Family planning

Population education:
Population means: A group of people living in a certain
geographical area.
Population education: Education to the population to lead a
healthy life, establish harmony and equal balance in the
community, nation.
Population pyramid:
Population pyramid defined as the graphical representation
of the population from its fixed interval, lower level to
higher level. Male population is always present in Right side
and Female population is always present in Left side.
Population density: No of the population living in per
square kilometer. According to Census 2011, 180 population
in per square KM
Sex Ratio:
Sex ratio is defined as “the no of females per 1000 males.
One of the basic demographic characteristics of the
population is the sex composition. In any study of
population, analysis of the sex composition plays a vital role.
A low sex ratio indicates strong male child preference and
consequent gender in equalities, neglect of girl child
resulting in higher mortality in younger age, female

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infanticide, female foticide, higher maternal mortality and
male bias in enumeration of population.
Formula:
No of Female
Sex ratio: ×1000
No of Male

According to Census 2011 the sex ratio is 94.2 (94.2 male

in 100 female)

Family size: Family size means the total no of children. The

total family rate gives the approximate magnitude of the
completed family size.

Life expectancy:
Average no of years which a person of that age may expect
to live, according to the mortality pattern prevalent in the
country.

Fertility:
Fertility means actual bearing of the children. Some
demographers prefer to use the world “Natality” in place of
fertility.

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 1. Crude birth rate: It is generally expressed in per 1000
live birth of the infant per year. According to Central
beuaro of Statist 2014, the CBR is:22.4
2. Total fertility rate:
Total fertility rate represents the average number of
children a women would have if she were to pass
through her reproductive years bearing children at the
same rates as the woman now in each group. According
to the CBS2014 the Total fertility rate is 2.5.

Consequence of population growth:

1. Low quality of Health and Health services
2. In adequate Food and nutrition
3. Low quality education
4. Degradation of environment and natural resources
5. Competition in Employment
6. Low socio and economic development
7. Negative effect in Ecosystem.

Measures to solve the population problem:

1. Developing awareness on population

2. Women’s Empowerment
3. Delayed marriage
4. Family planning
a. Birth spacing
b. Birth control device
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 5. Incentive

Family planning:
An expert committee of WHO.(1971) defined family
planning as “A way of thinking and living that is adopted
voluntarily, upon the basis of knowledge, attitudes, and
responsible decisions by individual and couples, in order
to promote health and welfare of the family group and thus
contribute effectively to the social development of a
country”.
Objective of family planning:
1. To avoid unwanted births
2. To bring about wanted births
3. To regulate the interval between pregencies
4. To control the time at which birth occur in relation to the
ages of the parent
5. To determine the no of children family.
Eligible couple:
An “eligible couple” refers to a currently married couple
wherein the wife is in the reproductive age.

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Target couple:
The term target couple was applied to couples who have had
2-3 living children, and family planning was largely directed
to such couple.
Couple protection Rate:
It is defined as the percent of eligible couples effectively
protected against child birth by one or other approved
methods of family planning, eg, sterilization, IUD, Condom
or oral pills.

NON-HORMONAL METHODS
MALE CONDOM
Most male condoms are made of thin latex rubber while
some are made of animal tissue (lamb caecum) or of
polyurethane, polyisoprene and nitrile.
Effectiveness:-
Contraceptive effectiveness depends upon the way it is used.
The effectiveness is different for consistent and correct user,
and common user. For consistent and correct user, in the first
year of use it is 2 pregnancies per 100 women and for
common user it is 13 pregnancies per 100 women. (98%
Effectiveness).

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 Protection against unintended pregnancy, STI and HIV
• The male condom works by forming a barrier that keeps
the sperms out of the vagina, preventing pregnancy. Also
prevents transmission of infections of male and female
reproductive organ to each other.
• When used consistently and correctly, male condom use
prevents 80% to 95% of HIV transmission that would have
occurred without condoms.
• Male condoms protect against STIs spread by discharge
when used consistently and correctly during vaginal or anal
sex.
Return of Fertility:-
When the user stops using male condoms, fertility returns
instantly.
Indication
Male condom is particularly appropriate for the following
clients:
• A male partner who wishes to take responsibility for
contraception.
• A client who needs or desires protection against STIs,
including HIV transmission and unwanted pregnancy.
• A client who is worried about side effects of other
methods.

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• A client who needs a temporary, alternative or backup to
another method (e.g., for the backup following vasectomy, if
a woman forgets to take her COCs for 3 or more days).
FEMALE CONDOMS
Female condom fits loosely inside a woman’s vagina, made
of thin, transparent, soft film. It has flexible rings on both
ends. It works by forming a barrier that keeps sperm out of
the vagina, preventing pregnancy, STIs and HIV. It also
prevents transmission of infections of male and female
reproductive organ to each other.
Indication of female condom:
Particularly appropriate for the following clients:
• A female partner who chooses condom as her method of
choice for family planning.
• A client who needs or desires protection against STIs,
including HIV transmission and unwanted pregnancy.
• A client who is worried about side effects of other
methods.
• A client who needs a temporary alternative or backup to
another method (e.g., for the backup when a woman forgets
to take her COCs for 3 or more days)
FERTILITY AWARENESS METHOD (FAM)
A couple/partners voluntarily avoid/s sexual intercourse
during the fertile days of the woman’s cycle (time when the
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woman can become pregnant) or has intercourse during the
fertile days to achieve pregnancy
Types of Fertility Awareness Methods
1. The cervical mucus method :- It monitors the quality
and quantity of cervical mucus at the vaginal opening.
a. • Fertile mucus occurs approximately mid-cycle and

is abundant, thin, slippery and elastic, like an egg

white.
b. • Infertile mucus is thick, sticky and scant and is

found at the beginning and end of the cycle.

c. • Abstinence is practiced when fertile mucus is

present.
2. TwoDay Method:- It is based on identifying the fertile
days of a woman’s menstrual cycle.
Important: If woman has a vaginal infection or another
condition that changes cervical mucus, the TwoDay
Method will be difficult to use.

3. The basal body temperature method:- It monitors the

resting body temperature each day.
a. Just at or immediately after ovulation (mid-cycle),

there is 0.3–0.5° rise in body temperature.

b. Abstinence is practiced from the beginning of the

cycle until 3 days after the rise in body temperature.

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4. The sympto-thermal method :- It is a combines
observation of cervical mucus and monitoring of the
basal body temperature in order to more accurately
pinpoint the fertile period.

5. The calendar method uses a mathematical formula to

calculate the fertile period. The woman first must
observe the length of at least six menstrual cycles and
then apply the formula to these observations.
6. Locational Amenorrhea Method (LAM):- is based on
the natural post-partum infertility that occurs when
woman breastfeeds exclusively, baby is less than six
months and menstruation has not resumed.

7. Standard Days Method (SDM) – Malachakra identifies

cycle days 8–19 as fertile. It helps couple/ partners avoid
unprotected pregnancy by knowing which days they
should not have unprotected sex.
COITUS INTERRUPTUS (WITHDRAWAL)
Method:-
1 Introduction:-
Withdrawal is a traditional family planning method in
which the man completely removes his penis from the
woman’s vagina before he ejaculates and ejaculates
outside of vagina, keeping his semen away from her
external genitalia.
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 REMEMBER •
Coitus interruptus does not eliminate the risk of STIs:
pre-ejaculation can contain HIV-infected cells, and
lesions or ulcers on the genitals can transmit
infections.
 Although popularly considered an effective method,
coitus interruptus provides efficacy similar to that of
barrier methods of contraception.
Method Specific Contraception
COMBINED ORAL CONTRACEPTIVE PILLS
(COCS)
Combined Oral Contraceptives (COC) are pills that contain
low doses of 2 hormones – a progestin and an estrogen - like
the natural hormones progesterone and estrogen in a
woman’s [Link] Nepal, the most common COCs available
are “Nilocon White” and “SunauloGulaf”. They are
combined low dose pills in 28-day packages. COCs are
available at all GoN facilities, and contain norgestrel
(progestin) 0.3 mg and ethinyl estradiol (estrogen) 0.03mg in
each pill. The last 7 brown pills contain 75mg ferrous
fumarate (iron).
Effectiveness
• Consistent and correct use:- 0.3 pregnancies/100 women
in first year of use.
Return of Fertility
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 When the woman stops taking the pill, her fertility will
return to normal relatively quickly, although it may not be
immediate. If a woman does not resume normal cycles after
stopping the pill, a specific cause other than pill use should
be sought.

Supplies
• First supply for 3-months
• Re-supply for 3- to 6-months
Indications:-
COC is safe and suitable for nearly all women. COCs may
be particularly appropriate for those who:
• Want a highly effective method of contraception
• Are motivated and willing to use a method which requires
action daily, and will be able to obtain supplies on a
continuous basis
• Have or do not have child, married or single and after
abortion
Clinical Assessment
Service Provider should screening history and physical
examination to rule out certain precautions such as:
• Known or suspected pregnancy

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• Taking certain medications (rifampicin for tuberculosis and
medications for mental disorders (e.g. epilepsy)
• Thromboembolic disorders (blood clots in the legs, lungs
or eyes)
• Heavy smoker (if over 35 years of age)
• High blood pressure (systolic blood pressure between 140
and 159 mmHg or diastolic 90 and 99 mmHg or history of
hypertension if blood pressure not taken)
• Active liver diseases (e.g. jaundice)
COMBINED ORAL CONTRACEPTIVES FOR
WOMEN WITH HIV
• Women living with HIV or on antiretroviral (ARV)
therapy can safely use COCs.
• Urge these women to use condoms along with COCs. If
used consistently and correctly, condoms help prevent
transmission of HIV and other STIs.
When to start?
Within 5 days of menstruation period.
Side Effects of COCS
1. Amenorrhoea (absence of vaginal bleeding or spotting).

2. Spotting or Bleeding (common during the first three

months after starting the pills).

3. High Blood Pressure.

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 4. Nausea/ Dizziness/ Nervousness
5. Severe Vomiting.
Other Problems (May or May Not Be Method-Related)
1. Acne

2. Breast Fullness or Tenderness (usually improves within

3 months of starting the COCs).

3. Cholasma (“mask of pregnancy”)

4. Headaches

5. Significant Unwanted Weight Gain or Weight Loss.

6. Mood Change or Depression.

Note: There are also progestin-only pills (POPs)

containing 0.075 mg of norgestrel only. They are useful
for women who can’t tolerate estrogen and they are useful
during breastfeeding after 6 weeks of post-partum.
Instructions for missed pills
Clients may forget taking pills or be late in taking it.
Adolescents are more likely to forget pills. Therefore,
clients be explained in detail what to do in case of missing
pills. Various conditions related to missing pills and
instructions are given

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Condition COC should not be used
1. Breast feeding (<6 weeks post-partum)

2. Post-partum (not breastfeeding) = (<21 days)

3. Smoking and Age≥35 years

4. Cardiovascular disease.

5. Hypertension

6. Vascular disease

7. Deep venous thrombosis (DVT)/ Pulmonary embolism

(PE)
8. Surgery = Major surgery with prolonged immobilization

9. Neurological conditions (Migraine)

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 10. Reproductive tract infection and disorders (Breast
Cancer)
11. Endocrine conditions (Diabetes with kidney, eye or

nerve damage)
12. Drug interaction:- Anticonvulsant therapy Certain

anticonvulsants (barbiturates, carbamazepine,

oxcarbazepine, phenytoin, primidone, topiramate)
Antimicrobial therapy :- Rifampicin or rifabutin
therapy.
PROJESTIN ONLY INJECTABLE
CONTRACEPTIVES (DMPA)
Currently depot-medroxy progesterone acetate (DMPA)
known as DMPAÒ is the injectable contraceptive available
in Nepal. DMPA is also available as “Sangini” in the
private sector in Nepal. It consists 150 mg progesterone in
1 Ml Vial.
DMPA has been in used since 1960s. the standard dose is an
intramuscular injection of 150mg every 3 month. It also has
an indirect effect on the endometrium and direct action on
the fallopian tube and on the production of cervical mucus.
Another advantage is that it does not affect lactation.
Mechanism of action:
- It prevents maturation and ovulation of Ovum.
- Cervical mucus thickness
- Thickness endometrium
Effectiveness
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 Consistent and correct use: in the first year of use it is 0.2
pregnancies per 100 (2 pregnancy per 1000) women.
Return of Fertility
When a client stops taking DMPA, it takes several months
(generally 4 months and longer) to become pregnant after
stopping the method. The duration a woman has used
DMPA makes no difference on how quick her fertility
returns.
DMPA FOR WOMEN WITH HIV
1. Women who are infected with HIV, have AIDS, or are on
antiretroviral (ARV) therapy can safely use DMPA.
2. The time between injections does not need to be shortened
for women taking ARVs.
3. Urge these women to use condoms along with DMPA.
Used consistently and correctly, condoms help prevent
transmission of HIV and other STIs.
Conditions DMPA could be used
Age:- ( 18 to 45 years)
Parity :
o Nulliparous (has not given birth)
o Parous (has given birth)
Breast feeding:- ≥ 6 weeks to < 6 months post-partum
(primarily breast-feeding)
Smoking :Age<35 years, Age ≥ 35 years.
Obesity :- ≥30 km/m2 body mass index (BMI).
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 Valvular heart disease
Endometrial cancer
Ovarian cancer
 Uterine fibroid
HIV/AIDS
Tuberculosis
Malaria
Endocrine conditions:- Diabetes.
Drug interaction
o Anticonvulsant therapy :-(barbiturates,
carbamazepine, oxcarbazepine, phenytoin,
primidone, topiramate)
o Antimicrobial therapy:- Broad-spectrum
antibiotics , Antifungal and antiparasitic ,Rifampicin
or rifabutin therapy

Condition DMPA should not be used

a. Breast feeding:- (<6 weeks post-partum)

b. Cardiovascular disease:- Multiple risk factors for arterial

cardiovascular disease (old age, smoking, diabetes and

hypertension)
c. Deep venous thrombosis (DVT)/ Pulmonary embolism

(PE)
d. Neurological conditions :-Migraine with aura, at any

age.
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e. Gastrointestinal conditions :- Cirrhosis ,Liver tumours.
When to start DMPA?
1. Within the first 7 days of the start of monthly bleeding,

no need for a backup method.

Side Effects of DMPA
1. Amenorrhoea (absence of vaginal bleeding or spotting):-
a. Periods of amenorrhoea are common with DMPA
users (40%).
b. Reassure that there is no need to lose blood every
month and this is not harmful.
2. Bleeding/ Spotting (prolonged spotting or moderate
bleeding)
a. Prolonged spotting:- >8 days
b. Moderate bleeding: - same as normal menses
3. Weight Gain or Loss (change in appetite)
Other Problems (May or may not be method-related)
1. Breast Tenderness (mastalgia).
2. Jaundice
3. Nausea/dizziness or Nervousness.
4. Excess hair growth ,(hirsutism), acne/ dermatitis or hair
loss
5. Lower Abdominal/Pelvic Pain.

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INTRAUTERINE CONTRACEPTIVE DEVICES
(IUCD)
Intrauterine contraceptive devices are small, flexible
plastic frame with copper sleeves or wire around it. The
Copper T 380 (Cu-T) is shaped like a T of English
alphabet and copper on its stem and the arms, with a
total exposed copper area of 380 square mm.

IUCD Available in Nepal

The IUCD currently available in Nepal is the Copper T
380A. IUCD containing hormone is also available in
Nepal which is yet to be approved by GoN.
Effectiveness
The Cu T 380A is the most cost-effective reversible
contraceptive in the market today. Contraceptive
effectiveness depends upon the way it is used.
• For perfect user in the first year of use it is 0.6
pregnancies per 100 women.
Attention:-
After insertion, the effective contraceptive action lasts
for at least 12 years. Note that an IUCD inserted into a
client just before the shelf life of the packaging expires
is still effective for up to 12 years.
Return of Fertility
Fertility returns immediately after the removal of IUCD.
Mechanism of action of IUCD:

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 i. It inhibits sperm migration in the upper genital tract.
Cupper ion may affects sperm motility, capacitation
and survival.
[Link] stimulates foreign body reaction in the endometrial
and release macrophages, which prevent implantation.
iii. Cupper also causes changes in the endometrial wall
which prevents implantation of fertilized eggs.
The ideal IUCD Candidates:
a. Who has born at least one child
b. Has no history of pelvic disease
c. Has normal menstrual period
d. Is willing to check the IUD tail.
e. Has access to follow up and treatment of potential
problem
f. Is in a monogamous relationship.
Note: The IUD is not a method of first choice for nulliparous
women, who have no children, and multiple sex partners.
Because the risk of PID and possible Infertility.
Timing of insertion:
- The safest and optimum time for insertion is the last two
days of the menstruation but can be inserted within 7-10
days of the LMP.
- Immediately after MTP is performed

Contra indication (Absolute)

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 a. Suspected pregnancy
b. Pelvic inflammatory disease
c. Vaginal bleeding
d. Cancer of the cervix, uterus
e. Previous ectopic pregnancy.
Side effect and complication:
Bleeding.
Pain
Pelvic infection
Ectopic pregnancy
Expulsion etc..

B. Implant:
It has developed in New York. It consists of two small
(2.5mm×43mm)silicones rods each containing75 mg of
levonorgesterel in a polymer matrix
Efficacy: 99-99.95%
Mechanism of action:
- Preventing ovulation
- Thickening the mucus of the cervix
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 - Thinning the lining of the uterus, which makes
implantation of an embryo less likely.
Duration of work: 5year
Side effect:
- Weight gain
- Anxiety
- Headache
- Scalp hair loss
Contra indication:
- Liver disease
- Breast cancer
- Blood clots
Voluntary Sterilization Procedures
Types of Voluntary Surgical Contraception Depending upon
the surgical approaches
 For women:
o (tubectomy) –
o Minilaparotomy - Laproscopic
 For men: (Vasectomy)
o Non-Scalpel Vasectomy (NSV) –
o Conventional Vasectomy
1. Female Sterilization:
- Two procedure have become more common namely
Laparoscopy and Minilap
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Laparoscopy:
- This is the technique of female sterilization through
abdominal approach with a specialized instrument called
“Laparoscope”. Once the tube are accessible, the falope
rings are applied to occlude the tubes.
Minilap:
- The minilap technique is considered a revolutionary
procedure for female sterilization
When to perform?
Any time within 7 days after the start of her monthly
bleeding. No need to use another method before the
procedure.
o If it is more than 7 days after the start of her monthly
bleeding, she can have the procedure any time it is
reasonably certain she is not pregnant.
Surgical emergencies
I. Bladder injury
II. Bowel injury
III. Shock or acute distress (very rare)
IV. Intraoperative Haemorrhage.
During procedure
I. Uterine perforation

After procedure
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 a. Post-operative Fever
b. Haematoma (subcutaneous)
c. Pain at incision site
d. Superficial Bleeding
e. Haemorrhage External Internal.
Note:- Fasting for 8-12 hours before surgery and taking no
medications for 24 hours prior to surgery unless prescribed
by a physician.

1. Male sterilization (Vasectomy):

- Vasectomy is the permanent method of sterilization.
- It is important to stress that the acceptor is not
immediately sterile after the operation,, usually until
approximately 30 ejaculation have taken place.
- Healthcare worker should provide the client with
condoms for 3 months, and explain how to use them.

Post-operative danger signs

A. Fever (greater than 38ºC or 100.4ºF)
B. Dizziness with fainting
C. Persistent or increasing scrotal pain and/or swelling
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 D. Bleeding or fluid coming from the puncture site

RECANALIZATION OF VAS (VASECTOMY

REVERSAL)
Situation in Nepal Though the vasectomy is considered
permanent, there are conditions where reversal is needed.
Following conditions are the main reasons for vasectomy
reversal surgery in Nepal.30
o Second marriage (51.7 %) •
o Death of the child (27.6%) •
o Couple wanting another child (15.3%)

HTSP:- Healthy timing and Spacing Pregnancy

Family planning counseling:

GATHER approach for Family planning counselling
- G = Greet
- A = Ask
- T = Tell client about choice
- H = Help client make an informed choice
- E = Explain how to use chosen method
- R = Return visit should be welcomed

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 Techniques of counseling:
1. Building rapport
2. Identify clients need and problem
3. Finding ways to solve the problem
4. Maintaining patience
5. Keeping secrets
6. Follow up
Note:
1. Termination method means: Permanent method
(Vasectomy, Minilap)
2. Pearl index: Is normally used for studying the:
Effectiveness of a contraceptives
3. Pearl index is used to evaluate: Contractive failure
4. Population pyramid: also known as double histogram
5. Total fertility rate (TFR) gives magnitude of
approximately ‘completed family size’.
6. CU 380 A is the second generation IUD.
7. Most common side effect of woman with IUD: Increased
vaginal bleeding.
8. Pap smear test for detection of carcinoma of cervix is:
secondary prevention.
9. Vitamin ‘A’ prophylaxis to a child is: primary
prevention
10. Immunization is: Primary prevention.
11. School health check up comes under: secondary
12. Monitoring the blood pressure which type of
prevention: secondary.
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13. Life expectancy is: positive mortality Indicator

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cfsl:dsue{ lg/f]ws

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A. Post coital Contraception
- Post coital (or morning after) contraception is
recommending within 120 hours of an unprotected
intercourse. Two method are available
a. IUD. : The simplest technique is to insert an IUD, if
acceptable, especially copper devices within 5 days.
[Link]:
o Levonorgesterl 0.75mg tablet is approved for
emergency contraception.. It is used as one tablet of
0.75mg within 120hours of unprotected sex and
second tablet after 12 hours of first dose. Or
o Two oral contraceptive pills containing 50 mcg of
ethinylestradiol within 120hours after intercourse
and the same dose after 12hours. Or
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 o Four oral contraceptive pills containing 30 -35 mcg
of ethinyl estradiol within 120hours and 4 tablets
after 12 hours. Or
o Mifepristone 10 mg once within 120 hours.
Adverse effect:
a. Cardiovascular effect (The risk increased substantially
with age and cigarette smoking( cardiovascular effect is
associated with oestrogen content of the pills.)
b. Carcinogenesis: Cervical cancer may occur due to use
combine pill.
c. Metabolic effect: High blood pressure, myocardial
infarction, stroke.
d. Other adverse effect:
i. Liver disorder: the use of the pill may lead to
hepato cellular adenoma and gallbladder disease.
[Link] : Decrease in lactation due to high amount of
Estrogen

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