Nutrition and Family

Planning Integration:

Developing programmatic

approaches to addressing

infant and young child

feeding & LAM

Presenter:

Dr. Justine Kavle

Senior Technical Officer, MCSP/PATH

2

Birth-to-Pregnancy Spacing Among All Women Aged 15-

49, All Non-first Births in the Last 5 years, 2008-09

DHS, Kenya

4%

11%

35% 22%

11%

6% 11%

<6 months

6-11 months

12-23 months

24-35 months

36-47 months

48-59 months

60+ months

N of Non-First

Births=4,531

3

54

21 16

35

83

36

18

42

91

48

31

60

130

73

53

78

0

50

100

150

<15 Mos 15-26 Mos 27-38 Mos 39+ Mos

NNMRPMRIMRU5MR

Early Childhood Mortality Rates According to

Birth-to-Pregnancy Intervals, 2008-09 DHS, Kenya

NMR = Neonatal

Mortality Rate

PMR = Perinatal

Mortality Rate

IMR = Infant Mortality

Rate

U5MR = Under-5

Mortality Rate

Children conceived after longer durations were

less likely to be stunted and underweight

1.251.30

1.23

1.16

1.111.07

0.98

0.89 0.82

1.22

1.29

1.191.13

1.111.06

0.98 0.95

0.82

0.4

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

<6 6-11 12-17 18-23 24-29 30-35 36-47ref.

48-59 60-95 96+

Ad

j. R

ela

tiv

e R

isk

Interval in months

Child Malnutrition by Birth to Conception Interval

Stunted

Underweight

265,144 children

Source: Rutstein 2008

Significant Health Benefits of Birth Spacing,

for Maternal, Child Health and Nutrition

For Children

• Lower risk for:

• Stunted and underweight

child

• Small for gestational age

• Low birth weight

• Preterm birth

• Lower rates of newborn,

infant, and child mortality

Rutstein SO, 2008, Conde-Agudelo A, 2006, Zhu BP, 2005, King JC 2003

For Mothers

• More time to breastfeed,

improving infant health

• More time for women to

recover physically and

nutritionally between births

• Lower risk of maternal death

Lactational Amenorrhea Method (LAM)

LAM is a modern and effective method of family planning

(FP) based on the natural effect of breastfeeding on

fertility.

Menstruation has not returned

Mother is only breastfeeding

Baby is less than 6 months

LAM: Efficacy established in clinical research studies

Trial Multi-

center

Ecuador Chile Philippines Pakistan

N 519 330 422 485 391

# of

Pregnancies

5 1 1 2 1

Efficacy 98.5 99.9 99.6 99.0 99.4

Labbok et al, 1997, Perez et al 1992, FHI 1994a, FHI 1994 b, Wade, Sevilla and Labbok, 1994

Exclusive Breastfeeding and LAM:

Dual benefits for mother and baby

1. Prevents neonatal and infant illness

2. Prevents neonatal and infant mortality

3. Supports growth and development

4. Stimulates uterine contraction- reduce postpartum blood

loss

5. LAM promotion increased exclusive breastfeeding

- 58% intervention vs 47% in control group (p <0.01) in

Healthy Fertility Study

Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP, 2010

Early initiation of LAM or other FP method is

important if couple doesn’t not want to become

pregnant right away

Fertility May Return Soon after Delivery

• If not breastfeeding, ovulation will occur at 45 days

postpartum on average and as early as 21 days

• Breastfeeding women not practicing LAM are likely to

ovulate before return of menstrual period

- Between 8% and 10% of women conceive within the

first year postpartum

Integration;

Maximizing routine contact points

Pre-pregnancy adolescent

s

Antenatal Care

(ANC) visits 1-4+

Birth

• home

• facility

PNC visits

• home

• facility

Immunization visits

Introduction of complementary foods, return to

fertility

Measles immuniz.

Pharmacy/ drug shop

visits

Pregnancy Neonatal

period

Post-neonatal → 2nd year

Birth Spacing and Maternal, Infant and Young Child

Nutrition (MIYCN) Linkages

Lactational amenorrhea

Fertility return

Maternal nutrition

Maternal survival

Exclusive breastfeeding

Complementary feeding

Infant and young child

nutrition

Infant survival

Approach to MIYCN-FP Integrated

Service Delivery in Kenya

12

• Designed collaboratively with national and district

Reproductive Health (RH) and Nutrition stakeholders

• Informed by findings from formative assessment

• Implemented in 6 health facilities and adjacent

community units in Bondo, Kenya

• Implementation ran for ~ 1 year

Health Facility Approach

13

• A “One Stop Shop” model where

both FP and nutrition services are

accessed in the same room at various

service delivery points:

• ANC

• Intrapartum

• Postnatal Care (PNC)

• Well-child

• Family planning (FP)

counseling visits

• MIYCN/FP job aids, poster, brochure

used to support integration efforts

14

Community Approach

• Inclusion of MIYCN-FP messages within

routine community outreach activities

• Counseling cards, brochure, poster used

to support integration efforts, and serve

as complement to existing community-

level reproductive health (RH) and

nutrition materials

Greater Integration of Counseling and Services at Health Center

Versus Hospital Level, Bondo District

Bondo Sub-County Hospital Bondo Health Centers (x2)

# of

Clients

Total

Clients

Percentage

of total

Number

of clients

Total

clients

Percentage of

total

ANC

Nutrition 32 57 56.1% 21 23 91.3%

FP 1 57 1.8% 13 23 56.5%

LAM

counseling

0 57 0.0% 9 23 39.1%

Nutrition &

FP

1 57 1.8% 13 23 56.5%

Bondo Sub-County Hospital Bondo Health Centers (x2)

# of

Clients

Total

Clients

Percentage

of total

Number

of clients

Total

clients

Percentage of

total

PNC

Nutrition 19 29 65.5% 22 25 88.0%

FP 10 29 34.5% 21 25 84.0%

LAM

counseling

2 29 6.9%

15 25 60.0%

Nutrition &

FP

counseling

7 29 24.1%

21 25 84.0%

Nutrition &

FP services

21 228 9.2% 68 152 44.7%

Greater Integration of Counseling and Services at Health Center Versus Hospital Level, Bondo District

Exclusive Breastfeeding

0

10

20

30

40

50

60

70

80

90

Jul-Sept 12 Oct-Dec 12 Jan-Mar 13 April-June 13

% of Children Under 6 Months

Exclusively Breastfed,

Bondo District Hospital

(Source: CHIS)

“I have 3 exclusively

breastfeeding mothers and

one has a child who is

already 6 months. Some

know that when they are

breastfeeding exclusively

they cannot get pregnant...”

-- CHV, Bondo

Findings • Health workers saw benefits for infant health, noted client

willingness to transition to other FP methods.

• Majority of health workers demonstrated knowledge of

MIYCN-FP, however refresher training offered on return to

fecundity, LAM criteria and transition to address gaps.

• Challenges completing MIYCN-FP supplemental registers,

however providers reported marked increases in number of FP

clients.

• Greater integration of counseling and services at the health

center versus the hospital level. “One stop shop” approach

worked most effectively in the dispensary and health centers.

Factors Enhancing Success

• Buy-in from national and district nutrition + RH stakeholders

• Strategically designed social and behavior change communication

(SBCC) materials & working tools

• Supervisor buy-in, leadership, and on-the-job mentoring

• Involvement of community and religious leaders, male partners,

mothers/mothers-in-law

• Human resource availability and continuity

• Availability of FP methods and equipment

• Whole site trainings, especially at facilities where staff rotations

routinely occur

Recommendations for expanding

MIYCN-FP integration

• Involve sub-county health management team (SCHMT) and

hospital management teams to build buy-in and enhance

sustainability

• Pair facility-based integration with community maternal,

newborn, child health (MNCH) efforts – building health

provider capacity

• Build support among facility supervisors, health workers, and

community and religious leaders

• Encourage family members’ support of exclusive breastfeeding

• Engage champions

• Focus first on health centers with high client loads

For more information, please visit

www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the

United States Agency for International Development (USAID), under the terms of the Cooperative

Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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