Dr. Pandora Hardtman CNM, FACNM, FAAN is the Chief of Midwifery and Nursing, Jhpiego and Dr. Emi Nurjasmi, MPH, RM, is the President, Indonesian Midwifery Association
As midwives, we are passionate about the holistic role that those in our profession play in supporting women’s and girls’ wants and needs throughout their reproductive years and beyond. At the heart of this is an understanding that what midwives do—or fail to do—for women in the months during and after pregnancy impacts so much more than just this finite period of time.
It is well-established that access to effective family planning methods can have sweeping effects on the overall health and well-being of women. It influences how they care for their children and families, which in turn, impacts the health of communities, economies, and countries.
Offering contraceptive counseling and services as part of facility-based perinatal care prior to discharge is also recognized as a high-impact practice that can dramatically improve maternal and child health outcomes and save lives. Yet, post-pregnancy is the period of highest unmet need for contraception in a woman’s entire life: 61% of postpartum women want to space or prevent their next pregnancy within their first year postpartum but are not using family planning.
This window offers a pivotal opportunity to counsel women and their families about their options and ensurethat those who want contraception leave the facility with a method that is right for them. By extension, this same intervention could play a transformational role in unlocking several of the most urgent development priorities, including increased access to education, economic empowerment, and food security.
“In Kenya, the main reason women didn’t take up family planning after childbirth was the sentiment that they had to heal first. This provides an auspicious opportunity to counsel postpartum women about contraceptive safety and the benefits of healthy spacing on maternal and newborn health outcomes.”
Midwives are one of the strongest links to women, particularly now during the COVID-19 pandemic with so many delaying routine health services, and when women can benefit from the proximity and reliability that midwives offer. We must seize on this moment when women are in our care to offer the full range of services they want and need to thrive. That is our calling and our mandate.
Results from a groundbreaking five-year study offer compelling new evidence that should encourage every midwife to rethink their routine postpartum care and broader work environment. Led by Jhpiego and funded by the Bill & Melinda Gates Foundation and MSD for Mothers, Post-Pregnancy Family Planning Choices, or PPFP Choices, set out to generate actionable evidence to increase women’s access to and use of family planning immediately post-pregnancy. Now in its concluding months, it was informed by health care providers, facility managers, community leaders, policy makers, and some 9,000 clients in Indonesia and Kenya. It examined both public and private healthcare settings in both countries, whose vastly different contexts yielded important and diverse insights.
In Kenya, the midwifery community now has a clearer picture of how cultural or religious beliefs cause perceptions of low demand for PPFP among private sector providers. Many of those providers also say they were unaware of the World Health Organization’s guidelines recommending PPFP, and that they are “left out” of critical training opportunities. In Indonesia, a lack of coordination around PPFP education, training, and delivery was a commonly cited barrier, and bureaucracy in the insurance scheme created “extra work” for providers. With proper training and support for midwives, whether they work in public or private facilities, PPFP can become more seamlessly integrated into the standard care.
The counseling imperative
We also have a more nuanced understanding of the barriers women face—both large and small. In Kenya, the main reason women didn’t take up family planning after childbirth was the sentiment that they had to heal first. This provides an auspicious opportunity to counsel postpartum women about contraceptive safety and the benefits of healthy spacing on maternal and newborn health outcomes. In Indonesia, when counseling was provided during antenatal visits, at the time of delivery, immediately after birth, or six months after, people’s likelihood of using contraception increased significantly. It is clear that counseling makes the difference.
For many women, the immediate post-pregnancy period is the most likely time they will encounter a healthcare provider. Thus, it is vital that the idea and resources for family planning are introduced and available after birth or pregnancy loss.
Midwives must build upon their valuable relationships to educate the women and families in their care, and together encourage family planning awareness and use for those who wish to space or limit their next pregnancy. As demand grows, public and private facilities, regulatory bodies, midwifery schools, and governments alike will be compelled to elevate and prioritize post-pregnancy family planning along the continuum of care—in midwifery education, ongoing training, and support; in budgets and financing; and in services and supplies available in public and private facilities.
Through PPFP, midwives can more fully embrace their role as trusted healthcare providers and strengthen their partnership with the women in their care. In this way they fulfill their professional responsibility and personal commitment to women, while embracing the full scope of their competencies. What can follow is abeautiful and transformational experience for midwives and women— and indeed a world where babies are born by choice, not by chance.