Strengthening Family Planning and Pre-Service Nursing and Midwifery - PowerPoint PPT Presentation

Strengthening Family Planning and Pre-Service Nursing and Midwifery Education in India Dr Bulbul Sood September 18, 2012 Courtesy: HIP

Revitalizing PPFP/PPIUCD services Presentation Outline  India need and opportunity  How PPFP/PPIUCD services were initiated and scaled up  Lessons learned 2

10 Most Populous Countries in the World Population (Millions) Year 2008 Year 2030 China (1324.7) India (1484.6) India (1149.3) China (1462.5) USA (304.5) USA (370.0) Indonesia Indonesia (239.9) (271.5) Pakistan Brazil (195.1) … In next 20 years, India will be the (265.7) Pakistan most populous nation in the world Nigeria (226.7) (172.8) Nigeria (148.1) Brazil (217.2) Bangladesh Bangladesh (147.3) (203.2) Russia (141.9) Russia (128.9) Philippines Japan (127.7) (124.4) Source: World Population Prospects: 2008 Revision Population Database UN Population Division

Projected population of India: 2001-2026 Share of additional 371 million Jharkhand Bihar Madhya 3% 8% Pradesh Chhattisgarh Uttarakhand 7% 2% 1% Rajasthan 7% Orissa Uttar Pradesh Half the population 2% 22% growth will be in seven Four Southern northern states States 13% Southern states will contribute only 13% of Rest of the Country growth 35% Source: Registrar General of India, 2006 (Population Projections for India and

High unmet need….. Birth-to-birth Intervals Unmet Need across Postpartum Period and for past five years FP use among Sexually Active Women Modern Traditional Unmet need to space Unmet need to limit Total unmet need 7-17 80% 70% 11% 18-23 21% 60% 50% 16% 24-35 40% 19% 36-47 30% 34% 20% 48+ 10% 0% 0-3 4-6 7-9 10-12 N=1305 In months (NFHS 3: 2005-06) N=2374 N=2168 N=2661 N =39,215 births Source: NFHS 3: 2005-06 5

Gap in service delivery….. Current use of Family Planning Methods Male Pill IUD Condom Any Traditional Sterilization 6% 4% 2% method 1% 7% Female Sterilization 34% Non user 46% Source: DLHS-3 (2007-08), IIPS Mumbai

Resurgence of Interest in the PPFP/PPIUCD  GoI policy to reposition FP as JSY PERFORMANCE: MNCH initiative 2005-10  JSY was bringing women to facility-Immediate postpartum 12.00 100% 90% 88% 90% 84% insertion is convenient for 10.00 80% Percentage Against Total Deliveries No. of Beneficiaries 70% women 8.00 57% 60% (million)  New advances and new 6.00 50% 42% 10 40% understanding about PPIUCD 7.33 9.08 4.00 30% 20%  2.00 IUCD as spacing and long 3.16 0.74 10% term reversible method- 0.00 0% 2005-06 2006-07 2007-08 2008-09 2009-10 (prov.) alternative to sterilization for many couples 7

PPIUD: Quick Facts  Insertion times:  Post placental: • 10 minutes after delivery of placenta  Immediate post partum • within 48 hours after delivery  Intracesarean • During cesarean section  Interval / Delayed post partum • 6 or more weeks after delivery  Insertion Techniques:  Instrumental 8

Review of safety of PPIUD Cochrane database review, updated 2010  Safe and effective  Advantages:  Mother: high motivation and convenience  Provider: assurance woman not pregnant  No differences between manual and instrumental insertion  Few contraindications  Expulsion rates higher than with interval  Feasible: PPIUD insertion popular in diverse countries; China, Mexico, Egypt  Early follow-up important in identifying spontaneous IUD expulsions 9 Grimes D, Schulz K, van Vliet H, Stanwood N. Immediate post-partum insertion of intrauterine devices. The Cochrane Database of Systematic Reviews 2010, Issue 1

PPIUCD Program Requirements 10

Service Delivery Tools Training material, including Kelly’s Forceps & Job Aids an insertion animation video

Client Education Material & Data Collection Registers Leaflet and Follow Up Card Posters & Films

Strengthening Counseling and giving Choices to women………..  Counseling done on ALL methods including LAM, FABM, Injectables, PPIUCD etc.  ANC  During early stages of labor (PPIUCD)  In the postpartum period while in the hospital  Pre-discharge counseling Choice is verified before IUCD is inserted Counseled on return visit • Counselors hired/being hired • Several sites are using PMTC counselors 13

Rapid expansion of PPFP/PPIUCD services in India Start of PPFP/PPIUCD Now scaled up to 19 states program in U.P. in 2009  UP   Meghalaya Queen Mary Hospital,  Uttarakhand  Lucknow Chattisgarh  Jharkhand  Orissa  7 Faculty trained as trainers  Delhi – 1 from each unit  West Bengal  Haryana  ALL Ob/Gyns and residents  Gujarat  Punjab (59) oriented  Maharashtra  Rajasthan  Providers from District  Tamil Nadu  Bihar Women’s Hospitals -  Karnataka  Madhya Pradesh Allahabad and Jhansi trained  Andhra  Assam Pradesh >55,000 PPIUCD inserted Donor support from USAID, Gates, Packard, NIPI, UNFPA 14

Number of PPIUCD Insertion Reported (Feb-10 to May-12) N=50,649 18000 Number of PPIUCD insertions 15249 16000 14000 12000 10000 8004 8000 6368 6000 4273 4000 2796 2387 2184 1537 1376 1361 1145 874 714 688 631 582 413 2000 34 33 0 State 15 As on 04/07/2012 PPIUCD insertion data received from other facilities of Delhi included

State wise PPIUCD Acceptors by Type (Feb 10 – May 12) Post Placental Intra cesarean Post partum N=46,228 18000 15249 16000 Post partum 14000 21% Post 12000 Placental 43% 10000 Intra cesarean 8000 6368 36% 6000 4273 3583 4000 2796 2387 2184 1537 1376 1361 1145 874 714 688 631 582 413 2000 34 33 0 As on 04/07/2012

PPIUCD Insertion by Type Top 20 facilities Jan-2011 to May-2012 N=28,769 Post Placental Intra cesarean Post partum 4699 5000 4500 4000 3500 2718 3000 2335 2253 2211 2500 1790 1707 2000 1323 1500 1080 1075 1040 850 848 842 782 710 680 673 579 574 1000 500 0 As on 04/07/2012

Proportion of PPIUCD Acceptors among institutional deliveries Jan-2011 to May-2012 50% 45% 40% 35% 30% 23% 25% 19% 20% 15% 11% 10% 8% 8% 10% 7% 5% 5% 4% 4% 4% 3% 3% 3% 5% 2% 2% 2% 1% 0% Total Deliveries -6,20,722 Total Insertion-41,259 As on 04/07/2012

PPIUCD Follow-up Rates by State (Jan 11 to May 12) N- 41,259 100% 100% 90% 79% 80% 70% 65% 64% 62% 60% 57% 57% 55% 53% 60% 48% 44% 43% 39% 38% 50% 40% 28% 25% 21% 21% 30% 20% 10% 0% As on 04/07/2012

% PPIUCD acceptors by type of delivery (Jun 11 to May 12) % Intra-cesarean PPIUCD % Post-vaginal PPIUCD (Post-placental + Post-partum) 35% 30% 25% 20% 15% 10% 5% 0% State Intra-cesarean PPIUCD: 8% of cesarean deliveries (n= 1,64,550) Vaginal PPIUCD: 6% of vaginal deliveries (n=376219) 20

Follow-up findings (Jan-2011 to May-2012) N=19,956 Missing String 4% Expulsion 2% Infection 1% No Complaint 89% Other Complaint 4% N=Total number of Follow-up As on 04/07/2012

Lesson learnt in Use of PPIUCD 22

Advocacy at National and Regional level for PPFP/PPIUCD  Contraceptives and Beyond, Jaipur, May 26-27, 2010  AICC-FOGSI conf, Kolkata, Feb 26-27, 2010  10 th World Congress on RCH, Nagpur, Sept 2010  Annual Bihar Ob/Gyn Society’s Conference, Patna, Dec 4-5, 2010  FOGSI-FIGO International Addressing concerns around safety of Postpartum IUCD critical to the Congress on Recent Advances success… in Ob/Gyn. Mumbai, April 8-10, 2011  International Congress on Contraception, Kolkata, May 6-8, 23 2011

PPIUCD Side Effects/Complications  Perforation:  Entire world literature does not report ANY perforations when inserted at correct time  Uterine wall very thick, and PP uterus responsive to oxytocin  Infection:  Large series (more than 1000 patients) show infection rates of less than 1%  No need for prophylactic antibiotics  Increased cramping and bleeding:  Masked by normal postpartum symptoms 24

Expulsion Rates Are Related to Provider To reduce expulsion:  Use correct technique • place all the way at fundus • sweep instrument to the side • take care that IUCD does NOT come out during withdrawal  Use correct instrument • Kelly placental forceps (curved, longer) may be better than ring forceps  Insert at the correct time 25 • postplacental is better

What should be done while scaling up the PPFP/PPIUCD Program ? Institunalize the PPIUCD services  Scale up training of all providers within the facility to provide services competently, according to established standards  Place emphasis on ensuring quality of services including IP practices  Build up good client caseload  Ensure training management and monitoring is in place Strengthen Systemic Counseling  Counseling training on PPFP/PPIUCD of all providers especially nurses  Equip facilities with counseling job aides and support use of IEC Materials  Promote use of AV material in outdoor waiting area  Involve CBWs (AWW, ASHA) to create awareness about PPFP/PPIUCD Strengthen follow-up system  Establish a follow-up mechanism and regular monitoring of ALL CLIENTS  Regular systemic review of service data to further strengthen the services 26