integrating family planning into postpartum care through quality improvement in afghanistan,...

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Leveraging QI to integrate FP Services into Postpartum Care in Afghanistan

Kathleen Hill, MD MPHDeputy Director USAID ASSIST Project

USAID Applying Science to Strengthen and Improve Systems

Background: Afghanistan Maternal and Neonatal Mortality Rates and CPR

• High maternal mortality rate at 460 deaths per 100,000 live births(2010WHO, UNICEF, UNFPA)

• High neonatal mortality rate at 36 deaths per 1,000 live births (UNICEF 2012)

• Low contraceptive prevalence rate of 20% (2012 UNFPA)

*Acknowledgments: Youssef Tawfik, Mirwais Rahimzai, Annie Clark, Malalah Ahmadzai, Evelyn Kamgang

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Project Goal and Objectives

Goal: Improve future health status for women and families by reducing unmet FP need via better integration of FP services into routine post-partum care in 5 Kabul hospitals.

Objectives: 1. To improve quality of PPFP services in 5 maternity

hospitals in Kabul (2 public, 3 private)2. To ensure PP women leave the hospital with their preferred

method of FP3. To increase the proportion of PP women who use any

modern FP method for at least one year after delivery

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Methods

• Improvement teams formed in each of five hospitals in Kabul (2 public, 3 private)

• Teams coached to apply root cause analysis to understand obstacles to integrating FP services into PP care

• Teams regularly tested and adopted successful changes to integrate FP services into PP care --despite multiple constraints

• Teams tracked indicators on a monthly basis to assess progress


Implementation Challenges/Barriers

• Lack of private space for couples' counseling

• Some women unable to choose contraceptives without consulting husbands and/or mothers-in-law

• FP counseling and service provision not included in “usual flow” of routine PP care

• Insufficient availability of FP methods; lack of method mix5

USAID Applying Science to Strengthen and Improve Systems6

• Proportion of women receiving post-partum FP counseling

• Proportion of counseled women choosing modern FP method of choice at discharge

• Pregnancy rate among women 3, 6, 12 and 18 months after receiving post-partum FP services (phone interview with intervention and control group)

Indicators to Track Whether PPFP services are Improving

Private PPFP Counseling Rooms Created or Designated in Each Hospital

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Hospital Postpartum Ward Services Linked with on-site AFGA FP services for LARC

and Other Method Provision

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Team capacity-building in using QI approaches, FP clinical skills and monthly monitoring of indicators (register created)

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USAID Applying Science to Strengthen and Improve Systems11

% Women with Suspected or Confirmed Pregnancy at 6, 12 and 18 monthsAt 18 mos: Control group=34.7% versus 14% in intervention group

Intervention or Control

Duration since counseling

Sampletargeted for follow up

Sample contactedby telephone

# with suspected and confirmed pregnancy

% suspected and confirmed pregnancy

Intervention Group

3 months6 months12 months18 months

643303217207

303217207149

061221

02.8%5.8%14.1%

Control Group

3 months6 months12 months18 months

681380235196

380235196167

10344358

2.6%14.5%21.9%34.7%


Lessons Learned

• Providers in busy hospitals can use improvement approaches to integrate FP services into routine PP care

• Creating a private space allows family decision-makers to participate in FP counseling

• Creating real-time linkages between postpartum ward and nearby (in-hospital) FP clinic expands method options

• Front-line teams in busy hospitals can track PPFP quality measures using modified local registers• Women receiving a PPFP method may be less likely to become pregnant at 12 & 18 months

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Thank You

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