“A Rolling Thunder of Events”

Postpartum Family Planning and Postabortion Family Planning as High Impact Practices

Around the world, close to 287,000 women and girls die each year from pregnancy or delivery-related causes, and expanding access to voluntary family planning could prevent over 100,000 of these maternal deaths annually. Despite this, an estimated 218 million women in low- and middle-income countries have an unmet need for family planning, meaning they want to prevent or delay a future pregnancy but are not using a modern method of contraception.

Postpartum and postabortion family planning are recognized as High Impact Practices (HIPs)—evidence-based practices that have demonstrated impact on increasing access to and use of modern contraceptive methods. The practice of providing family planning counseling during antenatal care and during the postpartum and postabortion period can improve women’s and their partner’s knowledge and comfort with contraception, increasing the likelihood that they will use it to avoid unplanned or closely spaced pregnancies in the future.

However, despite proven benefits, the global scale-up of PPFP and PAFP services has encountered several persistent challenges. Many barriers continue to hinder progress, including restrictive country policies, harmful social and gender norms that limit youth access to contraception, and limited provider capacity. Additionally, a lack of integration between family planning and maternal and newborn health (MNH) services in budgets, policies, and delivery further complicates efforts to expand access. As the global family planning community works to strengthen and expand PPFP and PAFP, it is essential to focus not only on the proven benefits of these practices but also to be mindful of the social and cultural contexts in which these services exist, ensuring that all programming centers around a human rights-based approach.

A Rolling Thunder of Events: The Precursors to the Call to Action

Recognizing the need for a bold and comprehensive strategy to advance PPFP and PAFP, a group of global partners came together in December 2023 to publish a Call to Action to scale-up access to contraception during the postpartum and postabortion period. However, a series of earlier events laid the groundwork for this critical initiative and publication.

In 2023, the focus on reducing maternal mortality intensified as the global community approached the midpoint of the Sustainable Development Goals (SDGs). Because PPFP and PAFP are recognized as evidence-based interventions to advance maternal health outcomes, the world witnessed renewed interest in these critical areas. This momentum, described by Saumya Ramarao, as a “rolling thunder of events,” included a string of large-scale conferences, events, and PPFP and PAFP-related projects that brought advocates together to address the key question of why there had not yet been significant momentum in their scale-up.

Amidst this backdrop, the global health field was witnessing a rise in countries introducing universal health coverage (UHC) and primary health care (PHC) packages, which presented exciting opportunities for integration but also raised concerns from family planning and MNH stakeholders about ensuring that PPFP and PAFP were not overlooked. One particular concern was that, while the spectrum of labor and delivery services—including PPFP and PAFP—is considered part of PHC, lifesaving MNH interventions are often not delivered at primary care facilities (although they are part of a comprehensive PHC approach), putting these interventions at risk of being left out of key PHC policies and guidelines.

As such, advocates emphasized the importance of collaborating with policymakers and country stakeholders to ensure PPFP and PAFP’s inclusion in these frameworks, with Ramarao underscoring the urgency of this work, stating, “If these UHC and PHC plans roll out without inclusion of PPFP and PAFP, if we miss the boat now, we won’t get that momentum later, and we risk this work remaining fragmented.”

#StrongerTogether: Efforts to Bridge the Gap Between Maternal and Newborn Health and Family Planning

Despite global advances in antenatal care and the rate of facility deliveries, immediate PPFP and PAFP have not seen the same improvements, highlighting a systemic failure to effectively integrate family planning with MNH care. This issue is worsened by the way global funding is structured, as family planning and maternal health funding is often siloed, with specific restrictions on how resources can be used, further complicating integration efforts. As long as these funding streams remain vertical and unaligned around shared health outcomes or over the life course, efforts to integrate these complementary fields will continue to face significant challenges. 

Emphasizing the broader implications, Vandana Tripathi sheds light on the widespread nature of these challenges:

With systemic barriers keeping family planning and MNH services apart, the struggles towards achieving integration can feel overwhelming. To help address these challenges, Tripathi shares a suggestion put forward by Jane Wickstrom, Senior Technical Advisor at USAID, which invites a thoughtful reconsideration of how family planning and maternal health care are interconnected.

While Wickstrom’s suggestion represents a goal to strive for—where MNH services fully include PPFP and PAFP as inherent components—this goal has yet to be realized. Additionally, many working in this space, including prominent funders, organizations, and communities of practice, continue to rely on the “integration’” terminology to describe efforts to bring these services together.

However, to continue alignment efforts, FP2030, MOMENTUM Safe Surgery, and FIGO worked in 2023 to chart a roadmap of events with promising opportunities to strengthen family planning and MNH integration. Events in April and May 2023 started the conversations on evidence for coupling family planning with maternal health, including a side event co-hosted by FP2030, FIGO, and the International Confederation of Midwives (ICM) at the International Maternal Newborn Health Conference. This was followed by additional convenings for medical practitioners like the ICM Conference, as well as more technical and advocacy-focused events like Women Deliver. Through these events, the coalition continued to build momentum towards the Call to Action, engaging a wide range of stakeholders across the globe. Throughout the year, they used the hashtag #StrongerTogether, emphasizing the importance of bringing together family planning and MNH practitioners to collaborate towards their common goals.

Including All Voices: Crafting the Call to Action at the Dar es Salaam Global Consultation

Following a series of global family planning and reproductive health events in early 2023 where advocates pushed for increased momentum around PPFP and PAFP, the MOMENTUM Safe Surgery project brought together key partners for a pivotal global consultation in Dar es Salaam, Tanzania, in June 2023. The meeting, titled “Revitalizing and Scaling Up Postpartum and Postabortion Family Planning within Universal Health Coverage,” convened a diverse group of stakeholders including multilateral organizations, NGOs, and key global and local partners, including the Bill & Melinda Gates Foundation, FP2030, and the World Health Organization (WHO).

Throughout the three-day event, participants reviewed country case studies that highlighted both progress and challenges in scaling up PPFP and PAFP. Presentations also explored how the three pillars of UHC—access, service delivery, and financing—intersect with PPFP and PAFP efforts, while delving into key issues such as task sharing, private-sector engagement, and digital health interventions.

The heart of the workshop, however, lay in a collaborative exercise aimed at capturing a comprehensive list of the priority PPFP and PAFP actions that attendees felt most passionate about and thought needed urgent action. After initial discussions on the key issues shaping PPFP and PAFP within UHC, participants divided into four groups to delve deeper into the identified challenges and to propose actionable solutions. Following a series of participatory “voting” exercises, the group narrowed down their list, coming to consensus on what they felt were the most critical priority actions for strengthening PPFP and PAFP scale up, quality, and coverage within UHC and PHC frameworks.

Recognizing that key stakeholders—such as leaders from the maternal health community, those designing and implementing PHC frameworks, representatives from the Global Financing Facility, and more—were not present at the Dar es Salaam consultation, the collaborative list of priorities was next shared with a number of external partners, including ICM, FIGO, and UNFPA, to gather additional insights and garner stronger buy-in from these important entities.

This input enriched and strengthened the initial list, offering new perspectives that deepened the group’s understanding of key priorities. For example, Margaret Bolaji, a representative from the FP2030 North, West, and Central Africa (NWCA) Regional Hub, helped the group think more deeply about youth inclusion, while representatives from UNFPA pushed the collective to think more about how this work can center a rights-based approach, and FIGO members encouraged inclusion of PPFP and PAFP indicators in national Every Newborn Action Plan frameworks. This extensive feedback process helped the group reach consensus on the five priority actions, which were introduced in a draft Call to Action at the FIGO World Congress in October 2023. After final revisions concluded, the official Call to Action was released on UHC Day on December 12, 2023.

The five priority actions endorsed within the 2023 Call to Action to scale-up PPFP and PAFP in the UHC and PHC contexts:

Translating Global Priorities Into Country-Level Action: The Nepal Workshop

The 2023 consultation in Tanzania focused on bringing together practitioners from around the world to generate fresh thinking and innovative solutions for scaling up PPFP and PAFP within UHC and PHC and to identify the priority actions that would become the global Call to Action. However, while the Call to Action was designed to be a high-level global initiative—with rich insights shared from partners around the world—the true success of the Call to Action will be determined as countries continue to prioritize and engage with these issues, identifying key action items for their own contextualized action plans. 

One notable example of this continued engagement took place in November 2023 at a workshop hosted by FP2030 and USAID in Kathmandu, Nepal. Titled “Accelerating Access to Postpartum and Postabortion Family Planning,” the event gathered representatives from 15 countries in Anglophone Africa and Asia, including government officials working in MNH and family planning, civil society participants, global donors, and technical experts. 

As the workshop attendees came together, including during a session on the soon-to-be launched Call to Action, tangible progress emerged. One of the critical outcomes of the Kathmandu workshop was the development of three key action items by each country delegation, which they committed to advancing. For example, delegates from Bangladesh prioritized a focus on strengthening partnerships with the private sector. These commitments were not just theoretical, as delegates from countries like Sierra Leone and Rwanda have already followed through on some of these commitments and have presented their progress at the USAID Postabortion Care Connection community of practice meeting in April 2024. Furthermore, attendees from Rwanda shared their progress towards introducing PAFP indicators in their health management information systems (HMIS), while Sierra Leone representatives developed national PAFP guidelines and updated their HMIS tools to include PAFP indicators. These efforts are part of an ongoing exchange, with countries continuing to share experiences post-workshop in a series of virtual whiteboard sessions convened by the MOMENTUM Country and Global Leadership project and FP2030.

Additional successes during the workshop came out of a deep dive session on PPFP and PAFP indicators and measurement. During the workshop, facilitators provided an overview of the pre-existing indicators for measuring PPFP and PAFP as HIPs—which had been agreed upon by over 16 organizations and verified by 11 countries. However, despite its consensus and broader dissemination, many of the partners present were not aware of these standardized indicators.

According to Laura Raney, “Reintroducing workshop attendees to these indicators was incredibly valuable. For example, the Rwanda Ministry of Health representative that was there took the information on the indicators for PAFP and said, ‘We’ll get this in our HMIS system,’ and within six months, he did,” demonstrating the tangible impact of the workshop discussions. Raney also mentioned related plans underway with the WHO to develop a small number of quality of care indicators, including for PPFP, for inclusion in the existing Every Woman, Every Newborn, Everywhere (EWENE), formerly (ENAP/EPMM) global monitoring framework.

Looking Ahead: Sustaining Momentum in Postpartum and Postabortion Family Planning Implementation

As demonstrated at the Nepal workshop, the Call to Action and the rolling momentum from the 2023 convenings on family planning and MNH integration have sparked ongoing dialogue and collaboration, ensuring that this global momentum leads to tangible progress across regions and countries. But as the field moves forward, the question of sustaining momentum remains. The continued success of the Call to Action relies on stakeholders maintaining PPFP and PAFP as top priorities in their work.

“It’s important that you find the right value proposition for every actor to actually care, and I think that work never stops,” Tripathi shared. “You can never just say, ‘We identified some priorities,’ but you have to be constantly linking these priorities to everybody’s specific values, and that’s hard work that takes time. So in addition to looking for successes, it is important to keep looking for what are those levers, those motivators.” 

Because of the ongoing nature of the work, Tripathi and Raney say that creating moments when everyone can come together and get energized is so important to continuing to advance progress.

“Ultimately,” Raney pointed out, “we hope that these convenings and the momentum that comes out of them will help give fresh ideas to the professionals who live and breathe this work and who are implementing these programs. By learning from each other’s experiences and successes,” she says, “the field can continue to build on the momentum generated in 2023 and push for even greater progress in the years to come.”

Next on the agenda? The FP2030 NWCA hub has partnered with the community of practice for PPFP integrated with Maternal, Newborn, and Child Health and Nutrition (PPFP-MNCH-N) to host a Francophone workshop focused on scaling up the integration of PPFP, PAFP, and MNH services. This meeting, taking place in Lomé, Togo, from October 22-24, 2024, will be the first time since the creation of the PPFP-MNCH-N community of practice in which Central African countries, as well as Madagascar and Comoros, will participate. The event, themed “Intensify the scaling up of the integration of RMNCH-N services and the synergy of action between partners to achieve the 2030 Goals in the French-speaking countries of the African region,” marks a significant step forward in expanding these critical discussions to more partners around the globe.

Looking for further readings on the global state of postpartum and postabortion family planning? Don’t miss the 2024 commentary on FP/MNH integration published in the International Journal of Gynecology and Obstetrics, as well as the 2024 Postabortion Care Curriculum, both published by the MOMENTUM Safe Surgery in Family Planning and Obstetrics project. To strengthen your understanding around advancing measurement of the scale, reach, and quality of PPFP and PAFP implementation in the HIPs, view the two-part 2024 webinar series [here and here], and stay tuned for a forthcoming white paper on PAFP and PPFP.