Integrated Family Planning Research Articles

Maternal & Newborn Health Road Maps: a review of progress in 33 sub-Saharan African countries, 2008–2009

AbstractThe 2006 Maputo Plan of Action aimed to help African nations to achieve the Millennium Development Goals related to reducing maternal mortality, combatting HIV and AIDS, and reducing infant and child mortality within integrated sexual and reproductive health care plans. In 2008 and 2009, UNFPA worked with senior Ministry of Health officials and national UNFPA, UNICEF and WHO teams in 33 African countries to review their development of national Maternal and Newborn Health strategies and plans through a self-assessment survey. The survey showed that many key components were missing, in particular there was poor integration of family planning; lack of budgetary, infrastructure and human resources plans; and weak monitoring and evaluation provisions. The maternal and newborn health Road Map initiative has been the single most important factor for the initiation and development of the national maternal and newborn health plans for many African countries. However the deficiencies within these national plans need to be addressed before a significant reduction in maternal and newborn mortality can realistically be achieved.

Impact of Integrated Family Planning and HIV Care Services on Contraceptive Use and Pregnancy Outcomes

To determine the impact of routine care (RC) and integrated family planning (IFP) and HIV care service on family planning (FP) uptake and pregnancy outcomes. Retrospective cohort study conducted between October 10, 2005, and February 28, 2009. United States Agency for International Development-Academic Model Providing Access To Healthcare (USAID-AMPATH) in western Kenya. Records of adult HIV-infected women. Integration of FP into one of the care teams. PRIMARY OUTCOMES MEASURES: Incidence of FP methods and pregnancy. Four thousand thirty-one women (1453 IFP; 2578 RC) were eligible. Among the IFP group, there was a 16.7% increase (P < 0.001) [95% confidence interval (CI): 13.2% to 20.2%] in incidence of condom use, 12.9% increase (P < 0.001) (95% CI: 9.4% to 16.4%) in incidence of FP use including condoms, 3.8% reduction (P < 0.001) (95% CI: 1.9% to 5.6%) in incidence of FP use excluding condoms, and 0.1% increase (P = 0.9) (95% CI: -1.9% to 2.1%) in incidence of pregnancies. The attributable risk of the incidence rate per 100 person-years of IFP and RC for new condom use was 16.4 (95% CI: 11.9 to 21.0), new FP use including condoms was 13.5 (95% CI: 8.7 to 18.3), new FP use excluding condoms was -3.0 (95% CI: -4.6 to -1.4) and new cases of pregnancies was 1.2 (95% CI: -0.6 to 3.0). Integrating FP services into HIV care significantly increased the use of modern FP methods but no impact on pregnancy incidence. HIV programs need to consider integrating FP into their program structure.

HIV infection and contraceptive need among female Ethiopian voluntary HIV counseling and testing clients

Despite political endorsement of voluntary HIV counseling and testing (VCT), and family planning integration in Ethiopia, little is known about the reproductive health needs of VCT clients. We estimated contraceptive prevalence and need among 646 Ethiopian female VCT clients. We compared socio-demographic characteristics of contracepting VCT clients to those with unmet need and examined how these characteristics are associated with having unmet contraceptive need and being HIV-positive using multinomial logistic regression. We also assessed the quality of VCT services from clients' reports of reproductive health topics discussed in VCT sessions. Nearly 34% of female VCT clients have unmet contraceptive need. Three socio-demographic characteristics are consistently associated with both risk for unintended pregnancy and HIV: older age, marriage, and lower education. In the multivariate analysis, older age, marriage, and belonging to a minority ethnic group are significantly associated with being both HIV-positive and having unmet contraceptive need. Conversely, higher education, larger families, and frequent sexual activity are associated with reduced likelihood of experiencing these two adverse health outcomes. VCT clients report infrequent reproductive health counseling, although HIV-positive women are more likely than HIV-negative women to have discussions about contraception with VCT counselors. At the time of this study, family planning was not offered as part of VCT programs, although VCT clients demonstrate considerable need for contraceptive services.

Reaching the Underserved: Family Planning for Women with HIV

This article focuses on increasing access to family planning among people living with HIV and discusses two key strategies - integrating family planning and HIV services and strengthening existing vertical family planning programs. It explains the rationale for the strategies and the different populations they reach.

Increasing Support for Contraception as HIV Prevention: Stakeholder Mapping to Identify Influential Individuals and Their Perceptions

BackgroundVoluntary contraceptive use by HIV-positive women currently prevents more HIV-positive births, at a lower cost, than anti-retroviral drug (ARV) regimens. Despite this evidence, most prevention of mother-to-child transmission (PMTCT) programs focus solely on providing ARV prophylaxis to pregnant women and rarely include the prevention of unintended pregnancies among HIV-positive women.Methodology/Principal FindingsTo strengthen support for family planning as HIV prevention, we systematically identified key individuals in the field of international HIV/AIDS—those who could potentially influence the issue—and sought to determine their perceptions of barriers to and facilitators for implementing this PMTCT strategy. We used a criteria-based approach to determine which HIV/AIDS stakeholders have the most significant impact on HIV/AIDS research, programs, funding and policy and stratified purposive sampling to conduct interviews with a subset of these individuals. The interview findings pointed to obstacles to strengthening linkages between family planning and HIV/AIDS, including the need for: resources to integrate family planning and HIV services, infrastructure or capacity to provide integrated services at the facility level, national leadership and coordination, and targeted advocacy to key decision-makers.Conclusions/SignificanceThe individuals we identified as having regional or international influence in the field of HIV/AIDS have the ability to leverage an increasingly conducive funding environment and a growing evidence base to address the policy, programmatic and operational challenges to integrating family planning with HIV/AIDS. Fostering greater support for implementing contraception for HIV prevention will require the dedication, collaboration and coordination of many such actors. Our findings can inform a targeted advocacy campaign.

Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in Africa

This letter to the editor brings up the point that PEPFAR has had no success in lowering HIV prevalence in adults and states that to be most effective PEPFAR-supported prevention programs must ensure that all persons have access to the full range of information and services to protect themselves from HIV throughout their lives including female and male condoms. In addition it states that PEPFARs effectiveness also requires integration of family planning and other HIV services access to comprehensive sex education and protection of all human rights to live free of stigma discrimination and violence.

HIV/AIDS and family planning services integration: review of prospects for a comprehensive approach in sub-Saharan Africa

In most parts of the world, family planning and HIV-related services are usually offered separately. Family planning services, especially those that are government-supported, primarily serve married women and couples of reproductive age, while HIV-related services target individuals at higher-risk of exposure to HIV. However, the integration of family planning into HIV/AIDS programmes, or vice versa, would permit women of reproductive age who are infected or affected by HIV to benefit from family planning and/or HIV-prevention counselling and services. Sub-Saharan Africa is characterized by low modern contraceptive prevalence (below 20%), along with unmet needs for contraception, high use of abortion and the feminisation of HIV. Furthermore, the majority of children infected by HIV live in this region. The use of contraception would permit HIV-positive women to avoid unintended pregnancies and would reduce the number of children who are born with the virus. However, funding for family planning has decreased steadily over the last decade; the UNFPA recently reported that current assistance is less than half the amount needed. Donors more often support responses to HIV and AIDS, rather than other health interventions. This article reviews the difficulties and limitations facing the integration of family planning and HIV-related services. In addition, it suggests strategies to promote information for women and men of reproductive age about family planning, HIV prevention and referrals, including outside the context of health facilities.

Family planning and HIV: strange bedfellows no longer

Women of reproductive age are disproportionately affected by the HIV/AIDS epidemic especially in sub-Saharan Africa where women account for nearly 60% of people living with HIV[1].Consequently the family planning and HIV fields intersect in a number of crucial ways: (1) Many women are simultaneously at risk for both unintended pregnancy and HIV infection. Countries with the greatest burden of HIV also have high levels of unmet need for family planning [2]. (2) Like all women HIV-positive women have a right to make reproductive decisions free of coercion. (3) For women with HIV who want to become pregnant use of antiretroviral prophylaxis during pregnancy can reduce mother-to-child transmission of HIV. Afterwards family planning services that promote healthy timing and spacing of pregnancies are important to reduce the risk of adverse pregnancy outcomes such as low birth weight preterm birth and infant mortality [3-5]. (4) For women with HIV who do not wish to become pregnant family planningis a proven cost-effective strategy for preventing mother-to-child transmission of HIV (PMTCT) and therefore reducing the number of children needing HIV treatment care and support [26-9]. (5) Barrier methods of contraception -namely male and female condoms -can protect against both unintended pregnancy and sexual transmission of HIV. (6) HIV services provide an opportunity to reach women and men at risk of and living with HIV with family planning information and services. (7) Family planning services particularly in generalized epidemics provide an opportunity to increase access to HIV counseling and testing and other HIV services. However rather than being natural allies family planning and HIV have remained strange bedfellows [1011]. Despite the established connections between the fields they are not effectively bridged in practice. Rates of unintended pregnancies remain alarmingly high in women with HIV and family planning interventions have been underutilized in HIV prevention care and treatment programs [12-14]. In addition HIV programs have emerged primarily as separate silos and only minimal efforts have been made to leverage and integrate them with existing family planning infrastructures. This supplement originated from the belief that more evidence is needed to compel funders policymakers program planners and implementers to act on the synergies between the two fields and enhance the public health impact of reproductive health and HIV programs. The contents of this supplement represent research being conducted within three broad areas: behavioral research examining contraceptive practices and fertility desires of HIV-positive women and couples; biomedical research addressing the safety and effectiveness of contraceptive methods for HIV-positive women; and programmatic research evaluating service delivery approaches to integrating family planning and HIV services. Taken together the studies published in this supplement expand the evidence base regarding how the family planning andHIV fields are related and how they can be better integrated in practice.

From effectiveness to impact: contraception as an HIV prevention intervention

Background:Most efforts to date to prevent mother-to-child transmission of HIV have focused on provision of antiretroviral prophylaxis to HIV-infected pregnant women. Increasing voluntary contraceptive use has been an underused approach,...

The need for integrating family planning and postabortion care in China

Objective To assess the need for integrating postabortion care with family planning services in China. Method We collected data from a clinic-based study of 24 abortion clinics in 3 large cities in China. Results There was a total of 287 (10.3%) high-risk abortions among the 2780 respondents, 974 (35%) of whom had had repeated abortions and 48.4% had had 2 abortions within 1 year; 63.7% of the current pregnancies resulted from not using contraceptives; 28.8% and 19.8% of these new pregnancies, respectively, were due to the failure of the rhythm or the withdrawal method; only 9.7% of the respondents consistently used condoms; and only 9.1% could identify the correct time of their first ovulation following an abortion. Conclusion Contraceptive neglect and the high rates of repeated and high-risk abortions call for the integration of postabortion care with family planning services in China.

Family planning methods among women in a vaginal microbicide feasibility study in rural KwaZulu-Natal, South Africa.

This study investigated contraceptive use among women in rural KwaZulu-Natal, South Africa. Of 866 sexually active women not intending pregnancy and screened for a microbicide feasibility study, 466 (54%) reported currently using modern contraceptives: injectables (31%), condoms (12%), sterilization (60%) and pills (4%). Multivariable logistic regression analyses revealed statistically significantly higher odds of current contraceptive use among married vs. engaged/unmarried women (aOR 1.64), multiparous vs. nulliparous (aOR 4.45) and women who completed secondary education or above vs. primary or less (aOR 1.64). Significantly lower odds of use were observed among women aged 40+ vs. age 15-19 (aOR 0.38). Age, marital status, education level and parity were associated with different contraceptive method choices. Among 195 women followed longitudinally for 9 months, contraceptive use increased significantly from 56% to 70%, largely due to increased condom use (15% to 28%). Results highlight the importance of integrating family planning and HIV/STI prevention counseling and informing promotion of further contraceptive uptake among women not intending pregnancy.

HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2–13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9–7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.

Pregnancy, Hormonal Contraceptive Use, and HIV-Related Death in Rwanda

Few studies have examined the influence of pregnancy and hormonal contraception on HIV-related deaths in African women. Rwanda is a country with high fertility, high HIV prevalence, and frequent use of hormonal contraception in urban areas. Data from a prospective cohort study of 460 HIV-infected urban childbearing (18-35 years) women followed at 6-monthly intervals for 6 years in Kigali, Rwanda, were analyzed. The relationship of time-dependent measures of pregnancy and hormonal contraceptive use to death from HIV disease was assessed with multivariate models. Incident pregnancy was not associated with elevated risk of death among HIV-infected women. Oral and injectable hormonal contraceptive use had borderline protective effects associated with reduced mortality (HR 0.40, 95% CI 0.15-1.07 and HR 0.48, 95% CI 0.21-1.08 for mortality, respectively) in a multivariate model including time-dependent measures. The results point to the benefits of integrating family planning and HIV services. In a highly pronatalist society, such as Rwanda, which is experiencing high HIV prevalence, service integration affords an opportunity to provide HIV testing to women at risk of pregnancy and to promote family planning among HIV-positive women.

Does the delivery of integrated family planning and HIV/AIDS services influence community-based workers' client loads in Ethiopia?

Community-based reproductive health agents (CBRHAs) can increase community knowledge of and offer immediate access to reproductive health services, including HIV/AIDS. Due to growing interest in integration of family planning and HIV services in Ethiopia, it is important to examine whether CBRHAs are efficiently offering both service types. The present analysis uses survey data collected from Ethiopian CBRHAs and examines associations between agents' demographic, personality and work-related characteristics and their capacity to provide integrated services and have high client volumes. Multivariate probit and bivariate probit regression models are fitted for the two outcomes of interest. Nearly half of CBRHAs in our sample offer integrated services, but this is not jointly associated with increased productivity. Personality traits and work experience are more strongly associated with agents' capacity to provide integrated services than demographic characteristics, while agents' gender and work-related characteristics are significantly associated with increased likelihood of serving more clients.

Integrating family planning and prevention of mother-to-child HIV transmission in resource-limited settings

Every year, about 700 000 children under the age of 15 years are newly infected with HIV. More than 90% of paediatric HIV infections are due to mother-to-child transmission, and more than 90% are in sub-Saharan Africa.1 In June, 2001, the UN General Assembly Special Session on HIV/AIDS set targets to reduce the proportion of infants infected with HIV by 20% by 2005, and by 50% by 2010.2 The UN Interagency Task Team on Mother-to-Child Transmission of HIV Infection has proposed a four-component strategy: (1) prevent HIV infection in all people, especially young women; (2) prevent unintended pregnancies in HIV-infected women; (3) prevent HIV transmission from HIV-infected women to their infants through antiretroviral therapy, safe delivery practices, and counselling and support on infant-feeding methods; and (4) provide care and support to HIV-infected women, their infants, and families.

Potential Impact of the Mass Media on Family Planning in an Urban Community in South Western Nigeria

Context: The role of radio and television message is an important factor in creating and changing the values, ideas and attitudes of people in Public Health. Fertility regulation in Nigeria is still yet to meet the optimum level. Objectives: The research therefore is designed to assess the role of mass media, radio and television in family planning messages. Study Design, Setting and Subjects: The study involved 503 females and males of child bearing age at Ife Central District, South Western of Nigeria. Information on respondents socio-economic characteristics family planning practices, their knowledge and attitude, source of information and use of family planning methods including habits and media preference of the respondent were also collected. Results: Radio was found to be the most common source of information. Fifty-three percent reported that they got family planning messages through the radio as against 10.1% through the television in spite of the fact that 68.5% of the respondents had television and 89.1% had radio. Seventy-two percent of the respondents had never visited family planning clinic. The most favourite programme on T.V. was drama while that of the radio was the news. Conclusion: The need to intensify and integrate family planning message into television drama and radio news was identified as this could play a significant role in family planning. Key Words: Family Planning Messages, Radio, Television, Mass Media. [ Trop J Obstet Gynaecol, 2004;21:88-90]

Rethinking Contraception in Africa in the Era of HIV / AIDS / Reconsideration de la contraception a l'epoque du VIH / SIDA

Rethinking Contraception in Africa in the Era of HIV / AIDS / Reconsideration de la contraception a l'epoque du VIH / SIDA

Opportunities and pitfalls in integration of family planning and HIV prevention efforts in developing countries.

Recognizing that HIV/AIDS is a paramount health priority for virtually all the developing world “integrating” HIV with existing services such as family planning is highly attractive. At first blush it would seem that the same reproductive health arena that both interventions share should provide opportunities for integration. But the reality is far more complex. Our central proposition is that in the developing world the family planning clinic arena—with its emphasis on providing contraceptive methods—is a weak platform to promote the behavior change so essential to HIV prevention. On the other hand other elements of family planning programming that operate outside the clinic (though they support clinical services) often provide a strong platform for HIV prevention. At the same time growing areas of HIV programming such as Voluntary Counseling and Testing (VCT) Mother-to-Child Transmission (MTCT) and long-term Antiretroviral Therapy (ART) offer strong programmatic opportunities to fulfill the unmet need for family planning. (excerpt)

Pregnancy--reducing maternal deaths and disability in Sri Lanka: national strategies.

The declining trend in the maternal mortality rate (MMR) from the 1930s to the late 1990s resulted from several strategies implemented within and outside the health sector. Expansion of both field-based and institutional services through the past decades contributed to improved geographical access and provision of 'free' services improved economic access. These led to increased use of antenatal and natal services provided by trained midwives and other personnel followed by improvements in the availability of specialized care and emergency obstetric care. Integration of family planning and other inputs to the maternal health programme has yielded positive results. The role of the private sector is limited to provision of a component of antenatal services. The organization for service provision and an information system made significant contributions towards improvement. The commitment of the health sector to provide services free of charge supported by non-health inputs, especially female education, has enabled Sri Lanka to make gains in maternal health.

Is Integration the Answer for Africa?

Since the International Conference on Population and Development in 1994 much rhetoric and some action have been expended on the attempt to integrate family planning (FP) with services that manage sexually transmitted infections and HIV/AIDS. It is noted that for some regions in the developing world integration may be both feasible and appropriate. However in sub-Saharan Africa the effort to integrate services may not be successful and is subject to risks that should be considered carefully. Service programs in this area are severely challenged and fragile. The central problem is that FP and AIDS programs serve two different constituencies and needs in Africa. They have different structures employ different kinds of staff and have distinct motivations and histories. They should not be sacrificed to conform to international donors ideologies and unrealistic expectations of greater efficiency and cost savings. In the end the pursuit of integrated services in Africa is likely to do more harm than good and the cost will be measured in lives and unwanted pregnancies as well as money.