• Women who recently had an abortion or

UPDATING THE ASHA miscarriage.

on New Methods For Family Planning • Women who are breastfeeding (it can be started as
early as 6 weeks after childbirth)
In Module 7 you were taught about the need for family
planning among various groups and the different • Women who are HIV infected, irrespective of
methods of contraception. Recently two new methods whether they are on medicines or not.
have been approved by Government of India for use in
government facilities which will increase the choice of What are the benefits of MPA
methods available to women in your community. In Benefits of MPA:
this update you will learn about the benefits and side
effects of two contraceptives: • Requires to be taken only once in three months,
rather than daily.
1. A contraception that can be given every 3 months
through an injection: called • Can be used by women who are not able to take
Medroxyprogesterone Acetate (MPA). hormonal oral contraceptive pills like Mala N/
Mala D etc.
2. A contraceptive tablet that has to be taken once a
week called Chhaya. • Safe for breast feeding mothers as it does not
affect quality and quantity of milk.
Remember that when you counsel the couple or
individual regarding contraceptives, you must • It does not cause problems with getting pregnant
understand the needs of the couple or individual. after stopping. After discontinuing the method,
the woman can get pregnant.
We will first discuss the:
• Does not interfere with sexual intercourse/
pleasure.

THE INJECTABLE • Reduces menstrual cramps (in some cases).

• It causes changes in the menstrual cycle,
CONTRACEPTIVE, MPA sometimes by stopping the monthly bleeding
which is not harmful. This actually takes care of
This contraceptive is now available in government
anemia by reducing menstrual blood loss.
health facilities through a programme called Antara. It
can be given by a trained provider (Doctor, Nurse, ANM) • Does not interfere with any medicine.
in the health facility.
• Protects from uterine and ovarian cancer.

What is MPA? • The privacy of client can be ensured.

• Does not require any laboratory investigation
MPA is given every 3 months by injection. It prevents
before starting the dose.
pregnancy over a long period of time and helps in
achieving spacing between children. Effects of MPA: Some women could experience the
following:
• Menstrual Irregularities- Irregular bleeding,
prolonged heavy bleeding or amenorrhea.
• Weight gain
• Headaches

Figure 1: Injectable Contraceptive MPA • Mood changes

Limitation:
Who can use Injectable Contraceptive • It does not protect from HIV and RTI/ STI.
MPA • It takes 7-10 months from the date of last injection
• Women of any age, including adolescents and for return of fertility.
women over 45 years old, irrespective of whether
Where can women get MPA and how it should be
they have children or not.
taken?
• Unmarried women in reproductive age group.
Women, who decide to start taking MPA, require repeat
injections every three months. You know from previous
training that it is important to use contraceptives
regularly. MPA is available at the facilities where
providers have been trained in using the method. The
first dose can be administered by a trained doctor or a
trained staff nurse/ ANM under the supervision of a
doctor. Once a woman in your community starts the first
dose, your role as an ASHA is to follow up with the
woman, to understand if she has any side effects, to
remind her when the next dose is due and motivate her
to visit the health facility where trained provider is
available for the repeat dose.
Schedule: One injection provides contraception for at
least 3 months. It is best to take the injection exactly 3
months after the previous dose. However, it can be
taken 2 weeks before or 4 weeks after the scheduled
date.

Figure 3: Facility section (Counterfoil) on MPA card kept at the

Health Facility

What is to be done during follow up

care?
One experience from countries where MPA is
commonly used is that sometimes women, who start
MPA, can discontinue the method after a few injections.
They either forget the date, lose motivation to continue,
or are not able to cope with the side effects. Your role is
to support all women who start MPA to continue with
the method and reassure them about the side effects.

Role of ASHAs:
• Maintain the list of women who opt for MPA as a
Figure 2: MPA Client Card
contraceptive option.
Just like you have details of those women who are on
• Discuss the importance of follow up visits with the
any method of contraception, you should help every
clients and remind them just before the due date,
woman who receives MPA to get an MPA card. The card
to go the facility.
should have information about the details of the
woman, it includes dates of current dose and the next • Visit women who taking MPA at least once a
due dose. Every client should be encouraged to carry month to discuss her experiences with the
this card to the facility where repeat doses are given. method and reassure her regarding her concerns.
This card helps in remembering the date of next dose. If she is very concerned about side effects,
The counterfoil of this card is maintained at the facility motivate her to consult the ANM or the doctor who
providing the first dose of Injectable MPA. has given the injection.
Dose and site: The injection is given in the upper arm, • One concern that women may have is related to
buttocks or thigh under the muscle or skin. the changes in the menstrual cycle. These include
irregular or heavy bleeding. Some women may
After the woman gets the injection, she should be
complain that their monthly period has stopped.
cautioned not to massage the injection site or apply
Tell them that these changes are normal. Women
hot fomentation.
 need to be told that the 'period' may completely Where can women get Centchroman
stop because that is the way the method works
and is not harmful. Reassure the woman that the
(Chhaya)?
menstrual cycle will start when they decide they It is available in all public health facilities and can be
want to get pregnant again and discontinue the provided by doctors (MBBS and above, AYUSH), SNs,
contraceptive. LHVs and ANMs. It would also be a part of your ASHA kit
which can be distributed by you to the clients. However
It may be explained in the following way to the the first dose should be provided only by a trained
client, “Every month a woman's body prepares for provider after proper screening at a health facility.
conception. An egg is released and uterus also
Availability: Centchroman (Chhaya) is available in two
prepares to nurture the baby. Hence inner lining of
packages: ASHA supply and free supply. Each pack
the uterus becomes thick and soft as it gets more
contains 8 tablets. ASHA supply is for home distribution
blood supply. If she does not conceive that month,
and free supply is for distribution at health facilities.
this inner lining of blood is thrown out of her body
as menstrual flow. This is repeated every month,
causing menstrual cycles. But with MPA, the
monthly preparation for pregnancy in woman's
body does not occur. There is no release of
egg/ovum and thickening of inner lining of uterus.
The menstrual cycle gradually comes to a stop after
irregular bleeding for some time.”

NEW ORAL
CONTRACEPTIVE
The second contraceptive that you will learn about in
this update is Centchroman (Chhaya)

What is Centchroman (Chhaya)?

Chhaya is an oral contraceptive pill which does not
contain any hormone. It is available in the market in
some places as 'Saheli' tablet. It has been introduced in
the public health system in the name of 'Chhaya' to
benefit more women at no cost. It is a safe spacing
option for both breast feeding and non-breast feeding
women and needs to be taken only twice a week for the
first 3 months and then once a Week.
Fig3: Centchroman (Chhaya): a) ASHA Supply and b) Free Supply

Who can use Centchroman (Chhaya)? Schedule: Centchroman (Chhaya) is to be taken twice a
week for the first 3 months followed by once a week
• Centchroman (Chhaya) can be safely used by all thereafter.
women once it is confirmed that they are not
pregnant. To begin the use of Chhaya, the woman is advised to take
the first pill on the first day of period (which is the first
• Can be used by women of any age, whether she has day of bleeding) and the second pill three days later (on
children or not. 4th day of bleeding). This pattern of days is repeated
• Women who had side effects with MALA N/ MALA through the first 3 months.
D can also opt for this method. Starting from the fourth month, the pill is to be taken
• It can be used by postpartum women who are once a week on the first pill day and should be
breastfeeding as soon as she feels comfortable. continued on the weekly schedule regardless of her
Centchroman does not affect quantity, quality and menstrual cycle.
composition of breast milk.
What should be suggested to clients in duration and amount of bleeding during
menstrual cycle, reassure her that these are
case of 'missed pills'? temporary changes and will subside with regular
You should tell the woman, that if she forgets to take the intake of pills.
pill, she should take the missed pill as soon as she
• If there is a delay in the menstrual cycle by over 15
remembers that it has been missed. If she misses taking
days then you should help the woman to test for
the tablet by 1-2 days (less than 7 days), she should take
pregnancy.
the missed pill as soon as she remembers and continue
the normal schedule. In addition she should use a • Support the woman to remember the schedule of
backup method like condom, just to ensure complete taking Chhaya.
protection.
• Maintain line listing of eligible couples that
If she forgets to take pills by more than 7 days, then the require spacing.
current pack should be discarded and she needs to start
• Record all relevant information like name,
taking a new pack like a new user; that is, twice a week
address and contact number.
for first 3 months followed by once a week thereafter.
• Maintain monthly record of contraceptives
distributed to each couple.
What are the benefits, side effects and
limitations of Centchroman (Chhaya)? • Submit the record of distribution of
contraceptives on monthly basis to ANM.
Benefits:
• Chhaya causes less bleeding during the monthly
period, and also makes the interval between two POST ABORTION FAMILY
menstrual cycles longer. This is beneficial for
anemic women PLANNING
• Safe for breast feeding women.
What is the importance of Post Abortion
• Women, who are not recommended to use Family Planning?
hormonal method, can use this method.
Many women die of abortion or abortion related
Side effects: complications in India every year. Repeated abortions
Chhaya has very few side effects. In a few women there affect the health of women. They also affect the
is delay in periods in the first three months. pregnancy outcome of next pregnancy (increased
Limitations: chances of still birth, low birth weight, mortality). Post
Abortion Family Planning is important for the women
Every client should be screened by a trained provider
to end the cycle of repeated pregnancies. Post Abortion
before starting Centchroman, just like other oral pills.
Family Planning enables women to use a contraceptive
method after she has had an abortion to prevent
The Role of ASHA: unintended pregnancy again and have recommended
spacing of at least 6 months between abortion and next
• Undertake regular follow up visits to those
pregnancy. If a woman does not begin to use
women who choose to use Chhaya
contraception immediately after having an abortion,
• If the woman complains of any changes in the she can conceive as early as within 10 days of abortion.
Table 2: Timing of Initiating Contraceptive method in Post Abortion period

Which contraceptive methods can be Ezy Pill (Emergency Pills). The newly introduced
Chhaya Pill (Centchroman pill) would be a part of ASHA
used in Post Abortion period and when? kit. The salient features of the scheme are as follows:-
All available contraceptives under the National Family
3 ASHA would make a list of all the eligible couples
Planning program can be provided in post abortion
of village and preferred method of contraceptive
period.
of each couple. This data of users should be
updated regularly and shared with Sub Center and
What is to be done during follow up PHC.
care? 3 ASHA shall replenish her contraceptive stock
You have already learnt about the follow up after the every month from the Sub Center/ PHC/ block (as
woman in your community begins to use a method. per the existing system established by the state).
This is the same for any woman using contraception Monthly meetings could be one of the
after an abortion. You should maintain the list of women opportunities to receive contraceptive stocks
who opt for post abortion family planning. Just as you every month.
would for a woman using any other method, you should 3 The ASHA may charge Re.1/- for pack of 3 Nirodh
undertake regular follow up visits, and reassure woman (condoms); Re. 1/- for one cycle of Oral pills and
about her anxieties or concerns. If necessary you should Rs. 2/- for a pack of one tablet of Ezy pill
motivate the woman to visit a trained provider so that (emergency pill) from the clients.
she can feel reassured about continuing the method.
This will enable her to maintain healthy birth spacing
between children. Ensuring spacing at birth scheme
Under this scheme, the ASHA would counsel the newly
SCHEMES FOR ASHA married couples to delay the birth of first child for two
years after marriage and couple with 1 child to have
UNDER NATIONAL FAMILY spacing of 3 years between 1st and 2nd child birth. For
this, ASHA would be given incentives as per following*: -
PLANNING PROGRAM a) Rs. 500/- to ASHA for delaying the birth of first
child for two years after marriage
Home delivery of contraceptives by
b) Rs. 500/- to ASHA for ensuring spacing of 3 years
ASHA between 1st and 2nd child birth
Under this scheme, ASHA delivers the contraceptives at c) Rs. 1000/- to ASHA in case the couple opts for
the doorstep of the clients as per the need. The permanent limiting method after 2 children
contraceptives include Nirodh (Condoms), Mala-N and
*This scheme is applicable in 18 states and one Union 3 ASHA should refer the client, as per client's need
Territory of the country (Bihar, Chhattisgarh, Madhya and pregnancy test results.
Pradesh, Jharkhand, Rajasthan, Uttar Pradesh,
Uttarakhand, Odisha, Gujarat, Haryana, Assam,
Meghalaya, Manipur, Mizoram, Tripura, Arunachal
Pradesh, Nagaland, Sikkim and Dadar Nagar Haveli).
Additionally, in 7 other states, only spacing components
(i.e. a) and b)) are applicable. These states are: Andhra
Pradesh, Telangana, Karnataka, Maharashtra, West
Bengal, Punjab, and Daman and Diu.

ASHA is eligible for the above incentives if: -

3 ASHA counsels the couple on benefits of spacing 3 If test is positive:
between children and limiting family size • Woman wants to continue pregnancy- Refer the
3 ASHA prepares and updates the list of following woman for ANC registration and check up
and gets them certified by ANM/ MO • Woman doesn't want to continue pregnancy
• Newly married couples, along with date of (wants to terminate pregnancy)- Refer the
marriage in her register woman to service provider for safe abortion
services and offer PAFP choices
• Couples with 1 child/ women pregnant with 1st
child, along with date of birth of first child. 3 If test is negative:
Production of birth certificate is mandatory. • Woman does not want to get pregnant: Counsel
• Couples with 2 children/ women pregnant with for family planning methods, provide
2nd child, along with date of birth of the child. contraceptive pills/ condoms or refer to health
facility for IUCD/ Sterilization procedure
3 Use Nichay Kit (Pregnancy test kit) to confirm
pregnancy status of the woman • Woman wants to get pregnant: refer the woman
to service provider (for screening of RTI/ STI or
3 Regularly submit the information to MO and ANM treatment of infertility, as the case may be).
who would certify the information for ASHA
incentives.
Role of ASHA in generating demand for
Pregnancy Testing Kit (Nischay Kit) Family Planning Services
Under this scheme, ASHA would regularly collect ASHA should ensure following activities in their
Nischay kit from the Sub center and provide it to the community: -
women for detection of pregnancy. 3 Prepares line list of all eligible couple as well as
Salient features of the scheme are as follows: - pregnant women in her village
3 Counsel the couple for adoption of appropriate
3 ASHA should inform the women about availability
Family Planning/ postpartum/ post abortion
of Nischay Kit with them.
family planning method.
3 ASHA should counsel the women regarding
3 Counsel the couple on benefits of spacing between
advantages of early detection of pregnancy
children and limiting family size
3 Inform the client about the availability of family
planning services in the health facility.
3 Escort the client to health facility if client choses to
adopt PPIUCD/ Post Abortion IUCD services.
ASHA's are eligible for incentives for:
Figure: Pregnancy Testing Kit (Nischay Kit) 1) Motivating the client for sterilization services (as
per the Revised Compensation Scheme/
3 ASHA should provide the Nischay kit to client for Enhanced compensation scheme/ HTD plus
early detection of pregnancy and tell her how to compensation scheme)
use the Kit. She should also tell the client how to
read the pregnancy test results. ASHA may help 2) Motivating and Escorting client for PPIUCD
and conduct the test for clients who are not able to services (PPIUCD incentive scheme)
understand how to read the results on their own.