Charigram, Bangladesh—When her first child was only three months old, Laily Begum learned she was pregnant again. After giving birth, she had no idea that she could become pregnant before her menses returned, even though she was breastfeeding. Begum, 21, realized that within months she would be feeding and caring for a newborn infant and a one-year-old daughter. The prospect overwhelmed her.
Begum is not alone.
Four in 10 of the 186 million pregnancies that occur in developing countries each year are unplanned and many of them occur within a short interval of a previous birth.
Sylhet District, where Begum and her family live, has among the worst health indicators for women and children in Bangladesh. The maternal mortality ratio in Sylhet (471 per 100,000 live births) exceeds the national average of 322 and is the highest in the country. The infant mortality rate is twice what it is elsewhere in the country, according to country health data. Women in Sylhet District have about four children, compared to an average of about three in the five other divisions of the country. Only 32 percent of currently married women of reproductive age use any method of contraception, compared to 56 percent for the country as a whole. And, about 26 percent of women in Sylhet have children who are born less than two years apart, an unhealthy interval that leads to increased risk of poor health outcomes for mothers and their babies.
A visit by a community health worker offered Begum the information she needed to delay her next pregnancy long enough to protect the health and well-being of mother and baby and make it easier to ensure proper care and feeding of all her children. After the birth of a second child, Begum and her husband decided to practice family planning.
The community health worker is part of the Healthy Fertility Study, a partnership of the Bangladesh Ministry of Health and Family Welfare, the U.S. Agency for International Development’s flagship Maternal, Newborn and Child Health Integrated Program (MCHIP), which Jhpiego leads, the Johns Hopkins Bloomberg School of Public Health and two local nongovernmental organizations—Shimantik and the Center for Data Processing and Analysis. The Sylhet study, under way since 2007, is designed to address the unmet family planning need in the postpartum period. It is among the Jhpiego-related presentations to be showcased at the International Conference on Family Planning in Dakar, Senegal (November 29‒December 2, 2011).
With Jhpiego’s technical support, the study tests a package of maternal and newborn health interventions, including postpartum family planning services provided by female community health workers. By including simple counseling messages on pregnancy risks during the first year postpartum, the importance of exclusive breastfeeding and the benefits of healthy pregnancy spacing, together with the provision of pills, condoms and injectable contraceptives, these community health workers are making a difference in the lives of many women in the program area who want to avoid closely spaced pregnancies.
The results from 18 months postpartum have been extremely promising: contraceptive use in the intervention area has increased 20 percent compared to the control area. In addition, through the promotion of effective use of the lactational amenorrhea method (LAM), the study showed an additional increase of 10 percent in the practice and duration of exclusive breastfeeding.
After a home visit by Mousumi Apa, a community mobilizer with the Healthy Fertility Study, Begum and her 26-year-old husband decided to practice family planning following the birth of their second child. Mousumi met with Begum, her mother-in-law and sisters-in-law and counseled them on the return to fertility, family planning methods, where to access the methods and the advantages of wide birth intervals. Begum practiced LAM for 40 days after the delivery of her second daughter and subsequently transitioned to using an injectable contraceptive, which she obtained from the local health clinic.
Community health worker Sajed Apa has provided follow-up doses of the injection to Begum during home visits. This convenience as well as the education provided during her meetings with Apa have pleased Begum.
“Now I know that, after giving birth to a child, there should be at least three years gap to give birth to another child for better health outcomes for the baby and the mother,” says Begum. “There is only 13 months space between my two girls. That’s why neither of the two children gets proper breastfeeding. Even I could not take care of them properly.”
Begum is among more than 4,000 women participating in the Healthy Fertility Study and benefiting from the health education and services. Now she knows the benefits of delaying a future pregnancy for at least 24 months to reduce the risk of poor maternal, perinatal and infant outcomes. And with access to lifesaving contraception, she can practice healthy spacing.
The study has the potential to benefit women beyond those living in Sylhet District. It will be used to inform maternal and newborn health programs on the integration of family planning services and addressing unmet need for family planning in the postpartum period. The MCHIP MaMoni Project has used the model for scale-up in Bangladesh, and other countries have adapted the model. Dr. Catharine McKaig, MCHIP Family Planning Technical Team Leader, discussed the implications of the study at a meeting held in Dhaka last month.
“The Healthy Fertility Study is a landmark study that allows us to examine the effect of an integrated package on key newborn and infant health practices as well as persuasively demonstrate the effect on early contraceptive adoption and sustained use,” said McKaig. “These findings have important implications for the effective integration of family planning in maternal and child health programs worldwide.”