Multicenter study of the Lactational Amenorrhea Method (LAM): II. Acceptability, utility, and policy implications

An overview of contraception in women with obesity

The use of safe and effective contraception is essential for preventing unplanned pregnancy in women of all body sizes. When counseling women with obesity about contraception, it is important to consider the pharmacokinetic alterations of obesity on various modern contraceptive methods. However, evidence is reassuring that most contraceptive methods are safe and effective in women with obesity. Individual countries and the World Health Organization have published Medical Eligibility Criteria to guide contraceptive selection in women with medical issues including obesity. When choosing contraception, specific risks of the method relative to any underlying medical disorders must also be balanced against the risks of unintended pregnancy in this group.

Understanding of Lactational Amenorrhea As a Contraceptive Method Among U.S. Pregnant Women

Introduction: The lactational amenorrhea method (LAM) of postpartum contraception is more effective than typical use of condoms or birth control pills. However, LAM may be underutilized due to incomplete perinatal counseling. Methods: We compared perceptions of the effectiveness of postpartum contraceptives including LAM among U.S.-born nulliparous pregnant women recruited using social media for a trial (NCT04601987). We used descriptive statistics to summarize data. Results: Of 760 individuals screened, 627 were invited to participate, and 451 (72%) were enrolled. Most (81%) had a college degree; 79% intended to breastfeed for at least 1 month. Only 8% believed exclusive breastfeeding reduces the chance of pregnancy "a lot" within 6 months of delivery and 2% indicated that exclusive breastfeeding is typically more effective than birth control pills or condoms. Compared with those planning to use other postpartum contraceptives, the 17% of respondents who planned to use LAM were more likely to know that breastfeeding delays return of menses (84% versus 44%, p ≤ 0.0001) and provides protection from pregnancy until menses return (54% versus 22%, p ≤ 0.0001). Although 25% of those planning to use LAM believed exclusive breastfeeding reduces pregnancy risk by "a lot," only 5% thought LAM is more effective than birth control pills and only 9% thought that it is more effective than condoms. Conclusions/Implications: First-time U.S. mothers are often unaware of breastfeeding's effects on menses and fertility. Clinicians providing counseling about postpartum contraceptive options should include more information on LAM.

Competency assessment of the medical interns and nurses and documenting prevailing practices to provide family planning services in teaching hospitals in three states of India

Objectives

The objectives of the study were to assess the knowledge and skills of medical interns and nurses regarding family planning (FP) services, and document the prevailing FP practices in the teaching hospitals in India.

Study design

A cross-sectional study was conducted in three states (Delhi, Rajasthan, and Maharashtra) of India, among randomly selected 163 participants, including medical interns (n = 81) and in-service nurses (n = 82), during 2017. The semi-structured, pre-tested interview schedule, was used to assess the knowledge and status of training received; and objective structured clinical examination (OSCE) based checklist was used to evaluate the skills.

Results

About 60% of the interns and 48% of the nurses knew more than five contraceptives that could be offered to the clients. About 22% (11.1% interns and 33.3% nurses) respondents believed that contraceptives should not be given to a married woman coming alone, and 31.9% (17.3% interns and 46.3% nurses) respondents reported that it was illegal to provide contraceptives to unmarried people. Nearly 43.3% interns and 69.5% nurses refused to demonstrate intrauterine contraceptive device (IUCD) insertion in the dummy uterus as per OSCE, and among those who did, 12.3% interns and 18.3% nurses had failed. About 63% interns and 63.4% of nurses had observed IUCD insertion, and 12.3% interns and 17.1% had performed IUCD insertion, during their training.

Conclusions

Knowledge and skills of interns and nurses regarding FP services were inadequate. The medical training during graduation or internship, and during the job, was found to be inadequate to provide quality FP services as per guidelines of nursing/medical council of India and Government of India on FP.

Transition from the Lactational Amenorrhea Method to other modern family planning methods in rural Bangladesh: barrier analysis and implications for behavior change communication program intervention design

The timely transition from Lactational Amenorrhea Method (LAM)(2) to another modern family planning method contributes to healthy spacing of pregnancies by increasing the adoption of family planning during the first year postpartum. Yet, literature suggests challenges in completing a timely LAM transition. To guide program implementation in Bangladesh, this study identified factors influencing women's transition decisions. Eighty postpartum women, comprising 40 who transitioned from LAM(3) and 40 who did not,(4) participated. Half of each group participated in in-depth interviews to explore the decision-making process. All participants responded to a "Barrier Analysis" questionnaire to identify differences in eight behavioral determinants. More than half of transitioners switched to another modern method before or within the same month that LAM ended. Of the 18 transitioners who delayed,(5) 15 waited for menses to return. For non-transitioners, key barriers included waiting for menses to return, misconceptions on return to fertility, and perceived lack of familial support. The LAM transition can help women prevent unintended pregnancy during the first year postpartum. Increased emphasis on counseling women about the risk of pregnancy, and misconceptions about personal fertility patterns are critical for facilitating the transition. Strategies should also include interventions that train health workers and improve social support.

ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

[The postnatal contraception: upon 600 patients of whom 129 were postnatal controlled]

OBJECTIVE

To draw a parallel between the contraceptive methods prescribed in the post-natal ward and the contraceptive methods taken by patients during their postnatal visit.

PATIENTS AND METHODS

This piece of work draws information from a prospective 10 weeks study at a University Teaching Hospital post-natal ward on the contraception that is prescribed upon leaving the maternity ward and also at the time of the post-natal visit.

RESULTS

From the 600 cases studied, the analysis is about 129 patients reviewed in the post-natal visit. The percentage of loss was 78.5%. A hormonal contraceptive pill was prescribed to 73.5% of women (441 patients) after birth in which 63.5% had microprogestative pills. At the earliest, the IUD was given at about 5.4 weeks postpartum. At the time of the postnatal visit, compliance was bad for one third of women with either estrogen plus progestin methods, microprogestative or natural methods. Women who chose a barrier method were only 45.5% to follow this choice, the others left without contraception.

DISCUSSION AND CONCLUSION

The prescription of postpartum contraception was followed by only 66.6% of women. In order to prescribe a more effective contraceptive method, we must improve the prescriber's timing in sharing contraceptive information and completeness of the contraceptive methods offered.

Operations research to add postpartum family planning to maternal and neonatal health to improve birth spacing in Sylhet District, Bangladesh

BACKGROUND

Short birth intervals are associated with increased risk of adverse maternal and neonatal health (MNH) outcomes. Improving postpartum contraceptive use is an important programmatic strategy to improve the health and well-being of women, newborns, and children. This article documents the intervention package and evaluation design of a study conducted in a rural district of Bangladesh to evaluate the effects of an integrated, community-based MNH and postpartum family planning program on contraceptive use and birth-interval lengths.

INTERVENTION

The study integrated family planning counseling within 5 community health worker (CHW)-household visits to pregnant and postpartum women, while a community mobilizer (CM) led community meetings on the importance of postpartum family planning and pregnancy spacing for maternal and child health. The CM and the CHWs emphasized 3 messages: (1) Use of the Lactational Amenorrhea Method (LAM) during the first 6 months postpartum and transition to another modern contraceptive method; (2) Exclusive, rather than fully or nearly fully, breastfeeding to support LAM effectiveness and good infant breastfeeding practices; (3) Use of a modern contraceptive method after a live birth for at least 24 months before attempting another pregnancy (a birth-to-birth interval of about 3 years) to support improved infant health and nutrition. CHWs provided only family planning counseling in the original study design, but we later added community-based distribution of methods, and referrals for clinical methods, to meet women's demand.

METHODS

Using a quasi-experimental design, and relying primarily on pre/post-household surveys, we selected pregnant women from 4 unions to receive the intervention (n = 2,280) and pregnant women from 4 other unions (n = 2,290) to serve as the comparison group. Enrollment occurred between 2007 and 2009, and data collection ended in January 2013.

PRELIMINARY RESULTS

Formative research showed that women and their family members generally did not perceive birth spacing as a priority, and most recently delivered women were not using contraception. At baseline, women in the intervention and comparison groups were similar in terms of age, husband's education, religion, and parity. CHWs visited over 90% of women in both intervention and comparison groups during pregnancy and the first 3 months postpartum.

DISCUSSION

This article provides helpful intervention-design details for program managers intending to add postpartum family planning services to community-based MNH programs. Outcomes of the intervention will be reported in a future paper. Preliminary findings indicate that the package of 5 CHW visits was feasible and did not compromise worker performance. Adding doorstep delivery of contraceptives to the intervention package may enhance impact.

Contraception and the obese woman

PURPOSE

Obesity has reached epidemic rates among U.S. women of reproductive age, many of whom want to use contraception. However, some forms of contraception can have adverse effects on an obese woman's health. This article explores risks of contraception available in the United States and provides clinical recommendations for use by obese women.

DATA SOURCES

Information was compiled by reviewing the scientific literature on contraception and female obesity using CINAHL, MEDLINE, PubMed search engines.

CONCLUSIONS

The evidence is largely supportive of combined oral contraceptive (COC) use in carefully screened obese women without known risks factors for cardiovascular disease. The efficacy of COCs may be slightly reduced in obese women because of increased body mass. Other types of hormonal contraceptives have varying safety and efficacy reports when used by obese women. Intrauterine devices do not have reduced efficacy nor increased risks for obese women but insertion may be more difficult. Obesity has no effect on efficacy of barrier methods of contraception.

IMPLICATIONS

Clinicians should conduct a careful history and physical exam with selected supporting laboratory tests when considering prescription of hormonal contraceptives for obese women. Obese women require health counseling to carefully follow directions for contraceptive use to avoid unintended pregnancy.

Acceptance of lactational amenorrhoea for family planning after postpartum counseling

OBJECTIVE

To determine the impact of postpartum counseling on the acceptance of lactational amenorrhoea method (LAM) for family planning.

METHODS

In a prospective cross-sectional study 1490 postpartum women were included. Women who accepted or refused LAM for family planning were identified by means of a written survey. Twelve socio-demographic and clinical variables were included as predictors in a logistic regression analysis, the acceptance or refusal of LAM was the dependent variable; an Alpha level was set at 0.05.

RESULTS

There were 807 (54.2%) women who accepted LAM as a contraceptive method; 683 (45.8%) refused it. Main reasons for accepting LAM were: conviction following counseling (54.4%) and use of LAM initially before switching to another contraceptive modality (18.3%). Main reasons for LAM refusal were: belief that the method was unsafe (62.2%) and fear of some undesirable effect on health (15.8%). In the logistic regression analysis the variables occupation outside the home (P = 0.01) and previous knowledge of LAM (P < 0.001) emerged as predictors of LAM acceptance.

CONCLUSIONS

Postpartum counseling of LAM had a very positive impact on its acceptance. Although it is recommended that information about LAM be given antenatally, in some settings postpartum counseling could improve its acceptance rate.

Transdisciplinary breastfeeding support: creating program and policy synergy across the reproductive continuum

This paper was presented at the symposium on Breastfeeding and Feminism: A Focus on Reproductive Health, Rights and Justice. It underscores the power and potential of synergy between and among organizations and individuals supporting breastfeeding, the mother-child dyad, and reproductive health to increase sustainable breastfeeding support. These concepts were brought together to lay the groundwork for working group discussions of synergy in program and policy actions.

Promotion of WHO feeding recommendations: a model evaluating the effects on HIV-free survival in African children

In Africa, HIV and feeding practices deeply affect child mortality. To prevent mother-to-child transmission, the World Health Organization recommends exclusive breastfeeding for 6 months and replacement feeding when acceptable, feasible, affordable, and sustainable. Determining the proportion and number of children saved with exclusive breastfeeding and replacement feeding is essential to design and implement crucial nationwide policies. Using data on 31 sub-Saharan countries and a decision tree for risk assessment, the authors estimated the number of children's lives potentially saved according to 6 scenarios that combine exclusive breastfeeding for 6 months or replacement feeding with 3 promotion strategies. Among all HIV-negative children born to HIV-positive mothers who die in sub-Saharan Africa per year, 52,315 (9.6%) would be saved yearly with exclusive breastfeeding versus 21,638 (4.0%) with replacement feeding. Promotion support would double these numbers (110,625 vs 45,330; ie, 20.3% vs 8.3%), and with additional prenatal group education, 132,633 versus 54,192 lives would be saved (24.3% vs 9.9%). Wherever replacement feeding is not possible, exclusive breastfeeding with promotion support and prenatal group education would save 1 of 4 exposed children.

ABM clinical protocol #13: contraception during breastfeeding

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may influence breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Lactational amenorrhea as a method of family planning in Egypt

Because of the potential importance of the lactational amenorrhea method (LAM) as a family-planning option in Egypt, we analyzed data from the 1995 Egyptian Demographic and Health Survey (EDHS) to study breastfeeding practices, use of contraception, reproductive history and sociodemographic factors for 5504 mothers with children under 3 years. According to the EDHS data, about 80% of Egyptian women breastfed for at least 6 months, and 40% breastfed for 15-18 months. Over half of breastfeeding mothers used no additional contraception. Thirty-six percent of mothers breastfeeding children younger than 6 months who reported using no additional contraception were exclusively breastfeeding and amenorrheic, but only 4% reported relying on breastfeeding for family planning. We also held eight focus group discussions with breastfeeding mothers from urban and rural Upper and Lower Egypt on their use of contraceptive methods, breastfeeding, lactational amenorrhea and LAM. Participants showed strong recognition of the contraceptive effects of breastfeeding but differed widely in their understanding of lactational infecundability and knowledge of LAM as a method. These results suggest that LAM would be widely acceptable to Egyptian women, but that an educational program about the method is needed.

Introdução da lactação e amenorréia como método contraceptivo (LAM) em um programa de planejamento familiar pós-parto: repercussões sobre a saúde das crianças

OBJETIVOS: avaliar o efeito da introdução da lactação e amenorréia como método anticoncepcional sobre a saúde da criança em um programa puerperal. MÉTODOS: pesquisa operacional que avalia a duração do aleitamento materno total e exclusivo, e alguns indicadores de saúde das crianças até um ano de idade, antes e após a introdução da LAM como método oferecido às mulheres no pós-parto, com reforços educativos sobre amamentação e planejamento familiar. Foram incluídas 698 mulheres que tiveram pré-natal e parto no Instituto Materno Infantil de Pernambuco divididas em: Grupo A, que recebeu assistência antes e B, após a intervenção. Na análise estatística utilizaram-se o teste Qui-Quadrado, análise de sobrevivência e regressão logística de Cox. RESULTADOS: o Grupo A teve 85,6% de episódios mórbidos até 12 meses e o Grupo B 72,1%. O número de internações foi mais que o dobro para as crianças do Grupo A. O peso, a estatura das crianças aos 12 meses e as taxas acumuladas de aleitamento materno total foram significativamente maiores no Grupo B. CONCLUSÕES: esta intervenção educacional associa-se a melhores resultados infantis e pode ser aplicada em outros serviços também pelos benefícios à saúde das crianças.

Effects of breastfeeding on the mother

In the rush to find nutrient alternatives to breastfeeding, a theme that dominated research on infant feeding throughout the twentieth century, only recently have new findings that reconfirm the importance of breastfeeding for maternal and child health begun to influence medical texts and health policy. Approximately 30 years of increasingly rigorous and positive research findings have led to the rediscovery of breastfeeding as a valid and evidence-based health intervention for infants. Unfortunately, because much of the research was designed to assess human milk as a nutrient replacement for infant formula, the literature on the effects of breastfeeding on maternal health remain limited. Nonetheless, a clear pattern of positive physiologic changes that lead to improved short-term and long-term health sequelae are emerging. All patients and their families should be informed fully as to the positive preventive health effects of breastfeeding not only for infants but also for mothers. Women have many difficult choices to make; it behooves physicians to ensure that they receive all of the facts on which to base these decisions.

Multicenter study of the lactational amenorrhea method (LAM) III: effectiveness, duration, and satisfaction with reduced client-provider contact

The objective of this effort was to assess the use and efficacy of the Lactational Amenorrhea Method (LAM) with reduced numbers of client-provider contacts. A co-sponsored multicenter study of LAM was performed to test the efficacy and acceptability of the method under "post-marketing" conditions, with investigator-initiated contact occurring only twice: at the time of intake and then again at month 7 of postpartum. These data are assumed to provide an assessment of LAM's use, efficacy, and performance that more closely reflects the prevailing conditions of these populations during normal use. Three hundred and sixty-two subjects were recruited through centers that had participated in the previous, more contact-intensive studies. Using a cooperatively developed protocol, data were gathered prospectively on at least 10 and up to 50 LAM acceptors at nine sites, and entered and cleaned on site. Data were further cleaned and analyzed at the Georgetown University Institute for Reproductive Health (IRH) and the Department of Nutrition at the University of Connecticut. Using country-level and pooled data, descriptive statistics and life tables were produced. LAM efficacy in this sample is 100% because there were no pregnancies at any of the participating sites. Satisfaction with the method was high, and the rate of continuation on to another method after LAM was 66.7% at 7 months postpartum. Of the women who had never used family planning prior to LAM, 63.0% went on to use another method of family planning in a timely manner. LAM can be highly effective as an introductory postpartum family planning method when offered in a variety of cultures, health care settings, and industrial and developing country locales. Under conditions of limited client-provider contact, LAM remains effective and leads to acceptance of another method by about two-thirds of the acceptors. Women are able to use LAM effectively without extensive counseling or follow-up, with a high level of user satisfaction.

The role of the Swedish Child Health Services in breastfeeding promotion

Sweden has one of the highest breastfeeding incidence and duration rates among industrialized countries. Although the Child Health Services offer breastfeeding support to all mothers, there are geographical differences in breastfeeding frequency at different ages. The aims of this study were to describe the present activities in the Child Health Services regarding breastfeeding promotion and to find research evidence regarding interventions. Thirty-three out of 42 healthcare districts replied to a questionnaire. Differences were found in the transfer of responsibility for newborn infants from hospital to Child Health Centres, criteria for and timing of home visits and recommendations regarding introduction of supplementary food and breastfeeding education for parents and professionals. There were also regional differences in breastfeeding statistics and follow-up periods. The following recommendations were made on the basis of the survey and relevant literature: transfer of responsibility for newborn infants must guarantee follow-up of all mother-infant pairs; uniform breastfeeding assessment and documentation must be established; all mother-infant pairs must be offered early home visits, continued on a regular basis by health visitors; drop-in consultations must be established; a telephone hotline must be set up; for preventive purposes, growth charts must be used based on breastfed infants; evidence-based guidelines for the introduction of other foods must be followed; information must be provided in parent groups; breastfeeding statistics must use WHO definitions; polyclinics must be available for service to mothers/infants after early discharge and as resources for Child Health Centres; Child and Maternal Health Centres must collaborate; quality assurance programs must be established; breastfeeding courses must be offered in the under- and postgraduate training of professionals; compulsory in-service education must be offered; lactation consultant training must be offered at the university level; and lactation consultant positions must be established.

Policy considerations for the introduction and promotion of the lactational amenorrhea method: advantages and disadvantages of LAM

Some attributes of LAM are unquestionably positive, such as the fact that it is effective. Clinical trials of LAM have upheld the Bellagio Consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breastfeeding. Secondary data analyses in numerous settings have drawn the same conclusion. Whether as a strategy or a method, used correctly or even if used imperfectly, LAM is a reliable way to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also clearly positive since a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method, and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost effective, for households and/or for programs, this will also make the method extraordinarily attractive. Conversely, some aspects of LAM are negative, such as the fact that it affords no protection against STDs, it requires counseling from a well-informed provider, and intensive breastfeeding can make heavy demands on the woman's time. Many of the remaining attributes of LAM may not be important to a policy decision about LAM promotion. For example, whether LAM is actualized as a strategy or a method may not be important to a decision to promote LAM, although it has a huge impact on how services are delivered. Some factors may be profound on a local or individual level. For example, one simple factor, such as the absence of full/nearly full breastfeeding, can rule out the method as an option, while another, such as the fact that it provides the needed waiting period during vasectomy counseling, can make LAM the method of choice. Although LAM seems unlikely to have widespread popularity in societies like the United States, within such settings are breastfeeding women for whom other contraceptive choices are not satisfactory and to whom LAM is attractive. Although clinicians cannot be expected to directly provide LAM education in every setting, women should be informed about LAM as an effective contraceptive choice, and clinicians should be prepared to make referrals to competent sources. The future of LAM, especially in terms of formal, programmatic initiatives, may continue to be focussed in transitional and less developed settings. Comparative cost/benefit analyses for both the family planning program and the household will contribute meaningfully to decisions about whether to use LAM and whether to include LAM in national and local family planning policies and programs. The most important call to action is to implement operations research designed to determine what factors, if any, will maximize the uptake of a second modern contraceptive method after LAM protection expires among never-users of family planning, to compare this with other contraceptive strategies, and to evaluate the cost aspects. If the potential of LAM to be a conduit to other modern contraceptive methods is effectively realized, the method can be profoundly important in the development of communities and in family formation. Because LAM is effective in preventing pregnancies, and because it extends the range of contraceptive choices, considering LAM on the policy level is always appropriate. Despite the array of drawbacks to LAM, as with any other family planning method, the potential assets of LAM, especially the promise to introduce nonusers to contraception, are sufficiently important to warrant the introduction of LAM within an operations research framework to both capitalize on its intrinsic strengths and determine its programmatic robustness. In the 10 years since the concept of LAM was pronounced as the Bellagio Consensus, claims have been made both for and against its use. During this time, program and policy leaders have been giv

Users' understanding of the lactational amenorrhea method and the occurrence of pregnancy

It is unknown whether a user's understanding of the Lactational Amenorrhea Method (LAM) is related to its successful use. A study of 876 LAM users in Pakistan and the Philippines collected information about women's understanding of LAM. The present analysis aims to determine: (1) the proportion of LAM users who understand the method, (2) whether any known factors can distinguish those who understand LAM from those who do not, and (3) whether an understanding of LAM is related to subsequent pregnancy. Over 75% of LAM users could consistently recite the LAM guidelines correctly for a full year postpartum. However, 38% of users failed to display, at least once, an understanding of LAM during the first year postpartum mainly by failing to abstain, to use another method or to explain their nonuse of another method when their LAM protection expired. LAM understanding generally could not be predicted by sociodemographic factors. The occurrence of pregnancy during the first year postpartum was not related to LAM understanding, regardless of how LAM understanding was defined, nor could it be predicted by any other measured characteristic of the users.

Multicenter study of the Lactational Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application

A multicenter study of the Lactational Amenorrhea Method (LAM) was carried out to test the acceptability and efficacy of the method. Additionally, the data are used to test new constructs for improvement of method criteria. A protocol was designed at the Institute for Reproductive Health (IRH), Department of Obstetrics and Gynecology, Georgetown University Medical Center, a World Health Organization (WHO) Collaborating Center, and was reviewed and modified in collaboration with the co-sponsors, the World Health Organization and the South to South Cooperation for Reproductive Health, and the principal investigators from each site. Data were gathered prospectively on LAM acceptors at 11 sites. Data were entered and cleaned on-site and further cleaned and analyzed at IRH, using country-level and pooled data to produce descriptive statistics and life tables. The 98+% efficacy of LAM is confirmed in a wide variety of settings. In addition, the results yield insight on the possibility of continued use beyond 6 months. LAM is found to be highly effective as an introductory postpartum method when offered in a variety of cultures, health care settings, socio-economic strata, and industrial and developing country locales. In addition, LAM acceptance complements breastfeeding behaviors without ongoing breastfeeding support services. The parameters studied yield high efficacy and method continuation. Therefore, the basic tenets of the 1995 Bellagio consensus on LAM is reconfirmed and it is recommended that LAM be reconfirmed and it is recommended that LAM be incorporated into hospital, maternity, family planning, maternal and child health, and other primary health care settings.