FAMILY PLANNING

Specific Learning Outcomes

 Appreciate the benefits of family planning
 Understand requirement of successful delivery of FP services
 Appreciate the Linkage of FP and STI/HIV/AIDS services
 Internalize the determinants of quality of care
 Understand the WHO Medical Eligibility Criteria
 Comprehend the types of contraceptives and their use

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What is family planning?
 A key intervention for improving the health of women, men and
children.
 An important component of reproductive health.
 A human right issue
 To access, choice, and benefits of family planning
Historical perspective of family planning
 Initially focused on individual woman and her well-being
 However, falling death rates in the twentieth century,
 Without a similar reduction in numbers of births, led to
 Concerns about the adverse effects of large populations
 Around 1952, International Planned Parenthood Foundation and
Population Council established, thus
 Marking what is arguably the start of
 Modern family planning movement.
 Multiple approaches are required for successful programme
implementation
 By 1974 Social development had a role in reducing fertility rate by
 Creating a more conducive environment
 By mid-1990s, focus had moved from the narrow area of
 FP to reproductive rights and reproductive health
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Population dynamics
Definition
 A branch of knowledge concerned with the
 Sizes and composition of populations and the factors
 Involved in their maintenance, decline, or expansion
 The sequence of population changes characteristic of a particular
organism

Components
 Fertility
 Mortality and
 Migration

Fertility
 Very complex phenomenon
 Affected by a host of social, cultural, psychological, economic and
 Political variables
Migration
 An important force in development and a high-priority issue
 Almost half of all migrants are women, and
 Most are of reproductive age
 Have specific needs and human rights concerns

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Role and status of women in population and development
 Female domestic labour provides a critical and necessary support
 Enabling the male workforce and society to function
 Role in society a combination of productive and reproductive role
 Productive role includes all tasks that enhance the
 Income and economy of household and community, e.g.
 Crop and livestock production and wage employment
 Reproductive activities carried out to reproduce and care
 For the household and community, including the activities
 Involved in fuel, water collection, food preparation
 Child care, education
 Health care and home maintenance

 Activities often be viewed as

 Non-economic,

 Generally carrying no monetary compensation and

 Usually out of budgets of national income accounts

 Reality of social reproduction derives from

 A sexual division of labour tied to

 Gender division and male dominance

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Benefits of using family planning

 Could prevent up to one-third of all maternal deaths by

 Allowing women to delay motherhood

 Space births

 Avoid unintended pregnancies and unsafely performed

abortions

 Stop childbearing after achieving desired family size.

Mother

 Enables her to regain her health after delivery

 Gives enough time and opportunity to love and provide attention
to her husband and children
 Gives more time for her family and own personal advancement.
 When suffering from an illness, gives enough time for treatment
and recovery.
Children

 Healthy mothers produce healthy children

 Will get all the attention, security, love, and care they deserve
Father

 Lightens the burden and responsibility in supporting his family.

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  Enables him to give his children their basic needs
 Food, shelter, education, and better future
 Gives him time for his family and own personal advancement
 If suffers from an illness, has enough time for treatment and
recovery.
Community and Nation
 Improvement in socio-economic development
 Reduction in poverty and even crime
Factors that contribute to the gap between access to, and use of
services
 Obstacles that stem from the way the services are organized
 Difficult access to modern contraceptive methods
 Low quality health care services
 Little perceived risk of becoming pregnant
 Stated reason for one- to two-thirds of women with unmet need
 Opposition from husbands, families, communities
 Fears about contraceptive side effects
 Lack of knowledge about contraceptive methods or sources of supply
Requirement of successful delivery of family planning services
 Proper co-ordination of activities in various steps of
 The service delivery chain

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 Counseling
 Provision of a wide choice of contraceptives
 Follow-up and appropriate
 Referral, supervision, monitoring and evaluation
 Functional logistics systems
Counselling
 Important for the initiation and continuation of FP method
 No incentives or coercions to adopt FP or particular method
 FP clients also have HIV/AIDS service needs, and vice versa
 Both FP and VCT providers must have
 Basic counseling skills appropriate to both
Provision of Contraceptives
 In accordance with the approved method-specific guidelines
 By providers trained in provision of that method
 A “supermarket” approach best
 Provide clients with a wide choice of methods
Follow-up and Referral System
 Inform of the appropriate follow-up requirements
 Encouraged to return to providers if with any concerns.
Record Keeping
Proper records on each client and the distribution of contraceptives

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 Supervision
 Essential component of programme evaluation
 Ensures that guidelines are followed and client needs met
 Facilitative supervision should be encouraged
Logistics
 Help providers avoid both under-stocking and overstocking
 Proper storage and handling of contraceptive commodities
 For the stipulated shelf life

Cost Considerations
 Both financial and opportunity costs involved
 The time taken off work to visit the SDP
 Direct including contraceptives and professional services cost
 National programme related to
 Procurement of commodities and consumable supplies
 Logistics
 Supervision and monitoring.

Linkage of family planning and STI/HIV/AIDS services

Rationale
 Opportunity to discuss sexual matters and sexual habits during
counseling for FP methods. And thus:-
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  Risk assessment, screening, diagnosis and treatment of
 STIs including HIV/AIDS
 Information and skills needed to
 Assess and reduce risk of acquiring these infections
Reasons why FP and STIs/HIV/AIDS services should be linked:
 Both cater for similar clientele women and men of
 Reproductive age who are sexually active
 Same providers can be oriented with minimal inputs to serve in
both areas
 FP programmes good entry points for most of
 STI/HIV/AIDS services, and vice versa
 Good approach to access hard-to-reach clients, including men and
youth.
 Can overcome the stigma of stand-alone HIV/AIDS or FP clinic

Prevention of STIs, including HIV/AIDS and Hepatitis B

 Give information on modes of transmission
 Promote use of condoms & other barrier methods for high risk
clients
 Treatment of clients with STIs using syndromic approach
 Providers offering treatment should follow contact tracing
guidelines.

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 CBDs and TBAs should be trained to recognize
 STIs, ophthalmia neonatorum and refer
 All clients should be educated about
 High-risk sexual behaviours
 Protective benefits of condoms
 Need to have sex partner(s)
 Evaluated and treated if found to have an STI
 Importance of knowing one’s HIV status and
 Where VCT services may be obtained
Linkage of FP and VCT Services
 Those with HIV infection may wish to
 Plan pregnancy, limit family size or avoid pregnancy
 Four levels of integration of FP into VCT services
Levels differ in the methods that are provided on site:
 Level1: Condoms and pills
 Level II: Condoms, pills, and injectables
 Level III: Condoms, pills, injectables and intrauterine devices
 Level IV: A full range of contraceptive methods
 Two levels of VCT integration into FP services
 Level I:
 Risk assessment for STI and HIV
 IEC on VCT and availability of VCT centres
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  Referral to post-test clubs and other appropriate services

 Level II:

 All VCT services in Level I

 Pre-and post-test counseling and testing
The Key Role of FP in PMTCT
 Ensure safe and effective contraception to HIV-positive
Drug Interaction and Hormonal Contraception
 Oestrogens and progestin metabolized in the liver
 Some drugs increase or reduce their metabolism and
 Interfere with contraceptive efficacy
 Some anti-epileptics, anti-TB drugs, antifungals and certain anti-
retrovirals, can reduce efficacy e.g.
 Phenytoin, carbamazine, griseofulvin, rifampicin,
nevirapine, ritonavir
Infection Prevention (IP)
Two primary objectives:
 To prevent major postoperative infections when
 Providing clinical contraceptive methods
 To prevent transmission of serious diseases such as
 Hepatitis B and AIDS to or from clients

Based principles:

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 Consider every person potentially infectious
 Wash hands to prevent cross-contamination
 Wear gloves before touching anything wet, such as
 Broken skin, mucous membranes, blood or
 Other body fluids (secretions or excretions) or
 Soiled instruments and other items
 Use safe work practices such as
 Handling sharp instruments and disposing medical waste
 Isolate patients if secretions or excretions cannot be contained

Quality of care

 Inform client about the methods available:

 How they work, advantages, limitations, side effects,
 How to use them, re-supply and
 The importance of follow-up
 The service delivery points (SDPs) should be clean
 With well organized client flow and at a minimum
 Provide services during normal working hours
 Service providers should
 Avoid long waiting times for clients
 Be trained and given regular updates
 Care should be individualized
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 An adequate supply of quality contraceptives should be
maintained.
 Privacy should be maintained.
 Clients should be treated with dignity
 A good supervision system should be followed.
 Care should be provided for adolescents, who have special needs.
 Regular support supervision of clinical services should be ensured.

Successful programmes require well-trained staff, who exhibit:

 Care, sensitivity and thoroughness in informing the client about

 The method, and allowing the client to make informed choice
 Knowledge, attitude and skills for providing family planning
services
 Knowledge of and ability to recognize real or potential problems
 Capability to make good clinical judgment and to take
 Appropriate clinical action in response to problems, including
 Knowing when and where to refer clients

Values and Attitudes

Everyone has a right to her or his own beliefs.

Health care providers have a professional obligation to provide care

in a respectful and non-judgmental manner.
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  Ability to listen and to retain important information

 Capacity to make decisions that accurately reflect their situation,

needs and concerns

 Commitment to adopt new health-related behaviours

Services for adolescents

 WHO - adolescents (10-19 years) and youths (10-24 years)

 The group has major demographic, social and economic

implications.

 Their optimal health will increase productive capacity for the

nation’s development.

 Denial of reproductive health services would negatively

 Affect their general wellbeing

Provision of adolescent-friendly RH services

 Address factors that affect accessibility and quality of care, such as

 Provider attitudes, privacy, confidentiality and hours of service

 Adopt positive attitude

 Ensure easy access to services they need, including

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  Information, counseling and services

Services for clients with special needs

 Decisions on appropriate contraception must take into account

 The nature of the disability

 Individual desires and the method

 Decisions must be based on informed choice unless

 Individual not able e.g. serious psychiatric disease but

 Consider individual rights though

Counselling

Vital as it helps clients to:

 Arrive at an informed choice of reproductive options

 Select a contraceptive method with which they are satisfied
 Use the chosen method safely and effectively

A good counselor:

 Understands and respects the client’s rights

 Earns the client’s trust
 Understands the benefits and limitations of all contraceptive methods

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 Understands the cultural & emotional factors that affect choice of
method
 Encourages the client to ask questions
 Uses a nonjudgmental approach, which shows the client respect and
kindness
 Presents information in an unbiased client-sensitive manner
 Actively listens to the client’s concerns
 Understands the effect of nonverbal communication
 Recognizes when not sufficiently able to help a client and
 Refers the client to someone who can

To be effective, counseling must be based on establishment

 Of trust and respect between client and counselor

In serving clients it is important to remember that they have:

 The right to decide whether or not to practice family planning

 The freedom to choose which method to use
 The right to privacy and confidentiality
 The right to refuse any type of examination
 The freedom to choose where to seek services

Acknowledge method failure can occur so that

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  The client is counseled, informed about the options available &

 Referred for appropriate services

Counselling Process

Service providers should briefly review all available methods, even if a

client knows which method she/he wants

Important factors:

 Reproductive goals of the women or couple

 Spacing or timing of births
 Personal factors including the time, travel costs, pain or
 Discomfort likely to be experienced
 Accessibility and availability of other products that
 Are necessary to use the method
 The need for protection against STs and HIV

Steps in Family planning counseling

The provision of counseling should be a part of every interaction

with the client

Counseling can be divided into three phases:

 Initial counseling at reception

 All methods are described and the client is helped
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  To choose the method appropriate for him /her
 Method-specific counseling
 Prior to and immediately following service provision
 Client given instructions on how to use method &
 Common side effects are discussed
 Follow-up counseling
 During return visit, use of the method, satisfaction and
 Any problem that may have occurred are discussed)

FP counseling within the context of HIV/AIDS:

 Whether or not FP method protects against STIs, including HIV

 Safety reassurance of FP method if used by HIV+ person.
 Interactions between methods and some drugs used
 In treatment of HIV/AIDS
Knowledge and guidance on “dual protection” practices
(abstinence or use of condoms)

Method effectiveness and safety

The two most important considerations for choice of method are

effectiveness and safety.

 Effectiveness largely depends on use, which depends on

 The kind of counseling and

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  Information clients receive from service providers

Return to Fertility
 Prompt with all methods, except
 DMPA and Norethisterone enanthate (NET-EN)
 Median delay with DMPA and NET-EN 10 & 6 months
respectively

 From date of last injection, regardless of duration use

 Male and female sterilization regarded as permanent

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The WHO Medical Eligibility Criteria and their Application in
Kenya

The WHO Groups, medical conditions into four categories:

1. Conditions with no restriction on the use of the contraceptive

method.
2. Conditions where advantages generally outweigh theoretical or
proven risks.
 Method can generally be used, but careful follow-up may be
required.
3. Conditions that theoretical or proven risks usually outweigh the
advantages of the method.
 Use not usually recommended unless other more
 Appropriate methods are not available or not acceptable
4. Conditions which present an unacceptable health risk if method is
used.
 Method should not be used.

 FP services in Kenya are provided in

 Diverse settings which

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  Differ in resource availability and

 Level of provider training and skills, hence

 Eligibility criteria adapted to the local situations

CATEGORIES OF MEDICAL ELIGIBILITY CRITERIA FOR TEMPORATY METHODS (ADAPTED FROM WHO,2004)
WHO Where clinical judgement is Where clinical
Category possible judgement is not
possible or is limited
1  Method can be used in any  Method can be used
circumstances in any circumstances
 Use the method
2  Generally use the method  Use the method with
with care care or refer
3  Method should not be used  Do not use the
unless a clinician makes a method
clinical judgement that the
method can be used by the
client safety
4  Method shout not be used  Do not use the
 The condition represents an method
unacceptable health risk if
method is used

Hormonal Contraceptive Methods

Containing synthetic hormones (oestrogen, progestin, or a combination
of both)
Methods commonly available in Kenya:

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 Combined oral contraceptive pill (COC)
 Progestin only contraceptive pill (POP)
 Progestin only injectable contraceptives (DMPA, NET-EN)
 Progestin only contraceptive implants (Norplant, Jadelle)
Less commonly available methods in Kenya:
 Combined injectable contraceptive
 Cyclofen, Cycloprovera, Mesigyna, Norigynon
 Combined vaginal contraceptive ring
 Combined contraceptive (skin) patch
Guidelines for the methods commonly available in Kenya
Combined oral contraceptive pills (COCS)
Contain synthetic oestrogens and progestin
Most common available COCs in Kenya contain 30 – 35 micrograms.
They primary prevent pregnancy by:

 Suppressing ovulation
 Thickening the cervical mucus, thereby
 Preventing penetration of the sperm
 Possibly change endometrial lining
 Making implantation less likely

Types

 Pills come in packets of 21 or 28 tablets.

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  In the 28 pill packet only the first 21 are active pills

Come in three types:

 Monophasic
 Same amount of oestrogen and progestin e.g.
 Microgynon, Lo-femenal, Nordette, Marvelon.
 Biphasic
 Active pills contain two different dose-combinations of
oestrogen and progestin e.g.,
 10 one combination while 11 another
 E.g., Biphasil, Ovanon, Normovlar.
 Triphasic
 Active pills contain three different dose combinations of
oestrogen and progestin,e.g,
 6 pills one combination, 5 another and 10 another
 E.g, Logynon and Trinordial.

Advantages

Contraceptive Benefits

 Highly effective
 Effective immediately
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  When started within first 7 days of menstrual cycle
 Easy to use
 Can be provided by trained non-clinical service provider
 Pelvic exam not essential to initiate use

Other Benefits

 Reduce menstrual flow

 Lighter, shorter periods
 Decrease dysmenorrhoea
 Improve and prevent anaemia
 Protect against ovarian and endometrial cancer
 Decrease benign breast disease
 Prevent ectopic pregnancy

Limitations

Minor Side Effects

 Nausea (common in first 3 months)

 Intermenstrual spotting or bleeding especially with irregular taking

of pills

 Mild headaches, breast tenderness, slight weight gain and

amenorrhoea

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Major Side Effects

Though rare, include myocardial infarction, stroke, and venous

thrombosis/embolism

Note:

 Effectiveness may be lowered

 When certain drugs are taken concurrently
 In the presence of gastroenteritis, vomiting and diarrhea
 Offer no protection against STIs,
 Including hepatitis B and HIV/AIDS
 Must be taken daily to be effective

Who Should Not Use COCs (Category 3 and 4)

 Breastfeeding mothers before 6 months postpartum

 History of blood clotting disorder
 Those who have undergone major surgery with
 Prolonged immobilization
 Those who have thrombogenic mutations, which
 Increase risk for blood clotting disorders
 Women with current or history of
 Ischaemic heart disease or complicated valvular heart disease
 Women with active liver disease
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  Viral hepatitis, cirrhosis, benign or malignant tumours
 Women with a history of hypertension
 Women with adequately controlled BP

 Women with moderate to severe hypertension or

 Hypertension complicated by vascular disease
 Women with diabetes mellitus complicated by vascular disease
 Women who smoke and are 35 years or older.
 Women with a history of or current breast cancer
 Women with symptomatic gall bladder disease including those on
medical treatment
 Women receiving treatment with drugs that affect liver enzymes

Progestin only pills (POPS)

Must be taken at the same time every day (within 2 hours) to avoid
pregnancy and minimize side effects.
Prevent pregnancy by:
 Thickening the cervical mucus, thereby preventing sperm to passage
 Suppressing ovulation in about 50% of cycles
 Possibly by changing the endometrial lining, making implantation
less likely

Types
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Include micronor, microval, microlut and ovrette

Advantages

Contraceptive Benefits

 Do not affect breastfeeding

 Lighter and shorter periods
 Decrease breast tenderness
 Decrease dysmenorrhoea
 Do not increase blood clotting
 Protect against endometrial cancer

Limitations

 Slightly lower level of contraceptive protection than COCs

 Require strict daily pill taking, preferably at the same time
 Side effects include
 Intramenstrual spotting or bleeding,
 Amenorrhoea,
 Possibly headaches and
 Breast tenderness
 Although less common than with COCs
 Effectiveness may be lowered when certain drugs are taken
 Do not protect against STIs including hepatitis B and HIV/AIDS
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 Who Should Not Use (Category ¾)

 Breastfeeding women less than 6 weeks postpartum

 Women who have breast cancer or a history of breast cancer
 With active liver disease
 Viral hepatitis, severe cirrhosis or
 Liver tumour (benign and malignant)
 Women with current DVT or pulmonary embolism (PE)
 Women who take drugs which affect liver enzymes

Emergency hormonal contraception

Prevents pregnancy following unprotected intercourse by:

 Preventing ovulation
 Inhibiting transport of ovum and /or sperm through fallopian tubes

Types and Dosage

Combined Oral Contraceptives
 50-microgram oestrogen pills (e.g. Eugynon):
 Two tablets to be taken as soon as possible, but
 Within 120 hours of unprotected intercourse then
 Repeat same dose in 12 hours
 30-microgram oestrogen pills (e.g, Microgynon):
 Four tablets to be taken as soon as possible, but
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  Within 120 hours of unprotected intercourse
 Repeat same dose in 12 hours.
 May be given as a total single dose
Progestin-only Oral Contraceptives
 One 750-mcg levonorgestrel pill (e.g., Postinor-2)
 Taken as soon as possible, but
 Within 120 hours of unprotected intercourse
 Repeat same dose in 12 hours
 Regular progestin-only pill (POP) may be use:
 20 tablets taken within 120 hours of unprotected intercourse
 Repeated in 12 hours
 May be given as a total single dose
 More effective than COCs
Advantages
Provides emergency protection (prevents pregnancy)
in about 85% of those at risk.
Limitations
 Reasonably effective only within 120 hours of unprotected
intercourse
 Not to be used as a regular method

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 Does not protect against STIs, including HIV/AIDS
 May cause nausea

Who Can Use Emergency Contraception

In emergency, for example:

 A woman has had coerced sexual intercourse, such as rape

 A condom has broken
 An IUCD has come out of place
 A woman who
 Has run out or oral contraceptives
 Has missed two or more POPs
 Is more than a few weeks late for her DMPA injection and
 Has had unprotected intercourse
 Sex took place without contraception, and the woman wants to avoid
pregnancy

Who Should Not Use

 ECP is not to be used as a regular method.

 ECP should not be given to women who are known to be pregnant.

Injectables contraceptives

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Progestin-only injectables prevent pregnancy by:
 Suppressing ovulation
 Thickening cervical mucus so as to prevent sperm passing through it
 Thinning the endomerium to interfere with implantation

Types

 Depot-medroxyprogesterone acetate (DMPA):

 Depo-Provera,
 Megestron
 Three- monthly but
 Can be given up to 28days earlier or 14 days later.
 Norethisterone enanthate (NETEN): Noristerat.
 Two monthly but
 Can be given up to 14 days earlier or 7 days later.
 Monthly injectable:
 Cyclofen, Cycloprovera, Mesigyna, Norigynon.
 Contain oestrogen in addition to progestin
 Given once every 30 days, but
 could be given up to three days earlier or later

Progestin only injectables

Advantages

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Contraceptive benefits

 Highly effective
 Pelvic exam is not required to initiate use
 No oestrogen associated side effects
 Long acting methods
 Reduce menstrual flow (long term), hence reduce
 The risk of iron deficiency anaemia
 Decrease sickle cell crises
 Protect against endometrial cancer and possibly ovarian cancer
 Help prevent ectopic pregnancy

Limitations

 Return of fertility may be delayed for about

 Four months or more after discontinuation
 Common side effects include menstrual changes, such as
 Light spotting/bleeding, heavy bleeding and amenorrhoea
 Other side effects –
 Headache, breast tenderness, mood swings and nausea
 Do not protect against STIs including hepatitis B and HIV

Women Who Should Not Use

 Breastfeeding <6 weeks postpartum

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 Active liver disease and severe cirrhosis
 Benign or malignant liver tumours
 Unexplained abnormal vaginal bleeding before evaluation
 Breast cancer or a history of breast cancer
 Multiple risk factor for arterial cardiovascular disease
 Various combinations of older age, smoking, diabetes and
hypertension
 Current or history of ischaemic heart disease
 Diabetes mellitus complicated by vascular disease
 BP equal to or >160/100 and with vascular disease
 Stroke or history of CVA
 Current DVT or pulmonary embolism (PE)

Contraceptive implants

Effects reduced if client above 70Kg.

Act by:

 Suppressing ovulation in many cycles

 Making endometrium too thin for implantation to take place
 Making cervical mucus too thick for sperm to pass through
Types

Implanon – 3 years; Jadelle – 5 years; Norplant – 7 years

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Advantages

Contraceptive Benefits

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 Highly effective  Help prevent ectopic
 Effective within 24 hours pregnancy
after insertion  Do not affect breastfeeding
 Immediate return to fertility  Protect against iron
 Offer continuous, long-term deficiency anaemia
protection  May make sickle cell crises
 Reduce menstrual flow less frequent and less
 Protect against endometrial painful
cancer

Limitations
 Must only be inserted and removed by trained providers
 Must have infection prevention practices for insertion & removal
 Common side effects include
 Intermenstrual spotting or bleeding and amenorrhoea
 Others include prolonged bleeding, headache, dizziness, nausea
and breast tenderness
 Removal services must be available at sites of insertion
 Do not protect against STIs, including hepatitis B and HIV

Women Who Should Not Use Contraceptive Implants

 Breastfeeding <6 weeks postpartum

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 Active liver disease (viral hepatitis, severe cirrhosis, tumours)
 Undiagnosed abnormal vaginal bleeding before evaluation
 Breast cancer or women with a history of breast cancer.
 Cannot tolerate menstrual changes
 Currently have DVT, ischaemic heart disease or stroke
 Migraine with aura
 Rifampicin use for TB and certain anticonvulsants for epilepsy

Intrauterine contraceptive devices (IUCD)

Only 0.6% of women (with perfect use) and 0.8% (with typical
use of an IUD) will become pregnant

The Copper IUCD prevents pregnancy primarily by:

 Preventing sperm from fertilizing the egg

 Changing intrauterine environment making it difficult

 For the egg and sperm to meet

The IUCD does not cause abortion.

Hormone-releasing IUCDs

 Less widely available

 Contain progesterone
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  Hormone responsible for prevention of pregnancy by IUCD

Prophylactic antibiotics are generally not recommended for Cu-

IUCD insertion.
TYPES

DEVICE DURATION OF
EFFECTIVENESS

Copper T 380A Up to 12 years

NOVA T 5 years

Multiload-MLCu-375 5years

Multiload-MLCu- 3 years
250

Copper T 220 3 years

Gynefix 8 years

Hormone releasing 5 years

IUCDs:
e.g., Mirena (LNG-
IUCD), Progestasert
Progesterone IUCD)
Advantages

 Highly effective  Long-term protection

 Immediate effectiveness
37
 Immediate return of fertility  Can be used by women who
upon removal are breastfeeding
 Do not interfere with  Help prevent ectopic
intercourse pregnancies

38
Women Who Should Not Use?

 Postpartum after 48 hours and before end of 4 weeks

 Puerperal sepsis or immediately post-septic abortion
 Unexplained vaginal bleeding before evaluation
 Trophoblastic disease, benign or malignant
 Pelvic cancer (cervical, endometrial and ovarian cancers)
 Fibroids distorting the uterine cavity
 Anatomical abnormalities of the uterus and cervix which
 Interfere with insertion and retention of IUCD
 Current PID or current purulent cervicitis
 High individual likelihood of exposure to gonorrhea and/or
Chlamydia
 Known to have pelvic TB

Voluntary Surgical Contraception

 No medical condition that would absolutely

 Restrict a person’s eligibility for sterilization

 Some conditions and circumstances will require that

 Certain precautions are taken

 Including those where the recommendation is C (Caution), D

(Delay), or S (Special).
Female Voluntary Surgical Contraception

 Highly effective, failing in < 1% in the first year after surgery

 Can be performed under conscious sedation and local anaesthesia

 It is considered as a permanent FP

Types

 Minilaparotomy (postpartum or interval)

 Laparoscopic tubal ligation-interval
 At caesarean section or other abdominal surgery

Advantages

Contraceptive Benefits

 Highly effective
 Immediately effective
 Does not interfere with intercourse
 Permanent
 Few known side effects
 Good choice for client if pregnancy would be a serious health risk
 Does not affect breastfeeding
 Decreases risk of ovarian cancer

Who should Not Use

 Clients who are uncertain of their desire for future fertility
 Clients who cannot withstand surgery
 Clients who do not give voluntary informed consent

Male Voluntary Surgical Contraception: Vasectomy

 Performed under a local anaesthetic

 Failure rate of <1% in most studies
 Clients use condoms or another FP method for
 3 months after the operation to be completely safe
 Reversal not assured
Types

Scalpel and non-scalpel vasectomy techniques

Advantages/Contraceptive Benefits

 Highly effective
 Does not interfere with sexual intercourse
 Permanent

Who Should Not Use

 Clients who are uncertain of their desire for future fertility

 Clients who do not give voluntary informed consent

Male Condom
 Most condoms are made of thin latex rubber

 Some coated with a dry lubricant or with spermicide

Advantages

 Fairly effective if used properly

 Immediately effective
 Offer contraception only when needed (no daily intake)
 Easy to obtain, can be used without seeing a health care provider
 Safe
 Highly effective protection against STI/HIV/AIDS
 With consistent and proper use
 May prevent premature ejaculation
 Can be used by almost every man
 Easy to use with a little practice
 No health risk associated with the method

Who Should Not Use

 Couples who want highly effective protection against pregnancy

The Female Condom

Advantages

Contraceptive Benefits
 Fairly effective if used properly
 Immediately effective
 Effectiveness similar to male condom and to other vaginal methods
 Highly effective protection against STI/HIV/AIDS
 With consistent and proper use
 Protects against PID
 Woman-controlled method
 Can be used by almost every woman
 No need to see health care provider before using
 Easy to use with a little practice

Who Should Not Use

 Couples who want highly effective protection against pregnancy

Diaphragm, Cervical Cap and Spermicide

Advantages

Contraceptive benefits

 Effective immediately
 Do not affect breastfeeding
 Woman controlled method
 Can be used by almost every woman
 Easy to use with a little practice
 No serious health risk associated with the methods
 Protect against STI/HIV/AIDS;
 However, this protection is not complete

Women Who Should Not Use

 Desire highly effective protection against pregnancy

 Dislike touching their genitals or are unable to feel
 Cervix or posterior fornix (for diaphragm & cervical cap)
 With vaginitis
 Couples are allergic to spermicide or the material
 From which the device is made
 Vaginal abnormalities, or poor vaginal muscle tone
 Have had toxic shock syndrome, no diaphragm or cervical cap
 Recently gave birth or had second trimester abortion
 Wait 6 to 12 weeks for diaphragm or cervical cap use
 Increased risk of STIs including HIV Nonoxynol – 9 spermicides use

Lactational Amenorrhoea Method (LAM)

 Based on lack of ovulation after exclusive breastfeeding

 Used during the first 6 months postpartum only
 Infant fed solely on breast milk
 Effective at about 2% for typical use in the first 6 months
 With all LAM criteria met, the pregnancy rate 0.5%
  Applicable alone only if the three LAM criteria met
LAM is defined by three criteria:

 Menstrual periods have not resumed and

 Baby exclusively or nearly exclusively breastfed and
 The baby is less than 6 months old

Advantages

 Protection against pregnancy if all three LAM criteria met

 Does not interfere with sexual activity
 Breastfeeding provides passive immunization for the child
 Decreases exposure to pathogens in water or other milk
 Best source of nutrition for infants
 Affordable-no direct cost for family planning
 Counselling for LAM encourages starting
 A follow-on method at the proper time

Women Who Should Not Use

 Not breastfeeding at least nearly fully
 Resumed menses
 Baby more than 6 months old
 Couples want highly effective protection against pregnancy

Natural Family Planning (NFP)

Types
Cervical Mucus or Billings Ovulation Method
 Identification of fertile time by the
 Increasing amounts of cervical mucus
 As soon as mucus noticed & until 4 days after the peak day
 Avoids sex
 Uses a barrier method or
 Uses withdrawal
Basal Body Temperature (BBT)
 Body temperature record orally, rectally or vaginally
 Same time morning before getting out of bed
 Temperature readings recorded on a special graph paper
 Temperature rises by 0.2-0.50C, around time of ovulation
 Abstain from sex, use a barrier method or withdrawal from
The last day of menstrual bleeding until the woman’s
 Temperature has risen above her regular readings and
 Stayed up for a full 3 days, thereby ensuring that
 Ovulation has occurred and passed
 After this the couple can have unprotected sex
 Over the next 10 to 12 days until
 Next menstrual bleeding begins
Cervical Mucus + BBT (Sympto-thermal Method)
 Fertility awareness methods identify
 Fertile and infertile days by combining
  BBT and cervical mucus observations and often
 Other signs and symptoms of ovulation, such as
o Abdominal pain, cervical changes and breast tenderness
 Avoiding sex or use barrier method or withdrawal from
 Last day of menstrual bleeding, until fourth day after
 Peak cervical mucus & third full day after rise of BBT
 If one of these events happens without the other
 Wait for other event before having unprotected sex.
Calendar or Rhythm Method
 Used to identify start and end of the fertile time
 Record length of menstrual cycles for at least 6 months.
 First day of menstrual bleeding counted as day one
 Subtract 18 days from length of shortest recorded cycle
 To get the estimated first day of the fertile time
 Subtract 11 days from length of longest recorded cycle
 To get the estimated last day of the fertile time

 Use barrier method or withdrawal during the fertile time

 Method may require 16 days or >each cycle in a row of
 Avoiding sex, withdrawal or barrier method especially if
 Irregular menstrual cycles
Much abstinence may be too restrictive for some couples.

The Standard Days Method (SDM)

Natural method of FP developed though scientific analysis of fertile
time in a menstrual cycle.

 Cycle beads (pictured above) used with standard days method

 To prevent pregnancy,

 Couple abstains from sex, uses barrier method or withdrawal on

days 8 to 19 of the cycle

 Formula based on computer analysis of thousands of menstrual

cycles

Advantages

 No physical side effects

 Free
 No need for prescriptions by medical person
 Improved knowledge of reproductive system and
 Possible closer relationship between couples
Who Should Not Use?

 Women with irregular or not well established cycles

 Women who dislike touching their genitals
 Women whose partners will not co-operate
 Couples who want highly effective protection against pregnancy

Withdrawal (coitus interruptus) method

 Intercourse in until ejaculation is about to occur
 At which point the male withdraws the penis
 Requires no devices, involves no chemicals, available at no cost and
 It can be used any time
 Demands consistent self-control on part of the male partner, which
 May be lacking at times
 Possibility that pre-ejaculatory fluid containing sperm may flow out
 During the excitement phase, before penis is withdrawn
 With conscientious use 14 – 23 pregnancies per 100 woman per year
among actual users

Dr. D. K. Ngotho – Snr Lecturer (Obs/Gynae)