a neglected area of care throughout sub-Saharan Africa and other resource-limited settings. Few developing countries have mechanisms in place to ensure that mothers and their newborns are assessed early and monitored during the initial six-week postpartum period.

Some of the challenges include lack of clearly defined standards, including the content and timing of both postpartum and postnatal services, and a discontinuity of services limiting linkages to other key postpartum services for new mothers, including family planning and HIV care services for women living with HIV.

According to the World Health Organization, over 60 per cent of maternal deaths occur within the first 48 hours after childbirth [2], while newborn morbidity and mortality, including postnatal transmission of HIV to infants, are more likely to happen soon after birth [3, 4]. In high HIV prevalence settings, there is also evidence that women living with HIV are at 1.5–2 times greater risk of maternal mortality than women who are HIV-negative [5]. Providing adequate and effective services to meet the needs of mothers and their infants during this postpartum period can substantially reduce maternal and infant morbidity and mortality.

It is often assumed that women who deliver in a facility will have received adequate care prior to discharge and do not need further attention until the six-week consultation. Women giving birth at home are least likely to receive any care, especially within the first two days, when they are most susceptible to postpartum hemorrhage and hypertensive disorders [6].

However, our research has supported other studies that have found that regardless of where a woman gives birth, she is unlikely to receive the comprehensive care she needs. Two critical issues need further attention – the first, to promote family planning and prevent future unintended pregnancies, and the second, to prevent vertical transmission of HIV during the postpartum period.

To promote family planning, research has shown that during the extended postpartum period (12 months after birth), women may want to delay or avoid future pregnancies, but do not have access to a modern contraceptive method. A review of data from Demographic and Health Surveys (DHS) in 27 developing countries found that 67 per cent of women who gave birth within the previous year had an unmet need for family planning [7]. Although unmet need for family planning during the postpartum period is widespread among all women, evidence from recent studies has shown that substantial proportions of women living with HIV also have an unmet need. Studies in Zambia and Kenya found that 39 per cent and 65 per cent of postpartum women living with HIV reported that they were not using any contraceptive method with their regular sexual partner [8].

To prevent vertical transmission of HIV, there is evidence that even if counseling and information on family planning is available within programmes for the prevention of mother-to-child transmission of HIV (PMTCT), this does not necessarily translate into the initiation of contraception [9].

Evidence has shown that providing a continuum of care from antenatal, delivery, postnatal services and beyond results in improved maternal and neonatal health outcomes [10-12].  For example, in Swaziland, integration of PMTCT into postnatal care led to considerable improvements in follow-up visits during the first three days postpartum, a significant increase in the proportion of postpartum women and their partners who got tested for HIV, an increase in the proportion of women and infants who received HIV treatment and care, and significant improvements in the proportion of mothers practicing exclusive breastfeeding [11].

However, there is still a paucity of evidence from southern and eastern Africa (where HIV prevalence is highest) focused on measuring the benefits of integrated HIV and sexual and reproductive health services, particularly, postnatal care services.

As part of the Integra Initiative, our study in Kenya has contributed to filling this gap and aimed to build the evidence base by assessing the effect of integrating HIV and postnatal care services on the uptake of provider-initiated HIV testing and counseling and family planning services among women attending postnatal care in public health facilities. Preliminary results indicate that an integrated delivery approach of postnatal services is beneficial in increasing the uptake of HIV testing and family planning services among postpartum women, including the uptake of long-term family planning methods. However, there are important gaps in the uptake of these services based on facility-type and socio-demographic characteristics. This has important implications in addressing the sexual and reproductive health and HIV needs of women, including prevention of unintended pregnancies.

References listed in the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April