Family planning

• Family planning is the ability of an individual or couple to

decide:-
 When to have children

 How many children they desire in a family

 And how to space their children.

• It is a means of promoting the health of women and families.

• Family planning is part of a strategy to reduce the high
maternal, infant and child mortality and morbidity.
 ADVANTAGES
• For women
– Avoid unwanted and high risk pregnancies
– Reduce morbidity and mortality
Children
– Avoid morbidity and mortality
– Better feeding, Care, Clothing, Schooling
Family
– Improves family well-being
– Better food, clothing, housing, living
 Objectives

 Limit family size

 Adequately space children
 Reduce maternal and child morbidity and mortality
 Its prevent STI and HIV
 Avoid unintended pregnancies
 Counselling

Counseling is a two way process in which

clients are helped to arrive at informed choice

of reproductive options and knows how to use
them safely, effectively and continuously.
 GATHER
• G= Greet
• A=Ask
• T=Tell(avliable choose)
• H=Help
• E=Explain
• R=Repit
 A good counsellor
• Understands and respects the client’s rights
• Earns the clients trust
• Understands the benefits and limitations of all
contraceptive methods
• Understands the cultural and emotional factors
that affect a woman’s (or acouple’s) decision to
use a particular contraceptive method
• Encourages the client to ask questions
 Family Planning Methods

 Methods (Mechanisms) of working

 Prevent the egg to be produced
 Prevent the egg and sperm meeting
 Prevent growth of fertilized egg in the uterus
 classification
1. Natural method
 Rhythm
 Lactation amenorrhea
 Withdrawal
 Abstinence
 The basal body temperature
2. Artificial Methods
 Hormonal
 IUD
 Barrier
 Surgical
3. Emergency Methods
 1. Rhythm
• This method requires counting the number of days in the shortest and longest
menstrual cycle during a 6- to 12-month span.
• N.B (if her menses is irregular)
• From the shortest cycle, 18 days are subtracted to calculate the first fertile day.
• From the longest cycle, 11 days are subtracted to identify the last fertile day.
• N.B. With regular cycles (every 28 days or
close to it).
Example: The woman's regular cycle is 30 days.
Regular cycle 30 - 14 = 16
 First day of fertile phase 16 – 7 = 9
 The last day of fertile phase = 16 + 2 = 18
 Breast Feeding Method/Lactational Amenorrhea Method (LAM)

• Criteria
• 1. Frequently BF(10-12 times)
• 2. <6 mon b/c estrogen decrease then not
ovulation occur
Withdrawal/Coitus Interrupts/Pulling Out
Method
 Interrupting sexual intercourse just before
ejaculation
 The ejaculation must be far away from the
vagina and external genitalia
 Abstinence Method

Its provides a time barrier between spermatozoa and the ovum

by avoiding sexual intercourse during the fertile phase of the
menstrual cycle.
 Periodic abstinence is generally indicated to couples that do
not wish to use another method because of:
 fear of side effects,
 religious or other cultural constraints, and
 difficult access to other methods.

Contraindication:- None
 Temperature Rhythm Method

This method relies on slight changes—sustained

0.4 degree Fahrenheit increases—in the basal
body temperature that usually occur just before
ovulation
 Cervical Mucus Rhythm Method

This so-called Billings method depends on awareness of

vaginal "dryness" and "wetness."
• These are the consequences of changes in the amount
and quality of cervical mucus at different times in the
menstrual cycle.
• Abstinence is required from the beginning of menses
until 4 days after slippery mucus is identified.
 2.Artficial methods
• Combined oral contraceptives (COCs)
The contraceptive actions of COCs are multiple, but the most
important effect is to prevent ovulation by suppression of
hypothalamic gonadotropin-releasing factors.
Mechanism of Action
1. Progesterone increase then mucus production in cervix is thick
so, can’t penetrate the sperm.
2. Estrogen increase FSH decrease egg doesn’t .
mature.
3.In vagina estrogen maintains the thickness of virginal wall and
promotes lubrication. Uterus :estrogen enhance and maintain the
mucous membrane that lines the uterus.it also regulates the flow
and thickness of uterine mucus secretion.
• COCs are taken daily for a specified time 21
days and then omitted for a specified time 7
days called the "pill-free interval."
• During these pill-free days, withdrawal
bleeding is expected.
• Ideally, women should begin COCs on the first day of a menstrual
cycle, in which case a back-up contraceptive method is unnecessary.
• With a women who start pills after seven days of the onset of menses
a back-up method is needed for 1 week to prevent conception.
• For maximum efficiency, pills should be taken at the same time each
day.
• If one dose is missed, contraception is likely not diminished with
higher-dose monophasic COCs.
How to Take COCs:
Schedule and Missed Pills
Schedule:
• Take one pill every day
• 21-day packs  7-day break
• 28-day packs  no break between packs

Missed pill:
• Take missed pill as soon as remembered
Missed 1 or 2
• Keep taking other pills on schedule
active pills
• No backup method needed

Source: WHO, 2004.

How to Take COCs:
Missed Pills
Miss 3 or more • Take first missed pill as soon as you remember
active pills or • Continue daily pill taking as usual and use
start pack 3 or backup method or abstain for next 7 days
more days late • Count number of active pills remaining in pack

7 or more active Fewer than 7 active

pills left in the pack pills left in the pack

• Finish active pills

• Finish active pills
• Discard inactive pills
• Take hormone-free break
• Start new pack immediately

Source: WHO, 2004.

 Advantages
Disadvantages
 Highly effective  Challenge of daily compliance: not highly
 Safe: Low dose combined pills are very effective unless taken everyday. Difficult for
safe for almost all women; some women to remember everyday.
 Can be used at any age from  New packate of pills must be at hand
adolescence to menopause; every 28 days.
 Fertility returns soon after stopping;  Not recommended for breast-feeding
 No need to do anything at time of women because they affect quality and
sexual intercourse; quantity of milk.
 Can be used as emergency  In few women it may cause mood changes
contraceptive after unprotected sex; including depression, less interest in sex.
 Reduction of acne and hirsutism  Do not protect against sexually
 Monthly periods are regular; lighter transmitted infections (STI's) including
monthly bleeding and fewer days of AIDS.
bleeding; milder and fewer menstrual
cramps.
 Contraindication
 Liver cirrhosis
 Breast CA
 DM
 Gall bladder disease
 < 6 month Breast feed
 Progestin - only pills
• is an oral hormonal contraceptive containing
only progesterone in a smaller dose than in
the combined pill.
• These are often an excellent choice for
lactating women because it does not impair
milk production.
 Progestin - only pills
Advantages Disadvantages
 No estrogen side effects.  If even taking a pill more than a
 Can be used by nursing mothers few hours late increase the risk
starting 6 weeks after childbirth. of pregnancy, and missing 2 or
 Women take one pill every day more pills increases the risk
with no break. Easier to greatly.
understand than 21 day combined  Lack of protection against STIs
COCs. including HIV.
 Can be very effective during  Ectopic pregnancy is more likely
breast-feeding. among women who become
 May help prevent: benign breast pregnant as a result of minipill
disease, endometrial and ovarian failure than among women who
cancer and pelvic inflammatory use other oral contraceptives.
diseases.  Interaction with anticonvulsants.
 Injectable Progestin Contraceptives
 The most common type of injectable contraceptive
DMPA (depot - medroxy Progesterone acetate) also
know as Depo - provera which is given every three
months.
 It contains a progestin, similar to the natural hormone
that woman's body makes.
 There are other injectable contraceptives such as NET EN
(Norethisterone enanthate) which is given every two
months.
 Other monthly injectable contraceptives include
cyclofem, cycloprovera and mesigyna
• The mechanisms of action are multiple and
include ovulation inhibition, increased cervical
mucus viscosity, and creation of an endometrium
unfavorable for ovum implantation.
• Initial injection should begin within the first 5
days following menses onset
Advantage Disadvantages

• Contraceptive effectiveness • Irregular menstrual bleeding

comparable with or better than and
COCs, and
• Prolonged anovulation after
• Minimal to no lactation
discontinuation, which
impairment
results in delayed fertility
• Iron-deficiency anemia is less
likely in long-term users resumption.
because of amenorrhea
 IMPLANTS

• Small plastic rods or capsules,

• Matchstick size,
• Are only progestin
• Minor surgical procedure
– Under the skin on the inside of upper arm
 Norplant provides levonorgestrel in six
silastic rods that are implanted subdermally.
 Jadelle originally named Norplant-2, is a two-
rod system. It provides similar contraception
for 5 years,
 Implanon is a single-rod subdermal implant with 68 mg
of the progestin etonogestrel (ENG),
• The implant is placed in the medial surface of the upper
arm 6 to 8 cm from the elbow in the biceps groove
within 5 days of onset of menses.
• It may be used as contraception for 3 years and then
replaced at the same site or opposite arm.
 1-rod
• 6- rods Implanon
2-rods Jadelle
• Norplant
Advantages
 Prevent ectopic pregnancy
 Prevent Anemic
 No need to do anything at time of sexual intercourse,
 Increased sexual enjoyment because no need to worry
about pregnancies,
 Nothing to remember. Requires no daily pill taking or
repeated injections,
 No repeated clinic visits required,
 Implants: Limitations
• Changes in menstrual bleeding pattern

• Require trained provider for insertion and removal

• Provider dependent:
– Provider/ clinic dependent for insertion or removal

• Effectiveness lowered with certain drugs use:

– phenytoin and barbiturates in epilepsy or

– rifampin in tuberculosis

• Do not protect against STth of use Ds

• Local inflammation or infection at the site of implants

 Implants: Drug Interactions

Most interactions relate to increased liver

metabolism of levonorgestrel:
– Rifampin (tuberculosis)
– Anti-epilepsy (seizures):
• Barbiturates, phenytoin, carbamzepine
– Griseofulvin (long-term use only)
 Intrauterine Device (IUD)
• Small flexible devices made of metal and/or plastic that
come in different shapes and sizes and are inserted in the
uterus through the cervix.
• The various shapes include ring, loop, spiral, T shape, 7
shape and others
• Some are coated with copper, and some contain small
amounts of the female hormone progesterone.
• The most commonly used type in most countries including
Ethiopia is Copper 380A.
Effectiveness
12 Years
 Advantage Disadvantage
 Very little supervision or  Not suitable for all women because of risk of
increased infection
follow up.  Needs a trained health worker for the initial
 Highly effective with low screening and insertion or removal.
 Does not protect against STDs, including
failure rate. HIV/AIDS.
 Doesn't reduce breast milk  In about 0.1% of cases there is uterine
perforation during insertion.
(can be used by breast  May increase risk of PID (Pelvic
feeding mother). inflammatory diseases).

 Can be used to May come out of the uterus without the
client knowing.
menopause  Increases menstrual blood flow and cramps

 Safe for lactate mother

• N.B. Advice the women to return to the clinic as soon as possible if
she:
 sees the following danger signs:
 P - Period late (pregnancy) abnormal spotting or bleeding,
 A - Abnormal pain, pain with intercourse,
 I - Infection exposure (such as Gonorrhea) abnormal discharge,
 N - Not feeling well - fever, chills and
 S - String missing, shorter or longer.
• Feels the hard part of the device in the vagina or cervix
• Expels the device
• N.B. In the mean time she should use a non-hormonal method of
contraception such as condoms.
 Contraindications/not eligible
 Pregnancy or suspicions of pregnancy

 Uterine abnormalities/anomalies –myoma, didelphic uterus

 Acute PID or Hx of PID in the past 3 months

 Postpartum endometritis/septic abortion

 Pelvic malignancies; cervical ca, endometrial ca, GTD

 Undiagnosed AUB

 Untreated acute cervicitis or vaginitis, including gonococcus, chlamydia

 Allergic to Cu

 Client or her partner has multiple sexual partners

 Parts of IUCDs (Tcu 380A)

Arms
(Rt./Lt.)
Copper sleeve
(33mm×2=66mm2
) Stem

Copper
wire
(314mm2 )
String/
Thread
Main frame:- T shaped, flexible & containing
barium sulfate
 Barrier Methods

• Condoms
– Male and Female Condom

• Diaphragms

• Spermicides / Nonoxynol-9
 Male Condom

• The failure rate with strongly motivated couples has

been as low as 3 or 4 per 100 couple-years of exposure.
• The contraceptive effectiveness of the male condom is
enhanced appreciably by a reservoir tip and probably
by the addition of spermicidal lubricant.
• lubrication, should be water-based. Oil-based products
destroy latex condoms and diaphragms.
key steps to ensure maximal condom effectiveness:
 A condom must be used with every coital act

 It should be in place before contact of the penis with the

vagina
 Withdrawal must occur with the penis still erect

 The base of the condom must be held during withdrawal

 Either an intravaginal spermicide or a condom lubricated

with spermicide should be employed.
 Female Condom
• It is a polyurethane sheath with one flexible polyurethane ring
at each end.
• The open ring remains outside the vagina, and the closed
internal ring is fitted under the symphysis like a diaphragm.
• The female condom can be used with both water-based and oil-
based lubricants.
• Following use, the female condom outer ring should be twisted
to seal the condom so that no semen spills out.
• The pregnancy rate is higher than with the male
condom .
• The female condom has a 0.6-percent breakage rate.

• The slippage and displacement rate is about 3 percent

compared with 3 to 8 percent for male condoms.
• In vitro tests have shown the condom to be
impermeable to HIV, cytomegalovirus, and hepatitis
B virus.
Female Condom: Insertion

45 45
 Diaphragm

• The diaphragm consists of a circular latex dome

of various diameters supported by a
circumferential latex-covered metal spring.
• It is effective when used in combination with
spermicidal jelly or cream
• The device is then positioned so that the cup faces
the cervix and
•
 Cervical cap

• Is a soft, silicone cup holding spermicide designed to fit over the

cervix
• Put a spermicide in cap and slide it into the vagina. Protects for
42 hours, needs to stay in at least 6 hours after sex
• Neither partners should feel the cap. Less effective for multipara
• It needs prescription and fitting
• Effectiveness: 77%
 Spermicides

• Typically, spermicides function by providing a

physical barrier to sperm penetration as well as a
chemical spermicidal action.
• The active ingredient is nonoxynol-9 or
octoxynol-9.
• Spermicides must be deposited high in the
vagina in contact with the cervix shortly
• Douching should be avoided for at least 6 hours
after intercourse.
• High pregnancy rates are primarily attributable
to inconsistent use rather than to method failure.
• It has 5 to 12 pregnancies per 100 woman-years
of use.
Voluntary Surgical Contraception (VSC)
 Tubal Ligation-VSC for women

 By ligating the fallopian tubes, sperm are prevented from reaching ova & causing

fertilization

 The right choice for couples with the number of children they want

 Limitations

 Non-reversible

 Small risk of surgical complications

 Short term discomfort following the procedure

 Requires trained physician

 Vasectomy-VSC for men
 blocking the vas deferens to avoid passage of
sperm
 So sperm is absent in the ejaculate
 Same limitations and advantage as that of tubal
ligation
 Emergency contraceptive

• EC is given with in 120 hrs or 5 days after unprotected intercourse

Types
• Emergency contraceptive pills (ECPs)
– COC or
– POP
• Copper-releasing IUDs

1. Progesterone only pills

– Levonorgestrel(0.75mg) such as postinor-2, Optinor, post pill etc.
 1 pill as soon as possible followed by 1 pill 12 hours later.
– Levonorgestrel (1.5mg) : 1 pill only

– Levonorgestrel(0.03mg): E.g. microlute

 20 pills as soon as possible then 20 pills 12 hours later
Combined OCP
– High dose pills. Eg. neogynon, eugynon
2 pills as soon as possible then 2 pills 12 hours
later
– Low dose pills. Eg. microgynon
4 pills for the 1st & 2nd dose
‘