By Jillian Litman, FP2030 Intern
In November, the High Impact Practices in Family Planning (HIP) partnership shared an updated version of its brief on integrating childhood immunizations and family planning initiatives during the extended postpartum period — a high-impact practice that is critical to promoting both maternal and child health. Globally, immunizations are one of the most widely used health care practices: In the past decade, more than a billion children received vaccinations. Data shows that in many low- to middle-income countries, many women have an unmet need for contraception during the postpartum period. As a result, mothers may have consecutive unplanned births in rapid succession, despite recommended spacing intervals. Child immunization services require several clinic visits with mothers during the first year of life, as the World Health Organization (WHO) recommends that infants receive vaccinations at birth, 6 weeks, 10 weeks, 14 weeks, and 9 months of age. Because of their frequency and widespread utilization, immunization services for infants provide a straightforward way to reach postpartum women and give them critical family planning information and services. Recent research has shown that with proper design and implementation, the integration of family planning and childhood immunizations can lead to large increases in the number of postpartum women using family planning services and that this type of linked programming does not decrease use of immunization services.
To this end, the family planning and immunization HIP brief recommends that clinics and health care systems implement an integrated model of care, as evidence suggests that this model has high levels of acceptability among clients and service providers alike and that it does not have a negative effect on the uptake of immunizations. The brief suggests three service delivery models for integrated care: combined service provision, combined service provision plus referral, and single service provision plus referral.
The combined service provision model involves same-day, same-location family planning services during routine immunization visits and usually offers a wider range of options for contraceptive methods than the other models. In this model, the most common types of family planning (FP) services include group counseling about contraceptives, use of informational posters and brochures, individualized health screenings to determine a mother’s risk of becoming pregnant again, and the delivery of brief motivational messages on the importance of postpartum family planning. For example, while the infant is being immunized, a service provider would ask the mother about the likelihood of becoming pregnant and would emphasize the health benefits of postponing pregnancy during the postpartum period. Other interventions that use this model have been able to successfully integrate direct provision of contraceptive methods during immunization appointments. One intervention in Malawi offered a referral to FP services during the health screening conducted by the immunization provider; if the mother accepted, she was ushered into a nearby room where she would receive educational counseling and the contraceptive method of her choice.
The combined plus referrals model builds on the previous model by including offsite referrals for FP services and can be implemented outside of the health care setting through community outreach. This model was also successfully implemented in Malawi, where community health workers known as health service assistants who were linked to primary care facilities provided both immunization services and family planning counseling. They also made short-acting contraceptive methods available and made referrals for long-acting, permanent methods. Mothers of infants could receive FP methods and immunization services either in the health care facility or from health service assistants during community outreach sessions.
Finally, under the single service provision plus referral model, immunization services are provided, along with a referral for FP services at an offsite location or as a follow-up visit at the same location. This model is best suited for clinics where same-day, co-located service provision is not practical. For example, a mother bringing her infant for a routine immunization visit would be given a referral to return in a few days to receive contraceptive methods. Research using all three models has documented increased access to family planning information and counseling for women who participated in immunization services for their infants.
The HIP brief includes recommendations for successful implementation of the integrated model for family planning and immunizations, along with information on what not to do when starting an integrated model. Integrated family planning and immunization programs are most effective when their designs are tailored to already existing systems and when they are focused on increasing family planning service provision while not negatively affecting immunization uptake. Incorporating family planning services into mass vaccination campaigns is not recommended, as these campaigns are often sporadic and highly dependent on donations, while family planning provision requires ongoing services and continuous funding. Ensuring there is a simple protocol for women to follow regarding referrals is also critical, and clinics implementing this approach should strive, when possible, to provide same-day referrals to FP providers, rather than just informational counseling. When same-day referrals are not possible, creating a time-bound pathway for women to receive both services is recommended. Programmatic monitoring and evaluation are also key to effective integration of family planning and immunization services. Collecting data and engaging staff as well as clients are necessary to identify any potential problems that arise and to promote ongoing collaboration.
The integration of family planning into childhood immunization services is needed now more than ever, but it also might be more difficult to implement due to the ongoing COVID-19 pandemic. According to the United Nations Population Fund (UNFPA), the pandemic caused an estimated 12 million women to go without critical family planning services due to various barriers to access. And while an integrated approach has been documented to increase access because of the widespread utilization of immunization services, the pandemic has also affected the provision of childhood vaccines. As a result of the pandemic, childhood immunization globally was significantly lower in 2020; according to recent data from WHO and the United Nations Children’s Fund (UNICEF), in the past year, 23 million children did not receive basic vaccines, 3.7 million more than in 2019. For this reason, future efforts to integrate family planning into childhood immunizations may face extra challenges relating to the ongoing pandemic, and integrated models may require additional features to ensure effective implementation.