Maternal and infant mortality has profoundly detrimental consequences (1). Despite national policies resolving to reduce these deaths, Nigeria continues to bear among the highest maternal mortality ratios (MMR) and infant mortality rates (IMR) worldwide (2, 3) . Family planning has the potential to eliminate 25-40% of maternal deaths globally, in part by reducing the number of high-parity pregnancies (4). Pregnancies spaced fewer than 18 months apart are associated with increased risk of neonatal, perinatal and infant death, low birth weight, small size for gestational age, pre-term delivery, maternal anemia, pre-mature membrane rupture, gestational diabetes, and maternal death (5, 6). To safeguard the health of women and their babies, the World Health Organization (WHO) promotes interpregnancy intervals of at least two years (7). Clinically, the postpartum period is often defined as the first six weeks following birth (8). However, because of the preponderance of evidence supporting spacing pregnancies two years apart, as well as the changing needs and preferences of women throughout this timeframe many policies and programs refer to the postpartum period as up to 12 months to two years after childbirth (9-11).
Many women in the postpartum period want to delay their next pregnancy but are not using an effective method of contraception; these women have an unmet need for family planning (12). In Nigeria, unmet need ranges from 78% in the first 0-5 months postpartum to 51% among women 12-23 months postpartum (13). In 2012, the Federal Government of Nigeria aimed to increase the modern contraceptive prevalence rate (mCPR) from 10% in that year to 27% by 2020 (14). By 2019, the mCPR among all women had increased to 14.2%, but still fell below the government’s goal (15). Increasing contraceptive use, particularly among postpartum women, remains critical in Nigeria. Policies that focus on increasing access to contraception in the postpartum period encourage healthy birth spacing, and thus contribute to reduced MMR and IMR.
One approach to address high unmet need for family planning in the postpartum period is the integration of family planning services with routine child immunization services. The Nigerian government recommends immunization at birth, six weeks, ten weeks, fourteen weeks, nine months, twelve months, and fifteen months, which aligns with WHO recommendations (16). While immunization coverage in Nigeria is lower than in other sub-Saharan African countries, it has been improving in recent years (17). Integration provides an opportunity to provide immunization while simultaneously addressing the family planning needs of mothers. While numerous integration approaches exist, the two most common are: (1) combining service provision efforts such that family planning and immunization services are provided on the same day at the same facility and (2) providing one of the two services at a facility and referring the woman for the other service at another time or facility (18, 19). Although the Nigerian Ministry of Health promotes integration to increase access to family planning services, it does not advocate a specific model (20).
Despite its potential to improve service delivery and health outcomes, there is little research evaluating policies and programs that support integration (21, 22). Integration of family planning and immunization services in sub-Saharan Africa is feasible and may increase contraceptive prevalence without detriment to immunization rates (23-25); however, recent studies show no significant increase in family planning when family planning services are integrated with immunization visits (26-28). Systematic reviews highlight the need for more robust evidence about the effects of integration on service delivery and health outcomes (21, 22). Despite the lack of conclusive evidence, numerous international organizations, donors, and national governments promote policies supporting integration (29, 30).
Nigerian Urban Reproductive Health Initiative
The Nigerian Urban Reproductive Health Initiative (NURHI) is a Bill & Melinda Gates Foundation-funded project launched in 2009 that sought to increase modern contraceptive use in urban areas, especially among the urban poor (31). Phase I of NURHI (2009 to mid-2015) aimed to dismantle supply and demand side barriers to contraceptive use by: (a) providing facility-level systems strengthening and quality improvement support; (b) generating demand for family planning services and sustained contraceptive use; (c) testing private sector approaches to increase access to and use of family planning among the urban poor; and (d) improving the policy environment for family planning initiatives in urban areas. Within health facilities, NURHI supported systems strengthening to improve the quality and accessibility of family planning services through: (a) improved contraceptive supply chains and logistics; (b) training health providers in family planning counseling and provision; and (c) improving facility level management systems (32). NURHI promoted integration of family planning into: (a) maternal, newborn, and child health services; (b) post-abortion services; and (c) HIV/AIDS services. The NURHI integration strategy specifically identified integrating family planning into child immunization as a top priority because of its potential to increase family planning uptake among postpartum women. At the facility level, NURHI incorporated the following family planning approaches into immunization services: (a) provision of information, education, and counseling materials on all methods; (b) group counseling; and (c) referral of prospective clients to the family planning clinic (33). NURHI Phase II (2015-2020) continued its focus on increasing contraceptive prevalence through advocacy, demand generation and service delivery support. NURHI Phase II incorporated evidence from Phase I into its approach and continued to support integration of family planning services into maternal, newborn and child health services, including immunization.
Only a few studies have attempted to develop categorical or continuous measures of integration (34, 35). Generally, studies classify a facility as ‘integrated’ if an intervention to improve integration has been implemented in the facility (25, 36, 37). More nuanced integration measures may be able to more accurately reflect dynamic service delivery environments and the effect of integration on service delivery and health outcomes. In a previous study, we developed Provider and Physical Integration Indexes and measured the degree of facility-level family planning and immunization services integration attained across approximately 400 facilities in Nigeria and found substantial heterogeneity in provider and facility capacity to offer integrated services (38). Using these integration indexes as outcomes, this study exploits a longitudinal dataset to identify associations between facility-level characteristics and integration and the impact of NURHI on integration index scores.
Facility-Level Characteristics Associated with Integration
It is critical to identify facility-level characteristics associated with integration in order to design interventions that effectively support family planning and immunization services integration (26). Some studies have used qualitative methods to document that contextual characteristics influence integrated care (39). To our knowledge, this is the first study that utilizes quantitative measures to identify facility-level characteristics associated with family planning and child immunization services integration. The objectives of this study are to: 1) determine whether facility-level integration changes over time, 2) assess the impact of NURHI on integration, and 3) identify facility-level characteristics associated with integration. The results of this study are relevant to policy makers, programmers, and donors seeking to better understand the evolution and facility-level characteristics associated with family planning and immunization services integration so as to develop health interventions that will have the greatest positive impact on critical health outcomes, such as MMR and IMR.