TABLE OF CONTENTS

ACRONYMS 1
CHAPTER I. INTRODUCTION 3
CHAPTER II. BACKGROUND OF FAMILY PLANNING IN MYANMAR 5
CHAPTER III: HUMAN RIGHTS PRINCIPLES GUIDING FAMILY PLANNING SERVICES 7
CHAPTER. IV: COUNSELLING IN FAMILY PLANNING 9
4.1: OVERVIEW OF THE STAGES OF COUNSELLING FOR FAMILY PLANNING .......................................................... 9

4.2: STEPS IN FAMILY PLANNING COUNSELLING .................................................................................................. 10

4.3: HEALTHY TIMING AND SPACING OF PREGNANCY (HTSP) .............................................................................. 14

CHAPTER V: QUALITY OF CARE 17

5.1: INFORMATION AND SERVICE......................................................................................................................... 17

5.2: SAFETY ........................................................................................................................................................... 17

CHAPTER VI. ACCESS TO FAMILY PLANNING SERVICES 22

[Link]: SPECIFIC CONTRACEPTIVE METHODS 24
7.1: ORAL CONTRACEPTIVE PILLS ......................................................................................................................... 25

7.2: EMERGENCY CONTRACEPTIVE PILLS ............................................................................................................. 33

7.3: INJECTABLE CONTRACEPTIVES ...................................................................................................................... 39

7.4: MALE AND FEMALE CONDOMS ..................................................................................................................... 49

7.5. LONG ACTING REVERSIBLE CONTRACEPTION (LARC) – IMPLANTS ................................................................ 56

7.6 LONG ACTING REVERSIBLE CONTRACEPTION – INTRAUTERINE DEVICE (IUD) ................................................ 63

7.7: PERMANENT METHOD – STERILIZATION ....................................................................................................... 76

7.8: FERTILITY AWARENESS METHODS ................................................................................................................. 81

7.9: LACTATIONAL AMENORRHEA METHOD ........................................................................................................ 90

7.10: WITHDRAWAL ............................................................................................................................................. 94

CHAPTER VIII: SERVING THE PEOPLE WITH SPECIAL NEEDS 95

8.1. ADOLESCENTS AND YOUTHS ......................................................................................................................... 95

8.2: CLIENTS WITH STIS, HIV AND AIDS ................................................................................................................. 97

8.3: CLIENTS WITH DISABILITY .............................................................................................................................. 98

8.4: SURVIVORS OF SEXUAL VIOLENCE ................................................................................................................. 99

8.5: WOMEN NEAR MENOPAUSE .......................................................................................................................100

8.6: INFERTILITY .................................................................................................................................................102

8.7: FAMILY PLANNING IN POST ABORTION CARE ..............................................................................................105

8.8: MOBILE GROUPS INCLUDING MIGRANTS AND INTERNALLY DISPLACED PERSONS(IDPS)..................................................107

JOB AID AND TOOL 108

JOB AID AND TOOL: 1. COMPARING COMBINED METHODS ..............................................................................108

JOB AID AND TOOL: 2. COMPARING INJECTABLES..............................................................................................109

JOB AID AND TOOL. 4: COMPARING CONDOMS ................................................................................................110

JOB AID AND TOOL. 5: COMPARING IUDS ..........................................................................................................112

JOB AID AND TOOL. 6.A: HOW AND WHEN TO USE PREGNANCY CHECKLIST AND PREGNANCY TEST ................113

JOB AID AND TOOL. 6.B: PREGNANCY CHECKLIST ..............................................................................................114

JOB AID AND TOOL. 8: THE MENSTRUAL CYCLE ..................................................................................................116

JOB AID AND TOOL. 9.A: MALE ANATOMY .........................................................................................................117

JOB AID AND TOOL. 9.B: FEMALE INTERNAL ANATOMY ....................................................................................117

JOB AID AND TOOL. 9.C: FEMALE EXTERNAL ANATOMY ....................................................................................118

ANNEX 120
ANNEX. 1: BASIC RULES OF INFECTION PREVENTION .........................................................................................120

ANNEX. 2: INSERTION AND REMOVAL OF IMPLANTS .........................................................................................122

ANNEX. 3: INSERTION PROCEDURE OF IUD ........................................................................................................126

ANNEX. 4: WASTE DISPOSAL ..............................................................................................................................129

FORM 130
COMSUMPTION REPORT FORM OF CONTRACEPTION .......................................................................................130

CLIENT REPORT FORM OF CONTRACEPTION ......................................................................................................131

CONTRIBUTORS 132
REFERENCES 134

2
ACRONYMS
AIDS Acquired immunodeficiency syndrome
ARV Anti-Retro Viral
BBT Basal Body Temperature
BCS+ Balance Counseling Strategy Plus
CIC Combined Injectable Contraceptives
COC Combined Oral Contraceptive
DMPA Depot Medroxyprogesterone Acetate
DMPA-SC Depot Medroxyprogesterone Acetate - Sub-Cutaneous
DVT Deep vein thrombosis
ECPs Emergency Contraceptive Pills
EPHS Essential Package for Health Services
FP 2020 Family Planning 2020
HIV Human Immunodeficiency Virus
HTSP Healthy Timing and Spacing of Pregnancy
IUD Intra Uterine Device
LAM Lactational Amenorrhea
LMP Last Menstrual Period
LARC Long Acting Reversible Contraceptive
MRH Maternal and Reproductive Health
MEC Medical Eligibility Criteria
NET-EA Norethisterone enanthate
NSAID Non-steroidal anti-inflammatory drug
OC pills Oral Contraceptive pills
PE Pulmonary embolism
PID Pelvic inflammatory disease
POP Progestogen Only Pills
PSI Population Services International
STIs Sexually Transmitted Infections
WHO World Health Organization
MMCWA Myanmar Maternal and Child Welfare Association

UNITS
μg microgram mg milligram

1
2
CHAPTER I. INTRODUCTION
Reproductive and sexual health and rights (SRHR) is a part of overall human health, and concepts
related to this important aspect of health have been deliberated upon at many platforms, in
particular at the International Conference of Population and Development (ICPD) at Cairo in 1994. In
the global Reproductive Health Strategy of WHO1, which Myanmar has adopted and included in the
Five Years Reproductive Health Strategy (2014-2018), family planning is one of the components of
reproductive health.

According to WHO, family planning allows people to attain their desired number of children and
determine the spacing of pregnancies. It is achieved through use of contraceptive methods and the
treatment of infertility2. The importance of family planning is well-established and well-known. If all
women and girls in developing countries who want contraception have access to it, unintended
pregnancies will drop by more than 70 percent, and each year nearly 100,000 mothers would not die
from complications during pregnancy and childbirth, and more than half a million newborns would
not die. Access to family planning information, services and supplies is equally critical for preventing
HIV and other sexually transmitted infections. Women and couples who can decide on the number,
spacing, and timing of their children are better able to increase their household income and invest in
their existing children. Girls who are able to delay marriage and delay their first pregnancy are better
able to gain the skills, confidence and assets they need to take up opportunities and improve their
own lives.

Family planning is strongly linked to the third component of reproductive health (eliminating unsafe
abortion). Unsafe abortion is a serious public health problem, and in Myanmar, and abortion related
complications are the third leading cause of maternal deaths3. Primary prevention of unsafe
abortion can only be achieved by preventing unwanted pregnancies where family planning plays a
critical role.

Family planning services are included in Myanmar’s basics essential package of health services
(EPHS) under National Health Plan (2017-2021). Increase access to basic EPHS is integral to attaining
Universal Health Coverage4. Along with other components to improve service delivery, it is
important to guarantee quality of care of basic EPHS regardless of types of service providers.
Moreover, in the delivery of family planning services ensuring quality is central not only to delivering
positive health outcomes for the families but also to certifying that human rights are respected,
protected and fulfilled.

3
Thus, the ‘Family Planning Guideline for Service Providers 2018’ has been developed to reduce the
unmet need for contraception by increasing knowledge and services provided by the health service
providers in Myanmar. With increase service delivery points in the community, the ultimate goal is
to reduce untended pregnancies and maternal morbidity and mortality.

This guideline will serve as a reference guide5 for health service providers at different levels of health
system to provide quality and right-based family planning services to their clients. The guideline
spells out the background of family planning in Myanmar and the details of processes and
procedures relevant in directly delivering family planning services. These details are arranged in six
chapters: human rights principles; counselling; quality of care; access to family planning services;
and different contraceptive methods available in Myanmar; serving people with special needs, and
job aids as annexes.

This guideline was developed in line with country’s policy and context adapting from evidence based
global guidelines. Guideline development was under taken through a highly consultative process
consisting of:

• Setting up a core group for developing the guideline: including the Central Maternal and
Reproductive Health Division, Professor and Head of Obstetrics and Gynaecology from four
medical universities, representatives from WHO, UNFPA, Jhpiego and concerned partners.

• Review of the existing evidence based global guidelines on family planning: The Four
Cornerstones of Family Planning (WHO)
(1) Medical Eligibility Criteria for Contraceptive Use 2015 (MEC6)
(2) Selected Practice Recommendations for Contraceptive Use 2016 (SPR7)
(3) The Decision-Making Tool for Family Planning Clients and Providers 2005 (DMT8)
(4) Family Planning: A Global Handbook for Providers 20189

• Organize discussions and working group meetings for drafting the guideline
• Conduct the finalization meeting and dissemination of the draft guideline to key
stakeholders
Much of the information in this guideline have been adapted from WHO Family Planning: A Global
Handbook for Providers 2018 and will be revised accordingly.

4
CHAPTER II. BACKGROUND OF FAMILY PLANNING IN MYANMAR

Myanmar has been endeavoring to reduce maternal morbidity and mortality aiming to achieve the
Sustainable Development Goals, however, maternal mortality ratio (MMR) is currently the second
highest among ASEAN countries.10As of 2014 Census, MMR in Myanmar amounts to 282 deaths per
100,000 live births.11

In this connection, reproductive, maternal, newborn, child and adolescent health (RMNCAH) care
has been accorded as a priority issue in the action plan of National Health Plan (2017-2021). In
addition, Myanmar has also committed to the ICPD goals, and United Nations Secretary General’s
Global Strategy for Women’s, Children’s and Adolescent's Health to improve women and children’s
health.

As Family planning is evidence-based intervention for improving the maternal and newborn health
as well as cost-effective powerful tool for development, Myanmar demonstrated strong
commitment by joining the Family Planning 2020; a global initiative to fulfilling the unmet need for
family planning and reducing the maternal and newborn mortalities, in 2013.12

Myanmar has been endeavoring the quality family planning services to achieve the FP 2020 targets
with the guidance of RH policy (2002), Five years Reproductive Health Strategic Plans (RHSP) and
Costed Implementation Plan for FP 2020 through the coordination with the private sector, UN
agencies, INGOs, NGOs and donor agencies.

Myanmar’s family planning program started in 1991 as public sector’s pilot in one township and
then progressively extended to 164 out of 330 townships in 2014 with the support of UNFPA. Since
2012, the government of Myanmar has been increasing the health budget and investing more in
family planning program. Myanmar became one of the 47 countries of UNFPA's Global Programme
enhancing Reproductive Health Commodity Security (GPRHCS) in 2013 and received US$ 5.2 million
worth of contraceptive commodities in 2014. UNFPA and John Snow Inc. supported Maternal and
Reproductive Health Unit of MOHS in establishing a Reproductive Health Commodity Logistic System
(RHCLS) to ensure that contraceptives supplies reach women at the last mile in the community level.
It started in 2013 and has reached 115 townships in 2018.

In 2011, Government’s investment in family planning started from US$ 20,000 and had increased
annually up to US$ 3 million in 2016 whereby women including those in hard reach areas, ethnic

5
groups, migrants as well as young unmarried population have access to informed choice of variety of
contraceptive methods including long acting reversible contraceptive methods (LARC) - promotion of
which was part of FP 2020 commitment.

Collaboration between government, UNFPA, PSI, MSI, MMA, IPPF-MMCWA, Jhpiego and other
partners the introduction of increased contraceptive methods including implants in public sectors
since early 2016 serves as a good example of public-private-partnerships. Through advocacy,
community awareness, capacity building of providers, and distribution of supplies and equipment,
contraceptive prevalence has increased from 41% to 52.2% and is on track to reach the goal of 60%
by 2020.13,14
Myanmar has come a long way to achieve greater impact as the DHS-2016 shows that unmet need
for family planning has been reduced from 19% to 16%, towards the target of less than 10% in
2020.13,14 However, there is much work to be done regarding rights based approach, quality of care
and services regarding family planning and this National Guideline is timely and appropriate to
empower health care providers in providing better choices of family planning information and
services to reach all women and girls regardless of their age or marital status.

These good practices in family planning can be accelerated as the Government of Myanmar is highly
committed to the health and welfare of women and had made sustainable investments in family
planning programmes.

6
CHAPTER III: HUMAN RIGHTS PRINCIPLES GUIDING FAMILY PLANNING
SERVICES
All people deserve the right to determine,15 as best they can the course of their own lives. Whether
and when to have children, how many and with whom are important parts of this right. Family
planning service providers have the privilege and responsibility to help people to make and carry out
these decisions.

High-quality family planning services and the people who deliver them respect, protect, and fulfill
the human rights of all their clients. Everyone working at every level of the health system plays an
important part. Family planning service providers express their commitment to human rights every
day in every contact with every client.

As a family planning provider, you contribute to all of them. 15

Principle 1 Non-discrimination
What you can do: Welcome all clients equally. Respect every client’s needs
and wishes. Set aside personal judgments and any negative opinions.
Promise yourself to give every client the best care you can.

Principle Availability of contraceptive information and services

2 What you can do: Know the family planning methods available and how to
provide them. Help make sure that supplies stay in stock. Do not rule out
any method for a client, and do not hold back information.

Principle Accessible information and services

3 What you can do: Help make sure that everyone can use your facility, even
if they have a physical disability. Participate in outreach, when possible. Do
not ask clients, even young clients, to get someone else’s permission to use
family planning or a certain family planning method.
Principle Acceptable information and services What you can do: Be friendly and
4 welcoming and help make your facility that way. Put yourself in the client’s
shoes. Think what is important to the clients—what they want and how they
want it provided.

Principle 5 Quality
What you can do: Keep your knowledge and skills up-to-date. Use good
communication skills. Check that contraceptives you provide are not out-of-
date.

Principle Informed decision-making

6 What you can do: Explain family planning methods clearly, including how to
use them, how effective they are, and what side effects they may have, if any.
Help clients consider what is important to them in a family planning method.

Principle 7 Privacy and confidentiality

What you can do: Do not discuss your clients with others except with
permission and as needed for their care. When talking with clients, find a place
where others cannot hear. Do not tell others what your clients have said.
Promptly put away clients’ records.

7
Principle 8 Participation
What you can do: Ask clients what they think about family planning services.
Act on what they say to improve care.

Principle Accountability
9
What you can do: Hold yourself accountable for the care that you give clients
and for their rights.

The fulfillment of human rights requires that health-care facilities, commodities and services be
scientifically and medically appropriate and of good quality. Quality of care and human rights are
therefore two intrinsically connected approaches. Realization of a rights-based approach without
ensuring quality of care is not possible. Similarly, programs cannot achieve quality of care without
guaranteeing human rights of clients.

As the schematic below highlights the high degree of overlap between the approaches, both are
mutually dependent and reinforce each other.

Figure: 1. The relationship between quality of care and human right16

8
CHAPTER. IV: COUNSELLING IN FAMILY PLANNING

Good counseling helps clients choose and use family planning methods that suit them. Clients differ,
their situations differ, and they need different kinds of help. The best counseling is tailored to the
individual client.

Family planning counselling17 is defined as a continuous process that you as the counselor provide
to help clients and people in your village make and arrive at informed choice about the size of their
family. (number of the children they wish to have).

Informed choice 17is defined as a voluntary choice or decision, based on the knowledge of all
available information relevant to the choice or decision. In order to allow people to make an
informed choice about family planning, you must make them aware of all the available methods, and
the advantages and disadvantages of each. They should know how to use the chosen method safely
and effectively, as well as understanding possible side- effects. Counseling is an essential part of
quality family planning services to assure that the clients make informed and voluntary decisions
about their contraception use and family planning. Counselling using active listening and effective
communication skills allows a woman feels in control of her choice of a contraceptive method and
hence increases client satisfaction and encourages consistent use of the method chosen.

Well-informed clients are more likely to be satisfied with their method and to use it longer. Clients
need to understand how that method works, how effective it is, how to make the method most
effective, what are the most likely side effects, and what to do if such side effects occur.

Many different people can learn to inform and advise people about family planning and to provide
family planning methods. When more types of health workers are authorized and trained to provide
family planning methods, more people have access to them.

4.1: OVERVIEW OF THE STAGES OF COUNSELLING FOR FAMILY PLANNING

General counselling 17
The first contact usually involves counselling on general issues to address the client’s needs
and concerns. You will also give general information about methods and clear up any
mistaken beliefs or myths about specific family planning methods. During this session you
would also give information on other sexual and reproductive health issues, like sexual
transmitted infections, human immunodeficiency virus, acquired immunodeficiency
syndrome and infertility.
In counselling, it is not possible or necessary to provide complete information about every
method. Clients do, however benefit from key information especially, about the method that
they want. The goal of counseling about method choice is to help client find a method that
she or he can use successfully and with satisfaction.

Method specific counseling17

You give more information about chosen methods. You can explain
• Benefit of the method
• Risk of the method

9
 • Alternatives of the method
• Inquiries about the method
• Decision to withdraw from using method
• Explanation of the method chosen
• Documentation of the session for you own report
You can explain the examination for fitness(screening) and instruct on how and when to use
given method. (using MEC wheel- Figure.3)

Return/follow-up counselling 17
Follow- up counselling should always be arranged. Main aim of follow-up counseling
is to discuss and manage any problem and side effects related to given contraceptive methods.

4.2: STEPS IN FAMILY PLANNING COUNSELLING

When you counsel a new client in your village about family planning, you should follow step by step
process. GATHER is an acronym that will help you remember the 6 basic steps for family planning
counseling.

Family planning counselling – The GATHER approach17

G Greet the client respectfully

A Ask them about their family planning needs (reproductive goal)
T Tell them about different contraceptive options and methods
H Help them to make decisions about choices of methods
E Explain and demonstrate how to use the methods
R Return/refer, schedule and carry out a return visit and follow up.

Integration to information on Protection against HIV and sexually transmitted infections are very
important. Condoms can also be used in conjunction with other methods of contraception – this is
called “dual protection” to protect against pregnancy as well as STIs and HIV. 15

Good counselling9 helps clients choose and use family planning methods that suit them. Clients
differ, their situation differ, and they need different kinds of help. The best counseling is tailored to
the individual clients.

10
 Clients Type Usual counseling tasks

Returning clients • Provide more supplies or routine follow-up

with no problems • Ask a friendly question about how the client is doing with
the method
Returning clients • Understand the problem and help resolve it- whether the
with problems problem is side effects, trouble using the method, an
uncooperative partner, or another problem
New clients with • Check that the client’s understanding is accurate
method in mind • Support the client’s choice, if client is medically eligible
• Discuss how to use method and how to cope with any side
effects.
New clients with no • Discuss the client’s situation, plans, and what is important
method in mind to her or him about a method.
• Help the client consider methods that might suit her or
him. If needed, help her or him reach a decision.
• Support the client’s choice, give instructions on use, and
discuss how to cope with any side effects.

Give time to clients who need it. Many clients are returning with no problems and need
little counseling. Returning clients with problems and new clients with no method in mind
need the most time, but usually they are few.

Tips for successful counseling

• Show every client respect, and help each client feel at ease.
• Encourage the client to explain needs, express concerns, ask questions.
• Let the client’s wishes and needs guide the discussion.
• Be alert to related needs such as protection from sexually transmitted infections
including HIV, and support for condom use.
• Talk with the client in a private place, where no one else can hear.
• Assure the client of confidentiality— that you will not tell others about your
conversation or the client’s decisions.
• Listen carefully. Listening is as important as giving correct information.
• Give just key information and instructions. Use words the client knows.
• Respect and support the client’s informed decisions.
• Bring up side effects, if any, and take the client’s concerns seriously.
• Check the client’s understanding
• Invite the client to come back any time for any reason.

11
Counseling has succeeded when:

• Clients feel they got the help they wanted

• Clients know what to do and feel confident that they can do it
• Clients feel respected and appreciated
• Clients come back when they need to
• And, most important, clients use their methods effectively and with satisfaction.

Counseling about Effectiveness

The effectiveness of a family planning method is very important to most clients. The
effectiveness of family planning methods varies greatly. Describing and discussing
effectiveness is an important part of counseling.

Describing effectiveness to clients takes thought and care. Instead of talking about
pregnancy rates, which can be hard to understand, it may be more useful to compare the
effectiveness of methods and to discuss whether the client feels able to use the method
effectively. Following chart can help the contraceptive methods according to their
effectiveness as commonly used. Also, it points out how the user can obtain the greatest
possible effectiveness.

12
Comparing Effectiveness of Different Contraceptive Methods9

13
4.3: HEALTHY TIMING AND SPACING OF PREGNANCY (HTSP)

Multiple studies have shown that closely spaced pregnancies could lead to adverse maternal and
perinatal outcomes. Adolescents are as twice likely to die from pregnancy and child birth-related
causes as older counterparts; and the risk of their babies before age 1 is 50 percent higher than
babies born to women in their twenties.18,19 Health service providers could promote health timing
and spacing of pregnancy since HTSP offers: Reduced risks after a live birth, reduced risks after a
miscarriage or post Abortion, reduced risks for adolescents. 21

What is HTSP?
Healthy Timing and Spacing of Pregnancy (HTSP)18 is an intervention to help women and families
delay or space their pregnancies, to achieve the healthiest outcomes for women, newborns, infants
and children, within the context of free and informed choice, taking into account fertility intentions
and desired family size. 20
Recommendations regarding HTSP
• After a live birth, the recommended interval before attempting the next pregnancy should be at
least 24 months (this is equivalent to 33 months birth-to-birth interval);
• After a miscarriage or induced abortion, the recommended minimum interval to next pregnancy
should be at least six months; and
• To delay first pregnancy until at least 18 years of age

Ensuring No Missed Opportunity for Post-Partum Family Planning

Continuum of care throughout a woman’s pregnancy, childbirth and postpartum provides
opportunities to provide her family planning services. Health care system should integrate PPFP with
maternal, newborn and child health interventions ensure no missed opportunity for PPFP. 21Health
care providers should be able to recognize opportunities throughout the continuum of health care
contacts during antenatal care, Intrapartum care, postpartum care and well-child care including
immunizations visits, growth monitoring, event days, and illness visits. 22

Continuum of Health Care Contacts with Opportunities to Offer PPFP

Antenatal Labor and Postpartum Well-child

Care Birth Care care

14
Figure.2. Postpartum contraceptive options (timing of method initiation and breastfeeding
considerations)

15
16
CHAPTER V: QUALITY OF CARE

5.1: INFORMATION AND SERVICE

Service quality is equally important to promote consistent use of FP service. A minimum set of
service delivery standards in the clinics like privacy and ensuring confidentiality can help create a
comfortable and welcoming environment for clients seeking contraception advice. Precautions
must be taken to ensure that client records are stored safely and confidentially to reflect respect to
client rights in contraception and their methods choice. Special attention is required on privacy and
confidentiality when providing contraceptive services to young and unmarried clients.

5.2: SAFETY
It is the one of the competencies of family planning service providers to assure safety. To provide
safe and quality service the providers must be competent in screening the clients, performing safe
medical procedures, and providing continuity of care for both counseling for informed choice and
arranging follow-up visit for management of complications or consequences of choose method.

5.2.1: Screening the Clients

Before providing the method of choice, the provider must be reasonably sure that the client is not
pregnant, and that the method chosen is safe for the client. The provider should use the checklist
(see job aids:6) to rule out pregnancy.

The health care providers must properly screen clients for service eligibility, according to WHO
Medical Eligibility Criteria (MEC). The MEC wheel, and quick reference chart for the WHO Medical
Eligibility Criteria on Contraceptive Use presented in Figure 2 will help service provider easy
reference for client screening. All providers should have access to the updated medical eligibility
criteria information to screen their clients. Using Medical Eligibility Wheel will facilitate the screening
process.

17
Figure.3.
2015 Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use –
to initiate or continue use of combined oral contraceptives (COCs), depot-medroxyprogesterone
acetate (DMPA), progestin-only implants, copper intrauterine device (Cu-IUD)

Condition Sub-Condition COC DMPA Inplant Cu-IUD

Pregnancy NA NA NA
Breastfeeding Less than 6 weeks postpartum
6 weeks to < 6 months postpartum See i.
6 months postpartum or more
Postpartum and not < 21 days
breastfeeding <21 days with other risk factor for VTE*
VTE = venous throm- See i.
> 21 to 42 days with other risk factors for VTE*
boembolism
> 42 days
Postpartum and <48 hours or more than 4 weeks
breastfeeding or not > 48 hours to less than 4 weeks See ii. See ii. See ii.
breastfeeding Puerperal sepsis
Postabortion Immediate post-septic
Smoking Age > 35 years, < 15 cigarettes / day
Age > 35 years, > 15 cigarettes / day
Multiple risk factors for cardiovascular disease
Hypertension History of (where BP cannot be evaluated)
BP = blood pressure BP is controlled and can be evaluated
Elevated BP (systolic 140 – 159 or diastolic 90-99)
Elevated BP (systolic > 160 or diastolic > 100)
Vascular disease
Deep venous History of DVT/PE
thrombosts (DVT) and Acute DVT/PE
pulmonary embolism DVT/PE, established on anticoagulant therapy
(PE)
Major surgery with prolonged immobilization
Known thrombogenic mutations
Ischemic heart disease (current or history of ) or stroke (history of) I C
Known hyperlipidemias
Complicated valvular heart disease
Systemic lupus Positive or unknown antiphospholipid antibodies
erythemastosus Servere thrombocytopenia I C I C
Immunosuppressive treatment I C
Headaches Non-migrainous (mild or servere) I C
Migraine without aura (age < 35 years) I C
Migraine without aura (age > 35 years) I C
Migraines with aura (at any age) I C I C
Category 1 There are no restrictions for use
Category 2 Generally use; some follow-up may be needed
Category 3 Usually not recommended; clinical judgment and
continuing access to clinical services are required for use
Category 4 The method should not be used.

18
 Condition Sub-Condition COC DMPA Inplant Cu-IUD
Unexplained vaginal bleeding (prior to evaluation) I C
Gestational Regressing or undetectable –hCG levels
trophoblastic disease
Persistenty elevated –hCG levels or malignant disease
Cancers Cervical (awaiting treatment) I C
Endometrial I C
Ovarian I C
Breast disease Undiagnosed mass ** ** **
Current cancer
Past w / no evidence of current disease for 5 yrs
Uterine distortion due to fibroids or anatomical abnormalities
STIs / PID Current purulent cervicitis, chlamydia, gonorrhea I C
Vaginitis
Current pelvic inflammatory disease (PID) I C
Other STIs (excluding HIV / hepatitis)
increased risk of STIs
Very high individual risk of exposure to STIs I C
Pelvic tuberculosis I C
Diabetes Nephropathy / retinopathy / neuropathy
Diabetes for > 20 years
Symptomatic gall bladder disease (current or medically treated)
Cholestasis Related to pregnancy
(hstory of) Related to oral contraceptives
Hepatitis Acute or flare I C
Chronic or client is a carrier
Cirrhosis Mild
Severe
Liver tumors (hepatocellular adenoma and malignant hepatoma)
High risk of HIV or HIV-infected (Stage 1 or 2)
AIDS No antiretroviral therapy (ARV) I C
(HIV-Infected Stage Improved to Stage 1 or 2 on ARV therapy See iii. See iii. See iii.
3 or 4)
Not improved on ARV therapy I C
Drug Interactions Rifampicin or rifabutin
Anticonvulsant therapy***
This chart shows a complete list of all conditions classified by WHO as Category 3 and 4.
Source: Adapted from Medical Eligibility Criteria for Contraceptive Use, 5th Edition, Geneva: World Health Organization, 2015.
Available: [Link]
I/C Initiation/continuation: A woman may fall into either one category or another, depending on whether she is initiating or continuing
to use a method.
NA Not Applicable: Women who are pregnant do not require contraception. If these methods are accidentally initiated, no harm will
result.
i See condition "Postpartum and breastfeeding or not breastfeeding" instead.
ii See condition "Breastfeeding" or condition "Postpartum and not breastfeeding" instead.
iii Women who use methods other than IUDs can use them regardless of HIV stage or used of ART.
* Other risk factors for VTE include : previous VTE, thrombophilia, immobility, transfusion at deliver, BMI>30kg/m²,
postpartum hemorrhage, immediately post-caesarean delivery, pre-eclampsia, and smoking.
** Evaluation of an undiagnosed mass should be pursued as soon as possible.
*** Anticonvulsants include: phenytoin, carbamazepine, barbiturates, primidone, topiramate,
oxcarbazepine, and lamotrigine.

19
5.2.2: Safe Medical Procedure
Providers must follow appropriate infection prevention practices depending on the method they
provide considering safety for the clients, providers and community. Infection Prevention practices
such as hand washing, safe injection practices, instrument processing, using appropriate Personal
Protective Equipment, housekeeping and proper waste management should be strictly followed.
(Annex.1, Annex.4)

5.2.3: Assuring Continuity of Care

Continuity of care is also essential in ensuring client safety. Having rapport with clients helps assure
continuity of care. To assure continuity of care, service providers should be able to
• Perform counseling on side effects, warning signs and when and where to seek health care
as necessary
• Manage follow up cases accordingly
Establish a referral channel for provision of service as well as for management of certain
complications (Management of side effects and complications of specific methods is discussed in
Session)

5.2.4: Secure contraceptive commodities in public sector

Good-quality reproductive health care requires a continuous supply of contraceptives and other
commodities. Family planning providers are the most important link in the contraceptive supply
chain that moves commodities from the manufacturer to the clients.

Where contraceptive services are available in the public center, commodities may not be, leading
most women to tend to the private center as an alternative source. If the contraceptives are not
available to the users in time, unwanted pregnancies and sexually transmitted infectious diseases
can occur. And it is important for unmet needs of women. So, the availability of commodities and
consumables in the right quality at the public-sector delivery points is an integral component of
good quality RH/BS service including forecasting, procurement and distribution. Successful use must
include assess to a consistent supply of the product.

5.2.5: safe disposal and waste management of unwanted or unused

Good quality reproductive health care requires a continuous supply of contraceptives and other
commodities.23 Hormonal contraceptive waste is not disposed of in a proper manner, there are risks
of environmental pollution. Family planning providers are the most important link in the
contraceptive supply chain that moves commodities from manufacturer to the clients.
Accurate and timely reports and orders from providers help supply chain managers determine what
products are needed, how much to buy, and where to distribute them.9 Logistics responsibilities in
the clinic in daily are track the number and types of contraceptives dispensed to clients using
appropriate record forms, maintain proper storage conditions for all supplies, clean, dry storage,
away from direct sunlight and protect from extreme heat. And then provide contraceptives to clients
by “: first expiry, first out” management of the stock of supplies.
Disposal methods are land fill, waste immobilization, incineration, chemical decomposition, return to
donor or manufacture for disposal.

20
Disposal of contraceptives will inevitably involve waste of these materials and environmental
pollution at the same time.

The choice of disposal method within option will depend on the local circumstances (decision made
by township level and above) as will the need for prior treatment of the condoms to minimize the
risk of re- use. The availability of the above options will depend on the country in question.

21
CHAPTER VI. ACCESS TO FAMILY PLANNING SERVICES

To lower unmet needs for family planning, health systems should assure access to family planning
services for all people, including adolescents, persons with disabilities, ethnic minorities, migrants,
people living with HIV, internally displaced people and others.11Services are delivered through clinic,
hospital, outreach and mobile.

To have a balanced method mix, the different components of the health system such as service
delivery points with adequate commodities and supplies to meet the demand; trained health
workforce; and quality services which are affordable will help to ensure equitable access to quality
Family Planning services.24 Therefore, there needs to develop and maintain a health system with a
budget, supportive and clear policies and protocols that favors providing quality services, physical
infrastructures including basics items needed for delivery of methods offered by the facility. As the
provision of family planning services is client-right based and choice based, the providers are not
subject to any targets or quotas.

6.1: Service delivery points

At any service delivery level, the availability of contraceptive methods/commodities and
consumables in the right quantities at the facility is an integral part of quality health services. At the
facility level, the facility manager should project commodities and supplies according to demand to
avoid stock outs. Moreover, to maintain the efficacy of the drugs, the commodities must be stored
in recommended way by the product manufacturer. In addition, there should be a clear mechanism
for maintenance of infrastructure.

Organized health facility responsive to local needs are important to provide readily accessible
services. Facilities should have comfortable waiting area and ensure minimum waiting time. It is
good to consider operating facility with sufficient flexibility to make local-level changes based on
client/community feedback.

In addition to improving access of FP services, it is important to make sure information being

accessible and understandable to all individuals and ensuring that services are affordable.

6.2: Competent Service Providers for Family Planning

Providers competent in necessary skills to provide family planning services play a major role to
increase service accessibility. Providers must be well trained, competent and confident in providing
different methods to the range of clients as necessary.

22
Table 2: Range of services available

Auxiliary Midwives, Lady Specialist

Method medical doctor
Midwives Health Visitor (ob/Gyn)
Oral contraceptive pills √ √ √ √

Condoms √ √ √ √

Injectable IM √ √ √

Injectable SC √ √ √ √

IUD √ √ √

Implants √ √

Female sterilization √ √
Medical doctors who have
Male sterilization
adequate specific training

All level of service providers could provide the information and counselling of all contraceptives. A
proper referral system set up is necessary and the staff in the facility trained for provision of a range
of contraceptives.

23
[Link]: SPECIFIC CONTRACEPTIVE METHODS
In this session, the following contraceptive methods (common usage in Myanmar) will be discussed.
The information mentioned in this session are referenced from WHO global handbook for providers
2018, WHO medical eligibility criteria (MEC) 2015 and 2015 quick reference chart for WHO MEC.

Program Method Mix

Short Term Contraceptive Methods

Combined Oral Contraceptive Pills (COCs)
1. Oral Contraceptive Pills
Progestin-Only Pills (POPs)
Progestin-Only Injectable
2. Injectables
Monthly Injectable
Male Condoms
3. Condoms
Female Condoms
Long Term Contraceptive Methods
Jadelle
1. Implants Implanon NXT
Levoplant (Sino-Implant 2)
Copper-Bearing Intrauterine Device
2. Intrauterine Device (IUD)
Levonorgestrel Intrauterine Device (LNG-IUD)
Permanent Methods
Female Sterilization
1. Sterilization
Male Sterilization
Emergency Methods
1. Emergency Contraceptive Ulipristal acetate (UPA),
Pills (EPPs) Progestin Only Pills with Evonorgestrel or
Norgestrel
Combined Oral Contraceptive with oestrogen and
progesterone (COC)
2. Intrauterine Device (IUD) Copper-Bearing Intrauterine Device
Natural Methods
1. Fertility Awareness Methods
2. Lactational Amenorrhea Method (LAM)
3. Withdrawal

There are other methods such as patch, vaginal ring, spermicide, diaphragm, cervical caps. These
are not mentioned extensively in this guideline.

24
7.1: ORAL CONTRACEPTIVE PILLS

• Combine Oral Contraceptives (COC) Pill

• Progestin only pills

Blood pressure measurement is desirable before starting a hormonal method. However, where the
risks of pregnancy are high, and few methods are available, a woman should not be denied a
hormonal method simply because her blood pressure cannot be measured. If possible, she can have
her blood pressure measured later at a time and place convenient for her (WHO, Global handbook
2018)

Key Points for all oral contraceptive pills:

• Take one pill every day. For greatest effectiveness a woman must take pills
daily and start each new pack of pills on time.
• Bleeding changes are common but not harmful. Typically, irregular bleeding for
the first few months and then lighter and more regular bleeding.
• Take any missed pill as soon as possible. Missing pills risks pregnancy and may
make some side effects worse.
• Progestin-Only Pills (POP) is safe for breastfeeding women and their babies.
• Can be given to a woman at any time to start now or later.
• No delay in return to fertility after stop taking

7.1.1. Combine Oral Contraceptives (COC) Pill

• Contain low doses of 2 hormones—a progestin and an estrogen—like the natural hormones
progesterone and estrogen in a woman’s body.
• Works primarily by preventing the release of eggs from the ovaries (ovulation).

Health Benefits, and Health Risks

Known Health Benefits

Help protect against -

• Risks of pregnancy
• Endometrial and ovarian cancer
• Pelvic Inflammatory diseases (PID)

25
Reduce -

• Ovulation pain, menstrual cramps and menstrual bleeding problems

• Symptoms of endometriosis (pelvic pain, irregular bleeding)
• Polycystic ovarian syndrome (irregular bleeding, excess hair on face or body)
• Ovarian cysts
• Iron-deficiency anemia

Known health risks

• Very rare- blood clot in deep veins of legs or lungs (deep vein thrombosis or pulmonary
embolism)
• Extremely rare: stroke and health attack
Who Can Use COC

Safe and Suitable for Nearly All Women

Nearly all women can use COCs safely and effectively, including women who:

❖ Have or have not had children

❖ Are not married
❖ Are of any age, including adolescents and women over 40 years old
❖ After childbirth and during breastfeeding, after a period of time
❖ Have just had an abortion or miscarriage or ectopic pregnancy
❖ Smoke cigarettes—if under 35 years old
❖ Have anemia now or had in the past
❖ Have varicose veins
❖ Are infected with HIV, whether or not on antiretroviral therapy

Women who can’t use COC (see detail in Medical Eligibility Criteria: MEC)

❖ Breastfeeding a baby <6 months

❖ ≥35 years smoke any amount of cigarettes
❖ High Blood Pressure (>140/90 mmHg)
❖ Heart diseases, stroke and vascular disease. Deep venous thrombosis and pulmonary
embolism
❖ Serious active liver disease, cirrhosis of liver, liver cancer and symptomatic gall bladder
disease
❖ Diabetes for >20 year with complication
❖ Breast cancer
❖ migraine
❖ Taking rifampicin and anticonvulsant therapy
❖ Planning major surgery

26
When to start oral contraceptive pills (COC)

❖ A woman can start using oral contraceptives anytime she wants if it is reasonably certain she
is not pregnant.
❖ If a woman is fully breastfeeding, she can take COC pills 6 month after delivery.
❖ If a woman starts taking COC more than 6 months after delivery and her monthly bleeding has
not returned, she can start taking pills anytime if she is not pregnant. She will need a backup
method for the first 7 days of taking COC.
❖ If a woman is partially breastfeeding or no breastfeeding, and if her monthly bleeding has not
returned, she can start OC pills anytime it is reasonably certain she is not pregnant. She will
need a backup method for the first 7 days of taking COC pills.
❖ If a woman is switching from consistent correct use of hormonal method, she can use OC pills
without waiting for next menstrual bleeding and no need backup methods. If a woman’s
previous method was an injectable contraceptive, OC pills should be initiated when the repeat
injection would have been given and no need for backup methods.
❖ If woman is switching from non-hormonal method (other than IUD) or having within 5 days
after her menstrual cycle, she can take the pills immediately and no need for a backup
method. If she takes more than 5 days after the start of her monthly bleeding, she can start OC
pills anytime it is reasonably certain she is not pregnant. She will need a backup method for
the first 7 days of taking COC pills.
❖ If woman is switching from an IUD, she can take the pills immediately if it is within 5 days after
her menstrual cycle. There is no need for a backup method and IUD can be removed at that
time. If she takes more than 5 days after the start of her monthly bleeding, she can start OC
pills any time and it is reasonably certain she is not pregnant.
o Sexually active in this menstrual cycle: it is recommended that IUD be removed at
the time of her next menstrual period.
o Not sexually active in this menstrual cycle: she will need to abstain from sex or use
additional contraceptive protection for the first 7 days of taking COC pills. If that
additional protection is to be provided by IUD she is using, it is recommended that
this IUD be removed at the time of her next menstrual period.
❖ After miscarriage or abortion, start OC pills immediately. If she starts more than 7 days after
miscarriage or abortion, use backup method for first 7 days of taking COC
❖ After taking emergency contraceptive pills (ECPs), she can start OC pills as soon as possible. All
women need backup method for the first 7 days of taking OC pills.
❖ If a woman is less than 4 weeks after delivery and not breastfeeding she can take OC pills on
days 21-28 without any backup method. If a woman is more than 4 weeks after delivery and
not breastfeeding and no menstrual return yet, she can start COC pills anytime it is reasonably
certain she is not pregnant. She will need a backup method for the first 7 days of taking COC
pills.
❖ If a woman has no monthly bleeding (not related to childbirth or breastfeeding), she can start
COC pills anytime it is reasonably certain she is not pregnant. She will need a backup method
for the first 7 days of taking COC pills.

27
Side Effects
Changes in bleeding patterns including:
– Lighter bleeding and fewer days of bleeding
– Irregular bleeding
– Infrequent bleeding
– No monthly bleeding
Headaches, dizziness, nausea, breast tenderness, weight changes, acne, increased blood
pressure

Managing side effects for COC

Irregular Bleeding Reassure. Become less or stop after the first few months.
To reduce, urge her to take a pill each day and at the same time
each day. She can try 800 mg ibuprofen 3 times daily after meals
for 5 days or other nonsteroidal anti-inflammatory drug (NSAID),
beginning when irregular bleeding starts.
No monthly bleeding Reassure and exclude pregnancy and advice for any missed pills

Headache Can give paracetamol (325–1000 mg), ibuprofen (200–400 mg),

Aspirin (325-650 mg) or other pain reliever. Any headaches that
get worse or occur more often during COC use should be evaluated
Nausea Take COCs at bedtime or with food.
Breast tenderness Wear supportive bra, try hot or cold compresses.
Weight changes Review diet and counsel as needed
Mood changes Provide appropriate support.
Refer if major depression and other serious mood changes
occurred.

7.1.2: Progestin-Only Pill (POP)

o Contains very low doses of a progestin like the natural hormone progesterone in a
woman’s body.
o Do not contain estrogen, and so can be used throughout breastfeeding and by women
who cannot use methods with estrogen
o Work primarily by thickening cervical mucus (blocks sperm from meeting an egg) and
disrupting the menstrual cycle, including preventing the release of eggs from the ovaries
(ovulation).

Known Health Benefits (POP)

Help protect against
• Risks of pregnancy

Known health risks

• None

28
Who can use POP
Safe and Suitable for Nearly All Women
Nearly all women can use POPs safely and effectively, including women who:
❖ Are breastfeeding (she can start immediately after childbirth)
❖ Have or have not had children
❖ Are married or are not married
❖ Are of any age, including adolescents and women over 40 years old
❖ Have just had an abortion or miscarriage or ectopic pregnancy
❖ Smoke cigarettes—regardless of age and number of cigarettes smoked
❖ Have anemia now or had in the past
❖ Have varicose veins
❖ Are infected with HIV, whether or not on antiretroviral therapy.

Women who can’t use POP (see detail in Medical Eligibility Criteria: MEC)
High Blood Pressure (≥160/100 mmHg)
❖ Ischemic heart disease, stroke and vascular disease
❖ Acute DVT/PE
❖ Cirrhosis, liver cancer
❖ Diabetes for >20 year with complication
❖ Had breast cancer but no recurrent for 5 years.
❖ Migraines with aura
❖ Unexplained vagina bleeding

When to start oral contraceptive pills (POP)

❖ A woman can start using oral contraceptives anytime she wants if it is reasonably certain she
is not pregnant.
❖ If a woman is fully breastfeeding, POP immediately after delivery.
❖ If a woman starts taking POP more than 6 months after delivery and her monthly bleeding has
not returned, she can start taking pills anytime if she is not pregnant. She will need a backup
method for the first 2 days of taking POP.
❖ If a woman is partially breastfeeding or no breastfeeding, and if her monthly bleeding has not
returned, she can start OC pills anytime it is reasonably certain she is not pregnant. She will
need a backup method for the first 2 days of taking POP.
❖ If a woman is switching from consistent correct use of hormonal method, she can use OC pills
without waiting for next menstrual bleeding and no need backup methods. If a woman’s
previous method was an injectable contraceptive, OC pills should be initiated when the repeat
injection would have been given and no need for backup methods.
❖ If woman is switching from non-hormonal method (other than IUD) or having within 5 days
after her menstrual cycle, she can take the pills immediately and no need for a backup
method. If she takes more than 5 days after the start of her monthly bleeding, she can start OC
pills anytime it is reasonably certain she is not pregnant. She will need a backup method for
the first 2 days of taking POP.

29
 ❖ If woman is switching from an IUD, she can take the pills immediately if it is within 5 days after
her menstrual cycle. There is no need for a backup method and IUD can be removed at that
time. If she takes more than 5 days after the start of her monthly bleeding, she can start OC
pills any time and it is reasonably certain she is not pregnant.
o Sexually active in this menstrual cycle: it is recommended that IUD be removed at
the time of her next menstrual period.
o Not sexually active in this menstrual cycle: she will need to abstain from sex or use
additional contraceptive protection for the first two days of taking POP. If that
additional protection is to be provided by IUD she is using, it is recommended that
this IUD be removed at the time of her next menstrual period.
❖ After miscarriage or abortion, start OC pills immediately. If she starts more than 7 days after
miscarriage or abortion, use backup method for the first 2 days of taking POP if reasonably
certain that she is not pregnant.
❖ After taking emergency contraceptive pills (ECPs), she can start OC pills as soon as possible. All
women need backup method for the first 2 days of taking POP.
❖ If a woman is less than 4 weeks after delivery and not breastfeeding she can take POP pills at
any time without any backup method. If a woman is more than 4 weeks after delivery and not
breastfeeding and no menstrual return yet, she can start POP anytime it is reasonably certain
she is not pregnant. She will need a backup method for the first 2 days of taking POP pills.
❖ If a woman has no monthly bleeding (not related to childbirth or breastfeeding), she can start
POP pills anytime it is reasonably certain she is not pregnant. She will need a backup method
for the first 2 days of taking POP.

Side Effects

Changes in bleeding patterns including:

• For breastfeeding women, longer delay in return of monthly bleeding
• Frequent, Infrequent, Irregular, Prolong bleeding or No monthly bleeding
Headaches, dizziness, nausea, breast tenderness, abdominal pain, mood changes

30
Managing side effects of POP

Irregular Reassure. Become less or stop after the first few months.
Bleeding To reduce, urge her to take a pill each day and at the same time. Teach her to
make up for missed pills including after vomiting and diarrhea. She can try 800
mg ibuprofen 3 times
daily after meals for 5 days or other nonsteroidal anti-inflammatory drug
(NSAID), beginning when irregular bleeding starts.

No monthly Reassure. It is not harmful.

bleeding

Heavy/ Prolong Reassure. Become less or stop after few months. To reduce, she can try Non-
bleeding Steroidal Anti-inflammatory Drugs (NSAID), beginning when heavy bleeding
starts.
Headache Can give paracetamol (325–1000 mg), ibuprofen (200–400 mg), asprin (325-650
mg) or other pain reliever. Any headaches that get worse or occur more often
during POP use should be evaluated
Nausea, Take POPs at bedtime or with food.
dizziness
Breast Wear supportive bra, try hot or cold compresses. Check breast engorgement or
tenderness other problems in the lactating women.
Severe lower May be due to various problems such as enlarged ovarian follicles or cyst which
abdomen pain need no treatment unless they grow abnormally large, twist or burst.
However, exclude ectopic pregnancy although it is quite rare.

Mood changes Provide appropriate support.

Refer if major depression and other serious mood changes occurred.

7.1.3. Explain how to use the oral contraceptive pills

❖ Take one pill each day

❖ Take pills at the same time each day
❖ For 28 pills packs, when she finishes one pack, she should take the first pill from the next
pack on the very next day. But for 21 pills pack, she needs to have 7 days break between
packs.
❖ Provide backup method and explain use - Back up methods include abstinence, condoms,
spermicides and withdrawal. (spermicides and withdrawal are the least effective methods)
❖ For women who choose POP, explain that the effectiveness decreases when breastfeeding
stops. When she stops breastfeeding, she can either continue taking POP or change to
another method.

31
7.1.4. Instructions on missed pill
• (See in job aids tool 7 for instruction on missed pill (COC))
• For POP, if the client late taking the pills 3 or more hours (late 12 hours or more for
desogestreal 75 mg containing POP pills) or completely missed the pills, take a pill as soon as
possible and continue a pill, once each day and consider ECP if she also had sex at that time. If a
woman does not have regular monthly bleeding, she needs to use backup method for the next
2 days. If she had sex in the past 5 days, can consider taking ECP
• If she vomits within 2 hours after taking a pill, she should take another pill from her pack as
soon as possible, and then keep taking pills as usual. If she has vomiting or diarrhea for more
than 2 days, follow instructions for 3 or more missed pills, as above.

7.1.5. Managing any problems

1. Schedule a regular follow up annually or as necessary. This offers an opportunity to answer any
questions, help with any problems, and check on correct use. Check the blood pressure
annually.
2. For continuing users, provide any information or help that she needs.
3. For problems reported as side effects or related to the use of oral contraceptives, encourage
the client to keep taking a pill every day. Many side effects will subside after a few months of
use.
4. For new health problems that may require switching methods or if problems cannot be
overcome, offer to help the client choose another method.
5. For minor problems, manage accordingly as described in the following table.
6. New problems that may require switching methods.
If the woman developed the following symptoms, oral contraceptive pills usage should be
stopped or switching to another method:
❖ Unexplained vaginal bleeding (that suggests a medical condition not related to the
method) or heavy or prolonged bleeding
❖ Starting treatment with anticonvulsants, rifampicin, rifabutin or ritonavir– it can cause
reducing effectiveness of pills.
❖ Migraine headaches
❖ Circumstances that will keep her from walking for one week or more
❖ Certain serious health conditions (specify eg. suspected heart or serious liver diseases,
high blood pressure, blood cloths in deep veins of legs or lungs, stroke, breast cancer, etc.
❖ Suspected pregnancy

32
7.2: EMERGENCY CONTRACEPTIVE PILLS
Blood pressure measurement is desirable before starting a hormonal method. However, where the
risks of pregnancy are high, and few methods are available, a woman should not be denied a
hormonal method simply because her blood pressure cannot be measured. If possible, she can have
her blood pressure measured later at a time and place convenient for her (WHO, Global handbook
2018)

Key Points

• Emergency contraceptive pills (ECPs) help a woman avoid pregnancy after she has sex
without contraception.
• ECPs help to prevent pregnancy when taken up to 5 days after unprotected sex. The
sooner they are taken, the better.
• Do not disrupt an existing pregnancy.
• Safe for all women—even women who cannot use ongoing hormonal contraceptive
methods.
• Provide an opportunity for women to start using an ongoing family planning method.
• Many options can be used as emergency contraceptive pills. Dedicated products,
progestin-only pills, and combined oral contraceptives all can act as emergency
contraceptives.

• Emergency contraceptive pills (ECPs) are sometimes called “morning after” pills or post-
coital contraceptives.
• Work by preventing or delaying the release of eggs from the ovaries (ovulation). They do not
work if a woman is already pregnant.
(The copper – bearing IUD also can be used for emergency contraception.)

What Pills Can Be Used as Emergency Contraceptive Pills?

• A special ECP product with levonorgestrel only, or ulipristal acetate (UPA)
• Progestin-only pills with levonorgestrel or norgestrel
• Combined oral contraceptives with estrogen and a progestin— levonorgestrel, norgestrel, or
norethindrone (also called norethisterone)

When to Take Them?

• As soon as possible after unprotected sex. The sooner ECPs are taken after unprotected sex,
the better they prevent pregnancy.
• Can prevent pregnancy when taken any time up to 5 days after unprotected sex.

33
Pill Formulations and Dosing for Emergency Contraception

Pills to Take
Pill Type and Hormone Formulation
At First 12 Hours Later

Dedicated ECP Products

Progestin-only 1.5 mg LNG 1 0
0.75 mg LNG 2 0
Ulipristal acetate 30 mg ulipristal acetate 1 0
Oral Contraceptive Pills Used for Emergency Contraception
Combined 0.02 mg EE + 5 5
(estrogen-progestin) 0.1 mg LNG
oral contraceptives
0.03 mg EE + 4 4
0.15 mg LNG
0.03 mg EE + 4 4
0.15 mg LNG
0.03 mg EE + 4 4
0.125 mg LNG
0.05 mg EE + 2 2
0.25 mg LNG
0.03 mg EE + 4 4
0.3 mg norgestrel

34
 0.05 mg EE + 2 2
0.5 mg norgestrel
Progestin-only pills 0.03 mg LNG 50* 0

0.0375 mg LNG 40* 0

0.075 mg norgestrel 40* 0

* Many pills, but safe.

LNG = levonorgestrel EE = ethinyl estradiol

For information on brands of ECPs and oral contraceptive pills, see: The Emergency
Contraception Website (http:/[Link]) and the International Consortium for
Emergency Contraception (http: /[Link]).

How to take Emergency Contraceptive Pills?

• Take two pills (0.75 mg) of levonogestrel containing ECP at once (1.5 mg in a single dose) -
• For combined Emergency Pills (0.1 mg ethinyl estradiol + 0.5 mg levonogestrel) take two
doses 12 hours apart
• For combined Emergency Pills (0.1 mg ethinyl estradiol + 1 mg norgestrel) take two doses
12 hours apart
• For combined Emergency Pills (0.1 mg ethinyl estradiol + 2 mg norethindrone) take two
doses 12 hours apart
• If she vomits within 2 hours after taking pills, she should repeat the dose. (She can use
antiemetic medication with the repeat dose)

Side Effects, Health Benefits, and Health Risks

Known Health Benefits

Help protect against:
• Risks of pregnancy
Known Health Risks
• None

Who Can Use Emergency Contraceptive Pills

Safe and Suitable for All Women

Tests and examinations are not necessary for using ECPs. They may be appropriate for other
reasons—especially if sex was forced (see Violence against Women)

35
When to Use

• Any time within 5 days after unprotected sex. The sooner after unprotected sex that ECPs
are taken, the more effective they are.
• ECPs can be used any time a woman is worried that she might become pregnant. For
example, after:
• Sexual assault, any unprotected sex, mistakes using contraception such as: Condom was
used incorrectly, slipped, or broke.
• Couple incorrectly used a fertility awareness method (for example, failed to abstain or to use
another method during the fertile days)
• Man failed to withdraw, as intended, before he ejaculated.
• Woman has missed 3 or more combined oral contraceptive pills or has started a new pack 3
or more day late
• IUD has come out of place
• Woman has had unprotected sex when she is more than 4 weeks late for her repeat
injection of DMPA, more than 2 weeks late for her repeat injection of NET-EN or more than 7
days late for her repeat monthly injection

When to start or restart emergency contraceptive pills

A woman can start using ECPs any time within 5 days after unprotected sex. The sooner after
unprotected sex that ECPs are taken, the more effective.
ECPs can be used any time a woman is worried that she might become pregnant after sexual assault,
any unprotected sex and mistakes using contraception, such as condom was used incorrectly.

Hormonal methods
After taking progestin- only or combined ECPs: can start or restart any method immediately after she
takes the ECPs. No need to wait for her next monthly bleeding.
- The continuing user of oral contraceptive pills who needed ECPs due to error can resume use
as before. She does not need to start a new pack.
All women need to abstain from sex or use a backup for the first 7 days of using their methods.
If she does not start immediately, but instead returns for a method, she can start any method at any
time if it is reasonably certain she is not pregnant.
If a woman after taking ulipristal acetate (UPA) ECPs, she can start or restart any method containing
progestin on the 6th day after taking UPA-ECPs. No need to wait for nest menstrual bleeding. (if she
starts a method containing progestin earlier, both the progestin and UPA could be less effective)
If woman wants to use oral contraceptive pills, give her a supply and tell her to start on the 6th day
after taking UPA-ECPs. If woman wants to use injectables or implants, give her an appointment to
return for the method on the 6th day after taking UPA- ECPs or as soon as possible after that. All
women need to use a backup method from the time they take UPA- ECPs until they have been using
a hormonal method for 7 days (or 2 days for progestin- only pills). If she does not start on the 6th day,
but instead returns later for a method, she may start any method at any time if it is reasonably
certain she is not pregnant.

36
Levonogestrel intrauterine device (LNG-IUD)
After taking progestin- only or combined ECPs: woman can have the LNG-IUD inserted at any time it
can be determined woman is not pregnancy. Woman should use backup method* for the first 7 days
after LNG-IUD insertion.
After taking UPA-ECPs: woman can have the LNG-IUD inserted on the 6th day after taking UPA-ECPs if
it can be determined that she is not pregnancy. If she wants to use the LNG-IUD, give her an
appointment to return to have it inserted on the 6th day after taking UPA-ECPs or as soon as possible
after that.
She will need to use a backup method from the time she takes UPA-ECPs until 7 days after LNG-IUD
is inserted.
If she does not have the LNG-IUD inserted on the 6th day, but instead returns later, she can have it
inserted at any time if it can be determined she is not pregnant.

Copper bearing intrauterine device

After taking progestin- only, combined, or UPA- ECPs: If woman wants to use a copper- bearing IDU
after taking ECPs, woman can have it inserted on the same day she takes the ECPs. No need for a
backup method. If woman does not have it inserted immediately, she can have the copper- bearing
IUD inserted any time if it can be determined that she is not pregnancy.

Female sterilization.
After taking progestin – only, combined, or UPA-ECPs: the sterilization procedure can be done
within 7 days after the start of her next monthly bleeding or any other time if it is reasonably
certain she is not pregnant. Give her a back method to use until she can have the procedure.

Male and female condoms

After taking progestin – only, combined or UPA-ECPs – woman can use immediately.

Fertility awareness methods

After taking progestin-only, combined, or UPA-ECPs, woman can use Standard Days Method with
the start of her next monthly bleeding. She can use Symptoms-based methods once normal
secretions have returned. Give woman a backup method to use until she can begin the method of
her choice.

* Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell
her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give
her condoms.

37
Side Effects

Changes in bleeding patterns including:

• Slight irregular bleeding for 1–2 days after taking ECP

• Monthly bleeding that starts earlier or later than expected

In the week after taking ECPs:

• Nausea
• Abdominal pain
• Fatigue
• Headaches
• Breast tenderness
• Dizziness
• Vomiting

Managing problems

Slight irregular bleeding • Irregular bleeding due to ECPs will stop

without treatment.
• Assure the woman that this is not a sign of
illness or pregnancy.
Change in timing of next monthly bleeding or • Monthly bleeding may start earlier or later
suspected pregnancy than expected. This is not a sign of illness
or pregnancy.
• If her next monthly bleeding is more than
one week later than expected after taking
ECPs, assess for pregnancy. There are no
known risks to a fetus conceived if ECPs fail
to prevent pregnancy.

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7.3: INJECTABLE CONTRACEPTIVES
• The progestin-only injectable contraceptives
• Depot medroxyprogesterone acetate ( DMPA)
• Norethisterone enanthate( NET-EN)
• Combined injectable contraceptive (Monthly injectables)

Blood pressure measurement is desirable before starting a hormonal method. However, where the
risks of pregnancy are high, and few methods are available, a woman should not be denied a
hormonal method simply because her blood pressure cannot be measured. If possible, she can have
her blood pressure measured later at a time and place convenient for her (WHO, Global handbook
2018)

Key Points
❖ Bleeding changes are common but not harmful. Typically, irregular bleeding for the
first several months and then no monthly bleeding.
❖ Return for injections regularly and as scheduled. Coming back every 3 months (13
weeks) for DMPA or every 2 months for NET-EN and every 4 weeks for monthly
injectables is important for greatest effectiveness.
❖ Injection can be provided up to 4 weeks late for DMPA 2 weeks late for NET-EN and 1
week late or early for monthly injectable. Client should come back even if later than
scheduled date.
❖ Gradual weight gain is common.
❖ Return of fertility is often delayed. It takes several months longer on average to
become pregnant after stopping progestin only injectables than after stopping other
methods.

7.3.1. Progestin- only injectable contraceptives

The progestin-only injectable contraceptives; depot medroxyprogesterone acetate (DMPA) and
norethisterone enanthate (NET-EN),
• each contain a progestin like the natural hormone progesterone in a woman’s body. It does not
contain estrogen, so it can be used throughout breastfeeding and by women who cannot use
methods with estrogen. It can be given by (intramuscularly) and the hormone is then released
slowly into the bloodstream.
• A different formulation of DMPA can be injected (subcutaneously). A new type of prefilled,
single use syringe could be particularly useful to provide DMPA in the community (Sayana press
– DMPA-SC). This formulation of DMPA is available in conventional prefilled auto-disable
syringes and in the Uniject system, in which squeezing a bulb pushes the fluid through the
needle.

39
Women can begin using injectable contraceptives:

❖ Without a pelvic examination

❖ Without any blood tests or other routine laboratory tests
❖ Without cervical cancer screening
❖ Without a breast examination
Even when a woman is not having monthly bleeding at the time, if it is reasonably certain
she is not pregnant.

Health Benefits, and Health Risks of Progestin-only injection

DMPA
Known Health Benefits
Helps protect against:
• Risk of pregnancy
• Endometrial cancer
• Uterine fibroid
May help protect against:
• Symptomatic pelvic inflammatory (PID) disease
• Iron-deficiency anemia
Reduces:
• Sickle cell crises among women with sickle cell anemia
• Symptoms of endometriosis (pelvic pain, irregular bleeding)

NET-EN
Helps protect against:
• Risks of pregnancy
• Iron-deficiency anemia
Known Health Risks
None – DMPA/ NET-EN

Who Can Use Injection Contraceptives (DPMA)

Safe and Suitable for Nearly All Women

Nearly all women can use injectables safely and effectively, including women who:
❖ Are breastfeeding (as soon as 6 weeks after birth)
❖ Have or have not had children

40
 ❖ Are not married
❖ Are of any age, including adolescents and women over 40 years old
❖ Have just had an abortion or miscarriage
❖ Smoke cigarettes—regardless of age and number of cigarettes smoked
❖ Are infected with HIV, whether or not on antiretroviral therapy.
Women who can’t use DPMA Injectable Contraceptives (see detail in MEC)
❖ Fully breasting a baby <6weeks
❖ High Blood Pressure ≥160/100 mmHg
❖ Ischemic heart diseases, stroke and vascular disease
❖ Acute DVT/PE
❖ Cirrhosis of liver and liver cancer
❖ Diabetes for >20 years with complication
❖ Breast cancer
❖ unexplained vaginal bleeding

When to start projestin- only injectables

❖ A woman can start using contraceptive injections anytime she wants if it is reasonably certain
she is not pregnant. She will need a backup method for the first 7 days after the injection if the
injection is given after 7th day of menstrual cycle.
❖ If a woman is fully breastfeeding, she can take injection contraceptive 6 week after delivery.
❖ If a woman starts taking injectable contraceptives more than 6 months after delivery and her
monthly bleeding has not returned, she can start taking injection anytime if she is not
pregnant. She will need a backup method for the first 7 days after the injection.
❖ If a woman is < 6 weeks after delivery and partially breastfeeding delay injection until at least
6 weeks after delivery. If a woman is not breastfeeding, she can start injection anytime on days
21-28 after delivery without backup method.
❖ If a woman is > 6 weeks after delivery and partially breastfeeding or if a woman is > 4 weeks
after delivery without breastfeeding, and if her monthly bleeding has not returned, she can
start injection anytime it is reasonably certain she is not pregnant. She will need a backup
method for the first 7 days after injection.
❖ If a woman is switching from consistent correct use of hormonal method, she can use injection
without backup methods. If a woman is switching from another injectable, she can have new
injection when the repeat injection would have been given.

41
❖ If a woman is switching from non-hormonal method (other than IUD) or having within 7 days
after her menstrual cycle, she can take the injection immediately and no need for a backup
method. If she takes more than 7 days after the start of her monthly bleeding, she can start
injection anytime it is reasonably certain she is not pregnant. She will need a backup method for
the first 7 days after the injection.
❖ If woman is switching from an IUD, she can take the injection immediately if it is within 7 days
after her menstrual cycle. There is no need for a backup method and IUD can be removed at
that time. If she takes more than 7 days after the start of her monthly bleeding, she can start
injection any time and it is reasonably certain she is not pregnant.
o Sexually active in this menstrual cycle and more than 7 days since the start of menstrual
bleeding: it is recommended that IUD be removed at the time of her next menstrual
period.
o Not sexually active in this menstrual cycle and more than 7 days since the start of
menstrual bleeding: she will need to abstain from sex or use additional contraceptive
protection for the next 7 days. If that additional protection is to be provided by IUD she is
using, it is recommended that this IUD be removed at the time of her next menstrual
period.
❖ If a woman is after miscarriage or abortion, start injection immediately. If she starts more than
7 days after miscarriage or abortion, use backup method for first 7 days after the injection.
❖ If a woman is after taking emergency contraceptive pills (ECPs), she can take injectable on the
same day as the ECPs. She will need a backup method for the first 7 days after the injection.
❖ If a woman has no monthly bleeding (not related to childbirth or breastfeeding), she can start
injection anytime it is reasonably certain she is not pregnant. She will need a backup method for
the first 7 days after the injection.

42
Side Effects
Changes in bleeding patterns including,
For DMPA users:
First 3 months: Irregular/Prolong bleeding
At one year: No monthly bleeding, Infrequent/Irregular bleeding
For NET-EN users:
They have fewer days of bleeding in the first 6 months and are less likely to have no
monthly bleeding after one year than DMPA users
Weight gain, headaches, dizziness, abdominal bloating and discomfort, mood changes, less sex
drive, loss of bone density

Management of side effects of DPMA/NET-EN

No monthly bleeding Reassure. If no monthly bleeding bothers her, she may want to switch to
monthly injectable, if available.

Irregular Bleeding/ Reassure. Become less or stop after the first few months.
Heavy/ Prolong For modest short-term relief, she can take 500 mg mefenamic acid 2
bleeding (twice as times daily after meals for 5 days or 40 mg of valdecoxib daily for 5 days,
much as usual or beginning when irregular bleeding starts.
longer than 8 days)
If bleeding is heavy or prolong, she can try 50ug of ethinyl estradiol daily
for 21 days, beginning when heavy bleeding starts
Iron supplement and diet
If irregular or heavy bleeding persists for several months, consider
underlying conditions.
Weight changes Review diet and counsel as needed

Abdominal bloating Locally available remedies

and discomfort

Headache Can give paracetamol (325–1000 mg), ibuprofen (200–400 mg), aspirin
(325-650 mg) or other pain reliever. Any headaches that get worse or
occur more often during injectable use should be evaluated
Dizziness Consider locally available remedies
Mood changes or Provide appropriate support.
changes in sex drive Refer if major depression and other serious mood changes occurred.

43
7.3.2. Combined injectable contraceptives contain 2 hormones; a progestin and an estrogen and
also known as monthly injectables

Key Points
Bleeding changes are common but not harmful. Typically, lighter monthly bleeding, fewer days of
bleeding, or irregular or infrequent bleeding.
Return on time. Coming back every 4 weeks is important for greatest effectiveness.
Injection can be as much as 7 days early or late.

All injectable contraceptives provide the contraceptive effect primarily by preventing the ovulation.

Health Benefits, and Health Risks of CIC

Known Health Benefits (CIC)

(similar with COC, might difference in the effects on the liver)

Help protect against

• Risks of pregnancy
• Endometrial and ovarian cancer
• PID
May reduce
• Ovarian cysts
• Iron-deficiency anemia
Reduce
• Ovulation pain, menstrual cramps and bleeding problems
• Reduce symptoms of endometriosis

Known Health Risks (CIC)

Very rare
• (Deep vein thrombosis or pulmonary embolism)
Extremely rare
• Stroke
• Heart Attack

Who Can Use Combined injectable contraceptives (CIC)

Safe and Suitable for Nearly All Women
Nearly all women can use injectable safely and effectively, including women who:
❖ Breast feeding women at ≥6 months after birth
❖ Have or have not had children

44
 ❖ Are not married
❖ Are of any age, including adolescents and women over 40 years old
❖ Have just had an abortion or miscarriage
❖ Have anemia now or had anemia in the past
❖ Have varicose veins
❖ Are infected with HIV, whether or not on antiretroviral therapy

Women who can’t use CIC Injectable Contraceptives (see detail in MEC)
❖ Fully Breastfeeding a baby <6 months
❖ ≥35 year and Smoke any number of cigarettes a day( >15 cigarette a day)
❖ High Blood Pressure (>140/90 mmHg)
❖ Heart diseases, stroke and vascular disease
❖ Deep venous thrombosis and pulmonary embolism
❖ Serious active liver disease, cirrhosis of liver and liver cancer
❖ Symptomatic gall bladder disease
❖ Diabetes for >20 years with complication
❖ Had breast cancer but no recurrent for 5 years.
❖ Migraine
❖ Taking rifampicin or rifabutin and anticonvulsant therapy

When to start (Combined injectable contraceptive)

❖ A woman can start using contraceptive injections anytime she wants if it is reasonably certain
she is not pregnant. She will need a backup method for the first 7 days after the injection if the
injection is given after 7th day of menstrual cycle.
❖ If a woman is fully breastfeeding, she can take injection contraceptive 6 months after delivery.
❖ If a woman starts taking injectable contraceptives more than 6 months after delivery and her
monthly bleeding has not returned, she can start taking injection anytime if she is not
pregnant. She will need a backup method for the first 7 days after the injection.
❖ If a woman is < 6 week after delivery and partially breastfeeding, delay injection until at least 6
weeks after delivery. If a woman is not breastfeeding, she can start injection at any time on
days 21-28 after delivery.
❖ If a woman is > 6 weeks after delivery and partially breastfeeding or if a woman is > 4 weeks
after delivery without breastfeeding , and if her monthly bleeding has not returned, she can
start injection anytime it is reasonably certain she is not pregnant. She will need a backup
method for the first 7 days after injection.

45
❖ If a woman is switching from consistent correct use of hormonal method, she can use injection
without backup methods. If a woman is switching from another injectable, she can have new
injection when the repeat injection would have been given.
❖ If a woman is switching from non-hormonal method (other than IUD) or having within 7 days
after her menstrual cycle, she can take the injection immediately and no need for a backup
method. If she takes more than 7 days after the start of her monthly bleeding, she can start
injection anytime it is reasonably certain she is not pregnant. She will need a backup method for
the first 7 days after the injection.
❖ If woman is switching from an IUD, she can take the injection immediately if it is within 7 days
after her menstrual cycle. There is no need for a backup method and IUD can be removed at
that time. If she takes more than 7 days after the start of her monthly bleeding, she can start
injection any time and it is reasonably certain she is not pregnant.
o Sexually active in this menstrual cycle and more than 7 days since the start of menstrual
bleeding: it is recommended that IUD be removed at the time of her next menstrual
period.
o Not sexually active in this menstrual cycle and more than 7 days since the start of
menstrual bleeding: she will need to abstain from sex or use additional contraceptive
protection for the next 7 days. If that additional protection is to be provided by IUD she is
using, it is recommended that this IUD be removed at the time of her next menstrual
period.
❖ If a woman is after miscarriage or abortion, start injection immediately. If she starts more than
7 days after miscarriage or abortion, use backup method for first 7 days after the injection.
❖ If a woman is after taking emergency contraceptive pills (ECPs), she can take injectable on the
same day as the ECPs. She will need a backup method for the first 7 days after the injection.
❖ If a woman has no monthly bleeding (not related to childbirth or breastfeeding), she can start
injection anytime it is reasonably certain she is not pregnant. She will need a backup method for
the first 7 days after the injection.

46
Side Effects (Combined Injectable Contraceptive)
• Changes in bleeding patterns including,
• Lighter bleeding and fewer days of bleeding
• Irregular bleeding
• Infrequent bleeding
• Prolonged bleeding
• No monthly bleeding
Weight gain, headaches, dizziness, breast tenderness

Managing any problems

1. For minor problems, manage accordingly as described in the following table
2. If problems can’t be overcome, offer to help the client choose another method.

No monthly Reassure that is not harmful. It is similar to not having monthly bleeding
bleeding during pregnancy. Blood is not building up inside her.

Irregular Reassure. Become less or stop after the first few months.
Bleeding/ Heavy/ For modest short-term relief, she can try 800 mg ibuprofen 3 times daily
Prolong bleeding after meals for 5 days or other NSAIDs, beginning when irregular bleeding
starts.
If bleeding persists for several months, consider underlying conditions.
Consider iron supplement and diet.
Weight changes Review diet and counsel as needed

Headache Can give paracetamol (325–1000 mg), ibuprofen (200–400 mg), Aspirin (325-
650 mg) or other pain reliever. Any headaches that get worse or occur more
often during CIC use should be evaluated
Breast Wear a supportive bra
tenderness Try hot or cold compresses
Dizziness Consider locally available remedies

If the woman developed the following symptoms, injectable contraceptive usage should be
stopped:
❖ Unexplained vaginal bleeding (that suggests a medical condition that is not related to the
method) or heavy or prolonged bleeding to make diagnosis easier.
❖ Starting treatment with anticonvulsants, rifampicin, rifabutin or ritonavir (Progestin-Only
Injectables) and starting treatment with lamotrigine or ritonavir (CIC)

47
 ❖ Migraine headaches
❖ Certain serious health conditions
❖ Suspected pregnancy

7.3.3. Giving the Injection

❖ DMPA- 150 mg IM injection. NET-EN – 200 mg IM injection. DMPA-SC – 104 mg SC injection.
❖ The provider must follow the standard operating procedures for provision of a safe injection
procedures including hand washing, using sterile needle and syringe, gently shake the vial if
DMPA and MPA/estradiol cypionate, prepare vial into a normal temperature, and proper
disposal of used needles.
❖ Instruct the client not to massage the injection site.
❖ Tell the client the name of the injection and agree on a date for her next injection. Give
appointment according to the type of progestin-only injectable (3 months for DMPA, 2 months
for NET-EN and 1 month for monthly injectable).
❖ Ask the client to come back on time. However, with DMPA, she may come up to 4 weeks late,
with NET-EN, she may come up to 2 weeks late and with CIC, she may come up to 1 week late
and still get an injection. With either DMPA or NET-EN, she can come up to 2 weeks early and 1
week early for CIC monthly injectable.
❖ She should come back no matter how late she is for her next injection. If she is late for injection,
a woman should use a backup method until she can get an injection. If she has had sex without
using any contraceptive methods, she can consider ECP.
❖ A woman can receive her next injection, if a woman is >4 weeks late for DMPA or > 2 weeks late
for NET-EN, or > 1 week late for CIC exclude if she has had sex since 2 weeks after she should
have had her last injection, or confirm if she is fully or nearly fully breastfeeding and she gave
birth < 6 months, uses other backup methods or has taken ECPs. She would need a backup
method for the first 7 days after the injection. Discuss how to remember the date, perhaps
tying it to a holiday or other event.

48
7.4: MALE AND FEMALE CONDOMS

Key Points
❖ Male and female condoms help protect against sexually transmitted infections
(STI), including HIV. Condoms are the only contraceptive method that can protect
against both pregnancy and STI.
❖ Require correct use with every act of sex for greatest effectiveness.
❖ A male condom require both male and female partner’s cooperation.
❖ A woman can initiate female condom use, but the method requires her partner’s
cooperation
❖ May dull the sensation of sex for some men (Male condom).
❖ May require some practice. Inserting and removing the female condom from the
vagina becomes easier with experience

• Male Condoms are mostly made of thin latex rubber; and they are sheaths or coverings that
fit over a man’s erect penis.
• Female Condoms are sheaths or lining that fit loosely inside a woman’s vagina. They have
flexible rings at both ends. One ring at the closed end helps to insert the condom whereas
the open-end ring holds outside the vagina.
• Work by forming a barrier that keeps sperm out of the vagina and preventing pregnancy.
Also keep infections in semen, on the penis, or in the vagina from infecting the other
partner.

Health Benefits, and Health Risks

Known Health benefits
Help protect against:
• Risks of pregnancy
• STIs, including HIV
May help protect against (conditions caused by STIs):
• Recurring pelvic inflammatory disease and chronic pelvic pain
• Cervical cancer

49
Known Health Risks
Extremely rare:
• Severe allergic reaction (among people with latex allergy)

Who Can and Cannot Use Male Condoms

❖ All men and women can safely use condoms except those with severe allergic reaction to
latex rubber

When to Start
❖ Anytime the client wants

Correcting misunderstanding, Female condoms:

• Cannot get lost in the woman’s body
• Are not difficult to use, but correct use needs to be learned
• Do not have holes that HIV can pass through
• Are used by married couples. They are not only for use outside marriage
• Do not cause illness in a woman because they prevent semen or sperm from entering
her body

Side Effects
None

Managing Any Problems

❖ Problems with condoms affect clients’ satisfaction and use of the method. Offer to help the
client choose another method, unless condoms are needed for protection from STIs,
including HIV.
❖ ECPs can help prevent pregnancy if condom breaks or slips off.
❖ If the client has signs or symptoms of STIs after, condom breaks or slips off, assess the client
for treatment or refer.
❖ If the client has difficulty putting on the condoms, demonstrates by using a model or other
item and correct any errors.
❖ Discuss ways to talk about condoms with partners and dual protection rationales to
encourage the difficulty persuading partner.

50
 ❖ If the inner ring of female condom become uncomfortable or painful, suggest that she
reinsert or reposition the condom so that the inner ring is tucked back behind the pubic
bone and out of the way. If the condom squeaks or make noises, use more lubricants.
❖ For minor irritation, suggest putting lubricant to reduce rubbing or trying another brand of
condoms. If the symptoms persist, assess and treat possible vaginal infection or STI as
appropriate or refer.
❖ If the woman has the following conditions, male partner should stop using latex condom
Female partner is using miconazole or econazole, for treatment of vaginal infection, which
can damage latex.
❖ Severe allergic reaction to condom

How to use male/female condoms

Detail steps of using male/female condoms are illustrated in the table 3 and 4

51
Table .3:Explaining How to Use Male Condom
Explaining How to Use
IMPORTANT: Whenever possible, show clients how to put on a condom. Use a model of a penis, if available, or
other item, like a banana, to demonstrate.

Explain the 5 Basic Steps of Using a Male Condom

Basic Steps Important Details

1. Use a new condom • Check the condom package. Do not use
for each act of sex if torn or damaged. Avoid using a
condom past the expiration date. Do so
only if a newer condom is not available.
• Tear open the package carefully. Do not
use fingernails, teeth, or anything that
can damage the condom.
2. Before any physical • For the most protection, put the
contact, place the condom on before the penis makes any
condom on the tip genital, oral, or anal contact.
of the erect penis
with the rolled side
out

3. Unroll the ondom • The condom should unroll easily. Forcing it

all the way to the on could cause it to break during use.
base of the erect • If the condom does not unroll easily, it may
penis be on backwards, damaged, or too old.
Throw it away and use a new condom.
• If the condom is on backwards and another
one is not available, turn it over and unroll it
onto the penis.
4. Immediately after • Withdraw the penis.
ejaculation, hold the • Slide the condom off, avoiding spilling
rim of the condom semen.
in place and
• If having sex again or switching from one
withdraw the
sex act to another, use a new condom.
penis while it is still
erect
5. Dispose of the • Wrap the condom in its package and
used condom put it in the rubbish bin or latrine. Do
safely not put the condom into a flush toilet,
as
• it can cause problems with plumbing

52
Table .4:Explaining How to Use Female Condom

When to Start
Any time, whenever a woman or a couple wants protection from pregnancy or STIs.
Explaining How to Use
IMPORTANT: Whenever possible, show the client how to insert the female condom. Use a
model or picture, if available, or your hands to demonstrate. You can create an opening similar
to a vagina with one hand and show how to insert the female condom with the other hand.

Explain the 5 Basic Steps of Using a Female Condom

Basic Steps Important Details
1. Use a new female • Check the condom package. Do not use if torn or damaged.
condom for each act of Avoid using a condom past its expiration date. Do so only if
sex newer condoms are not available.
• If possible, wash your hands with mild soap and clean water
before inserting the condom

2. Before any physical • For the most protection, insert the condom
contact, insert the before the penis comes in contact with the
condom into the vagina. Can be inserted up to 8 hours before
vagina sex
• Choose a position that is comfortable for
insertion—squat, raise one leg,
• sit, or lie down.
• Rub the sides of the female condom together
to spread the lubricant evenly.

• Grasp the ring at the closed end, and squeeze

it so it becomes long and narrow.
• With the other hand, separate the outer lips
(labia) and locate the opening of the vagina.
• Gently push the inner ring into the vagina as
far up as it will go. Insert a finger into the
condom to push it into place. About 2 to 3
centimeters of the condom and the outer ring
remain outside the vagina.

53
Basic Steps Important Details
3. Ensure that the penis
• The man or woman should carefully guide the tip of his penis
enters the condom
inside the condom—not between the condom and the wall of
and stays inside the
the vagina. If his penis goes outside the condom, withdraw
condom
and try again.
• If the condom is accidentally pulled out of the vagina or the
outer ring is pushed into it during sex, put the condom back
in place.

4. After the man The female condom does not need to be

withdraws his penis, removed immediately after sex.
hold the outer ring of • Remove the condom before standing up, to
the condom, twist to avoid spilling semen.
seal
in fluids, and gently • If the couple has sex again, they should use a
new condom.
pull it out of the
vagina
• Reuse of female condoms is not
recommended

5. Dispose of the used • Wrap the condom in its package and put it
condom safely in the rubbish bin or latrine. Do not put the
condom into a flush toilet, as it can cause
problems with plumbing

54
What Condom Users Should Follow
❖ Avoid practices that can increase the risk of the condom break do not unroll the condom
first and then try to put it on the penis
❖ Do not use lubricants with an oil base because they damage latex.
❖ Do not use a condom if the color is uneven or changed.
❖ Do not use a condom that feels brittle, dried out, or very sticky
❖ Do not reuse condoms.
❖ Do not have dry sex.
❖ Do not use the same condom when switching between different penetrative sex acts, such
as from anal to vaginal sex. This can transfer bacteria that can cause infection.

Why some women say they like female condoms:

• Women can initiate their use
• Have a soft, moist texture that feels more natural than male latex condoms during sex
• Help protect against both pregnancy and STIs including HIV
• Outer ring provides added sexual stimulation for some women
• Can be used without seeing a health care provider

Why some men say they like female condoms:

• Can be inserted ahead of time so do not interrupt sex
• Are not tight or constricting like male condoms
• Do not dull the sensation of sex like male condoms
• Do not have to be removed immediately after ejaculation

55
7.5. LONG ACTING REVERSIBLE CONTRACEPTION (LARC) – IMPLANTS
Blood pressure measurement is desirable before starting a hormonal method. However, where the
risks of pregnancy are high and few methods are available, a woman should not be denied a
hormonal method simply because her blood pressure cannot be measured. If possible, she can have
her blood pressure measured later at a time and place convenient for her (WHO, Global handbook
2018)

Key Points
❖ Implants are small flexible rods or capsules that are placed just under the skin of
the upper arm.
❖ Provide long-term pregnancy protection. Very effective for 3-5 years, depending
on the type of implant, immediately reversible.
❖ Require specifically trained provider to insert and remove.
❖ Little required of the client once implants are in place. Avoids user errors and
problems with resupply.
❖ Bleeding changes are common but not harmful. Typically, prolonged irregular
bleeding over the first year, and then lighter, more regular bleeding or infrequent
bleeding.

• Small plastic rods or capsules, each about the size of a matchstick, that release a progestin
like the natural hormone progesterone in a woman’s body.
• Do not contain estrogen, and so can be used throughout breastfeeding and by women who
cannot use methods with estrogen.
• Types of Impants:
o Jadelle – 2 rods, effective for 5 years;
o Implanon NXT (Nexplanon)– 1 rod containing etonogestrel, labeled for up to 3 years of
use. Replace implanon: Implanon NXT can be seen on X ray and has an improved
insertion device ,effective for 3 years .
o Levoplant (Sino-Implant (II)), 2 rods containing levonorgestrel. Labeled for up to 4 years
of use.
• Work primarily by thickening cervical mucus (this blocks sperm from meeting an egg) and
disrupting the menstrual cycle, including preventing (ovulation).

56
Health Benefits, Health Risks, and Complications

Known Health Benefits

Help protect against:

• Risks of pregnancy

• Symptomatic PID

May help protect against:

• Iron-deficiency anaemia

Known Health Risks

• None

Complications

Uncommon:

• Infection at insertion site (most infections occur within the first 2 months after insertion)

• Difficult removal (rare if properly inserted and the provider is skilled at removal)

Rare:

Expulsion of implant (expulsions most often occur within the first 4 months after insertion)

Who Can Use LARC – Implants

Safe and Suitable for Nearly All Women

Nearly all women can use implants safely and effectively, including women who:

• Are breastfeeding
• Have or have not had children
• Are married or not married
• Are of any age, including adolescents and women over 40 years old
• Have just had an abortion or miscarriage or ectopic pregnancy
• Smoke cigarette – regardless of age and number of cigarette smoked.
• Have anemia now or in the past
• Have varicose veins
• Are infected with HIV, whether or not on antiretroviral therapy.

57
Women can begin using implants:
❖ Without a pelvic examination
❖ Without any blood tests or other routine laboratory tests
❖ Without cervical cancer screening
❖ Without a breast examination
❖ Even when a woman is not having monthly bleeding at the time, if it is reasonably certain
she is not pregnant

Women who can’t use Implants

❖ Cirrhosis of liver and liver cancer

❖ Acute blood clot in deep veins of legs or lungs
❖ Unexplained vaginal bleeding
❖ Had breast cancer but no recurrent for 5 years
❖ Positive or unknown antiphospholipid antibiotics
❖ Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies, and
not on immunosuppressive therapy

When to start providing implants

❖ A woman can start using implants anytime she wants if it is reasonably certain she is not
pregnant.
❖ If a woman is fully breastfeeding, she can receive implant insertion. No need to waits until 6
weeks after delivery (category 2 - WHO MEC 2015).
❖ If a woman has insertion of implants 6 months after delivery and her monthly bleeding has not
returned, she can receive implants insertions anytime if she is not pregnant. She will need a
backup method for the first 7 days after the implant insertion.
❖ If a woman is partially breastfeeding or no breastfeeding, and if her monthly bleeding has not
returned, she can receive implant insertion anytime it is reasonably certain she is not
pregnant. She will need a backup method for the first 7 days after implant insertion.
❖ If a woman is switching from consistent correct use of hormonal method, she can receive
implant insertion without backup methods and no need to wait for next monthly bleeding. If
the previous method was an injectable contraceptive the implant should be inserted when the
repeat injection would have been given and no need for backup methods.
❖ If a woman is switching from non-hormonal method (other than IUD) or having within 7 days
after her menstrual cycle, she can receive implant insertion immediately and no need for a
58
 backup method. If more than 7 days after the start of her monthly bleeding, she will need a
backup method for the first 7 days after the implant insertion.
❖ If woman is switching from an IUD, an implant can be inserted if it is within 7 days after the
start of menstrual bleeding. There is no need for a backup method and IUD can be removed at
that time. If she takes more than 7 days after the start of her monthly bleeding, the implant
can be inserted if it is reasonably certain she is not pregnant.
o Sexually active in this menstrual cycle and more than 7 days since the start of
menstrual bleeding: it is recommended that IUD be removed at the time of her
next menstrual period.
o Not sexually active in this menstrual cycle and more than 7 days since the start of
menstrual bleeding: she will need to abstain from sex or use additional
contraceptive protection for the next 7 days. If that additional protection is to be
provided by IUD she is using, it is recommended that this IUD be removed at the
time of her next menstrual period.
❖ After taking ulipristal acetate ECPs: Implants can be inserted on the 6th day after taking UPA-
ECPs. No need to wait for her next monthly bleeding. Implants and UPA interact. If an implant
is inserted sooner, and thus both are present in the body, one or both may be less effective.
❖ If a woman has no monthly bleeding (not related to childbirth or breastfeeding) she can
receive implant insertion anytime it is reasonably certain she is not pregnant. She will need a
backup method for the first 7 days after the implant insertion.

Inserting procedure of Implants

A woman who has chosen implants needs to know what will happen during insertion. Learning to
insert and remove implants requires training and practice under direct supervision. The following
description is a summary and help explain the procedure to her.
1. The provider uses proper infection- prevention procedure.
2. The provider marks the skin where the implant will be inserted on the inner’s side of the
women upper arm (usually the arm she uses less often)
3. The woman receives an injection of local anesthetics under the skin of her arm to prevent
pain while the implant is being inserted. This injection may be sting, but she should not feel
any pain when the implant is inserted. She stays fully awake throughout the procedure.
4. The provider uses a specially designed applicator to make an incision and insert the implant
under the skin.
5. After the implant is inserted, the provider closes the incision with surgical tape and an
adhesive bandage. Stitches are not needed. The incision is covered with dry piece of gauze (a
pressure dressing) and the arm is wrapped snugly with gauze.
59
Removing procedure
A woman need to know what will happen during removal. The following description can help
explain the procedure to her.
1. The provider uses proper infection prevention procedures.
2. The provider marks the location of implant.
3. The woman receives an injection of local anesthesia under the skin of her arm at the incision
site to prevent pain during implant removal. This injection may sting. She stays fully awake
throughout the procedure.
4. The health care provider makes a small incision in the skin near the site of insertion.
5. With the fingers, the provider pushes the implant toward the incision and then uses forceps
to pull out the implant. A woman may feel tugging, slight pain, or soreness during the
procedure and for a few days after.
6. The provider closes the incision with an adhesive bandage. Stitches are not needed. An
elastic bandage may be placed over the adhesive bandage to apply gentle pressure for 24
hours and keep down swelling.
The provider should ask whether the woman wants to continue preventing pregnancy and discuss
her option. If she wants new implants, they are placed above or below the site of implants or in
the other arm.

Provide client the following specific information:

a. To keep arm dry for 4 days. She can take off the elastic bandage or gauze after 24
hours and adhesive bandage after 5 days.
b. Expect soreness after anesthetic wears off, bruising at the insertion site. Will resolve
after a few days without treatment.
c. Length of pregnancy protection, type of implant inserted, date of insertion, month
and year when to remove or replace implants
d. Where to go if she has problems or question about her implants
e. Return for removal or replacement before the implant start losing effectiveness

60
Side Effects
• Changes in bleeding patterns including:

First several months:

o Lighter bleeding and fewer days of bleeding
o Prolong bleeding
o Irregular bleeding
o Infrequent bleeding
o No monthly bleeding

After about one year:

o Lighter bleeding and fewer days of bleeding
o Irregular bleeding
o Infrequent bleeding

Implanon NXT users are more likely to have infrequent or no monthly bleeding than irregular
bleeding. Users of Implanon and Implanon NXT are more likely to have infrequent bleeding,
prolonged bleeding or no monthly bleeding than irregular bleeding.

• Headaches
• Abdominal pain
• Acne (can improve or worsen)
• Weight change
• Breast tenderness
• Dizziness
• Mood changes
• Nausea
Other possible physical changes (Enlarged ovarian follicles)

Managing any problems

1. Schedule a regular follow up annually or as necessary. This offers an opportunity to answer

any questions and help with any problems.
2. For new health problems that may require switching methods or if problems cannot be
overcome, offer to help the client choose another method.
3. For minor problems, manage accordingly as described in the following table

61
Managing side effects of Implants
Irregular Bleeding Reassure. Become less or stop after the first year of use
For modest short-term relief, she can take 800 mg ibuprofen or 500 mg
mefenamic acid 3 times daily after meals for 5 days, beginning when
irregular bleeding starts.
If these drugs do not help her, she can try one of the following, beginning
when irregular bleeding starts: Combined oral contraceptives with the
progestin levonorgestrel. Ask her to take one pill daily for 21 days or 50 μg
ethinyl estradiol daily for 21 days.
If the bleeding persists, consider underlying conditions.
No Bleeding Reassure.
Heavy/ prolong Reassure.
bleeding (twice as For modest short-term relief, she can try any of the treatments for
much as usual or irregular bleeding, above, beginning when heavy bleeding starts.
longer than 8 days) Combined oral contraceptives with 50 μg of ethinyl estradiol may work
better than low-dose pills.
Iron supplement and diet.
Headache Can give paracetamol (325–1000 mg), ibuprofen (200–400 mg), asprin
(325-650 mg) or other pain reliever. Any headaches that get worse or
occur more often during use of implants should be evaluated
Mild abdominal pain Suggest paracetamol (325–1000 mg), ibuprofen (200–400 mg), asprin
(325-650 mg) or other pain reliever.
Acne, Nausea or Local remedies.
dizziness
Weight changes Review diet and counsel as needed
Breast tenderness Wear supportive bra, try hot or cold compresses.
Mood changes or sex Provide appropriate support.
drive Refer if major depression and other serious mood changes occurred.
Pain after insertion/ For pain after insertion, check that the bandage or gauze on her arm is
removal not too tight. Put a new bandage on the arm and advise her to avoid
pressing on the site for a few days.
Give her aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol
(325–1000 mg), or other pain reliever.
Infection at the Do not remove the implants. Clean the infected area with soup and water
insertion site or antiseptic. Give oral antibiotics for 7-10 days. Ask the client to return
after the antibiotic course. If the infection has not cleared, remove the
implants or refer for removal.
Expulsion or partial expulsion often follow infection. Ask the client to
return if she notices an implant coming out.

62
Abscess Clean the area with antiseptic. Cut open (incise) and drain the abscess,
treat the wound, give oral antibiotic for 7-10 days. Ask the client to return
after the antibiotic course. If the infection has not cleared, remove the
implants or refer for removal.
Expulsion Rare. Usually occurs within a few months of insertion or with infection. If
no infection is present, replace the expelled rod through a new incision
near the rods, or refer for replacement.
Severe Abdominal Rule out the ectopic pregnancy and other serious health conditions, and
pain refer as necessary

4. If the woman developed the following symptoms, Implants should be removed:

❖ Unexplained vaginal bleeding (that suggests a medical condition not related to the
method) or heavy or prolonged bleeding
❖ Migraine headaches
❖ Certain serious health conditions
❖ Heart disease or stroke
❖ Suspected pregnancy

7.6 LONG ACTING REVERSIBLE CONTRACEPTION – INTRAUTERINE DEVICE

(IUD)

Key Points
• Long-term pregnancy protection. Shown to be very effective for 12 years
(Copper-bearing IUD) and 5 years (Levonorgestrel IUD), immediately reversible.
• Inserted into the uterus by a specifically trained provider.
• Little required of the client once the IUD is in place
• Bleeding changes are common. Typically, longer and heavier bleeding and more
cramps or pain during monthly bleeding, especially in the first 3 to 6 months of
inserting copper-bearing IUD and lighter and fewer days of bleeding or irregular
bleeding with levonorgestrel IUD.

7.6.1. The copper-bearing intrauterine device (IUD) is:

• a small, flexible plastic frame with copper sleeves or wire around it.
• Almost all types of IUDs have one or two strings or threads, tied to them. The strings hang
through the cervix into the vagina

63
 • Works primarily by causing a chemical change that damages sperm and ovum (Copper-
bearing IUD).

Known Health Benefits (Copper IUD) health Benefits, and Health Risks and Complications –
copper- bearing IUD

Help protect against

Risk of pregnancy

Endometrial cancer

Cervical cancer

Reduce risk of ectopic pregnancy

Known Health Risks (Copper IUD)

Uncommon

May contribute to anaemia if IUD causes heavier monthly bleeding.

Rare
• PID may occur if the woman has chlamydia or gonorrhea at the time or IUD insertion

Who Can Use IUD (copper- bearing)

Safe and Suitable for Nearly All Women
Nearly all women can use IUD safely and effectively, including women who:
❖ Have or have not had children
❖ Are not married
❖ Are of any age, including adolescents and women over 40 years old
❖ Have just had an abortion or miscarriage (no evidence of infection)
❖ Are breastfeeding
❖ Do hard physical work
❖ Have had ectopic pregnancy
❖ Have had PID
❖ Have vaginal infection
❖ Have anemia
❖ Are infected with HIV or on antiretroviral therapy and doing well

64
Women who can’t use IUD (see detail in MEC – (ANNEX :1)

• A woman who delivered more than 48 hours to less than 4 weeks.

• Immediate post-abortion

• Puerperal sepsis

• Gestational trophoblast disease

• Uterine distortion

• Unexplained vaginal bleeding

• Cervical, endometrial and ovarian cancer

• Very high risk of STIs

• Currently with purulent cervicitis, gonorrhea, chlamydia, PID, pelvic tuberculosis

• AIDS patient who is not clinically well/ not on ART

• Systemic lupus erythematous with severe thrombocytopenia

When to start providing IUD (Copper bearing IUD)

❖ A woman can start using IUD anytime she wants if it is reasonably certain she is not pregnant.
❖ If a woman is fully breastfeeding, she can receive IUD insertion between 4 weeks to 6 months
after the delivery. No need for a backup method.
❖ If a woman is partially breastfeeding or no breastfeeding and > 4 weeks after delivery and if
her monthly bleeding has not returned, she can receive IUD insertion anytime it is reasonably
certain she is not pregnant.
❖ If a woman is switching from consistent correct use of another method, she can receive any
type of IUD without backup methods if it is reasonably certain she is not pregnant. No need to
wait for next monthly bleeding. No need for a backup method.
❖ If a woman is switching from injectables, she can have any IUD inserted at schedule for repeat
injection. No need for a backup method.
❖ If a woman is having menstrual cycles - if within 12 days for Copper bearing IUD/ after the
start of her menstrual cycle, she can insert IUD and no need for a backup method. If it is more
than 12 days after the start of her monthly bleeding, she can have the IUD inserted anytime it
is reasonably certain she is not pregnant. No need backup method for Copper IUD.
❖ If a woman is soon after childbirth – Copper-bearing IUD can be inserted anytime within 48
hours of giving birth including by caesarean delivery. If it is more than 48 hours after birth,
delay until 4 weeks or more after giving birth.

65
 ❖ If a woman is after miscarriage or abortion, insert implants immediately or within 12 days
(Copper-bearing IUD). If she starts more than 12 days after miscarriage or abortion and no
infection, she can start anytime and no need for backup method.
❖ If IUD insertion after second trimester abortion or miscarriage requires specific training. If not
specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion.
❖ After taking emergency contraceptive pills (ECPs), she can insert IUD on the same day and no
need for a backup method.
IUD can be used as emergency contraception within 5 days after unprotected sex. When the time of
ovulation can be estimated, she can have an IUD inserted up to 5 days after ovulation. Sometimes
this may be more than 5 days after unprotected sex. Side Effects
Changes in bleeding patterns (especially in the first 3 to 6 months) including:
• Prolonged and heavy monthly bleeding
• Irregular bleeding
More cramps and pain during monthly bleeding

66
Managing any problems

1. Schedule a regular follow up or as necessary. This offers an opportunity to answer any

questions and help with any problems.
2. For new health problems that may require switching methods or if problems cannot be
overcome, offer to help the client choose another method.
3. For minor problems, manage accordingly as described in the following table

Managing side effects of IUD (Copper-bearing IUD)

Heavy/ prolong Reassure.

bleeding (twice For modest short-term relief, she can try any of the treatments for irregular
as much as bleeding. Tranexamic acid (1500 mg) 3 times daily for 3 days, then 1000 mg
usual or more once daily for 2 days OR NSAID (except aspirin)2 times daily after meals for 5
than 8 days) days, beginning when heavy bleeding starts.

Iron supplement and diet.

Irregular Reassure. Become less or stop after the first year of use
Bleeding For modest short- term relief, she can take 400 mg ibuprofen or 25 mg
indomethacin 2 times daily after meals for 5 days, beginning when irregular
bleeding starts.

If the bleeding persists, consider underlying conditions.

Cramping She can expect cramping and pain for the first day or two after IUD insertion.
abdominal pain Explain that it is common in the first 3-6 months of IUD use, particularly
during monthly bleeding, generally not harmful and usually decreases over
time.

Suggest paracetamol (325–1000 mg), ibuprofen (200–400 mg), asprin (325-

650 mg) or other pain reliever.

If cramping became severe and can’t find other cause, discuss removing IUD.

Possible Anemia Due to heavier monthly bleeding. Iron supplement and dietary advice.

Partner can feel Explain that this happens when strings are cut too short. Options: strings can
IUD strings be cut shorter so that they are not coming out from cervical canal. Yet, the
during sex woman will no longer able to check the IUD strings.

67
Severe lower Pelvic Inflammatory Diseases or other abdominal conditions such as ectopic
abdominal pain pregnancy. Rule of ectopic pregnancy and do abdominal and pelvic
examination.
Treat PID or immediately refer. If ectopic pregnancy is suspected, refer.

Suspected If perforation is suspected at the time of insertion or sounding of the uterus,

uterine stop procedure immediately (and remove the IUD if inserted).
perforation Note vital signs 5-10 minutely up to 1 hour. If she remains stable after 1 hour,
do other investigations (to rule our intra-abdominal bleeding). Observe for
more hours, if she has no signs and symptoms, she can be sent home and tell
her to avoid sex for 2 weeks.
If her vital signs are not stable, refer immediately to higher level of care.
If the uterine perforation is suspected within 6 weeks after insertion or later
and causing symptoms, refer patients for removal of IUD.

Partial Expulsion Remove the IUD and counsel the client for another IUD or a different method.

Complete If the patient reports that IUD came out, discuss the client for another IUD or
Expulsion a different method.
If complete expulsion is expected and the client does not know whether IUD
came out, refer for X-ray or Ultrasound to assess whether the IUD might have
moved to the abdominal cavity. Give her a backup method.

Missing strings Ask the client:

– Whether and when she saw the IUD come out
– When she last felt the strings
– When she had her last monthly bleeding
– If she has any symptoms of pregnancy
– If she has used a backup method since she noticed the strings were missing.
Always start with minor and safe procedures and be gentle. Check for the
strings in the folds of the cervical canal with forceps. About half of missing
IUD strings can be found in the cervical canal.
If strings cannot be located in the cervical canal, either they have gone up into
the uterus or the IUD has been expelled unnoticed. Rule out pregnancy before
attempting more invasive procedures. Refer for evaluation. Give her a backup
method to use in the meantime, in case the IUD came out.

68
 4. If the woman developed the following symptoms, IUD should be removed:
❖ Unexplained vaginal bleeding (that suggests a medical condition not related to the
method) or heavy or prolonged bleeding
❖ Suspected pregnancy

7.6.2. The levonorgestrel intrauterine device (LNG-IUD) is:

Blood pressure measurement is desirable before starting a hormonal method. However, where the
risks of pregnancy are high and few methods are available, a woman should not be denied a
hormonal method simply because her blood pressure cannot be measured. If possible, she can have
her blood pressure measured later at a time and place convenient for her (WHO, Global handbook
2018)
• T-shaped plastic device that steadily releases small amounts of levonorgestrel each day.
(Levonorgestrel is a progestin widely used in implants and oral contraceptive pills.) Also called
the levonorgestrel-releasing intrauterine system, LNG-IUS or hormonal IUD

• A specifically trained health care provider inserts it into the uterus through the cervix.

• Works by preventing sperm from fertilizing an egg

Health Benefits, and Health Risks and Complications – (LNG-IUD)

Known Health Benefits

Help protect against -

Risks of pregnancy

Iron- deficiency anemia

PID

Reduces -

Menstrual cramps

Symptoms of endometriosis

Known Health Risks

None

Who can use (LNG- IUD)

Safe for all women.

69
Who can’t use (LNG- IUD)

❖ Cirrhosis of liver and liver cancer

❖ Acute DVT or Pulmonary Embolism
❖ Unexplained vaginal bleeding
❖ Had breast cancer but no recurrence for 5 years
❖ Positive or unknown antiphospholipid antibiotics

When to start providing IUD (LNG- IUD)

❖ A woman can start using IUD anytime she wants if it is reasonably certain she is not pregnant.
❖ If a woman is fully breastfeeding, she can receive IUD insertion between 4 weeks to 6 months
after the delivery. No need for a backup method.
❖ If a woman wants insertion of IUD 6 months after delivery and her monthly bleeding has not
returned, she can receive IUD insertion anytime if she is not pregnant. She will need a backup
method for the first 7 days after insertion.
❖ If a woman is partially breastfeeding or no breastfeeding, and if her monthly bleeding has not
returned, she can receive IUD insertion anytime it is reasonably certain she is not pregnant.
❖ If a woman is switching from consistent correct use of another method, she can receive any
type of IUD without backup methods if it is reasonably certain she is not pregnant. No need to
wait for next monthly bleeding. No need for a backup method.
❖ If a woman is switching from injectables, she can have any IUD inserted at schedule for repeat
injection. She will need a backup method for the first 7 days after insertion.
❖ If a woman is having menstrual cycles - if within 7 days for LNG – IUD after the start of her
menstrual cycle, she can insert IUD and no need for a backup method. If it is more than 7 days
after the start of her monthly bleeding, she can have the IUD inserted anytime it is reasonably
certain she is not pregnant. But need a backup method for the first 7 days after insertion.
❖ If a woman is soon after childbirth – (regardless of breast feeding status) LNG-IUD can be
inserted anytime within 48 hours of giving birth including by caesarean delivery. If it is more
than 48 hours after birth, delay until 4 weeks or more after giving birth.
❖ If a woman is after miscarriage or abortion, insert implants immediately or within 7 days
(LNG-IUD). If she starts more than 7 days after miscarriage or abortion and no infection, she
can start anytime and no need for backup method.
❖ If IUD insertion after second trimester abortion or miscarriage requires specific training. If not
specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion.
❖ After taking emergency contraceptive pills (ECPs), she can insert IUD on the same day and no
need for a backup method.

70
Side effects

Changes in bleeding patterns including:

• Lighter, Infrequent, Irregular, no monthly bleeding or prolong bleeding or
• Acne, headaches, nausea, dizziness, mood changes, weight gain, breast tenderness
or pain and ovarian cysts
• Perforation of the uterus by the IUD or an instrument used for insertion
• Miscarriage, preterm birth or infection if the woman becomes pregnant with the IUD
in place.

Managing any problem

1. Schedule a regular follow up or as necessary. This offers an opportunity to answer any
questions and help with any problems.
2. For new health problems that may require switching methods or if problems cannot be
overcome, offer to help the client choose another method.
3. For minor problems, manage accordingly as described in the following table
Managing side effects of IUD
Heavy/ prolong Reassure.
bleeding (twice as For modest short-term relief, she can try any of the treatments for irregular
much as usual or bleeding. Tranexamic acid (1500 mg) 3 times daily for 3 days, then 1000 mg
more than 8 days) once daily for 2 days OR NSAID (except aspirin)2 times daily after meals for
5 days, beginning when heavy bleeding starts.
Iron supplement and diet.
Irregular Bleeding Reassure. Become less or stop after the first year of use
For modest short-term relief, she can take 400 mg ibuprofen or 25 mg
indomethacin 2 times daily after meals for 5 days, beginning when irregular
bleeding starts.
If the bleeding persists, consider underlying conditions.
Cramping She can expect cramping and pain for the first day or two after IUD
abdominal pain insertion. Explain that it is common in the first 3-6 months of IUD use,
particularly during monthly bleeding, generally not harmful and usually
decreases over time.
Suggest paracetamol (325–1000 mg), ibuprofen (200–400 mg), asprin (325-
650 mg) or other pain reliever.
If cramping became severe and can’t find other cause, discuss removing
IUD.
Possible Anemia Due to heavier monthly bleeding. Iron supplement and dietary advice.

Partner can feel Explain that this happens when strings are cut too short. Options: strings
IUD strings during can be cut shorter so that they are not coming out from cervical canal. Yet,
sex the woman will no longer able to check the IUD strings.

71
Severe lower Pelvic Inflammatory Diseases or other abdominal conditions such as ectopic
abdominal pain pregnancy. Rule of ectopic pregnancy and do abdominal and pelvic
examination.
Treat PID or immediately refer. If ectopic pregnancy is suspected, refer.
Suspected uterine If perforation is suspected at the time of insertion or sounding of the
perforation uterus, stop procedure immediately (and remove the IUD if inserted).
Note vital signs 5-10 minutely up to 1 hour. If she remains stable after 1
hour, do other investigations (to rule our intra-abdominal bleeding).
Observe for more hours, if she has no signs and symptoms, she can be sent
home and tell her to avoid sex for 2 weeks.
If her vital signs are not stable, refer immediately to higher level of care.
If the uterine perforation is suspected within 6 weeks after insertion or
later and causing symptoms, refer patients for removal of IUD.
Partial Expulsion Remove the IUD and counsel the client for another IUD or a different
method.
Complete If the patient reports that IUD came out, discuss the client for another IUD
Expulsion or a different method.
If complete expulsion is expected and the client does not know whether
IUD came out, refer for X-ray or Ultrasound to assess whether the IUD
might have moved to the abdominal cavity. Give her a backup method.

Missing strings Ask the client:

– Whether and when she saw the IUD come out
– When she last felt the strings
– When she had her last monthly bleeding
– If she has any symptoms of pregnancy
– If she has used a backup method since she noticed the strings were
missing.
Always start with minor and safe procedures and be gentle. Check for the
strings in the folds of the cervical canal with forceps. About half of missing
IUD strings can be found in the cervical canal.
If strings cannot be located in the cervical canal, either they have gone up
into the uterus or the IUD has been expelled unnoticed. Rule out pregnancy
before attempting more invasive procedures. Refer for evaluation. Give her
a backup method to use in the meantime, in case the IUD came out.

72
 4. If the woman developed the following symptoms, IUD should be removed:
❖ Unexplained vaginal bleeding (that suggests a medical condition not related to the
method) or heavy or prolonged bleeding
❖ Suspected pregnancy
* In cases of uterine perforation or if removal is not so easy (for example, when IUD string are
missing), refer the woman to an experienced clinician who can use an appropriate removal
technique.

7.6.4. Intrauterine Devices for Women with HIV

❖ Women living with HIV can safely have an IUD inserted if they have mild or no clinical
disease, whether or not they are on antiretroviral therapy.
❖ Women who have HIV infection with advanced or severe clinical disease should not have an
IUD inserted. If a woman becomes infected with HIV while she has an IUD in place, it does
not need to be removed.
❖ An IUD user living with HIV who develops advanced or severe clinical disease can keep the
IUD but should be closely monitored for pelvic inflammatory disease.
❖ Urge women who have HIV or are at risk for HIV to use condoms along with the IUD. Used
consistently and correctly, condoms help prevent transmission of HIV and other STIs.
❖ Women who are at risk of HIV but not infected with HIV can have an IUD inserted. The IUD
does not increase the risk of becoming infected with HIV.

7.6.5 Assessing Women for Risk of Sexually Transmitted Infections

A woman who has gonorrhea or chlamydia now should not have an IUD inserted. Having these
sexually transmitted infections (STIs) at the time of insertion may increase the risk of pelvic
inflammatory disease.
If this risk for the individual client is very high, she generally should not have an IUD inserted.

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Possibly risky situations include:
• A sexual partner has STI symptoms such as pus coming from his penis, pain or burning during
urination, or an open sore in the genital area
• She or a sexual partner was diagnosed with an STI recently
• She has had more than one sexual partner recently
• She has a sexual partner who has had other partners recently
In contrast, if a current IUD user’s situation changes and she finds herself at very high individual risk
for gonorrhea or chlamydia, she can keep using her IUD.

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7.6.3. Insertion procedure of IUD (Annex:3)

A pelvic examination and STI risk assessment are essential before insertion.

Giving Specific instruction

Expect cramping and pain • Woman can expect some cramping and pain for a few
days after insertion.
• Suggest ibuprofen (200- 400mg) paracetamol( 325-
1000mg)

• Also, she can expect some bleeding or spotting

immediately after insertion. Irregular spotting can
continue during the first month after insertion.

Length of pregnancy protection Discuss how to remember the date to return for
removal or replacement.

Give each woman the following information (reminder

card)

• Type of IUD

• Date of IUD insertion

• Moth and year when IUD will need to be removed or

replaced

• Where to go if woman has problems or questions

about her IUD

Follow-up visit • A follow- up visit after her first monthly bleeding or 3

to 6 weeks after IUD insertion is recommended. No
woman should be denied an IUD, however, because
follow-up would be difficult or not possible.

Come Back Any Time; Reasons to return

• If the IUD was expelled or she thinks it may have been expelled from her uterus.
• She has symptoms of pelvic inflammatory disease (increasing or severe pain in the lower
abdomen, pain during sex, unusual vaginal discharge, fever, chills, nausea, and or vomiting),
especially in the first 20 days after insertion.
• Woman think she might be pregnant
• Woman wants the IUD removed, for whatever reason.

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7.7: PERMANENT METHOD – STERILIZATION

Key Points

❖ Permanent. Intended to provide life-long, permanent, and very effective

protection against pregnancy. Reversal is usually not possible.
❖ Involves a physical examination and surgery. The procedure is done by a
specifically trained provider.
❖ No long-term side effects.
❖ Male sterilization (vasectomy) is not routinely allowed in Myanmar. It can be done
only when the women has serious medical problems and does not suitable for any
types of contraception (Myanmar Penal Code).

Female Sterilization

Permanent surgical contraception for women who will not want more children

The two surgical approaches most often used: 1) minilaparotomy involves making a small incision in
the abdomen. The fallopian tubes are brought to the incision to be cut or blocked 2) Laparoscopy
involves inserting ta long, thin tube containing lenses into the abdomen through a small incision this
laparoscope enables the doctor to reach and block or cut the fallopian tubes in the abdomen

Works because the fallopian tubes are blocked or cut. Eggs released from the ovaries cannot move
down the tubes, and so they do not meet sperm.

Also called tubal sterilization, tubal ligation, voluntary surgical contraception, tubectomy, bi-tubal
ligation, tying the tubes, minilaparotomy and the operation. (2018 Global Handbook)

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Side Effects, Health Benefits, Health Risks and Complications

Side Effects

None

Known health benefits

Helps protect against:

• Risks of pregnancy

• Pelvic inflammatory disease (PID)

May help protect against:

• Ovarian cancer

• Reduces risk of ectopic pregnancy

Known health risks

Uncommon to extremely rare:

Complications of surgery and anaesthesis

Criteria for sterilization

1) Pregnant woman with 2 LSCS scars

2) Previous one classical scar
3) Grandmultip irrespective of age
4) Multipara with 35 completed years of age with 3 alive children
5) Multipara with 38 completed years of age with 2 alive children
6) 40 completed years old with one alive child
7) Previous child with genetic and chromosomal disorders that have a high risk of
recurrence
8) Any medical disorder endorsed by respective specialty (at least consultant level) that
contraindicate future can harm maternal health
9) Gynaecological diseases that can harm
10) Obstetric emergencies that can endanger the future pregnancy

Informed consent must be obtained prior to procedure. The following 7 points should be included
while counselling for informed consent.

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Counseling must cover all 7 points of informed consent. In some programs, the client and the
counselor also sign an informed consent form. To give informed consent to sterilization, the client
must understand the following points:
1. Temporary contraceptives also are available to the client, including long-acting reversible
contraceptives.
2. Voluntary sterilization is a surgical procedure.
3. There are certain risks of the procedure as well as benefits. (Both risks and benefits must
be explained in a way that the client can understand.)
4. If successful, the procedure will prevent the client from ever having any more children.
5. The procedure is considered permanent and probably cannot be reversed.
6. The client can decide against the procedure at any time before it takes place (without
losing rights to other medical, health, or other services or benefits)
7. The procedure does not protect against sexually transmitted infections, including HIV

When to perform Female Sterilzation

Performing the Sterilization Procedure
Explaining the Procedure
A woman who has chosen female sterilization needs to know what will happen during the
procedure. The following description can help explain the procedure to her. Learning to
perform female sterilization takes training and practice under direct supervision. Therefore, this
description is a summary and not detailed instruction.
(The description below is for procedures done more than 6 weeks after childbirth. The
procedure used up to 7 days after childbirth is slightly different.)

The Mini-laparotomy Procedure

1. The provider uses proper infection-prevention procedures at all times.
2. The provider performs a physical examination and a pelvic examination. The pelvic
examination is to assess the condition and mobility of the uterus.
3. Spinal/Local anesthesia was given.
4. The provider makes a small horizontal incision (2–5 centimeters) in the anesthetized area.
This usually causes little pain. (For women who have just given birth, the incision is made
horizontally at the lower edge of the navel.)
5. The provider inserts a special instrument (uterine elevator) into the vagina, through the
cervix, and into the uterus to raise each of the 2 fallopian tubes so they are closer to the
incision. This may cause discomfort.
6. Each tube is tied and cut or else closed with a clip or ring.
7. The provider closes the incision with stitches and covers it with an adhesive bandage.
8. The woman receives instructions on what to do after she leaves the clinic or hospital.

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 The Laparoscopy Procedure
1. The provider uses proper infection-prevention procedures at all times.
2. The provider performs a physical examination and a pelvic examination. The pelvic
examination is to assess condition and mobility of the uterus.
3. Spinal anesthesia was given for anesthetic effect.
4. The provider places a special needle into the woman’s abdomen and, through the needle,
inflates (insufflates) the abdomen with gas or air. This raises the wall of the abdomen away
from the pelvic organs.
5. The provider makes a small incision (about one centimeter) in the anesthetized area and
inserts a laparoscope. A laparoscope is a long, thin tube containing lenses. Through the
lenses the provider can see inside the body and find the 2 fallopian tubes.
6. The provider inserts an instrument through the laparoscope (or, sometimes, through a
second incision) to close off the fallopian tubes.
7. Each tube is closed with a clip or a ring, or by electric current applied to block the tube
(electrocoagulation).
8. The provider then removes the instrument and laparoscope. The gas or air is let out of the
woman’s abdomen. The provider closes the incision with stitches and covers it with an
adhesive bandage.
9. The woman receives instructions on what to do after she leaves the clinic or hospital.

Managing Any Problems

1. If the client reports complications of female sterilization, listen to her concerns, give advice
and support, and, if appropriate, treat. Make sure she understands the advice and agrees.
2. Infection at the incision site (redness, heat, pain, pus) – Clean the infected area with soap
and water or antiseptic. Give oral antibiotics for 7 to 10 days. Ask the client to return after
taking all antibiotics if the infection has not cleared.
3. Abscess (a pocket of pus under the skin caused by infection) – Clean the area with antiseptic.
Cut open (incise) and drain the abscess. Treat the wound. Give oral antibiotics for 7 to 10
days. Ask the client to return after taking all antibiotics if she has heat, redness, pain, or
drainage of the wound.
4. Severe pain in lower abdomen (if suspect ectopic pregnancy, manage accordingly)
5. Failed sterilization such as suspected pregnancy

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Tabl[Link] Shows explaining Self-Care for Female Sterilization
Before the • Use another contraceptive until the procedure.
procedure the • Not to eat anything for 8 hours before surgery. She can drink clear
woman should liquids until 2 hours before surgery
• Not to take any medication for 24 hours before the surgery
• Wear clean, loose – fitting clothing to the health facility possible.
• Not to wear nail polish or jewelry
• If possible, bring her partner, a friend, or a relative to help her go
home afterwards
After the procedure • Rest for 2 days and avoid vigorous work and heavy lifting for a week
the women should • Keep the incision clean and dry for 1 to 2 days
• Avoid rubbing the incision for 1 week.
• Nor have sex for at least I week and then only when she feels
comfortable having sex.
What to do about • She may have some abdominal pain and swelling after the
the most common procedure. It usually goes away within a few days. Suggests
problems Ibuprofen (200- 400 mg), paracetamol (325- 1000mg) , or other pain
reliever. She should not take aspirin which slows blood clotting. If
she had laparoscopy, she may have shoulder pain or feel bloated for
a few days.
Plan the follow- up Following up within 7 days or at least within 2 weeks is strongly
visit recommended. No woman should be denied sterilization, however, because
follow-up would be difficult or not possible.
A health care provider checks the site of the incision, looks for any signs of
infection, and remove any stitches. This can be done in the clinic, in the
client’s home. (by a specifically trained paramedical worker, for example), or
at any other health center.

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7.8: FERTILITY AWARENESS METHODS
Key Points
❖ Fertility awareness methods require partners’ cooperation. Couple must be committed
to abstaining or using another method on fertile days
❖ Must stay aware of body changes or keep track of days, according to rules of the specific
method.
❖ No side effects or health risks.

• “Fertility awareness” means that a woman knows how to tell when the fertile time of her
menstrual cycle starts and ends.
• Sometimes called periodic abstinence or natural family planning
• A woman can use several ways, alone or in combination, to tell when her fertile time begins
and ends
• Calendar-based methods involve keeping track of days of the menstrual cycle to identify the
start and end of the fertile time.
– Examples: Standard Days Method, which avoids unprotected vaginal sex on days 8
through 19 of the menstrual cycle, and calendar rhythm method.
• Symptoms-based methods depend on observing signs of fertility.
– Cervical secretions: When a woman sees or feels cervical secretions, she may be
fertile. She may feel just a little vaginal wetness.
– Basal Body Temperature (BBT): A woman’s resting body temperature goes up
slightly after the release of an egg (ovulation). Her temperature stays until the
beginning of the next monthly bleeding.
– Examples: Two Day method, BBT method, ovulation method and symptothermal
method
• Work primarily by helping a woman know when she could become pregnant. The couple
prevents pregnancy by avoiding unprotected vaginal sex during these fertile days—usually
by abstaining or by using condoms. Some couples use spermicides or withdrawal, but these
are among the least effective methods.
• No side effects and health risks.
• Women who are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy can
safely use fertility awareness methods.
• Urge these women to use condoms along with fertility awareness methods. Used
consistently and correctly, condoms help prevent transmission of HIV and other STIs.

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Who Can Use and Who Cannot Use Fertility Awareness Methods
All women can use calendar-based methods. No medical conditions prevent the use of these
methods, but some conditions can make them harder to use effectively.
Caution means that additional or special counseling may be needed to ensure correct use of the
method.
Delay means that use of a particular fertility awareness method should be delayed until the
condition is evaluated or corrected. Give the client another method to sue until she can start the
symptoms-based method.

Calendar-based Methods Symptoms-based Methods

Use caution in the following situations: Use caution in the following situations:
• Menstrual cycles have just started or have • Recently had an abortion or miscarriage
become less frequent or stopped due to • Menstrual cycles have just started or
older age (Menstrual cycle irregularities have become less frequent or stopped
are common in young women in the first due to older age
several years after their first monthly • A chronic condition that raises her body
bleeding and in older women who are temperature (for basal body
approaching menopause. Identifying the temperature and symptothermal
fertile time may be difficult.) methods)
Delay starting in the following situations: Delay starting in the following situations:
• Recently gave birth or is breastfeeding • Recently gave birth or is breastfeeding
(Delay until she has had at least 3 (Delay until normal secretions have
menstrual cycles and her cycles are returned—usually at least 6 months after
regular again. For several months after childbirth for breastfeeding women and
regular cycles have returned, use with at least 4 weeks after childbirth for
caution.) women who are not breastfeeding. For
• Recently had an abortion or miscarriage several months after regular cycles have
(Delay until the start of her next monthly returned, use with caution.)
bleeding.) • An acute condition that raises her body
• Irregular vaginal bleeding temperature (for basal body temperature
and symptothermal methods)
• Irregular vaginal bleeding
• Abnormal vaginal discharge

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 Delay or use caution in the following Delay or use caution in the following
situations: situations:
• Taking any mood-altering drugs such as • Taking any mood-altering drugs such as
anti-anxiety therapies (except anti-anxiety therapies (except
benzodiazepines), antidepressants benzodiazepines), antidepressants
(selective serotonin reuptake inhibitors (selective serotonin reuptake inhibitors
[SSRIs], tricyclic, or tetracyclic), long-term [SSRIs], tricyclic, or tetracyclic), anti-
use of certain antibiotics, or long-term use psychotics (including chlorpromazine,
of any NSAID (such as aspirin, ibuprofen, thioridazine, haloperidol, risperdone,
or paracetamol). These drugs may delay clozapine, or lithium), long-term use of
ovulation. certain antibiotics, any NSAID (such as
aspirin, ibuprofen, or paracetamol), or
antihistamines. These drugs may affect
cervical secretions, raise body
temperature, or delay ovulation.

When to start Fertility Awareness Methods

• A woman can start fertility awareness methods at any time, once she is trained how to use.
• If a woman has regular menstrual cycles, she can start anytime of the month and there is no
need to wait until the start of the next monthly bleeding.
• If a woman has no monthly bleeding, she needs to delay the use of fertility awareness
methods until monthly bleeding returns.
• After childbirth (whether or not breastfeeding):
– Delay the Standard Days Method until she has had 3 menstrual cycles and the last
one was 26–32 days long.
– She can start symptoms-based methods once normal secretions have returned.
– Regular cycles and normal secretions will return later in breastfeeding women than
in women who are not breastfeeding.
• After miscarriage or abortion:
– Delay the Standard Days Method until the start of her next monthly bleeding, when
she can start if she has no bleeding due to injury to the genital tract.
– She can start symptoms-based methods immediately with special counseling and
support, if she has no infection-related secretions or bleeding due to injury to the
genital tract.

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 • If a woman is switching from consistent correct use of hormonal method:
– Delay starting the Standard Days Method until the start of her next monthly
bleeding.
– If she is switching from injectables, delay the Standard Days Method at least until
her repeat injection would have been given, and then start it at the beginning of her
next monthly bleeding.
– She can start symptoms-based methods in the next menstrual cycle after stopping a
hormonal method.
• If a woman is after taking emergency contraceptive pills (ECPs):
– Delay the Standard Days Method until the start of her next monthly bleeding.
– She can start symptoms-based methods once normal secretions have returned.

Explaining how to use Fertility Awareness Methods

Standard Days Method
IMPORTANT: A woman can use the Standard Days Method if most of her menstrual cycles are
26 to 32 days long. If she has more than 2 longer or shorter cycles within a year, the Standard
Days Method will be less effective and she may want to choose another method.

Keep track of the days of the • A woman keeps track of the days of her menstrual cycle,
menstrual cycle counting the first day of monthly bleeding as day 1.

Avoid unprotected sex on • Days 8 through 19 of every cycle are considered fertile days
days 8–19 for all users of the Standard Days Method.

• The couple avoids vaginal sex or uses condoms or a

diaphragm during days 8 through 19. They can also use
withdrawal or spermicides, but these are less effective.

• The couple can have unprotected sex on all the other days
of the cycle—days 1 through 7 at the beginning of the cycle
and from day 20 until her next monthly bleeding begins.

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Calendar Rhythm Method

Keep track of the days of • Before relying on this method, a woman records the
the menstrual cycle number of days in each menstrual cycle for at least 6
months. The first day of monthly bleeding is always counted
as day I.
Estimate the fertile time • The woman subtracts 18 from the length of her shortest
recorded cycle. This tells her the estimated first day of
fertile time. Then she subtracts II days form the length of
her longest recorded cycle. This tells her the estimated last
day of her fertile time
Avoid unprotected sex during • The couple avoids vaginal sex, or uses condoms or a
fertile time diaphragm, during the fertile time. They can also use
withdrawal or spermicides, but these are less effective.
Update calculations monthly • She updates these calculations such month always using the
6 most recent cycles.
Example:
- If the shortest of her last 6 cycles was 27 days, 27-18=9. She
starts avoiding unprotected sex on day 9.
- If the longest of her last 6 cycles was 31 days 31-11=20. She
can have unprotected sex again on day 21.
- Thus, she must avoid unprotected sex from day 9 through
day 20 of her cycle.

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Two Day Method

IMPORTANT: If a woman has a vaginal infection or another condition that changes cervical
mucus, the TwoDay Method will be difficult to use.

Check for secretions The woman checks for cervical secretions every afternoon and/or
evening, on fingers, underwear, or tissue paper or by sensation
in or around the vagina.

• As soon as she notices any secretions of any type, color, or

consistency, she considers herself fertile that day and the
following day.

Avoid sex or use another • The couple avoids vaginal sex or uses condoms or a diaphragm
method on fertile days on each day with secretions and on each day following a day
with secretions. They can also use withdrawal or spermicides,
but these are less effective.

Resume unprotected sex • The couple can have unprotected sex again after the woman has
after 2 dry days had 2 dry days (days without secretions of any type) in a row.

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Basal Body Temperature (BBT) Method

IMPORTANT: If a woman has a fever or other changes in body temperature, the BBT method will be
difficult to use.

Take body • The woman takes her body temperature at the same time each
temperature daily morning before she gets out of bed and before she eats
anything. She records her temperature on a special graph.
• She watches for her temperature to rise slightly—0.2° to 0.5°C
(0.4° to 1.0°F)— just after ovulation (usually about midway
through the menstrual cycle).
Avoid sex or use • The couple avoids vaginal sex or uses condoms or a diaphragm
another method from the first day of monthly bleeding until 3 days after the
until 3 days after woman’s temperature has risen above her regular temperature.
the temperature They can also use withdrawal or spermicides, but these are less
rise effective.
Resume • When the woman’s temperature has risen above her regular
unprotected sex temperature and stayed higher for 3 full days, ovulation has
until next monthly occurred, and the fertile period has passed.
bleeding begins • The couple can have unprotected sex on the 4th day and until
her next monthly bleeding begins.

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Ovulation Method
IMPORTANT: If a woman has a vaginal infection or another condition
that changes cervical mucus, this method may be difficult to use.
Check cervical • The woman checks every day for any cervical secretions on fingers,
secretions daily underwear, or tissue paper or by sensation in or around the vagina.
Avoid unprotected • Ovulation might occur early in the cycle, during the last days of
sex on days of monthly bleeding, and heavy bleeding could make mucus difficult
heavy monthly bleeding to observe.
Resume • Between the end of monthly bleeding and the start of secretions,
unprotected sex the couple can have unprotected sex, but not on 2 days in a row.
until secretions (Avoiding sex on the second day allows time for semen to
begin disappear and for cervical mucus to be observed.)
• It is recommended that they have sex in the evenings, after the
woman has been in an upright position for at least a few hours and
has been able to check for cervical mucus.
Avoid unprotected • As soon as she notices any secretions, she considers herself fertile
sex when and avoids unprotected sex.
secretions begin • She continues to check her cervical secretions each day. The
and until 4 days secretions have a “peak day”—the last day that they are clear,
after “peak day” slippery, stretchy, and wet. She will know this has passed when, on
the next day, her secretions are sticky or dry, or she has no
secretions at all. She continues to consider herself fertile for 3 days
after that peak day and avoids unprotected sex.

Resume • The couple can have unprotected sex on the 4th day after her peak
unprotected sex day and until her next monthly bleeding begins.

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 Symptothermal Method (basal body temperature+ cervical secretions + other fertility
signs)

Avoid unprotected • Users identify fertile and nonfertile days by combining BBT and
sex on fertile days ovulation method instructions.
• Women may also identify the fertile time by other signs such as
breast tenderness and ovulatory pain (lower abdominal pain or
cramping around the time of ovulation).
• The couple avoids unprotected sex between the first day of
monthly bleeding and either the fourth day after peak cervical
secretions or the third full day after the rise in temperature (BBT),
whichever happens later.
• Some women who use this method have unprotected sex between
the end of monthly bleeding and the beginning of secretions, but
not on 2 days in a row.

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Managing any problems

• For a woman unable to abstain from sex during fertile time, suggest using a barrier method
or sexual contact without vaginal sex. If she has had unprotected sex in the past 5 days she
can use ECPs.
• If a woman has 2 or more cycle outside the 26-32-day range within any 12 months, suggest
her to use calendar rhythm method or a symptoms-based method.
• If a woman’s menstrual cycle is very irregular, suggest her using symptoms-based method.
• If a woman is difficult to recognize the different types of secretions for the ovulation
method, counsel and provide her additional guidance for how to interpret cervical
secretions or suggest her to use TwoDay Method which does not require the user to tell the
difference among types of secretions.
• If a woman is difficult to recognize the presence of secretions for the ovulation method or
the TwoDay Method, counsel and provide her additional guidance for how to recognize
cervical secretions or suggest her to use calendar-based method.

7.9: LACTATIONAL AMENORRHEA METHOD

Key Points
❖ A family planning method based on breastfeeding. Provides contraception for
the mother and best feeding for the baby.
❖ Can be effective for up to 6 months after childbirth, as long as monthly bleeding
has not returned and the woman is fully or nearly fully breastfeeding.
❖ Requires breastfeeding often, day and night. Almost all of the baby’s feedings
should be breast milk.
❖ Provides an opportunity to offer a woman an ongoing method that she can
continue to use after 6 months.

• A temporary family planning method based on the natural effect of breastfeeding on

fertility.
• The lactational amenorrhea method (LAM) requires 3 conditions. All 3 must be met:
1. The mother’s monthly bleeding has not returned
2. The baby is fully or nearly fully breastfed and is fed often, day and night
3. The baby is less than 6 months old

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 • “Fully breastfeeding” includes both exclusive breastfeeding (the infant receives no other
liquid or food, not even water, in addition to breast milk) and almost-exclusive breastfeeding
(the infant receives vitamins, water, juice, or other nutrients once in a while in addition to
breast milk).
• “Nearly fully breastfeeding” means that the infant receives some liquid or food in addition to
breast milk, but the majority of feedings (more than three-fourths of all feeds) are breast
milk.
• Can be effective for up to 6 months after childbirth, as long as monthly bleeding has not
returned and the woman is fully or nearly fully breastfeeding.
• Works primarily by preventing the release of eggs from the ovaries (ovulation). Frequent
breastfeeding temporarily prevents the release of the natural hormones that cause
ovulation.

Side Effects, Health Benefits, and Health Risks

Side Effects: None. Any problems are the same as for other breastfeeding women.
Helps protect against:
risks of pregnancy
Encourages that is the best breast-feeding patterns and there are health benefits for both mother
and baby.

Who can and cannot use LAM

All breastfeeding women can safely use LAM, but a woman in the following circumstances may want
to consider other contraceptive methods:
❖ Has HIV infection including AIDS
❖ Is using certain medications during breastfeeding (including mood altering drugs, reserpine,
ergotamine, anti-metabolites, cyclosporine, high doses of corticosteroids, bromocriptine,
radioactive drugs, lithium, and certain anticoagulants)
❖ The newborn has a condition that makes it difficult to breastfeed (including being small-for-
date or premature and needing intensive neonatal care, unable to digest food normally, or
having deformities of the mouth, jaw, or palate)

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Women who are infected with HIV or who have AIDS can use LAM.
Breastfeeding will not make their condition worse. There is a chance, however, that mothers with
HIV will transmit HIV to their infants through breastfeeding. Without any antiretroviral (ARV)
therapy, if infants of HIV-infected mothers are mixed-fed (breast milk and other
foods) for 2 years, between 10 and 20 of every 100 will become infected with HIV through breast
milk, in addition to those already infected during pregnancy and delivery. Exclusive breastfeeding
reduces this risk of HIV infection through breastfeeding by about half.
Reducing the length of time of breastfeeding also greatly reduces the risk. For example,
breastfeeding for 12 months reduces transmission by 50% compared with breastfeeding for 24
months. HIV transmission through breast milk is more likely among mothers with advanced disease
or who are newly infected.
Women taking ARV therapy can use LAM. In fact, giving ARV therapy to an HIV-infected mother or
an HIV-exposed infant very significantly reduces the risk of HIV transmission through breastfeeding.
At 6 months—or earlier if her monthly bleeding has returned or she stops exclusive breastfeeding—
a woman should begin to use another contraceptive method in place of LAM and continue to use
condoms. Urge women with HIV to use condoms along with LAM.
Used consistently and correctly, condoms help prevent transmission of HIV and other STIs.

When to start
❖ Start breastfeeding immediately (within one hour) or as soon as possible after the baby is
born. In the first few days after childbirth, the yellowish fluid produced by the mother’s
breasts (colostrum) contains substances very important to the baby’s health.
❖ Any time if she has been fully or nearly breastfeeding her baby since birth and her monthly
bleeding has not returned.
❖ An ideal pattern is feeding on demand (that is, whenever the baby wants to be fed) and at
least10 to 12 times a day in the first few weeks after childbirth and thereafter 8 to 10 times
a day, including at least once at night in the first months.
❖ Daytime feedings should be no more than 4 hours apart, and night-time feedings no more
than 6 hours apart.
❖ Some babies may not want to breastfeed 8 to 10 times a day and may want to sleep through
the night. These babies may need gentle encouragement to breastfeed more often. She
should start giving other foods in addition to breast milk when the baby is 6 months old.

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 Managing Any Breastfeeding Problems

If a client reports any of these common problems, listen to her concerns and give advice and
support. Make sure she understands the advice and agrees.
Baby is not getting enough milk

• Reassure the woman that most women can produce enough breast milk to feed their babies.
• If the newborn is gaining more than 500 grams a month, weighs more than birth weight at 2
weeks, or urinates at least 6 times a day, reassure her that her baby is getting enough breast milk.
• Tell her to breastfeed her newborn about every 2 hours to increase milk supply.
• Recommend that she reduce any supplemental foods and/or liquids if the baby is less than 6
months of age.
Sore breasts

• If her breasts are full, tight, and painful, then she may have engorged breasts. If one breast has
tender lumps, then she may have blocked ducts. Engorged breasts or blocked ducts may progress
to red and tender infected breasts. Treat breast infection with antibiotics according to clinic
guidelines. To aid healing, advise her to:

– Continue to breastfeed often

– Massage her breasts before and during breastfeeding

– Apply heat or a warm compress to breasts

– Try different breastfeeding positions

– Ensure that the infant attaches properly to the breast

– Express some milk before breastfeeding

Sore or cracked nipples

• If her nipples are cracked, she can continue breastfeeding. Assure her that they will heal with
time.
• To aid healing, advise her to:

– Apply drops of breast milk to the nipples after breastfeeding and allow to air-dry.

– After feeding, use a finger to break suction first before removing the baby from the breast.

– Do not wait until the breast is full to breastfeed. If full, express some milk first.

• Teach her about proper attachment and how to check for signs that the baby is not attaching
properly.
• Tell her to clean her nipples with only water only once a day and to avoid soaps and alcohol-based
solutions.
• Examine her nipples and the baby’s mouth and buttocks for signs of fungal infection (thrush).

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7.10: WITHDRAWAL

Key Points

❖ One of the least effective contraceptive methods:

❖ Always available in every situation.
❖ Promotes male involvement and couple communication.

What is withdrawal?
• The man withdraws his penis from his partner’s vagina and ejaculates outside the vagina,
keeping his semen away from her external genitalia. Also known as coitus interrupts and
“pulling out.”
• Works by keeping sperm out of the woman’s body.

Side Effects, Health Benefits, and Health Risks

None

Who can and cannot use Withdrawal

All men can use withdrawal. No medical conditions prevent its use.
Explaining how to use –
• Before sex he should urinate and wipe the tip of his penis to remove any sperm remaining if
man has ejaculated recently.
• When the man feels close to ejaculation, he should withdraw his penis from the woman’s
vagina and ejaculate outside the vagina, keeping his semen away from her external genitalia.
• Suggest the couple also use another method until the man feels that he can use withdrawal
correctly with every act of sex.
• Some men may have difficulty using withdrawal because he cannot sense consistently when
ejaculation is about to occur, or he ejaculate prematurely. Explain ECP use in case a man
ejaculates before withdrawing.

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CHAPTER VIII: SERVING THE PEOPLE WITH SPECIAL NEEDS

8.1. ADOLESCENTS AND YOUTHS

Adolescents are the young people between the age of 15 to 24 years.
Pregnancy among adolescents is associated with several potential medical problems, including: high
health risk, unsafe abortion, inadequate or lack of antenatal care and sexually transmitted disease
from unprotected sex. Adolescent pregnancy also has social consequences, such as loss of
educational and employment opportunities as well as emotional and financial unpreparedness for
raising a child.
Reproductive Health counseling and services must be made accessible, available, affordable, and
acceptable for adolescents and youths, in a supportive and non-judgmental environment. Just like
any client, young individuals must be assured of confidentiality and privacy and must not be
subjected to unnecessary procedures before they can avail of the appropriate contraceptive
method.

Provide Services with Care and Respect:

Young people deserve nonjudgmental and respectful care no matter how young they are. Criticism
or unwelcoming attitudes will keep young people away from the care they need.

To make services friendly to youths:

• Show young people that you enjoy working with them.
• Counsel in private areas where you cannot be seen or overheard. Ensure confidentiality and
assure the client of confidentiality.
• Listen carefully and ask open-ended questions such as “How can I help you?” and “What
questions do you have?”
• Use simple language and avoid medical terms.
• Use terms that suit young people. Avoid such terms as “family planning,” which may seem
irrelevant to those who are not married.
• Welcome partners and include them in counseling, if the client desires.
• Try to make sure that a young woman’s choices are her own and are not pressured by her
partner or her family. In particular, if she is being pressured to have sex, help a young
woman think about what she can say and do to resist and reduce that pressure. Practice
skills to negotiate condom use.

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 • Speak without expressing judgment (for example, say “You can” rather than “You should”).
Do not criticize even if you do not approve of what the young person is saying or doing. Help
young clients make decisions that are in their best interest.
• Take time to fully address questions, fears, and misinformation about sex, sexually
transmitted infections (STIs), and contraceptives. Many young people want reassurance that
the changes in their bodies and their feelings are normal. Be prepared to answer common
questions about puberty, monthly bleeding, masturbation, night-time ejaculation, and
genital hygiene.

Recommended Contraceptive Methods for Adolescents and Youths

All contraceptives are safe for young people. Unmarried and married youth may have different
sexual and reproductive health needs.
Young women are often less tolerant of side effects than older women. With counseling, however,
they will know what to expect and may be less likely to stop using their methods. Unmarried young
people may have more sex partners than older people and so may face a greater risk of STIs.
Considering STI risk and how to reduce it is an important part of counseling.
For young people, there are specific considerations for some contraceptive methods.
• Hormonal contraceptives (oral contraceptives, injectables, and implants): Injectables can be
used without others knowing. Some young women find regular pill-taking particularly difficult.
• Emergency contraceptive pills (ECPs): Young women may have less control than older women
over having sex and using contraception. They may need ECPs more often. Provide young
women with ECPs in advance, for use when needed. ECPs can be used whenever she has any
unprotected sex, including sex against her will, or a contraceptive mistake has occurred.
• Female sterilization: Provide with great caution. Young people and people with few or no
children are among those most likely to regret sterilization.
• Male and female condoms: Protect against both STIs and pregnancy, which many young people
need. Readily available, and they are affordable and convenient for occasional sex. Young men
may be less successful than older men at using condoms correctly. They may need practice
putting condoms on.
• Intrauterine device: IUDs are more likely to come out among women who have not given birth
because their uteruses are small.
• Fertility awareness methods: Until a young woman has regular menstrual cycles, fertility
awareness methods should be used with caution. Need a backup method or ECPs on hand in
case abstinence fails.

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 • Withdrawal: Requires the man to know when he is about to ejaculate so he can withdraw in
time. This may be difficult for some young men. One of the least effective methods of
pregnancy prevention, but it may be the only method available—and always available—for
some young people.

8.2: CLIENTS WITH STIS, HIV AND AIDS

Clients with STIs, HIV, AIDS, or on antiretroviral (ARV) therapy can start and continue to use most
contraceptive methods safely. In general, contraceptives and ARV medications do not interfere with
each other. However, dual protection is critical in reducing transmission of STIs and HIV. Using dual
method helps clients with STIs, HIV and AIDS to prevent transmission to an uninfected partner.
There are a few special family planning considerations for clients with SITs, HIV, AIDS or on
antiretroviral therapy as table below.

Client on Anti-
Method Client with STIs Client with HIV or AIDS
retroviral Therapy
Intrauterine Do not insert an IUD in a A woman with HIV can Do not insert an IUD
device woman who is at very high have an IUD inserted. if client is not
individual risk for A woman with AIDS clinically well.
gonorrhea and chlamydia, should not have an IUD
or who currently has inserted unless she is
gonorrhea, chlamydia, clinically well on ARV
purulent cervicitis, or PID. therapy. (A woman
(A current IUD user who who develops AIDS
becomes infected with while using an IUD can
gonorrhea or chlamydia or safely continue using
develops PID can safely the IUD.)
continue using an IUD
during and after
treatment.)
Female If client has gonorrhea, Women who are infected with HIV, have AIDS,
Sterilization chlamydia, purulent or are on antiretroviral therapy can safely
cervicitis, or PID, delay undergo female sterilization. Special
sterilization until the arrangements are needed to perform female
condition is treated and sterilization on a woman with AIDS. Delay the
cured. procedure if she is currently ill with AIDS-
related illness.

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 Client on Anti-
Method Client with STIs Client with HIV or AIDS
retroviral Therapy
Combined oral Can safely use combined Can safely use A woman can use
contraceptives, hormonal methods. combined hormonal combined hormonal
combined methods. Methods while
injectables taking ARVs
Progestin only Can safely use Can safely use A woman can use
pills progestin-only pills progestin-only pills. progestin only pills
while taking ARVs.
Progestin-only No special considerations. Can safely use progestin-only injectables or
injectables and implants.
implants

* If woman with ARV wants to use hormonal contraception, check with MEC wheel.

8.3: CLIENTS WITH DISABILITY

Health care providers should treat people with disabilities in the same way that they should treat
people without disabilities: with respect. People with disabilities have the same sexual and
reproductive health needs and rights as people without disabilities, but often they are not given
information about reproductive and sexual health or adequate care. The ability to make an informed
choice may be compromised in persons with disability, including mental disability. The ability of the
person with disability to use a contraceptive method in a timely way should also be considered. In
view of these: Counseling and informed decision should involve parents, or next of kin, or guardians,
depending on the degree of the mental disability. In the absence of these caretakers, the provider
may decide, in the best interests of the client with serious mental disability, on a method choice.
Some drugs that are used to treat mental disorders affect the bioavailability and efficacy of
hormonal contraceptives. Hence, alternative methods of contraception should be considered. As
much as possible, contraceptive methods that do not seriously demand user compliance (e.g. IUD,
implants, surgical methods) should be encouraged, to ensure efficacy.

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8.4: SURVIVORS OF SEXUAL VIOLENCE
Key points for violence against women

❖ Violence is not the woman’s fault. It is very common. All health care providers can do
something to help.
❖ Women experiencing violence have special health needs, many of them sexual and
reproductive health needs and providers consider to support physical needs as well as
psychological support.

Sexual violence is a public health problem and is associated with several physical, psychological, and
emotional consequences. Healthcare providers are expected to provide counseling and social
support to the survivors of sexual violence to promote quick recovery. Unwanted pregnancy is one
of the complications of sexual violence. Hence, emergency contraception should be provided for all
victims of sexual violence and rape, who are at risk of pregnancy.

Emergency contraceptive pills and the IUD are the two recommended types of emergency
contraception.
There are two Emergency Contraceptive Pill regimens that can be used:
1) The levonorgestrel-only regimen: 1.5 mg of levonorgestrel in a single dose (this is the
recommended regimen; it is more effective and has fewer side-effects), or
2) The combined estrogen-progestogen regime: two doses of 100 micrograms ethinylestradiol
plus 0.5 mg of levonorgestrel taken 12 hours apart.
3) Ulipristal acetate (UPA) regimen: 30 mg ulipristal acetate single dose

Treatment with either regimen should be started as soon as possible after the rape since efficacy
declines with time. Both regimens are effective when used up to 72 hours after the rape, and
continue to be moderately effective if started between 72 hours and 120 hours (5 days) after.
The levonorgestrel regimen has been shown to cause significantly less nausea and vomiting than the
Yuzpe regimen. If vomiting occurs within 2 hours of taking a dose, repeat the dose. In cases of severe
vomiting, ECPs can be administered vaginally.
ECPs will not be effective in the case of a confirmed pregnancy. ECPs may be given when the
pregnancy status is unclear and pregnancy testing is not available, since there is no evidence to
suggest that the pills can harm the woman or an existing pregnancy. There are no other medical
contraindications to use of ECPs.

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Whenever prepackaged ECPs are not available, oral contraceptives can be substituted. Considering
these facts, ECPs should be provided for all survivors of rape who are at risk of pregnancy and who
present within five days of the assault.
The Copper Bearing IUD can be used as emergency contraception if the survivor presents within five
days after the rape (and if there was no earlier unprotected sexual act in this menstrual cycle). It will
prevent more than 99% of expected subsequent pregnancies. Women should be offered counseling
on this service so as to reach an informed decision. A skilled provider should counsel the patient and
insert the IUD. If an IUD is inserted, make sure to give full STI treatment. The IUD may be removed at
the time of the woman's next menstrual period or left in place for future contraception.

8.5: WOMEN NEAR MENOPAUSE

Menopause usually occurs between the age of 45 to 55, a woman has reached menopause when her
ovaries stop releasing eggs. (Ovulating) Because bleeding does not come every month as menopause
approaches, a woman is considered no longer fertile once she has gone 12 months in a row without
having any bleeding.
To prevent pregnancy until it is clear that she is no longer fertile, an older woman can use any
method, if she has no medical condition that limits its use. By itself, age does not restrict a woman
from using any contraceptive method.

When helping woman near menopause choose the methods consider:

Combined hormonal methods (combined oral contraceptive (CoC) and mothly injectable)
• Women age 35 and older who smoke—regardless of how much—should not use COCs.
• Women age 35 and older who smoke 15 or more cigarette a day should not use monthly
injectables.
• Women age 35 or older should not use COCs, monthly injectables if they have migraine
headaches (whether with migraine aura or not)

Progestin only methods (progestin only pills, progestin only injectables, implants)
• A good choice for women who cannot use methods with estrogen.
• During use, DMPA decreases bone mineral density slightly. This may increase the risk of
developing osteoporosis and possibly having bone fracture later, after menopause. WHO has
conducted that this decrease in bone mineral density does not place age or time limits on
use of DMPA.

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Emergency contraceptive pills
• Can be used by women of any age, including those who cannot use hormonal methods on a
continuing basis.

Female sterilization and vasectomy

• May be a good choice for older women and their partners who know they will not want
more children.
• Older women are more likely to have conditions that require delay, referral, or caution for
female sterilization.

Male and female condoms, spermicides, cervical caps and withdrawal

• Protect older women well because of women’s reduced fertility in the years before
menopause.
• Affordable and convenient for women who may not have sex often

Intrauterine device
• Expulsion rates fall as women grow older and are lowest in women over 40 years of age.
• Insertion may be more difficult due to tightening of the cervical canal.

Fertility awareness method

• Lack of regular cycles before menopause makes it more difficult to use these methods
reliably.

When a Woman Can Stop Using Family Planning

• Because bleeding does not come every month in the time before menopause, it is difficult
for a woman whose bleeding seems to have stopped to know when to stop using
contraception. Thus, it is recommended to continue using contraception. Thus, it is
recommended to continue using a family planning method until 12 months with no bleeding
have passed.
• Hormonal methods affect bleeding, and so it may be difficult to know if a woman using them
has reached menopause. She can switch to a nonhormonal method. She no longer needs
contraception once she has had no bleeding for 12 months in a row.
• Copper- bearing IUDs can be left in place until after menopause. The IUD should be removed
12 months after woman’s last monthly bleeding.

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Relieving Symptoms of Menopause
• Women experience physical effects before, during, and after menopause: hot flushes, excess
sweating, difficult holding urine, vaginal dryness that can have sex painful, and difficult
sleeping.
• Providers can suggest ways to reduce some of these symptoms:
• Deep breathing from the diaphragm may make a hot flush go away faster. A woman can also
try eating foods containing soy or taking 800 international units per day of vitamin E.
• Eat foods rich in calcium (such as dairy products, beans, fish) and engage in moderate
physical activity to help slow the loss of bone density that comes with menopause.
• Vaginal lubricants or moisturizers can be used if vaginal dryness persists and causes
irritation. During sex, use a commercially available vaginal lubricants, water, or saliva as a
lubricant if vaginal dryness is a problem.

8.6: INFERTILITY

Key points for Infertility

❖ Infertility often can be prevented. Avoiding sexually transmitted infections and
receiving prompt treatment for these and other reproductive tract infections can
reduce a client’s risk of infertility.

Involuntary infertility is a disease of the reproductive system: the inability to become pregnant when
desired children, whether due to inability to achieve pregnancy or due to stillbirth or miscarriage.
Infertility is defined by “failure to establish a clinical pregnancy after 12 months of regular
unprotected sexual intercourse “between a man and a woman. (on average, 85% of women would
be pregnant by then)
There are differences among regions. In some countries or communities, infertility or childlessness
can have drastic consequences, especially for women but also with significant impact on men. These
consequences can include economic deprivation, divorce, stigma and discrimination, isolation,
intimate partner violence, murder, mental health disorders, and suicide.

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Causes of Involuntary fertility
• Counsel clients about STI prevention including HIV, encourage clients to seek treatment as soon
as they think they might have an STI or might have been exposed.
• Treat or refer clients with signs and symptoms of STI and clinical PID, treating these infections
can help to prevent infertility.
• Avoid causing infection by following proper infection-prevention practices when performing
medical procedures that pass instruments from the vagina into the uterus, such as IUD insertion.
• Treat or refer clients with signs or symptoms of infection postpartum or post abortion.
• Help clients with fertility problems become aware of risks to fertility not only infection but also
lifestyle and environmental factors.
• Counsel clients about available options for their future childbearing—that is, fertility
preservation techniques such as sperm freezing for men and in vitro fertilization for freezing
eggs- if they are being treated or are having surgery for cancer or other diseases that may affect
reproductive tissue or organs.

Contraceptives do not cause infertility

• With most modern contraceptive methods, there is no significant delay in the time to desired
pregnancy after contraception is stopped. On average, pregnancy occurs after 3 to 6 months of
unprotected sex. There is great variation around this average, however, related to the age and
the health status of the individuals in the couple. When counseling couples who stop
contraception, and want to have child, aging and other factors affecting the fertility of the
woman and the man to be considered.
• The return of fertility after injectable contraceptives are stopped usually takes longer than with
most other methods. In time, however, a woman is as fertile as before using the method, taking
aging into account.
• Among woman with current gonorrhea or chlamydia, IUD insertion slightly increases the risk of
pelvic inflammatory disease in the first 20 days after insertion. However, research has not found
that former IUD users are more likely to be infertile than other women.

Counseling clients with infertility problem

• Counsel both partners together, if possible. A man may blame his partner for infertility when he
himself may be responsible for the inability of the woman to become pregnant or to maintain a
pregnancy.

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• Explain that a man is just as likely to have fertility problems as a woman. In more than 40% of
couples with fertility problems, it is because of semen or sperm abnormalities, or other health
problems of the male partners. In 20% of couples with fertility problems, both male and female
factors reduce fertility. Sometimes it is not possible to find the cause of the problem.
• Recommend that the couple attempt pregnancy with unprotected sex for at least 12 months
before they suspect infertility. Provide educational materials and guidance on risks to fertility.
• The most fertile time of woman’s cycle is several days before and at the time of ovulation.
Fertility awareness methods can help couples identify the most fertile time of each cycle.
Provide educational material about these methods and/or refer the couple to fertility care
provider or specialist.
• If, after one year, following the suggestion above has not resulted in a pregnancy or live birth,
refer both partners to a qualified fertility care provider for evaluation and assessment, if
available. Referral to fertility care provider or specialist may be particularly helpful in the
following situation: the couple is affected by HIV or suspected genital TB; woman is age 35 or
older, she has polycystic ovary syndrome or has been diagnosed with endometriosis; the woman
or the man suspects they had an STI and it was not treated; either had been treated for a cancer
or had surgery that may have affected the reproductive tissue or organs.
• The couple also may want to consider adoption or other alternatives to having children
or more children of their own, such as taking in nieces and nephews.

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8.7: FAMILY PLANNING IN POST ABORTION CARE

Key points for providers and clients

• Post abortive care
• Fertility returns quickly within 8 days, after abortion or miscarriage. Women need to
start using a family planning method almost immediately to avoid unplanned
pregnancy. (post abortive family planning)

Women who have just been treated for post abortion complications need easy and immediate
access to family planning services, health care providers can offer these women family planning
services, including those who provide post abortive care. When such services are integrated with
post abortive care, are offered immediately post abortion, or nearby, women are more likely to use
contraception when they face the risk of unintended pregnancy.

Help women obtain family planning

Counsel with compassion

A woman who has had post abortion complications needs support. A woman who has faced the
double risk of pregnancy and unsafe induced abortion especially needs help and support. Good
counseling gives support to the woman who has just treated for post abortion complications. In
particulars:

• Try to understand what she has been through

• Treat her with respect and avoid judgement and critism
• Ensure privacy and confidentially
• Ask if she wants someone she trust to be present during counseling

Provide important information

A woman has important choices to make after receiving post abortion care. To make decisions about
her health and fertility, she needs to know:

Fertility returns quickly—within 8 days after a first-trimester abortion or miscarriage. Therefore, she
needs protection from pregnancy almost immediately.

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She can choose among many different family planning methods that she can start at once. Methods
that women should not use immediately after giving birth pose no special risks after treatment for
abortion complications.

• She can wait before choosing a contraceptive for ongoing use, but she should consider using
backup methods (abstinence, withdrawal, male or female condoms, spermicides) in the
meantime if she has sex. If a woman decides not to use contraceptives at this time,
providers can offer information on available methods and where to obtain them. Also,
providers can offer condoms, contraceptive pills for women to take home and use later.

• To avoid infection, she should not have sex until bleeding stops—about 5 to 7 days. If being
treated for infection or vaginal or cervical injury, she should wait to have sex again until she
has fully healed.

• If she wants to become pregnant again soon, encourage her to wait. Waiting at least 6
months may reduce the chances to low birth weight, premature birth, and maternal anemia.

A woman receiving post abortive care may need other reproductive health services. In particular, a
provider can help her consider if she might have been exposed to sexually transmitted infections.

When to start contraceptives

• Combined oral contraceptives, progestin-only pills, progestin-only injectables, monthly
injectables, implants, male condoms, female condoms, and withdrawal can be started
immediately in every case, even if the woman has injury to the genital tract or has a possible
or confirmed infection.

• IUDs, female sterilization, and fertility awareness methods can be started once infection is
ruled out or resolved.

• IUDs, female sterilization, and fertility awareness methods can be started once any injury to
the genital tract has healed.

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Special consideration

IUD insertion immediately after a second-trimester abortion requires a specially trained provider.

Female sterilization must be decided upon in advance, and not while a woman is sedated, under
stress, or in pain. Counsel carefully and be sure to mention available reversible methods.

Fertility awareness methods: A woman can start symptoms-based methods once she has no
infection- related secretions or bleeding due to injury to the genital tract. She can start calendar-
based methods with her next monthly bleeding, if she is not having bleeding due to injury to the
genital tract. (Difficult to use)

8.8: MOBILE groups including migrants and internally displaced persons(IDPs)

Key points for migrants, IDP and mobile communities

Due to the mobile nature of these clients they have specific vulnerability and
needs regarding sexual and reproductive health including family planning.
These groups might have access to family planning.

• Mobile groups often face health inequities, human rights violations, stigmatization,
marginalization and discriminatory policies. During transit and upon arrival, such vulnerability is
influenced by legal status, poverty, stigma/discrimination, insecure living conditions, fear of
authorities and cultural and linguistic differences. For instance, migrant women often work in
unregulated and often poorly paid informal sector, e.g. trade, domestic work, agriculture, etc., are
exposed to conditions that increase their health risks as well as their vulnerability to gender-based
violence. They have reduced access to sexual and reproductive health services, including where how
to access services. Thus, they often experience higher incidences of SRH negative outcomes.

• In humanitarian settings, child bearing risks are compounded for women, due to increased
exposure to forced sex, increased risk taking and reduced availability of and sensitivity to sexual and
reproductive health services, including adolescent sexual and reproductive health.

When counseling mobile clients keep in mind their barriers and address where possible. Also, in
recommending family planning methods, be aware of their mobile status.

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JOB AID AND TOOL
JOB AID AND TOOL: 1. COMPARING COMBINED METHODS
Characteristic Combined Oral Monthly
Contraceptives Injectables
How it is used Pill taken orally. Intramuscular injection.

Frequency of use Daily. Monthly: Injection every 4 weeks.

Effective- ness Depends on user’s ability to Least dependent on the user. User
take a pill every day. must obtain injection every 4 weeks
(plus or minus 7 days)

Bleeding patterns Typically, irregular bleeding for Irregular bleeding or no monthly

the first few months and then bleeding is more common than with
lighter and more regular COCs. Also, some have prolonged
bleeding. bleeding in the first few months.

Privacy No physical signs of use but No physical signs of use.

others may find the pills.

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JOB AID AND TOOL: 2. COMPARING INJECTABLES
Monthly
Characteristic DMPA NET-EN
Injectables
Time between 3 months. 2 months. 1 month.
injections
How early or 2 weeks before or 2 weeks before 7 days before or
late a client can 4 weeks after or after scheduled after scheduled
have the next scheduled injection injection date. injection date.
injection date.
Injection Deep intramuscular Deep intramuscular Deep intramuscular
technique (IM) injection into injection into the hip, injection into the hip,
upper arm, or buttock. upper arm, buttock, or
the hip, upper arm, or
May be slightly more outer thigh.
buttock.
painful than DMPA-IM.
Subcutaneous injection
into back of upper arm,
abdomen, or front of thigh.
Typical Irregular and prolonged Irregular or prolonged Irregular, frequent, or
bleeding bleeding at first, then no bleeding in first 6 months prolonged bleeding in
patterns in bleeding or infrequent but shorter bleeding first 3 months.
first year bleeding. About 40% of episodes than with DMPA. Mostly regular
users have no monthly After 6 months bleeding bleeding patterns by
bleeding after 1 year. patterns are similar to 1 year. About 2% of
those with DMPA. 30% of users have no
users have no monthly monthly bleeding
bleeding after 1 year. after 1 year.

Average 1–2 kg per year. 1–2 kg per year. 1 kg per year.

weight gain
Pregnancy About 4 pregnancies per Assumed to be similar About 3 pregnancies
rate, as 100 women in the first to DMPA. per100 women in the
commonly year. first year.
used
Average delay in 4 months longer than for 1 month longer than 1 month longer
time to women who used other for women who used than for women
pregnancy after methods. other methods. who used other
stopping methods.
injections

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JOB AID AND TOOL. 3: COMPARING IMPLANTS

Characteristic Jadelle Implanon NXT Levoplant

Type of progestin Levonorgestrel Etonogestrel Levonorgestrel

Number 2 rods 1 rod 2 rods

Approved lifespan 5 years 3 years 4 years

JOB AID AND TOOL. 4: COMPARING CONDOMS

Characteristic Male Condoms Female Condoms
How to wear Rolled onto man’s penis. Fits Inserted into the woman’s vagina.
the penis tightly. Loosely lines the vagina and does not
constrict the penis.

When to put on Put on erect penis right Can be inserted up to 8 hours before
before sex. sex.
Material Most made of latex; some of Most made of a thin, synthetic film; a
synthetic materials or animal few are latex.
membranes.

How they feel during sex Change feeling of sex. Fewer complaints of changed feeling
of sex than with male condoms.

Noise during sex May make a rubbing noise May rustle or squeak during sex.
during sex.
Lubricants to use Users can add lubricants: Users can add lubricants:

• Water-based or • Water-based, silicone- based, or

silicone-based only. oil-based (but not with latex

• Applied to outside of condoms).

condom. • Before insertion, applied to

outside of condom.

• After insertion, applied to inside

of condom or to the penis.

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Breakage or Tend to break more often than Tend to slip more often than male
slippage female condoms. condoms.

When to remove Require withdrawing from the Can remain in vagina after erection
vagina before the erection softens. Requires removal before
softens. woman stands.

What they protect Cover and protect most of the Cover both the woman’s internal
penis, protect the woman’s and external genitalia and the base
internal genitalia. of the penis.

How to store Store away from heat, Plastic condoms are not harmed
light, and dampness. by heat, light or dampness.

Reuse Cannot be reused. Reuse not recommended (see

Female Condoms, Question 5, p.
270).

Cost and Generally low cost and Usually more expensive and less
availability widely available. widely available than male condoms.

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JOB AID AND TOOL. 5: COMPARING IUDs

Characteristic Copper-Bearing IUD Levonorgestrel IUD

Effectiveness Nearly equal. Both are among the most effective methods.

Length of use Approved for 10 years. Approved for 3 to 5 years.

Bleeding patterns Longer and heavier monthly More irregular bleeding and spotting in
bleeding, irregular bleeding, the first few months. After 1 year no
and more cramping or pain monthly bleeding is more common.
during monthly bleeding. Causes less bleeding than copper-bearing
IUDs over time.

Anemia May contribute to iron- May help prevent iron- deficiency

deficiency anemia if a anemia.
woman already has low iron
blood stores before
insertion.

Main reasons for Increased bleeding and No monthly bleeding and hormonal side
discontinuation pain. effects.

Noncontraceptive May help protect against Effective treatment for long and heavy
benefits endometrial cancer. monthly bleeding (alternative to
hysterectomy). May also help treat
painful monthly bleeding. Can be used to
provide the progestin in hormone
replacement therapy.

Postpartum use Can be inserted up to 48 hours postpartum. After 48 hours, delay

until 4 weeks or more.
Use as emergency Can be used within 5 days Not recommended.
contraception after unprotected sex.

Insertion Requires specific training.

Cost Less expensive. More expensive.

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JOB AID AND TOOL. 6.A: HOW AND WHEN TO USE PREGNANCY CHECKLIST
AND PREGNANCY TEST

Client with amenorrhea Client between two regular menses

(postpartum or other type) Monthly bleeding *

Implants, pills, ring, IUDs Copper or LNG Implants, pills, ring,

injectables, or patch injectables, or patch IUDs Copper or LNG

Use Pregnancy Checklist.1 Use Pregnancy Checklist.1

Pregnancy ruled out: Provide method. pregnancy rule out, method, do not use pregnancy
test (in most cases, too early test is not effective)

Pregnancy not ruled out: Use a

Pregnancy not Pregnancy not ruled out:
pregnancy test.
rule out: Provide Do not provide method.
the method Advise woman to return
Pregnancy test is Pregnancy test is for LNG-IUD insertion
now.2 Return for
negative (or test negative (or test within 7 days of onset
a pregnancy test
is not is not immediately of her next menses,
available): Advise if next menses
immediately or within 12 days for a
woman to use COCs, are delayed. copper IUD; but in the
available): Provide
DMPA, or condoms or meantime, use COCs,
the method now.2 abstain for 3–4 weeks,
DMPA, or condoms or
Schedule a follow- then repeat the abstain. Return for a
up pregnancy test pregnancy test. pregnancy test if next
in Second pregnancy menses are delayed.
3–4 weeks. test is negative:
Provide the IUD.

1 See inside back cover for Pregnancy Checklist. * If the client presents with a late/missed
menses, use a pregnancy test to rule out
pregnancy. If using a highly sensitive pregnancy
2 For implants, counsel about the need to remove test (for example, 25 mIU/ml) and it is negative,
the implant if pregnancy is confirmed and she provide her desired method.
wishes to continue the pregnancy.
If using a test with lower sensitivity (for
In cases where pregnancy cannot be ruled out, example,50 mIU/ml) and it is negative during the
offer emergency contraception if the woman time of her missed period, wait until at least 10
had unprotected sex within the last 5 days. days after expected date of menses and repeat
the test. Advise the woman to use condoms or
Counsel all women to come back any time they
abstain in the meantime. If the test is still
have a reason to suspect pregnancy (for
negative, provide her desired method.
example, she misses a period).
If test sensitivity is not specified, assume lower
sensitivity.

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JOB AID AND TOOL. 6.B: PREGNANCY CHECKLIST
Ask the client questions 1–6. As soon as the client answers” yes” to any question, stop and follow
the instruction below.

NO YES

1 Did your last monthly bleeding start within the past 7 days?*
1

2 Have you abstained from sexual intercourse since your last

2 monthly bleeding, delivery, abortion, or miscarriage?

3 Have you been using a reliable contraceptive method

3 consistently and correctly since your last monthly bleeding,
delivery, abortion, or miscarriage?

44 Have you had a baby in the last 4 weeks?

5 Did you have a baby less than 6 months ago, are you fully or
5 nearly-fully breastfeeding, and have you had no monthly bleeding
since then?

66 Have you had a miscarriage or abortion in the past 7 days?*

* If the client is planning to use a copper-bearing IUD, the 7-day window is

expanded to 12 days.

If the client answered NO If the client answered

to all of the questions, YES to at least one of
pregnancy cannot be ruled the questions, you can be
out using the checklist. reasonably sure she is
Rule out pregnancy by not pregnant.
other means.

114
JOB AID AND TOOL. 7: MANAGING MISS PILLS (COC)

115
JOB AID AND TOOL. 8: THE MENSTRUAL CYCLE

116
JOB AID AND TOOL. 9.A: MALE ANATOMY

Male Anatomy

Penis
Male sex organ made of spongy tissue. When a man
becomes sexually excited, it grows larger and
stiffens. Semen, containing sperm, is released from
the penis (ejaculation) at the height of sexual
excitement (orgasm).
A male condom covers the erect penis, preventing
sperm from entering the woman’s vagina.
Withdrawal of the penis from the vagina avoids the Seminal vesicles
release of semen into the vagina.
Urethra Where sperm is
Tube through which mixed with semen.
semen is released
from the body.
Liquid waste (urine)
is released through
the same tube.

Prostate
Organ that produces
some of the fluid in
Foreskin
Hood of semen.
Skin covering .
the end of the
penis. Vas deferens
Circumcision
removes the Each of the 2 thin
foreskin.. tubes that carry
sperm from the
testicles to the
seminal vesicles.
Scrotum
Vasectomy
Sack of thin loose Testicles
skin containing involves cutting or
Organs that
the testicles. blocking these
produce sperm.
tubes so that no
sperm enters the
semen

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JOB AID AND TOOL. 9.B: FEMALE INTERNAL ANATOMY

Internal Anatomy

Womb (uterus) Fallopian tube

Where a fertilized egg grows and An egg travels along one of these tubes
develops into a fetus. IUDs are placed in once a month, starting from the ovary.
the uterus, but they prevent fertilization Fertilization of the egg (awhen sperm
in the fallopian tubes. Copper-bearing meets the egg) occurs in these tubes.
IUDs also kill sperm as they move into Female sterilization involves cutting or
clipping the fallopian tubes. This prevents
the uterus
sperm and egg from meeting. IUDs cause a
chemical change that damages sperm
Ovary
before they can meet the egg in the
Where eggs develop and
fallopian tube.
one is released each
month. The lactational
amenorrhea method
(LAM) and hormonal
methods, especially those
with estrogen, prevent
the release of eggs. Fertility
awareness methods require
avoiding unprotected sex
around the time when an
ovary releases an egg.

Uterine lining
(endometrium)
Lining of the uterus,
which gradually
thickens and then is
shed during
monthly bleeding.

Cervix Vagina
The lower portion of the uterus, which Joins the outer sexual organs with the
extends into the upper vagina. It uterus. The combined ring and the
produces mucus. Hormonal methods progesterone-releasing vaginal ring
thicken this mucus, which helps prevent are placed in the vagina, where they
sperm from passing through the cervix. release hormones that pass through
Some fertility awareness methods the vaginal walls. The female condom
require monitoring cervical mucus. The is placed in the vagina, creating a
diaphragm, cervical cap, and sponge barrier to sperm. Spermicides inserted
cover the cervix so that sperm cannot into the vagina kill sperm.
enter.

118
JOB AID AND TOOL. 9.C: FEMALE EXTERNAL ANATOMY

External Anatomy

Pubic hair
Hair that grows during puberty and
surrounds the female organs

Inner Lips
Clitoris (Labia minora)
Sensitive ball of tissue Two folds of skin, inside
creating sexual pleasure the outer lips, that
extend from the clitoris

Urethra Outer lips

Opening where (Labia Majora)
liquid waste (urine) Two folds of skin, one on
leaves the body either side of the vaginal
opening, that protect the
female organs

Vaginal opening
The man’s penis is inserted here during Anus
sexual intercourse. Blood flows from Opening where
here during monthly bleeding solid waste (feces)
leaves the body

119
ANNEX

ANNEX. 1: BASIC RULES OF INFECTION PREVENTION

These rules apply the universal precautions for infection prevention to the family planning clinic.
Wash Hands
• Hand washing may be the single most important infection-prevention procedure.
• Wash hands before and after examining or treating each client. (Hand washing is not necessary
if clients do not require an examination or treatment.)
• Use clean water and plain soap, and rub hands for at least 10 to 15 seconds. Be sure to clean
between the fingers and under fingernails. Wash hands after handling soiled instruments and
other items or touching mucous membranes, blood, or other body fluids. Wash hands before
putting on gloves, after taking off gloves, and whenever hands get dirty.
• Wash hands when you arrive at work, after you use the toilet or latrine, and when you leave
work. Dry hands with a paper towel or a clean, dry cloth towel If clean water and soap are not
available, a hand sanitizer containing at least 60% alcohol can reduce the number of germs on
the hands. Sanitizers do not eliminate all types of germs and might not remove harmful
chemicals.

Process instruments that will be reused

• High-level disinfect or sterilize instruments that touch intact mucous membranes or broken skin
• Sterilize instruments that touch tissue beneath the skin.

Wear Glass
• Wear gloves for any procedure that risks touching blood, other body fluids, mucous
membranes, broken skin, soiled items, dirty surfaces, or waste. Wear surgical gloves for surgical
procedures such as insertion of implants. Wear single-use examination gloves for procedures
that touch intact mucous membranes or generally to avoid exposure to body fluids. Gloves are
not necessary for giving injections.
• Change gloves between procedures on the same client and between clients.
• Do not touch clean equipment or surfaces with dirty gloves or bare hands.
• Wash hands before putting on gloves. Do not wash gloved hands instead of changing gloves.
Gloves are not a substitute for hand washing.
• Wear clean utility gloves when cleaning soiled instruments and equipment, handling waste,
and cleaning blood or body fluid spills.

120
Do pelvic examinations only when needed
• Pelvic examinations are not needed for most family planning methods—only for female
sterilization, the IUD, diaphragm, and cervical cap. Pelvic examinations should be done only
when there is a reason—such as suspicion of sexually transmitted infections, when the
examination could help with diagnosis or treatment.

For injections, use new autodisable syringes and needles

• Auto-disable syringes and needles are safer and more reliable than standard single-use
disposable syringes and needles, and any disposable syringes and needles are safer than
sterilizing reusable syringes and needles. Sterilizing and reusing syringes and needles should be
avoided. It might be considered only when single-use injection equipment is not available, and
the program can document the quality of sterilization.
• Cleaning the client’s skin before the injection is not needed unless the skin is dirty. If it is, wash
with soap and water and dry with a clean towel. Wiping with an antiseptic has no added
benefit.

Wipe surfaces with chlorine solution

• Wipe examination tables, bench tops, and other surfaces that come in contact with unbroken
skin with 0.5% chlorine solution after each client.

Dispose of single use equipment and supplies properly and safely

• Use personal protective equipment—goggles, mask, apron, and closed protective shoes—when
handling wastes.
• Needles and syringes meant for single use must not be reused. Do not take apart the needle
and syringe. Used needles should not be broken, bent, or recapped. Put used needles and
syringes immediately into a puncture-proof container for disposal. (If needles and syringes will
not be incinerated, they should be decontaminated by flushing with 0.5% chlorine solution
before they are put into the puncture-proof container.) The puncture-proof sharps container
should be sealed and either burned, incinerated, or deeply buried when three-fourths full.
• Dressings and other soiled solid waste should be collected in plastic bags and, within 2 days,
burned and buried in a deep pit. Liquid wastes should be poured down a utility sink drain or a
flushable toilet or poured into a deep pit and buried.
• Clean waste containers with detergent and rinse with water.
• Remove utility gloves and clean them whenever they are dirty and at least once every day.
• Wash hands before and after disposing of soiled equipment and waste.

Wash linens
• Wash linens (for example, bedding, caps, gowns, and surgical drapes) by hand or machine and
line-dry or machine-dry. When handling soiled linens, wear gloves, hold linens away from your
body, and do not shake them.

121
ANNEX. 2: INSERTION AND REMOVAL OF IMPLANTS

Insertion of Jadelle

• A woman who has chosen implants needs to know what will happen during insertion.
Inserting implants usually takes only a few minutes, but can sometimes take longer.

• Implant is inserted with a specially made applicator similar to a syringe. It does not require
an incision.

• Learning to insert and remove implants requires training and practice under direct
supervision.

(1) (2) (3)

(4) (5) (6)

(7)

122
1. Position the client’s arm and determine the optimal insertion site (8 cm above the elbow fold)
and mark the insertion points. Insert under aseptic condition.
2. Provide 0.5 – 2 ml of 0.5% local anesthesia (lignocaine) to prevent pain during insertion.
3. Make an incision and Insert disposable trocar and attached plunger, with the bevel on tip facing
upward, directly through the skin to the superficial subdermal layer at 20 -30 angle from the
skin. Tilt the trocar upward while tenting the skin. The trocar will move easily if it is in a proper,
shallow plane. Advance the trocar and plunger slowly and smoothly until the outer marks near
the hub.
4. Remove the plunger once the trocar has been advanced to the mark nearest the hub. Load the
first rod into the trocar with forceps. Slide the rod into the top of the trocar and reinsert the
plunger. Use the plunger to gently advance the rod toward the tip of trocar until encounter
resistance.
5. Keeping the plunger steady and stabilize the rod, withdraw the trocar back out until the first
ring mark (nearest to the tip) and the hub touches the handle of the plunger. The rod is now
free from the trocar and be lying beneath the skin.
6. Fix the first rod with forefinger of the free hand over the end of first rod, redirect the trocar
about 15 and slowly advance the trocar following a “V” shape toward the mark nearest the
hub.
7. Load the second rod into the trocar and using the same technique (repeat steps 4-8).
8. Palpate the rob to be sure the rods are placed correctly with the end of the rods 5 cm away
from the insertion point and two rods close to each other forming the tips of “V” shape.
Reassure the client, the rods are in place through her palpation.
9. Carefully withdraw the trocar and apply pressure on the insertion point with gauze for a minute
or so to stop bleeding. Apply surgical tape longitudinally and wrap Band-Aid over it. Clean the
area around with alcohol or boiled-cooled water.
10. Disposed the disposable trocar and plunger into sharp container for waste disposal.

123
Insertion of Implanon- NXT

1. Same steps 1-2 as Jedelle insertion

2. Check the implanon-NXT is pre-loaded inside the applicator
3. Puncture the skin with the tip of the needle angle about 30 degrees. (Figure 1)
4. Lower the applicator to a horizontal position while tending the skin with the tip of the needle
(Figure 2) to insert the rod superficially and sub-dermally. Advance the needle to its full length
until a resistance is felt.
5. Stabilize the applicator in the same position and unlock the purple slider by pushing it slightly
down, move the slider fully back until it stops. The implant is now remained sub-dermally and
the needle is locked inside the body of the applicator. Remove the applicator (Figure 3).
6. Verify the presence of the implant in woman’s arm immediately after insertion by palpation.
7. Ask the client to palpate and reassure the implant is in place.
8. Cover the insertion site.
9. Disposed the applicator into the sharp container for waste disposal.

124
 Removal of Implants

1. The provider must not refuse if woman desire to remove the implant for any reasons. All
providers must understand that client must not be pressured to continue implant.
2. Explain a woman what will happen during removal.
3. Determine the location of implant by palpation. Mark the tip(s) of the rod(s) to guide the
incision point (Figure 1).
4. Remove under aseptic and anaesthetize condition. (Inject 0.5 ml of 0.5% local anesthesia
(lignocaine) at the tip of incision under the implant to make it superficial (Figure 2).
5. Push down the proximal end of the implant to stabilize it and form a bulge showing the distal
end of the implant. Make a 2 mm long longitudinal incision toward the elbow and deep enough
to expose the rod (Figure 3).
6. Gently push the implant toward the incision until the tip is visible. Grasp the implant with a
curved mosquito forceps and gently remove the implant (Figure 4).
7. If the implant is encapsulated, use the forceps to gently grasp and stabilize the encapsulated
rod, then make a small incision into the tissue sheath to expose the rod. With another curved
mosquito forceps, grasp and gently remove the implant after releasing the first stabilized
forceps (Figure 5).
8. If the tip of the implant does not become visible in the incision, gently insert a forceps tip into
the incision. Flip the forceps over into your other hand, with a second pair of forceps, carefully
dissect the tissue around the implant and grasp the implant and remove it (Figure 6-7).
9. Confirm that the entire implant, which is about 4.0/4.3 cm long, has been removed by
measuring its length. If removing two-rod implants, repeat the procedure for the second rod.
10. If the client desires to continue contraception with implant, reinsert implant as insertion
procedure.
11. If not, covering the incision as do after insertion.
12. Dispose the implant as to surgical waste and decontaminate the instrument ready for next use.

125
ANNEX. 3: INSERTION PROCEDURE OF IUD

A pelvic examination and STI risk assessment are essential.

(1) (2)

(3) (4)

(5) (6)

126
 1. The provider uses proper infection prevention procedure
2. The provider conducts a pelvic examination to determine the position of uterus and assess
eligibility. The provider first does the bimanual examination and then inserts a speculum into
the vagina to inspect the cervix.
3. The provider cleans the cervix and vagina with appropriate antiseptic.
4. The provider slowly inserts the tenaculum through speculum and closes the tenaculum just
enough to gently hold the cervix and uterus steady.
5. The provider slowly and gently passes the uterine sound through the cervix to measure the
depth and position of the uterus
6. The provider loads the IUD into the inserter while both are still in the unopened sterile package.
7. The provider slowly and gently inserts the IUD into the uterus and remove the inserter.
8. The provider cuts the strings on the IUD, leaving about 3 centimeters hanging out of the cervix.
9. After the insertion, the woman rests. She remains on the examination table until she feels
ready to get dressed.
*Use high-level disinfected or sterile instruments. Ensure high-level disinfection is done by boiling,
steaming, or soaking them in disinfectant chemicals. Use a new, pre-sterilized IUD that is package
with its inserter.
After insertion, teach the client how she can check the strings on her own, at specific times, to
confirm that her IUD is still in place.
Give each woman the reminder card and explain: the type of IUD she has, date of IUD insertion,
month and year when IUD will need to be removed or replaced, where to go if she has problems or
questions with her IUD.
A follow-up visit after her first monthly bleeding or 3 to 6 weeks after IUD insertion is recommended.
No woman should be denied an IUD, however, because follow-up visit would be difficult or not
possible.

127
Removing the IUD

If a woman is finding side effects difficult to tolerate, first discuss the problems she is having.
Removing an IUD is usually simple. It can be done any time of the month. Removal may be
easier during monthly bleeding, when the cervix is naturally softened.
In case of uterine perforation or if removal is not easy (For example, when IUD strings are
missing) refer the woman to an experienced clinician who can use an appropriate removal
technique.

Removal procedure

❖ Explain the client before the procedure. The provider inserts a speculum to see the cervix
and IUD strings and carefully cleans the cervix and vagina with an antiseptic solution, such as
iodine.
❖ The provider asks the woman to take slow, deep breaths and to relax. The woman should
say if she feels pain during the procedure.
❖ Using narrow forceps, the provider pulls the IUD strings slowly and gently until the IUD
comes completely out of the cervix.

128
ANNEX. 4: WASTE DISPOSAL
Disposal of contraceptives waste
Methods/primary ingredients Disposal Method
Male condom (with primary packaging)
Latex Land fill
Incineration
Female condom (with primary packaging)
Polyurethane Incineration
Latex • Same as for male latex condoms
Oral pill ( with Primary packaging )
Estrogen and Progesterone Land fill
Incineration
Encapsultion
Inertization (only the pills after separating them from
the blisters. Blister material can be incinerated if it is of
aluminium or placed in a landfill
Hormonal Patch (with primary packaging)
Estrogen and progesterone Land fill
incineration (plastic other than PVC blister)

Hormonal ring (with primary packaging)

Estrogen and progesterone the ring is Incineration (plastic other than PVC blister)
made of plastic, so question is same
as above.
Hormoral IUD (with primary packaging)

progesterone Incineration (plastic other than PVC blister)

Implants (with primary covering)

Progesterone hormone in silastic Incineration
rods
Injectable contraceptives
Progesterone Land fill
Glass vials/ampule Crush the vials/ ampule and then dispose through
landfill
Copper IUD (with primary covering)

Copper and plastics Copper containing IUDs can be disposed of by

incineration after removing from primary packing
Packing materials and other related waste
Paper, cardboard (Bio-degradable Recycle, if possible
materials) Landfill
Incineration

129
FORM
COMSUMPTION REPORT FORM OF CONTRACEPTION

130
CLIENT REPORT FORM OF CONTRACEPTION

131
CONTRIBUTORS
Prof. Mya Thida National Consultant for Maternal and Reproductive Health
Department of Public Health, Ministry of Health and Sports
The Republic of the Union of Myanmar

Prof. Khin Htar Yi President

Obstetrical and Gynecological Society
Myanmar Medical Association

Prof. San San Myint Professor and Head of Obstetrics and Gynecology Department
University of Medicine (1) Yangon

Prof. Kyi Kyi Nyunt Professor and Head of Obstetrics and Gynecology Department
University of Medicine (2) Yangon

Prof. Saw Kler Ku Professor and Head of Obstetrics and Gynecology Department
University of Medicine Mandalay

Prof. Nwe Mar Tun Professor and Head of Obstetrics and Gynecology Department
University of Medicine Magway

Prof. Thin Thin Myat Professor, Obstetrics and Gynecology Department

University of Medicine Mandalay

Dr. Hla Mya Thway Einda Director

Maternal and Reproductive Health Division
Department of Public Health
Ministry of Health and Sports

[Link] Hnin Lwin Deputy Director

Maternal and Reproductive Health Division
Department of Public Health
Ministry of Health and Sports

Dr. Khaing Nwe Tin Deputy Director

Maternal and Reproductive Health Division
Department of Public Health
Ministry of Health and Sports

132
Dr. Myo Myo Mon Assistant Director
Maternal and Reproductive Health Division
Department of Public Health
Ministry of Health and Sports

Dr. Yu Mon Myint Medical Officer

Maternal and Reproductive Health Division
Department of Public Health
Ministry of Health and Sports

Dr. Tin Maung Chit Programme Analyst

UNFPA, Myanmar

Dr. Shwe Sin Yu National Professional Officer (RMNCAH)

WHO, Myanmar

Dr. Thida Moe Senior Technical Advisor

Jhpiego, Myanmar

Dr. May Sandi Htin Aung Technical Advisor

Jhpiego, Myanmar

Dr. Myint Myint Win Deputy Director, Reproductive Health

PSI, Myanmar

Dr. Moe Moe Aung Senior Programme Manager

MSI, Myanmar

Dr. Ni Ni Country Director

IPAS, Myanmar

[Link] Thu Lwin Senior Health Systems Advisor

IPAS, Myanmar

Stephanie Bleeker Consultant

UNFPA, Myanmar

133
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