FAMILY PLANNING

1
 Session objectives
At the end of this session students will be able to:-
Define family planning

Discuss family planning counseling

Describe natural family planning

Describe barrier method

Discuss the short acting contraceptive

Describe long acting contraceptive

Describe permanent family planning

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 Family planning

 Family planning is defined as the ability of

individuals and couples to anticipate and attain
their desired number of children and the spacing
and timing of their births
Both couple have equal rights to decide on their

future fertility.

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Family planning programme in Ethiopia

The modern family planning service in Ethiopia

started as the Family Guidance Association of
Ethiopia (FGAE), established in 1966.

FGAE’s only family planning services were provided

from a single-room clinic run by one nurse, at the
former St Paul Hospital in AA.

Currently, the service has been provided to rural

communities at household level by HEW.
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 In Ethiopia 2016 EDHS report
 CPR was 36% (EDHS 2016), (41%Modern, 1% traditional

as report of Min EDHS 2019)

 TFR was 4.6 children per woman.

 PGR -will double every 23 years (EDHS 2011)

 Unintended pregnancy and abortion is higher.

MMR 412/100,000 live births

U5MR 67/ 1,000 live births

5 The world population will be 12 billion by 2050.
 Rationale for FP Programs
1. Demographic Rationale
Dominant rationale in the 1960s and 1970s

Concerns over rapid population growth

 Rationale for FP Programs …
2. Health Rationale
Became prominent during the 1980s

The public health consequences of high fertility

became paramount
 High rates of infant, child, and maternal mortality

and morbidity
Abortion and its health consequences

FP could avert a third of maternal deaths

 Rationale for FP Programs …
3. Human Rights Rationale
Became preeminent in 1990s

The right to control reproductive decisions

 Partly in reaction to demographic rationale

 Benefits of family planning
1.Social and economic benefits
In general, having a larger proportion of well-educated,

healthy, productive and self-sufficient families can

contribute a great deal to the sustainable development of
a country.

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 Benefits F/P cont…..
2.Health benefits to the mother:-
Avoiding too early and too late pregnancies
Limiting the number of pregnancies
Save mothers life by prevents unintended pregnancy its
consequence.
3. Benefits to the children:-
 It also indirectly contributes to children’s wellbeing and
development by improving maternal health.
 Adequately spaced children can be well-fed and healthier
than closely spaced children.

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 Low FP service
Coverage

High rate of
Unwanted pregnancy

Family/
Unsafe Abortion Population size
Environmental
Degradation

Migration CSW
Increase
maternal Morbidity
High Poverty
MMR

Ill Healthand Social Wellbeing

Ill Health
COUNSELLING IN FAMILY PLANNING
What is counseling ?
 Definition of counseling

Counseling is a two-way communication

between a client and a health care provider
for the purpose of confirming or facilitating
a decision by the client, or helping the client
address problems or concerns.
 Why is Counseling Important?
It ensures clients’ right to informed and voluntary

decision making

It is an essential element of quality FP services

It is a key determinant of the adoption and

continuation of family planning

 Effective counseling do to FP
Enables clients to choose a method that suits their

needs
Enables clients to use their chosen method
correctly
Enables the client to continue using a FP method

with satisfaction
Informs and prepares clients for side effects
 Consequences of poor counseling
Effect Outcome
Incorrect method use Unwanted pregnancy

Not counseled for side effects Dissatisfaction and

Discontinuation

Failure to recognize serious Health risks

warning signs

Does not suit -Dissatisfaction • Drop out

with method • Poor word-of-mouth
• Low utilization
 Counselor’s Role
 Providing balanced and accurate information
 Ensuring that clients make their own decisions
 Helping clients gain access to the methods that
they desire.
 Characteristics of an effective counselor
Explores the client’s needs, thoughts, feelings and

circumstances
Tailors information to the needs of the client

Communicates effectively

Respects and help the client make an informed and

voluntary decision
Helps the client implement her/his decision

Answers client’s questions

 Skills for FP Counselors
 Communication skills
o Create comfortable atmosphere
o Present information clearly (language)
o Listen and observe attentively
o Ask questions effectively
 Knowledge for FP counselors
Knowledge on

 Clients culture, norms and values particularly

sexuality
 About misconception

 Contraception

 Family planning programs

 Policies and laws governing FP

 Factors affecting counseling

Factors affecting FP Counseling
Service Providers Factors
knowledge, attitudes, skills and behaviors of
the provider
Providers method bias
Providers own value
Difference in client-provider social class,
gender or education
Privacy and confidentiality
 Factors affecting FP Counseling
Client Factors
Ability to obtain method of choice
Level of trust and respect towards provider
Feelings of being treated with respect and dignity
Reproductive goals of woman or couple
Personal factors including time, travel costs, pain
or discomfort likely to be experienced
 Factors affecting FP Counseling
Programmatic Factors

Availability of different contraceptive methods

Counseling environment

Accessibility/ availability/Reliability of method

supply
Basic steps in counseling ( REDI Approach)
A process that enables one organize a counseling
session:
R-Rapport building
E-Exploration
D-Decision making
I-Implementing the decision
 R-Rapport Building (step one)
Greet the client

Make introductions

Ensure confidentiality

Help the client to relax and feel comfortable

Inform the need to talk about sensitive matters

 E-Exploration (step two).

 Explore the client’s needs, risks, sexual life, social

context
Assess the FP experience or knowledge and provide

information
Introduce the subject of family planning; explain

available methods
 D- Decision Making (step three)

 Identify what decisions the client needs to make

Help the client weigh benefits, side effect and

consequences
Mention the options for each decision

Confirm the decision is made by the client

I-Implementing the decision (step four)

 Make specific plan for carrying out the decision

Provide the skills that the client need to use the

method
Identify the barriers for implementing the decision

and help clients overcome them

Make a plan for follow up
 Similarities in GATHER & REDI

1. Rapport Building (Greet and Ask).

2. Exploration (Ask and Tell)

3. Decision Making (Tell and Help and Explain)

4. Implementing the Decision (Help, Explain and

Return date/Referral)
 Methods of family planning

1. Natural family planning method

2. Barrier methods

3. Intrauterine contraceptive device

4. Hormonal contraception

5. Permanent

6. Emergency contraception

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 Methods of family planning

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 Effectiveness of contraceptive method
It can be measured by the pearl index.

It indicates the number of pregnancies which would

occur if 100 women use a specific method for one year.

The pearl index of the pregnancy figure per 100 women

years of use = 100 (women) * 12 (ovulations per year) *

number of pregnancies / total months of use.
Failure rate is further less when methods are used

correctly and consistently.

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 A. Natural family planning
• Natural family planning (NFP) is the method that uses

the body’s natural physiological changes and symptoms

to identify the fertile and infertile phases of the
menstrual cycle.
• Such methods are also known as fertility-based
awareness methods.

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 Natural family planning cont…..
What Are Fertility Awareness Methods?
“Fertility awareness” means that a woman knows when

the fertile time of her menstrual cycle starts and ends.

Sometimes called periodic abstinence.

Since there is no sign or test to tell the exact time

ovulation, a woman can use several ways, alone or in

combination, to tell when her fertile time begins and
ends.
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 Natural family planning cont…..
General points
Natural family planning refers to methods used to prevent or

postpone pregnancy by giving attention to natural reproductive

events related to fertility
All natural methods except for LAM require partners’
cooperation.
Couple must be committed to abstaining or using another

method on fertile days.

Couple/client must stay aware of body changes

36 Methods do not have side effects or health risks


 I. Calendar Rhythm Method
 Keep track of the days of the menstrual cycle
 Before relying on this method, a woman records the
number of days in each menstrual cycle for at least 6
months.
 The first day of monthly bleeding is always counted
as day 1
 The woman subtracts 18 from the length of her
shortest recorded cycle.
-This tells the estimated first fertile day.
 Then she subtracts 11 days from the length of her
longest recorded cycle.
-This tells her the estimated last day of her fertile
time.
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 Calendar Rhythm Method cont….
Avoid unprotected sex during fertile time.
The couple avoids vaginal sex, or uses condoms,
withdrawal or diaphragm during the fertile time.
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

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through day 20 of her cycle
 Calendar Rhythm Method cont….
Effectiveness
With consistent and correct use, about 9 pregnancies per

100 women in the first year of use will occur.

Case scenario
W/ro Fantu comes to you and asks you about using

calendar method to prevent pregnancy. When you ask her

about the history of her menstrual cycle over the last six
months, she tells you that with length of 25, 21, 26, 24,
39 27 & 28 is the menses comes
 Calendar Rhythm Method cont….
In the following situations delay starting calendar-based
methods:
 Recently gave birth or is breastfeeding.
 Recently had an abortion or miscarriage
 Irregular vaginal bleeding.
 Drugs may delay ovulation like:
 Taking any mood-altering drugs such as anti-anxiety
therapies.
 Long-term use of certain antibiotics, or long-term
use of any non-steroidal anti-inflammatory drug.

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 Calendar Rhythm Method cont….

Advantages of Calendar Rhythm Method

Have no side effects.

Does not require procedures and require supplies.

Help women learn about their bodies and fertility

Allow some couples to adhere to their religious or

cultural norms about contraception.

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 Calendar Rhythm Method cont….

Drawback of Calendar Rhythm Method

Doesn't protect from STI

Partner cooperation is mandatory

It affects by physiologic factors

Needs other method to use until she can start the

calendar-based method
It affects by regularity of menstrual cycles

It affects by drugs

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 II. Basal Body Temperature (BBT) Method
 The BBT method is a symptom-based method that relies on the
woman’s ability to notice a slight increase in her body temperature.
 There is temperature rise of 0.2-0.5oc following ovulation
 The elevation in the temperature is as a result of hormonal changes
that result in ovulation.
 The 3rd day after the onset of elevated temperature is the end of the
fertile period
 The couple avoids unprotected sex from the first day of menstruation
until 3 days after the woman’s temperature has risen above her
regular temperature.
 The couple can have unprotected sex on the 4th day and until her
next monthly bleeding begins
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 BBT Method cont….

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 III. The cervical mucus or Billings method

 The woman checks every day for any cervical secretions on

fingers, underwear, or tissue paper or by sensation in or
around the vagina.
 The method works primarily by helping a woman know on
what days she could become pregnant.
 And, the couple avoids unprotected vaginal sex during the
fertile days

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 Cervical mucus cont…..

 Ovulation might occur early in the cycle, during the last days of

monthly bleeding, and heavy bleeding could make mucus difficult

to observe.
 Between the end of monthly bleeding and the start of secretions,

the couple can have unprotected sex.

 Avoid unprotected sex when secretions begin and until 4 days

after “peak day”:

 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

46 and has been able to check for cervical mucus.
 Lactational Amenorrhea Method(LAM)
A temporary family planning method based on the natural effect

of breastfeeding on fertility. (“Lactational” means related to

breastfeeding. “Amenorrhea” means not having monthly
bleeding)
The lactational amenorrhea method (LAM) requires 3 conditions.

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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 LAM cont….
NB: Exclusive breast feeding and the infant should suckle not less
than 8 times in 24 hours and at least 1 of the feeds should be during
the night.

Mechanism of action
LAM 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.

Suckling causes increased prolactin, which inhibits estrogen

48 production and ovulation

 LAM cont….

Effectiveness depends on the user:

As commonly used, about 2 pregnancies per 100

women using LAM in the first 6 months after

childbirth will occur.
When used correctly, less than 1 pregnancy per 100

women using LAM in the first 6 months after

childbirth occur

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 LAM cont….

Characteristics
LAM does not provide protection against sexually

transmitted infections.
It is a natural family planning method.

It supports optimal breastfeeding,

Providing health benefits for the baby and the mother

It has no direct cost for family planning or for feeding

the baby
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None fertility awareness methods
I. Coitus Interruptus (Withdrawal method

II. Abstinence:

III. Sex without intercourse

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 BARRIER METHODS OF FAMILY PLANNING

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 Cont….

Barrier Contraceptive
 Definition :-barrier contraceptive methods are used for

preventing pregnancy and certain STI.

Types of barriers
 Barrier contraceptives are broadly classified into
two main types:

1. Mechanical barriers

2.
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Chemical barriers
 Mechanical barriers
Mechanical barriers are devices that provide a physical

barrier between the sperm and the egg.

Examples
Male condom

Female condom –reading assignment

Diaphragm

Cervical cap

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 Chemical barriers

Chemical barriers or spermicides are sperm-killing

substances, available as foams, creams, gels, or

suppositories, which are often used in female
contraception in conjunction with mechanical
barriers and other devices.

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 Male Condoms
Definition :-Made of thin latex rubber, sheaths, or
coverings, that fit over a man’s erect penis.
 Work by forming a barrier that keeps sperm out of the

vagina, preventing pregnancy.

 Also keep infections in semen, on the penis, or in the

vagina infecting the other partner.

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 Male Condoms cont….

How Effective?
 Effectiveness depends on the user:

Very few pregnancies or infections occur due to

incorrect use, slips, or breaks.
As commonly used, about 15 pregnancies per 100

women whose partners use male condoms over the first

year.
 Protection against HIV and other STIs if use consistently
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and correctly
 Male Condoms cont….
Side Effects
None

Known Health Benefits

Help protect against:
 Risks of pregnancy

 STIs, including HIV

May help protect against conditions caused by STIs:

 Recurring PID and chronic pelvic pain

 Cervical cancer

58 Infertility (male and female)


 Male Condoms cont….

Known Health Risks

Extremely rare: Severe allergic reaction

Why Some Men and Women Say They Like Condoms

 Have no hormonal side effects

 Can be used as a temporary or backup method

 Can be used without seeing a health care provider

 Are sold in many places and generally easy to obtain

 Help protect against both pregnancy and STIs.

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 Male Condoms cont….

Basic Steps
 Check the condom package.

 Do not use if torn or damaged.

 Avoid using a condom past the expiration date

 Tear open the package carefully.

 For the most protection, put the condom on before the

penis makes any genital, oral, or anal contact.
 The condom should unroll easily b/se forcing it on could

60 cause it to break during use.

 Basic Steps cont….

 If the condom does not unroll easily, it may be on

backwards, damaged, or too old; 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.

 Withdraw the penis.

 Slide the condom off, avoiding spilling semen.

 If having sex again or switching from one sex act to

another, use a new condom.

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Male Condoms cont….
 Spermicidal

Definition:-Sperm-killing substances inserted deep in the

vagina, near the cervix, before sex.

This keeps sperm from meeting an egg.
 Available in foaming tablets, melting or foaming suppositories, jelly,

and cream.
 Can be used alone, with a diaphragm, or with condoms.

All women can safely use spermicides except:

 Are at high risk for HIV infection

 Have HIV infection

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 Spermicidal cont…..
How Effective?
Effectiveness depends on the user: Risk of pregnancy is
greatest when spermicides are not used with every act of
sex.
One of the least effective family planning methods.

When used correctly with every act of sex, about 18

pregnancies per 100 women using spermicides over the

first year.
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 Spermicidal cont….
Side Effects
Some users report the following:

Irritation in or around the vagina or penis

Other possible physical changes:

Vaginal lesions

Known Health Risks

 Uncommon: Urinary tract infection, especially when

using spermicides 2 or more times a day.

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 Diaphragms

Definition:-soft latex cup that covers the cervix.

- Plastic diaphragms may also be available.
The rim contains a firm, flexible spring that keeps the
diaphragm in place.
Used with spermicidal cream, jelly, or foam to improve
effectiveness.
Comes in different sizes and requires fitting by a
specifically trained provider.
Works by blocking sperm from entering the cervix;
spermicide kills or disables sperm.
 Both keep sperm from meeting an egg.

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 Diaphragms cont….
How effective?

Effectiveness depends on the user:

 Risk of pregnancy is greatest when the diaphragm with
spermicide is not used with every act of sex.
When used correctly with every act of sex, about 6

pregnancies per 100 women using the diaphragm with

spermicide over the first year.
Protection against STIs: but should not be relied for STI
67 prevention
 Diaphragms cont….

Side Effects.
Irritation in or around the vagina or penis

Vaginal lesions

Known Health Benefits

Help protect against risks of pregnancy

May help protect against: Certain STIs (Chlamydia,

gonorrhea, PID, trichomoniasis)

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 Basic Steps

1.Squeeze a spoonful of spermicidal cream, jelly, or foam

into the diaphragm and around the rim

-Insert the diaphragm less than 6 hours before having sex

2.Press the rim together; push into the vagina as far as it

goes

3. Feel diaphragm to make sure it covers the cervix

4.Keep in place for at least 6 hours after sex.

-
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 Basic Steps cont….

Leaving the diaphragm in place for more than one day may
increase the risk of toxic shock syndrom

-For multiple acts of sex, make sure that the diaphragm is

in the correct position and also insert additional spermicide
in front of the diaphragm before each act of sex.

5.To remove, slide a finger under the rim of the diaphragm

to pull it down and out

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Cont..

71
 Cervical Cap

Definition:-A soft, latex or plastic rubber cup that

comfortably covers the cervix.
Comes in different sizes -requires fitting by a specifically

trained provider.
The cervical cap works by blocking sperm from entering

the cervix-spermicides kill or disable sperm.

Both keep sperm from meeting an egg.

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 Cervical Cap cont…
How Effective?
Effectiveness depends on the user: Risk of pregnancy is greatest
when the cervical cap with spermicide is not used with every act
of sex.
One of the least effective methods, as commonly used.

As commonly used, about 32 pregnancies per 100 women using

the cervical cap with spermicide over the first year.

When used correctly with every act of sex, about 9 pregnancies

per 100 women using the cervical cap over the first year.
Protection against sexually transmitted infections: None
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 Cervical Cap cont…
 Side Effects, Health Benefits, and Health Risks & MEC:-Same as
diaphragms
Providing Cervical Caps
 Providing the cervical cap is similar to providing and helping
diaphragm users.
Inserting
Fill one-third of the cap with spermicidal cream, jelly, or
foam.
Press the rim of the cap around the cervix until it is
completely covered,
Insert the cervical cap any time up to 42 hours before having
sex.
74
 Cervical Cap cont…

Removing
Leave the cervical cap in for at least 6 hours after her partner’s

last ejaculation, but not more than 48 hours from the time it
was put in.
Leaving the cap in place for more than 48 hours may increase

the risk of toxic shock syndrome and can cause a bad odor and
vaginal discharge.
Tip the cap rim sideways to break the seal against the cervix,

then gently pull the down and out of the vagina.

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 Hormonal contraceptive methods

Implanon kit

12 years

76
 ORAL CONTRACEPTIVE PILLS

What is oral contraceptive pills?

77
 Oral contraceptive pills
Oral contraceptive pills include combined oral contraceptive

pills (COCs) and progestin only pills (POPs) are

contraceptive methods that contain either two or one female
sex hormones.
The hormones are synthetic estrogens and synthetic
progesterones.

78
A. Combined Oral Contraceptives (COC)
The COCs is a very effective short term reversible method of

family planning.
 It contains both estrogen and progesterone derivatives

in a single tablet.
There are two types of formulations.

Monophasic: All 21 active pills contain same amount of

estrogen/progestogen (E/P)
Biphasic: 21 active pills contain 2 different E/P combinations
79
 COCs: Mechanisms of action

Suppress ovulation
Reduce sperm transport
in upper genital tract
(fallopian tubes)

Change endometrium
making implantation less
likely

Thicken cervical
mucus (preventing
sperm penetration)

80
 COC.Cont…
Work primarily by
preventing the release of
eggs from the ovaries
(ovulation).
COCs prevent synthesis
of gonadotropins from
the pituitary.
Hence, ovarian follicles
do not mature and
ovulation does not occur

81
 COCs: Contraceptive benefits
Highly effective when taken daily

Pelvic examination not required to initiate use

Do not interfere with intercourse

Few side effects

Convenient and easy to use

Client can stop use

Can be provided by trained non-medical staff

82
 COCs: Non-contraceptive benefits
Decrease menstrual flow (lighter, shorter periods)

Decrease menstrual cramps

May improve anemia

Protect against ovarian and endometrial cancer

Decrease benign breast disease and ovarian cysts

Decrease menstrual blood loss

Prevent iron deficiency anemia

Decreased ovarian cancer risk by 40-80% compared to non-

users
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 COCs: Limitations
User-dependent (require continued motivation and

daily use)
Some nausea, dizziness, mild breast tenderness,

headaches or spotting may occur

Forgetfulness increases method failure

Rare serious side effects possible

Re-supply must be readily and easily available

Do not protect against STIs (HBV, HIV and AIDS)

84
 Who Can Use COCs
Women:
Any reproductive age or parity who want highly

effective protection against pregnancy

Who are breastfeeding (6 months or more postpartum)

Who are postpartum and are not breastfeeding (begin

after 3rd week)

Who are post abortion (start immediately or within 7

days)
85
 Cont…

Women:
With anemia

With severe menstrual cramping

With irregular menstrual cycles

With a history of ectopic pregnancy

In need of emergency contraception

86
 COCs: Who should not use
COCs should not be used in the presence of:
Breastfeeding and < 6 weeks postpartum

Current or history of ischemic heart disease

Smoking 15 or more cigarettes daily in women aged

35 years and more

Raised BP ( > 160 /100 mmHG)

Hypertension with vascular disease

 Severe migraine
87
 Cont..
Diabetes (> 20 years duration)
Past or present evidence of DVT/PE
Major surgery with prolonged immobilization
Complicated valvular heart disease
Breast cancer within the past 5 years
Active viral hepatitis
Benign or malignant liver tumour
Severe (decompensated) cirrhosis
• Drug treatment affecting liver enzymes: Rifampicin and
certain anticonvulsants

88
 COCs: When to start
Anytime you can be reasonably sure the client is not

pregnant.
Days 1 to 5 of the menstrual cycle

Beyond the 5th day of menstrual cycle, make reasonably

certain she is not pregnant and advise additional

contraceptive protection for next 7 days (Back-up)
Postpartum: after 6 months

Post abortion (immediately or within 7 days)

89
 COCs: Client instructions
Take 1 pill each day, preferably at same time

Take 1st pill on 1st to 5th day (1st day preferred) after

beginning of your menstrual period.

Some pill packs have 28 pills and others have 21 pills.

When 28-day pack is empty, immediately start taking

pills from a new pack.

90
 COCs: Client instructions
When 21-day pack is empty, wait 7 days and begin

taking pills from new pack.

If you vomit within 30 minutes of taking pill, take

another pill or use a backup method if you have sex

during next 7 days.

91
 Cont…
If you forget to take 1-2 pills, take it as soon as you

remember, take the next pill at the usual time, even if it

means taking 2 pills on one day, Keep taking active pills
as usual.
If you forget to take 3 or more pills, take the pill as soon

as possible and continue taking pills daily, one each day.

-Use a backup method (e.g., condoms) or do not have

sex for 7 days until pills have been taken for 7 days in a
row. (Missed 3pills in 1&2wks vs 3wks)
92
 COCs: Common side effects

High blood pressure

Nausea/dizziness/vomiting

Bleeding/spotting

Acne

Breast fullness or tenderness

Chest pain (especially if it occurs with exercise)

Depression (mood change or loss of libido)

93
 COCs: Warning signs
Contact healthcare provider if the develop any of the

following problems:
o Severe abdominal pain

o Severe chest pain or shortness of breath

o Severe headaches or blurred vision

o Severe leg pain

o Absence of any bleeding or spotting during pill-free week

(21-day pack) or while taking 7 inactive pills (28-day

94 pack) may be a sign of pregnancy
B. Progestin only pill (Minipill or POP)

95
 POP cont…
These pills contain only progesterone derivatives in very

low dose.
The progestins commonly used are levonorgestrel 75

µg is common.
 They have to be taken continuously with no hormone

free interval.
They are useful for women with estrogen
contraindicated.
96
 The mechanism of action POP
I. Cervical mucus thickening,

II. Decidualization of the endometrium

III. Changing tubal motility.

IV. Ovulation suppression is partial and occurs in only

50 %.

97
 Advantages of POP
 Elimination of side effects attributable to estrogen
Can be prescribed to lactating women and women with

hypertension, thrombosis, diabetes and smokers.

Disadvantages of POP
Increased incidence of menstrual changes like
breakthrough bleeding and amenorrhea
Very low dose and partially prevent ovulation which

increased failure rate especially if pill is missed or taken

98 late, increased risk of ectopic pregnancy
 POP Cont…

 A back up method like barrier methods have to used in the

first month, if there is delay in taking the pill on time or if

missed and if a woman is taking drugs that accelerate
clearance of the progesterone from the body like anti
epileptics and anti TB drugs.
 When pills are taken every day at the same hour of the day,

less than 1pregnancy per 100 women using POPs over the
first year (9 per 1,000 women)

99
 PROGESTERONE-ONLY INJECTABLE (POIS)

100
 Types of POIs

Depot medroxyprogestrone acetae (DMPA) for 3 months

Norethisterone enanthate (NET-EN) for 2 months

If breastfeeding, can start 6 weeks after childbirth.

Works best if you get your injections on time.

Site of injection deltoid muscle ,IM,150mg.

101
 Types of POIs cont…….

If late for an injection:

– DMPA: Can still get an injection up to 4 weeks late.

– NET-EN: Can still get an injection up to 2 weeks late

If later, use condoms and return for an injection as soon

as possible.

102
 POIs: Mechanism of action

Suppress ovulation

Reduce sperm transport

in upper genital tract
(fallopian tubes)

Change endometrium
making implantation less
likely
Thicken cervical mucus
(preventing sperm
penetration)

103
 POIs: contraceptive benefits
 When women who have injection on time, less
than 1 pregnancy per 100 women using POIs
 Pelvic examination not required prior to use
 Do not interfere with intercourse
 Do not affect breastfeeding
 Few side effects
 Convenient and easy-to-use
 Client can stop use
 Contain no estrogen
 Do not require daily action

104
 POIs: non-contraceptive benefits
 May decrease menstrual cramps

 May decrease menstrual bleeding

 May improve anemia

 Protect against endometrial cancer

 Decrease benign breast disease

105
 POIs: Limitations
 Cause changes in menstrual bleeding pattern

 Some weight gain or loss may occur

 Effectiveness may be lowered with certain drugs for

epilepsy (phenytoin and barbiturates) or TB (rifampin)

are taken
 Do not protect against STIs (e.g., HBV, HIV and AIDS)

106
 Who can use POIs
Women:
 Any reproductive age & any parity including nullipara
 Who want effective protection against pregnancy
 Who are breastfeeding (6 weeks or more postpartum)
and need contraception)
 Who are postpartum and not breastfeeding
 Who are post abortion
 Who have BP < 180/110, blood clotting problems
 Who smoke (any age, any amount)
 Who prefer not to or should not use estrogen

107
 POIs: Who should not use

POIs should not be used if a woman:

Is pregnant (known or suspected)

Breast cancer within the past 5 years

108
 Cont…
POIs are not recommended unless other methods are not
available or acceptable if woman:
DVT/PE

Active viral hepatitis

Liver tumour (benign or malignant)

History of breast cancer with no evidence of disease in

the last 5 years

Drug treatment affecting liver enzymes: rifampicin and

109 certain anticonvulsants

 POIs: Side effects
 Amenorrhea (absence of vaginal bleeding or spotting)

 Bleeding or spotting

 Heavy or prolonged bleeding=visit clinic

 Lower abdominal/pelvic pain (with or without symptoms

of pregnancy)- severe visit clinic

 Weight gain or loss (change in appetite)

 Headache –severe visit clinic

 Nausea/dizziness/vomiting
110
 POIs: Drug interactions

Most interactions relate to increased liver metabolism of

levonorgestrel:
Rifampin (tuberculosis)

Anti-epilepsy (seizures):

-Barbiturates, phenytoin, carbamzepine (but not

valproic acid)
Griseofulvin (long-term use only)

111
LONG ACTING FAMILY PLANNING METHODS

IMPLANTS
 Overview of implants
Implants are matchstick sized rods flexible progestin-

filled rods or capsules that are placed just under the skin
of the upper arm.
An excellent option for women at all phases of their

reproductive lives, to delay, space, or limit births

113
 Types of implants

Many types of implants:

 Norplant: 6 capsules, labeled for 5 years of use

 Jadelle: 2 rods, lasts 5 years

 75 mg of levonorgestrel=150mg

 Implanon: 1 rod, lasts 3 years

 68 mg of etonogestrel

 Sinoplant: 2 rods, lasts 4 years= most cost

114 75mg of levonorgestrel each rod=150mg

 Implants Description…cont

6 - Rods 2 - Rods
1-Rod
Norplant Jadelle
Implanon

115
 Norplant vs Jadelle vs Implanon

Norplant (6 capsules) Jadelle (2 rods) Implanon (one rod)

216 mg LNG 150 mg LNG 68 g etonogestrel
(ENG, 3-ketodesogestrel)
Silastic medical
adhesive
EVA copolymer rod
covered by a thin
EVA membrane
34 mm

Silastic tubing

40 mm
43 mm
Levonorgestrel 68 mg ENG
embedded in EVA
36 mg 75 mg copolymer
free crystals
crystals in silicone
copolymer
2.4 mm

116 2 mm
2.4 mm
 Mechanism of action
Implants continually release a small amount of
progestin steadily into the blood.
The primary mechanisms are:

 Increased cervical mucus viscosity (within 48-72 hrs).

 Inhibition of ovulation- in about 50% of menstrual

cycles.
 Alters endometrium, making it less conducive for
implantation

117
 Safety and effectiveness of IMPLANTS
Are one of the most effective and long-lasting methods

<1 preg. per 100 women over the first year

A small risk of pregnancy remains beyond the first year.

Start to lose effectiveness sooner for heavier women

No delay in return of fertility after removal

No protection against sexually transmitted infections

Do not increase frequency of ectopic pregnancy.

118
Drug interaction effect on implants effectiveness
Contraceptive effectiveness may be reduced when co-
administered with some:-
Antibiotics

Anti-fungals,

Anticonvulsants, and

Anti-HIV Protease Inhibitors:

Other drugs that increase the liver metabolism of

contraceptive steroids.

119
 Characteristics of implants
Are safe,
Easy to use,
Highly effective
Not motivation dependent
Discreet, virtually invisible
Rapidly reversible
Require minor surgical procedure for insertion /removal
Stable hormone levels
Contain no estrogen
120
 Characteristics of implants: continued…

Safe for Breast feeding mother (after 6 wks Post

partum),

No need for user compliance, Convenient

Can cause irregular bleeding

Does not protect from STIs

High initial cost

121
 Characteristics of implants: continued

Non-contraceptive health benefits include:-

Help protect against pelvic inflammatory disease

Help prevent iron deficiency anaemia,

May prevent endometrial cancer,

May reduce sickle crises in women with sickle cell

anaemia.

122
 Who Can Use Implants?
Suitable for Nearly All Women; including women who:
Prefers a long-acting method
Cannot remember to take a pill every day.
Is breastfeeding (starting 6 wks after childbirth)
Cannot take estrogen-containing contraceptives
Is post-abortion
Has moderate to severe menstrual cramping
Smokes.

123
 Who can not use Implants ?

Implants may not be appropriate for some women

Use the laminated WHO medical eligibility criteria

Generally avoid in case of

Serious liver disease

Current DVT

Unexplained vaginal bleeding

124
Breast cancer
Medical Eligibility Criteria for Contraceptive Use (MEC)

 Covers 19 contraceptive
methods, 120 medical conditions
 Over 1700 recommendations on

who can use various

contraceptive methods
 Gives guidance to providers for

clients with medical problems or

other special conditions
125
WHO Medical Eligibility Criteria Classification Categories

With clinical With limited

Classification
judgment clinical judgment

Use method in any

1
circumstances
Yes
Generally use:
2
Use the method
advantages outweigh
risks

Generally do not use:

3 risks outweigh No
advantages
Do not use the
4 Method not to be used method

126
127
 Client Assessment
Assess the client by taking a history that:-

-Identifies the client’s reproductive goals,

-Screens for precautions to the use of implants

Depending on the client’s history, perform P/E.

-Pelvic exam. not required for beginning the use

unless pregnancy testing is unnecessary except
in case where it is difficult to rule out pregnancy
128
 Client Assessment; contd…
If pregnancy is not ruled out,

o Counsel the client to use a temporary contraceptive

method or

o Abstain from intercourse until her menses occur or

the possibility of pregnancy is confirmed.

129
 Timing of insertion
A woman can start using implants any time she wants if
it is reasonably certain she is not pregnant.
Recommended times for insertion when changing from
another contraceptive
Natural FP or barrier method: before day 7 of cycle
COC: within 7 days of last active pill
Implant: when Implant is removed
Progestogen-only pill: on the day the last pill is taken
Injectable hormones: any time before next injection
IUD: any time, but… use back up.
130
 Timing of implant removal
At anytime during the menstrual cycle.

At 5 years of use for Jadelle and 3 years for Implanon.

Anytime client requests removal, after adequate

counseling.

131
 JADELLE

132
 Jadelle implant
Two thin, flexible rods, each rod containing 75mg LNG
Prevent pregnancy for up to 5years.
Packaged in a sealed, sterile plastic pouch
Currently provided with a sterile, single-use disposable
trocar.
Effectiveness

-0.1 pregnancies per 100 women in the first year of

use.

133
 Pre-insertion Counseling for Jadelle®
In a private setting, provide information on:-
How it works,
Its effectiveness,
How it is inserted,
Its characteristics,
Common side effects, and
When to return
Care of the site.
Answer any questions that the client may have

134
 Preparation
Check that all instruments and supplies are ready:

Examination table with arm support or side table.

Soap for washing the arm.
Marking or ballpoint pen.
Plastic template for marking the ’’V’’ shape position
rods
Set of two rods in the sterile pouch.
Equipments and other supplies (see figure next slide)

135
 Equipments needed to insert Jadelle implants

136
Recommendations for IP during Implant insertion & removal
IP is critical for quality & success of the service delivery.

Wash patient’s entire arm & hand before antiseptic use



Use sterile/high-level disinfected instruments and

surgical gloves
After use, decontaminate all items

Place sharps and other waste in puncture-proof

container
Clean and sterilize (or high-level disinfect) reusable
items
137
 Jadelle implant insertion procedures
Key points during Insertion Procedure

Confirm that informed consent is obtained

Check to be sure the client is eligible

Let her wash the entire arm with soap & water and rinse

Locate the best insertion area (8cm above the elbow fold).

Strictly use infection prevention practices

Use 2ml of local anesthetic (1% without epinephrine)

138
Jadelle implant insertion procedures;contd…
Key points ….

Hold the trocar at 45 degree angle with the bevel

facing up.
Do not remove the tip of the trocar form the incision
until …
The two rods should form an angle of about 15
degrees following the “V” shape marked on the arm.

139
 Post insertion client instructions
Client Instructions for Wound Care key points:
Keep the insertion area dry & clean for at least 48 hrs.
Leave the gauze pressure bandage in place for 48
hours
Leave the smaller bandage in place for 3-5 days).
Bruising, swelling, or tenderness may occur for few
days.
Routine work can be done immediately but avoid
bumping the area, carrying heavy loads or putting
unusual pressure to the site.

140
Post insertion client instructions; contd…
Return to the health facility in case of:-

Severe lower abdominal pain (ectopic pregnancy?)

Heavy bleeding
If the insertion site becomes red with increased heat
and/or tenderness, or if there is pus at the site,
Bleeding at insertion site
Expulsion
Migraine headache
For removal at the end of 5 years or anytime she
decides to stop using.
141
 Jadelle implant removal procedures
Key points:

An easy removal depends on correct insertion;

If the rods cannot be palpated a provider inexperienced in

removal should NOT begin the procedure- refer.

Inject local anesthesia under the ends of the implant

Remove first the implant that is closer.

If neither rod can be removed, stop the procedure, ask to return

when fully healed (4-6 wks) and try again or refer

If the client wants to continue using Jadelle, a new set can be
142 inserted at the time the current set is removed.
 Post- Removal Procedure and care
Post-removal procedures, client care and wound care

Press down on the incision with a gauze finger for a

minute.
Bring the edges together & close with Band-Aid/surgical
tape.
Check for bleeding.

Document procedure in the client’s record.

Observe the client for 15-20 minutes

Inform the client regarding wound care

143 Give a return visit appointment, if needed

 Side effects and complications
Side Effects
 Changes in bleeding patterns
Complications
-lighter and fewer days of
bleeding, irregular bleeding, Procedure site
infrequent bleeding & no problems (early)
monthly bleeding. Bleeding /
 Headaches,
hematoma,
 Breast tenderness,
Expulsion,
 Mood changes,
Infection
 Nausea, and
 All of which usually decrease /cellulites / abscess
over time.

144
 IMPLANON

145
 Implanon® implant
A single rod etonogestrel-containing, reversible,
implant
One of the most effective methods: Over 3 years of use
Less than 1 preg. Per 100 women (1/1,000 women)
Pre-loaded inserter
Easier insertion and removal
Store at 25°C (15°-30°C) and avoid direct sunlight.

146
 Implanon package

147
Pre insertion Counseling for Implanon®
In a private setting, provide more detailed information

How it works,
Its effectiveness,
How it is inserted,
Its characteristics,
Common side effects, and
When to return
Answer any questions that the client may have

148
 Implanon insertion procedures
Preparation and pre-insertion tasks - similar to
Jadelle.
Insertion performed with a specially designed
applicator
 Key points during Insertion Procedure:

• Ensure informed consent and eligibility for insertion.

• Use 1ml of local anesthetic (1% without

epinephrine)
• Post-insertion client instruction is similar to that for
Jadelle
149
 Implanon removal procedures
Mostly similar to that of Jadelle removal.
key points:

Generally is easier and takes less time than that of

Jadelle.
If the rod cannot be palpated, a provider
inexperienced in removal should NOT begin the
procedure.
Slowly inject 2cc local anesthesia under the end
Make a 2mm longitudinal incision at the distal end

150
 Implanon side effects and complications
Similar to that of Jadelle;
Besides irregular bleeding:-
 Mood swings,
 Weight gain,
 Breast tenderness,
 Headache,
 Acne, and

151
 SINO – IMPLANT (II)

152
 SINO – IMPLANT
 The product is composed of two thin, flexible, silicone

rods, each containing 75 mg levonorgestrel(a

synthetic form of the hormone progesterone).
 Is a sub dermal contraceptive implant

 It has an annual pregnancy rate of below 1 percent.

153
 Sino-implant
All the procedures are similar with Jeddale

Sino-implant (II) is available in Ethiopia and is effective

for four years.

154
INTRA-UTERINE CONTRACEPTIVE
DEVICES
(IUCD)

155
 IUCD as a method
 Small flexible device made of metal and/or plastic,
placed in the uterine cavity to prevent pregnancy.
 Release copper or hormone

 Safe, easy to use & effective long-term method

 Globally the 2nd most commonly used modern

method
 Cost effective and inexpensive

 Can be used as an emergency contraception

 Needs careful screening & counseling for successful

use.
156
 Type of IUCD

 Types of IUCDs available world wide are:-

Copper – bearing: which include the Cu-T

380A, Cu-T 380A with safe load, Cu-T 200C,

Multilaod (MLCu 250 and 375), and the Nova T.

Medicated: with a steroid hormone, such as the

levonorgestrel containing Mirena

IUS(intrauterine system)

157
 Copper T 380A (CuT 380A):
The CuT 380A is T-Shaped, with:-

-Polyethylene with barium sulfate.

-314 mm of copper wire wound around the vertical

stem.

-Each of the two arms of the T has a sleeve of copper

measuring 33 mm.

Prevention of pregnancy for 12 years

Efficacy – pregnancy rate < 1% woman years.

158
 Parts of IUCDs (cu T 380A)

Arms (Rt./Lt.)

Copper sleeve
(33mm×2=66mm2 )
Stem

Copper wire
(314mm2 )
String/Thread

Main frame: T shaped, flexible & containing barium sulfate

159
 Mechanisms of Action
 Principal mechanism: Sterile
foreign body reaction  hostile
environment  prevent
fertilization by affecting sperm
motility.
 Inhibits sperm/ovum migration
Inflammatory
 Interfere with fertilization Reaction : create
 Effect of progesterone, hostile environment
for sperm
 Thickening of cervical mucus, motility/transport +
spermicidal and for
 Not abortificant implantation of
blastocyst

160
 EFFECTIVENESS of IUCD

Is one of the most effective contraceptive methods.

As typically used, with 0.8 pregnancies per 100

women year in the first year of use.

Continuation rates and Client Satisfaction:

Continuation rates are also high.

Large trials conducted in many developing countries

show that approximately 70- 90% of women are still

161 using their IUCDs one year after insertion.
 Characteristics of IUCDs
Safe for most women.

Immediate effectiveness and reversible

May be safely used by lactating and postpartum women.

Good choice for older women with COC precautions.

Long duration of use.

Can be inserted on the day of visit.

No routine follow up visit is required after insertion.

162
 Characteristics of IUCDs; contd…
Because nothing is required during sexual
intercourse, allowing women privacy & control over
their fertility.

Does not interact with medications.

Can be removed whenever the client chooses.

Does not protect against STIs/HIV.

Trained provider dependent.

163
 Who Can Use IUCDs?
Can be used safely by woman who:
Has a healthy reproductive tract.
Wants to delay, space or limit child birth.
Have precaution(s) for hormonal methods such as
COCs.
Is breastfeeding ( IUCDs do not affect lactation)
Is immediately postpartum
Is post abortion.
HIV positive
Are at low or no individual risk for STI
164
 Who can not use IUCDs?
Use the WHO medical eligibility criteria for IUCD use
Generally not appropriate for women with/who:-
o Pregnancy (known or suspected)
o Unexplained vaginal bleeding
o Post partum between 48hrs-6wks
o Current pelvic infection (puerperal, post abortal, TB
& STI)
o GTD or cervical/endometrial cancer
o Uterine cavity distortion (myoma or congenital)

165
o AIDS cases
 Client Assessment
Careful screening is crucial for successful IUCD use.

Taking history: Client Assessment (History) Checklist

Perform brief P/E and complete pelvic exam to:

o Determine position and size of uterus.

o Rule out likelihood of pregnancy.

o Rule out presence of infections, masses, tumors, etc.

o Use pelvic, bimanual and speculum exam checklist

166
 Timing of insertion
Optimal times for insertion are

o Within 12 days from onset of menstrual bleeding

o Immediately or within 12 days after abortion (if no

infection is present)

o If post delivery <48 hours post partum or > 4 weeks

Switching from another method

For emergency contraception

167
 Timing for IUCD Removal
At any time during the menstrual cycle
Anytime the client requests for any reason
Evidence of uterine perforation
Known or suspected pregnancy
Partial expulsion- may be replaced with a new one.
Persistent side effects or other health problems.
When IUCD has been in utero for its effective life
Severe pain or server bleeding with marked anemia.

168
 Pre-insertion Counseling for CuT-380A;
In a private setting, provide more detailed information
on:-
o How it works,
o Its effectiveness,
o How it is inserted,
-Show the client the IUCD package, and describe how it
is inserted.
o Its characteristics,
o Common side effects, and
o When to return
Answer any questions that the client may have
169
170
Infra structure, supplies and instruments for IUCD insertion

Infrastructure
Clean water
Private space
Bed/table
Light source
Supplies
Cotton balls
Antiseptic solution
Gloves
IUCDs

171
Basic principles for IUCD insertion and removal
Be gentle during the procedures

Use No-touch technique,

The Cu T should be loaded using the no-touch

technique, inside the package.

The cervix and vagina should be thoroughly prepared

with antiseptic (Betadine or Povidone Iodine)

Sound uterus to confirm the position & depth of cavity.

Use withdrawal technique.

172
 Post insertion client instructions
Proper client instruction promotes continued use; in

particular, she should know:

 Type of IUCD inserted & when to be removed/replaced

 IUCD provides no protection against HIV or other STIs:

 When to come back for a check up:

 What are the health risks with IUCDs?:

 How soon after insertion is the IUCD effective?

173  Should the client check to see if the IUCD is in place?:

 Post insertion client instructions contd…
An IUCD user should be instructed to contact her
healthcare provider if:
o She thinks she is pregnant
o Persistent abdominal pain, fever or unusual vaginal
discharge
o She or her partner feel pain/discomfort during
intercourse
o Sudden change in her menstrual periods
o She wishes to have the device removed
o She cannot feel the IUCD’s threads
174
 IUCD side effects and complications
Most side-effects and other health problems associated

with the use of IUCD (CU-T 380A)s are not serious

Side effects may include:

o Cramping

o Prolonged and heavy menstrual bleeding

o Irregular bleeding

175
 IUCD side effects and complications; contd…
 Complications may include:
o Syncope/bradycardia, vasovagal episode during
insertion (fainting, becoming dizzy, or lowered
heart rate during insertion).
o Possible anemia
o Missing strings
o Expulsion of IUCD
o Pelvic inflammatory disease
o Suspected uterine perforation

176
 Permanent family planning methods

177
Permanent family planning methods
Female sterilization/ tubal ligation
Safe and permanent method – for women or couples

who will not want more children

One of the most effective methods

Simple operation
Tubal ligation
 Tubal ligation cont…..
What it is
– Makes small cuts to the tubes that carry eggs to the
womb.
– Cuts or blocks the tubes ,the womb is not removed.
– Can be done after she have enough a baby.
What to expect
– After procedure, nothing to remember and no side-
effects.
– Do not need to be put to sleep during procedure.
– Usually she can go home a few hours after procedure.
– May have soreness for a few days after procedure.
– Monthly bleeding will continue as usual for you.
 Vasectomy
• Safe and permanent method – for men or couples who
will not want more children

• One of the most effective methods

• Simple operation and must use back-up method for

first 3 months
 Vasectomy cont…..
What it is
– Makes two small cuts to reach the tubes that carry sperm.
– Cuts tubes ,testicles are not removed.
– Works by keeping sperm out of semen.
How to use
– 3-month delay in taking effect. Couple must use another method
until then.
– After 3 months, nothing to remember.
What to expect
– Do not need to be put to sleep during procedure.
– Usually you can go home a few hours after procedure.
– May have bruising and soreness for a few days after procedure.
 Reading assignment
Emergency contraceptives

183