Gaps and evidences on programming postpartum family planning services in Nepal

Ethical approval

Due to COVID-19 restrictions, data collection was completed via telephone with oral approval taken from the staff participating in the study to provide information prior to the interview. This work was done at the programmatic level hence ethical approval was not taken from an IRB. Approval for the study was obtained from the Ministry of Health and Population – Family Welfare Division, with the recommendation that verbal consent was obtained from participants prior to participation in the study.

Study design

A combination of three methods was used to conduct this situational analysis: (i) desk review of documents and literature published on PPFP in Nepal, (ii) secondary analysis of NDHS 2016, and (iii) rapid assessment of health facilities. The original study design included rapid assessment at eight health facilities, but COVID-19 related travel restrictions prevented that thus the information was collected over telephone. Data collection was done from December 2019-to May 2020.

(i) Desk review- Information for this analysis was collected using a non-systematic search strategy from the following electronic databases - PubMed and Google Scholar for all studies published between 2015 and 2020 in the English language. The following search terms were used: ‘postpartum family planning’, in combination with ‘policy, strategies and guidelines’, ‘human resources or training or work force’, ‘health management information system’, ‘commodities supplies or supply chain management’, ‘budget, resources’, and ‘community or male/men engagement’. Additionally, national policies, strategies, reports (annual reports of the Department of Health Services (DoHS) and NHFS), working papers, policy briefs, and conference presentations on PPFP were reviewed from the websites of MoHP (https://www.mohp.gov.np/eng/) / DoHS (https://dohs.gov.np/) / FWD (https://fwd.gov.np/) and other agencies including the Family Planning Association of Nepal, the Embassy of United States of America, Marie Stopes International, United States Agency for International Development Nepal, United Nations Population Fund, The Adventist Development, and Relief Agency, Nepal CRS company.

(ii) Secondary analysis of NDHS 2016- The NDHS 2016 was analyzed further using descriptive statistics, to determine the use of FP services, unmet need for FP, and contact points for women during the period from the last birth through 12 months postpartum. Secondary data analysis was conducted for 962 women with the dataset from NDHS 2016, which was based on a two-stage, stratified, nationally representative sample of households. NDHS 2016 survey is the latest national-level survey done on FP and other reproductive health components. The data are open for all¹⁰. There was no data and information regarding the postpartum FP in the regularly published report. Hence, we conducted a secondary analysis to retrieve additional information on PPFP. No other special inclusion and exclusion criteria in addition to postpartum criteria. The data was also used to analyse the patterns in contraceptive uptake in the postpartum women based on the following variables: birth order (1^st,2^nd, 3^rd), province (Bagmati, Gandaki, Karnali, Province 1, Province 2, Province 5, Sudur Pachhim), place of residence (Urban, Rural), education level (no education, primary, secondary, SLC & above), religion (Hindu, Buddhist, Muslim, Christian) and wealth quintile (richest, richer, middle, poorer, poorest).

(iii) Rapid assessment of health facility – Eight health facilities (four hospitals, two primary health care centers, and two health posts) with birthing centers were purposively selected for the assessment from Province no. 1, Bagmati and Lumbini provinces. We excluded health facilities without a birthing center. The key service providers were telephonically interviewed to collect the information. Two standard checklists were developed (one for hospital and another for primary health center and health post¹³, that consisted of questions on: the availability of FP services in the facility during the last three months, type of PPFP services in facility, details on FP counseling during ANC, immediately after delivery, post delivery room, post-natal, immunization and nutrition clinics, availability of IEC materials and guidelines/protocols on PPFP in facility, supply of FP commodities, and participation of staff in PPFP training in last 12 months. The interviewer contacted the main service provider of the health facility, who was identified from the records of the Family Welfare Division and the concerned District Health offices. They were informed about the purpose of the assessment and collected information using the checklist after getting verbal approval. It took approximately 60–90 minutes for the interview. The checklists were manually analyzed, by preparing dummy tables and entering data into these tables from the information in the checklists. Further interviews by telephone were conducted in two health facilities to collect missing information. While reviewing the checklist, a few points were missing, so the interviewees were called again to fill in missing data/information in the checklist.

A consultation meeting was held with 21 national stakeholders working in the area of family planning (government, non-government organizations, FP experts, and UN agencies) to share the objectives, methodology and findings of this analysis. These stakeholders were identified through the Family Welfare Division. They are members of the FP Sub-committee under the Family Welfare Division. Additional members were invited as FP experts who had contributed to the FP program in the past but did not hold any position formally. They were sent an email invite and their inputs were collected on the findings of the analysis. A blank English form was distributed to them for collection of their inputs especially on solving the problems identified in the draft report and recommendations from the situational analysis. The form collected their recommendation based on the thematic areas like health services, health workforce, medicine and technology, health financing, leadership and governance, and community and social-cultural issues. Their inputs were analyzed manually and used for the recommendations.

Health services

Availability of FP services across different health facilities. There are 3,808 health posts (HPs) in Nepal that serve as the first institutional contact point for service delivery. These health posts provide services and monitor activities of female community health volunteers (FCHVs) and centers for community-based activities. The minimum service standards (MSS) for HPs includes availability of FP services between 10 am to 4 pm, with a separate space for FP counseling and services and a dedicated health staff assigned¹⁵. The district hospital MSS does not mention any standards for FP service provision. The MSS at tertiary hospital includes availability of FP services between 10 am to 3 pm with a minimum of two mid-level health staff assigned for FP services¹⁶.

In Nepal, short acting reversible contraceptives (male condoms, oral pills, and depo injection/injectables) are provided through primary health care outreach clinics (PHC-ORC), primary health care center (PHCCs), and HPs. Long-acting reversible contraceptives (IUCDs and implants) are only available in hospitals, PHCCs, and selected HPs with trained and skilled providers¹⁷. The FCHVs provide information and educate the community, distribute condoms and resupply oral contraceptive pills. Table 1 shows the contraceptive methods offered by different levels of the public health system.

The National FP strategy 2011–12 envisioned the availability of five types of temporary FP methods (male condoms, pills, depo injection, IUCD, and implants) in all health facilities including PHCs and HPs¹¹. However, the NHFS 2015¹⁸ showed that only 14% of health facilities provide all five types of modern methods, while 93% of facilities provide three modern contraceptives (pills, depo injection, and male condom). Male and female sterilization services was offered by < 3% of health facilities, while IUCD and implants were offered by 20.9% and 19.8% facilities, respectively¹⁸.

Findings from the rapid assessment of health facilities is depicted in Table 2. Our assessment showed that five temporary FP methods were available in seven out of eight surveyed facilities. Male and female sterilization services, PPIUD, and postpartum tubal ligation were available in three out of four hospitals. All included facilities offered at least one PPFP method. The lack of trained service providers was the reason for one health post not offering IUD and implant services and one hospital not offering male and female sterilization services.

Availability of service guidelines, trained staff, and equipment. To offer quality FP services to clients, health facilities should have trained health providers, national FP guidelines, and adequate FP supplies. Around one-third (31%) of the eight facilities offering modern contraceptives have at least one staff trained in the past 24 months on some aspect of FP service delivery¹⁸. According to NHFS 2015, FP guidelines were available in 13% of facilities offering modern contraceptives, 29% of zonal and above hospitals, and were unavailable at all the urban health centers. Only 1% of private facilities have the FP guidelines available, as compared to 14% public facilities. The FP registers and FP kits were available in 89% and 29% of facilities.

The rapid assessment survey showed health staff from three facilities were trained in PPFP in the last 12 months and Medical Eligibility Criteria (MEC) wheel for contraceptive use and Decision Making Tool (DMT) were available at six facilities.

Utilization of FP services. Secondary data analysis of NDHS 2016 showed that the total unmet need for FP among postpartum women was 31.5% (17.8% for spacing and 13.7% for limiting) and this increased steadily from childbirth (21%) to end of five months after birth (34%). The unmet need for spacing among postpartum women (17.8%) is more than twice of that among currently married women (8%). The unmet need for spacing is highest among those aged 15–19 (33.5%), while unmet need for limiting is highest among 40–44 year old (26.9%). The mCPR is 46% lesser among postpartum women compared to currently married women (22.6% vs. 43%). Table 3 compares the FP indicators between all currently married women¹⁰ and women in the postpartum period.

The mCPR steadily increases from childbirth to end of one year, from 4% at < 2 months to 31% at 9–11 months. Figure 1 depicts the contraceptive uptake during postpartum period.

Figure 1. Trends in use of contraceptives during the postpartum period.

The three most popular contraceptive methods among postpartum women in Nepal are injectable depo/ injectables (8%), male condom (6.7%), and combined oral pills (2.5%), as compared to female sterilization (15%), male sterilization (6%), and injectable (9%) among all currently married women¹⁰. Use of traditional FP methods is similar among postpartum women (10%) and all currently married women (9%). The contraceptive prevalence rate (CPR) for all methods is highest among postpartum women aged 35–39 years (46%) and least among postpartum women aged 40–44 years (26%). Table 4 depicts the CPR among postpartum women by background characteristics.

Further analysis of NDHS 2016 showed the most common source of modern contraceptive methods among postpartum women is a health post or a sub-health post (31%), followed by a pharmacy (23%). Nearly 14% PP women avail the method from government hospitals. However, in private health facilities, 7.9% of postpartum women uptake PPFP.

Integration into reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH+N) services. Women are more likely to engage with the healthcare system throughout pregnancy and the first year following childbirth, for ANC visits, childbirth, PNC visits, and immunization of infant. In Nepal, 84% of women received ANC from a skilled provider, 57% women had institutional delivery, 57% received PNC within 48 hours of birth, and 98% of children received at least one vaccination during their 1^st year of life^10,19. However, among women who had a live birth, only 13% were given information on FP during the postpartum period¹⁰. A further analysis of NDHS 2016 confirmed that among 53.3% of postpartum mothers who were not using any contraceptives and were visited by a field worker in the 12 months preceding the survey, only 42% of them were counseled about FP. Similarly, of the 86% of postpartum mothers not using any contraceptives who visited a health facility in 12 months preceding survey, only 22% were told about FP.

The rapid assessment survey showed that seven facilities offered FP counseling during the ANC period, although no specific guidelines on counseling during ANC were available in these facilities. Three facilities offered FP counseling prior to discharge from the maternity ward. A dedicated space for FP counseling was available in five facilities.

Health workforce

In-service training- The majority of service providers in Nepal are trained on FP through in-service training. The National Health Training Center (NHTC) conducts FP trainings for different cadres of health staff. Among them, the comprehensive FP and counseling service training curriculum includes a separate chapter on PPFP, covering topics of extended PPFP, return to fertility, and post-partum contraceptive methods, including Lactational amenorrhea method (LAM)²⁰. In 2015, the Nepal Society of Obstetricians and Gynecologists (NESOG) with support from the International Federation of Gynecology and Obstetrics (FIGO) initiated a project to institutionalize immediate PPFP services by offering PPFP/PPIUD counseling and services²¹. The three- year project (2015–18) was conducted in two phases at eight hospitals. During the first phase 383 service providers were trained on PPIUD²². Following this, service providers were mentored to enhance knowledge, attitudes and skills. No further PPIUD training programs were conducted after the end of this project.

Pre-service training- The Bachelor of Science (BSc). Nursing courses, medicine, and paramedical courses curriculum were reviewed, and it was realized that none of them included content on PPFP^23–25. Though, the Bachelor of midwifery curriculum at the Kathmandu University included content on postpartum IUCD²⁶.

National tools and staff development- The Government of Nepal strengthened FP services by use of decision-making tool (DMT) and WHO medical eligibility for contraceptive (MEC) in five provinces and 16 districts. Both these job aids comprised of information about PPFP. A two-day orientation was conducted for staff of hospitals, PHCCs, and health posts. Similarly, FP micro planning was achieved in three provinces²⁷.

Health management information system (HMIS)

The HMIS Recording and Reporting Guidelines 2019²⁸, requires any person visiting a health facility for any type of FP service, to fill up designated registers and forms: master register (HMIS 1.1), health service card (HMIS 1.2), referral slip (HMIS 1.4), defaulter/discontinuation tracing slip (HMIS 1.5), tally sheet (HMIS 1.6), FP face sheet (HMIS 3.1), pills and depo register (HMIS 3.2), IUCD/ implant register (HMIS 3.3), and sterilization service register (HMIS 3.4).

Additionally, the maternal and newborn health card (HMIS 3.5) has a separate column to record PPFP use within 48 hours of delivery. Similarly, maternal and newborn health service register (HMIS 3.6) has a separate column to record PPFP services availed. The service providers should fill in column no 26 with a number; 1 for temporary short acting FP methods, 2 for temporary long-acting FP methods, and 3 for permanent methods. The FCHV register (HMIS 4.2) also consists of a column on PPFP. All information on PPFP from PHCC, HP, urban health clinic/center and community health unit monthly reporting form (HMIS 9.3), or hospital level monthly reporting form (HMIS 9.4) should be compiled and reported to the higher-level institutions²⁸.

Although the PPFP program managers’ guide, Nepal (2018), recommends use of stamp pad on ANC and PNC cards to report use of PPFP services and provides an algorithm for recording and reporting of these services²⁹, the ANC card does not document any information on FP counseling. The NFHS and NDHS does not collect information and data on PPFP.

Rapid assessment survey showed that FP counseling during ANC, PNC, before discharge from maternity ward, and immunization was recorded/documented at facilities 6, 5, 3, and 7 respectively. Three facilities report FP counseling and services to hospital HMIS and FP clinic once a month.

Medicines and technology

In 2015, the MoHP developed the National Reproductive Health Commodity Security (RHCS) Strategy, with an aim to ensure a secure supply and choice of quality contraceptives and other reproductive health (RH) commodities to meet every person’s needs at the right time and in the right place³⁰.

In 2016, UNFPA conducted a facility-based assessment of RH commodities and services at 585 health facilities (government, non-government, and private) in Nepal and results showed stock-out of male condoms, OCPs, injectables, IUDs and implants in 4%, 5%, 7%, 16%, and 32% facilities³¹. The DoHS annual report 2017–18 showed was out of stock for condoms, injectables, and OCPs in 9%, 8%, and 13% of the 5000 facilities surveyed³².

Our rapid assessment survey showed contraceptive supply was available for three months in seven facilities, while one facility had problems with the supply due to COVID-19 related transport restrictions.

Health financing

Nepal joined the FP 2020 movement in March 2015 and committed to increasing the Government FP budget by 7% each year up to 2020 and aimed to increase the number of additional users of FP by an estimated one million by 2020, provided the proportion of demand satisfied increased by 71% by then³³. The Government of Nepal (GoN) has increased its budget by 32% in FY 2016/17 and 22% in FY in family planning programs³⁴. An adequate flow of funds to manage the National FP program ensures that people receive regular FP services in all parts of the country.

The National Family Planning Costed Implementation plan (NFP-CIP) 2015–2020 was developed¹², to articulate national priorities for FP and provide guidance at national and district levels on evidence-based programming for FP to achieve the expected results, as well as to identify the resources needed for CIP implementation. However, this plan is not being thoroughly reviewed and applied by donors and agencies while developing a family planning program. Lack of an annual FP work plan further increases the likelihood of work being duplicated. In addition to MoHP, major agencies working towards strengthening FP in Nepal are United States Agency for International Development (USAID), Department of International Development (DFID), United Nations Population Fund (UNFPA), International Planned Parenthood Federation (IPPF), Marie Stopes International (MSI) and Ipas Nepal.

Leadership and governance

Family Planning is a priority program of GoN and a component of the RH package, essential health services of Nepal Health Sector Program II (2010–2015), National FP-CIP 2015–2020, Nepal Health Sector Strategy 2015–2020 and the GoN’s commitment to FP 2020³⁵.

The focus of National FP Strategy 2011/12¹¹ was to increase access to quality FP services in rural and marginalized communities and implement focused FP programs to fulfill the needs of special groups like post-partum mothers, post-abortion clients, migrants, and adolescents¹¹. Integration of PPFP services into routine FP and RH services is one of the strategic efforts stated in the National FP Strategy (2011/2012)¹¹ and National FP-CIP (2015–2020)¹².

The National Medical standard (NMS) for RH services Volume one (contraceptive services) set standards for provision of quality FP services at different levels of health care facilities. This standard was last revised in 2010 and includes chapters on PPFP, counseling, and informed choice³⁶. It is currently under further revision.

In 2010, the MoHP/FWD, with support of Nepal Family Health program, developed a PPFP reference book³⁷ to initiate PPFP services at the intervention hospitals in Nepal and to orient service providers, managers, and other staff of intervention districts. The National FP-CIP 2015–2020 envisioned developing PPFP strategy and operational guidelines by 2020¹². The MoHP/FWD has not developed a separate strategy or guideline on PPFP yet. It has recently drafted a Nepal safe motherhood and neonatal health roadmap 2030 emphasizing the importance of PPFP and recommending its promotion³⁸.

The Nepal Health Sector Strategy Implementation Plan (NHSS-IP) 2016–2021¹² aimed to increase CPR to 55% and reduce unmet need to 19.5% by 2020. The plan aims to improve method mix, expand PPIUCD services in 400 birthing centers and integration of FP into immunization, postpartum care, post-abortion care, HIV intervention in 20 districts by 2021³⁹.

The rapid assessment survey showed that none of the facilities have any special guidelines and protocols on PPFP.

Community and sociocultural issues

A study among 400 postpartum Nepali mothers showed 68.5% of them had a positive attitude towards use of PPFP⁴⁰. Another study on integration of FP services into an expanded program on Immunization (EPI) among women in a rural district of Nepal, found that more than half of them interviewed did not realize that they were at risk of pregnancy if they gave the infant supplementary food⁴¹.

The median birth interval in Nepal is 36.7 months; with 21% births occurring in less than 24 months after previous childbirth. The inter-birth interval remained constant since 2011 at 21%. There was a decline among infants who were exclusively breastfed from 80% at 0–1 month to 41% at 4–5 months¹⁰.

Organized FP programs in Nepal traditionally focus primarily on women⁴², hence knowledge among men is poor. Male involvement in FP counseling is important as they are often the decision makers and women may hesitate to take decisions without the approval of their partners⁴³.

The rapid assessment survey showed five facilities have FP related IEC material, but none of them have the provision to take the IEC material home. Two facilities facilitate dissemination of PPFP related messages at the community level.

Study limitations

Due to the COVID-19 pandemic restrictions, we were only able to conduct limited number of health facility assessments by telephone.

Recommendations

On the basis of the findings from this review, we propose the following recommendations (Table 6) for strengthening PPFP programming in Nepal.

Underlying data

Figshare: List of Reviewed Documents according to category.docx. https://doi.org/10.6084/m9.figshare.20098871.v3¹⁴.

The project contains the following underlying data:

Extended data

Figshare: Questionnaires for Rapid assessment of health facility for PPFP services. https://doi.org/10.6084/m9.figshare.20098898.v1¹³.

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).