Family Planning and

Contraception
What is family planning?
• The use of contraception to control the
frequency and timing of pregnancies
Family planning originated to provide help
and advice with planning and birth control

What is contraception?
The prevention of conception or pregnancy
development
 Classification of contraception
Reversible Permanent

Natural methods
male sterilization

Hormonal contraception
female sterilization

Barriers methods

Intrauterine devices IUDs

Emergency
contraception
 BEHAVIORAL METHODS
(natural method)
1. natural family planning
2. lactation
 Natural family planning

Abstaining from intercourse during fertile period of the
month.
Fertile period is calculated by various techniques: --Changes
in basal body temp, -- changes in cervical mucus; --changes in
the cervix; -- multiple indices
Failure rates are quite high. 20% per year

Lactational amenorrhea method (LAM) is used by fully

breastfeeding mothers

During the first 6 months of infant life, full breastfeeding gives more
than 98% contraceptive protection.
 Lactation
• Its based on the physiological effect of
suckling to suppress ovulation
• To be a successful Contraception there should
be:
– exclusive breastfeeding for the first 6 months
without any Addition
– no menstrual period
 Hormonal contraception
Available in 3 forms:
• Oral contraception
• Injectable
• Implant
 Oral contraception
• Pills is tablet contain female hormones
• 100 millions women use this method world
wide
• Available in 2 forms:
– Combined oral contraception
– Mini pills
 Combined Oral Contraceptives (COP)

The most extensively used method

Contains synthetic estrogen + synthetic progesterone
derivatives

Pills package contains 21 active pills + 7 placebo OR
pill free interval

Each pill contains 20-30 ug of ethinyl estradiol + 1 mg
19 – nor testosterone

The women started to take her first pill on the first
day of her menses to 21 day then take 7 placebo

The menses occur during placebo period
 Mini pills
• Ideal women who like pill taking but cant take COC
• Failure rate of POP is greater than that of COC
• If POP fails , there is a slightly higher risk of ectopic pregnancy
• Taken every day without a break ( for 28 days)
• Particular indication include: breastfeeding, older age,
• cardiovascular risk factors and diabetes
• must be taken on same time of day

 Mode of action
• Works mainly peripherally .
• Decreases sperm permeability by altering the cervical mucus.
• Reduces endometrial receptivity to implantation.
 Injectable progestogens
• 2 types :

Depot Medroxyprogesterone acetate (Depo-
Provera)

Morethisterone Enanthate
 Each injection of Depo-Provera lasts around
12-13 weeks (3m)
 Norethisterone enanthate lasts for 8 weeks so
it is not widely used
 benefits of Depo-Provera:

slow release

failure rate < 1% (0.5%)

v. effective

avoid 1st pass hepatic effect, patient will not
have GI upset
 Side effect of Depo-Provera :

Weight gain

Delay in return of fertility

Persistent menstrual irregularity (amenorrhea,
oligomenorrhea )

Increase the risk of osteoporosis

functional ovarian cyst
Contraindications of Injectable Hormonal
Agents:

Known/suspected pregnancy

Undiagnosed vaginal bleeding

Breast cancer

Liver disease

Note : prolonged use – increase in the side
effects
 Barrier methods of contraception :
 Male Condoms
 Female Barrier

Female Condom
 Male Condoms
• Made of latex rubber
• Cheap and available
• Various sizes and shapes
• Hypo allergic latex condom and plastic condoms are available
• Used to prevent STDs
• Emergency contraception if condom burst or slip off

Benefits :
• easy to use, to apply, cheap & available, doesn’t affect hormones
of patient, male participant, and only contraception effective in
protecting against STDs
Fail due to :
 not applied in a right way
 applied after a pre ejaculatory discharge
 Rupture

Drawbacks:
 Interruption of coitus
 Decreased sensation
 may cause a latex sensitivity to a patient.

Efficacy:

88 to 98%, depending on if used properly
Female Barrier :

 Diaphragm or Dutch cap is most commonly used

 Others include cervical caps & vault caps
 All used in conjunction spermicidal cream or gel
 Diaphragm should inserted immediately prior to
intercourse and removed no earlier than 6 hrs
later
 Increase risk of UTI and vaginal irritation
 Female Barrier
Benefits : disadvantages :

can be used multiple
expensive and not available
intercourse.
difficult to use

female participant.
patient has to go to the Dr to
insert them for Her (needs
professional)

Time Limitation

doesn’t save from STD's because the patient Needs to use

with them spermicidal ( injury to The vaginal mucosa, so it
becomes more prone To STD's).
Intrauterine contraception:

Intrauterine device (IUD): small device which is placed into
uterine cavity.

Two highly effective intrauterine contraceptives:

copper bearing IUD

Levonorgestrel-releasing IUD.

IUDs are safe, relatively inexpensive.

Highly effective, failar rate for copper IUD (1-2) and for LNG-IUS(0.5).

Should be performed by trained healthcare personnel

A fine thread is left protruding from cervix into vagina so it
can be removed by traction on this thread

Protect against intrauterine and ectopic pregnancy but if
pregnancy occurs there is increase risk of ectopic
 copper-bearing IUDs

Available in various shapes and sizes.

Licensed for between 3-5 years of use,
possibly up to 10 years.

The more copper wire a device has, the
more effective it is.

Some IUDs have silver cored copper for
add efficacy.

Mode of action of:

Copper-bearing IUDs work primarily
by a toxic effect on sperm which
prevent fertilization.

As all IUDs induce an inflammatory
response on the endometrium which
prevent implantation.
copper-bearing IUDs
Side effect of copper-bearing IUDs :

Increased menstrual bleeding.

Increased dysmenorrhoea.

Increased risk of pelvic infection in first few
weeks.
Hormone-releasing IUDS
-- levonorgestrel-releasing
-- progesterone-releasing

Mode of action of:

levonorgestrel-releasing IUS work locally on
cervical mucus and endometrium hormonal
effect:
-- It thickens mucus in cervix, so it helps to stop sperm
reaching the egg.
--It make lining of uterus thin, making periods lighter and
shorter.

As all IUDs induce an inflammatory response on
the endometrium which prevent implantation.
Levonorgestrel-releasing intrauterine
system
Aadvantages Disadvantages

Highly effective (0.5).
Persistent spotting

and irregular bleeding

Dramatic reduction in in first few months of
menstrual blood loss. use.

Progestogenic side

Protection aqainst effects, e.g. acne,
pelvic inflammatory breast tenderness.
disease.
Contraindication of IUDs :
 Previous PID
 Previous ectopic pregnancy
 Known malformation of uterus
 Copper allergy
 Implants(implanon)

A single elastic rod inserted subdermally under local
anesthesia into upper arm

Release progestogen etonogestrel

Lasts for 3 years

No genuine failure reported

A rapid return of fertility when it is removed.

Particularly useful for women who have difficulty
remembering to take a pill and who want highly effective
long-term contraception.

success rate good as sterilization (failure rate 1%)

the same mechanism, side effects and

Complications of progestogen but in low rate,
implanon
Emergency contraception :
Contraception method that is used after
intercourse has taken place and before
implantation has occurred .
 should be considered if :
Unprotected intercourse has occurred
Failure of barrier method
COC has been forgotten
There are 2 types :
1- Hormonal emergency contraception

Levonorgestrel in a single dose of 1.5 mg

Has to be taken within 72 hrs of unprotected
intercourse(2 doses should be taken 12h
apart) and is more effective the earlier it is
taken

No real contraindication

Not 100% effective

The precise mechanism of action is not
known but probably involves disruptionof
ovulation or corpus luteal function.
 An IUD for emergency contraception

A copper bearing IUD

Effective up to 5 days following the anticipated
day of ovulation

Can cover multiple episode of intercourse in
the same menstrual cycle

IUD prevent implantation and copper ions
exert an embryo toxic effect

Contraindication as any IUD

Hormonal releasing IUD has not shown to be
effective for EC and should not be used
 Characterized Family planning in
Indonesia:
• women in Indonesia first sexual intercourse occurs at
time of marriage
• average woman in Indonesia has become a mother or
is pregnant by age 21.
• More than one-fifth reproductive age women have had
4 children or more.
• average family size in Indonesia is roughly 3 children.
• Abortion is illegal in Indonesia and often performed
under unsafe conditions.
• Half of births occur 54 months afterprevious birth, up
from a birth interval of 45 months in 1997.
 Modern Contraceptive use in Indonesia

Source: Macro International Inc, 2009. MEASURE DHS STAT compiler.

http://www.measuredhs.com, September 9 2009
Modern Contraceptive use by age in Indonesia

Source: Macro International Inc, 2009

 Family planning has a direct influence on
improving lives worldwide in two other ways
• Enhanced national security – Family planning
stabilizes society.
• Optimize financial resources – Family planning
saves dollars
 Current Family Planning Efforts
• The Indonesian National Family Planning Programme is
implemented by government with involvement and
participation community and private sectors.
• The government aims to decrease TFR and make family
planning an integral part of government policy.
• Decentralized family planning programme, four years
after other sectors, including health, but still centrally
secures the budget for family planning.
• new decentralization laws, 249 regencies and 65
municipalities will absorb responsibility for planning,
financing and managing health and family planning
programmes.
 Challenges and Opportunities
• Capacity to provide appropriate and high
quality services
• Decentralization and programming at
different levels
• Diversification in contraceptive methods
used.