Presentation on theme: "Family planning Introduction to Primary Care"— Presentation transcript:
1 Family planning Introduction to Primary Care a course of the Center of Post Graduate Studies in FMPO Box – Riyadh 11417Tel: – Fax:
2 Objectives of this session Aim of family planningIslamic view of family planningMethods of family planningModern contraceptive methods indications, C.I., & side effectsFamily planning counselingObstacles to family planning.
3 Aim of family planning Essential intervention of safe motherhood Pregnancy/ birth spacingPromote women reproductive health.Decreased maternal mortality ratePromote women health.Decrease neonatal death rateBenefit couples, family & community.
4 Definition of family planning Use of contraceptive (CC) methods by a husband or wife with agreement between them to regulate their fertility.It compromises children spacing to allow breastfeeding (bf) & safeguard mother’s & child’s heath; timing pregnancies at a safe age & adjusting children no. to family’s need & to physical, financial, educational & child raising capabilities.
5 History of family planning Fertility control: thousands of years in different formsWithdrawal & bf oldest methods.Many CC recipes & instructions prescribed by Greeks, Egyptian & Islamic physicians.The terms family planning, CC and birth control are used interchangeably
6 Islamic view Sterilization prohibited unless medical need Allow temporary CCs use.Prophet Mohammed “peace be upon him”:did not object to withdrawal use.The Qur'an : no prohibiting textSupports child spacing - bf for 2 years.فتاوى ابن باز عند الضرورة لا بأس بأخذ الحبوب مؤقتا إذا كان هناك ضرر أو تعب للرحم بسبب الولادة أو إجراء عملية.س : ما الحكم في استئصال الرحم للتعقيم - أي منع الحمل - لأسباب طبية حاضرة ومستقبلية لما تتوقعها الجهات الطبية والعلمية؟ج : إذا كان هناك ضرورة فلا بأس لكن إذا كان هناك ضرورة فلا بأس ، كما يجوز تعاطي أسباب منع الحمل مؤقتا للمصلحة الشرعية.
8 The Pill Mini-Pill/ Progestin-only pills (POP) The Mini-PillMechanism of Action : stop ovulation.Combined Oral Contraceptives (COCs)..The PillContains both estrogen & progestogen hormones.Worldwide use: >100 million womenlast 4 decades: a dramatic increase in CC usage from 15% in 1960s to 54% in 2000.Minipill (Progestin-Only) : Brand names include:MicronorNor-QDOvretteMini-Pill/ Progestin-only pills (POP)The Mini-PillContains only progestogen..Come only in 28-day packs. All pills are active, so patient must take all of them.
9 The PillTypes of COC pillsMonophasic : active pills has same amount of estrogen & progestin,Multiphasic / biphasic & triphasic- active pills : varied amounts of hormones -.Ways of taking combination pills—for 21 days, 28 days, 91 days or continuously.28-day pills: take a pill at same time daily for 28 days. Usually, 1st 21 pills contain hormones & last 7 pills placebo (reminder) pills – withdrawal bleed.21-day pills: pack contains 21 pills, take one pill daily & then wait 7 days to start a new pack- withdrawal bleed. Monophasic: All of the 21 active pills contain the same level of hormones.Brand names include:AlesseBreviconDemulenDesogenLevlenLoestrinNorinylOrtho-CeptOrtho-CyclenOrtho-NovumYasminYaz (contains 24 active pills and four placebo pills)Biphasic: The 21 active pills contain two different levels of estrogen and progestin. Brand names include:Jenest-28MircetteNecon 10/11Ortho-Novum 10/11Triphasic: The 21 active pills contain three different doses of hormones. The dose changes every seven days. Brand names include:Ortho-Novum 7/7/7Ortho Tri-CyclenTri-LevlenTri-NorinylTriphasil
10 Continuous use pills / extended-cycle / 91-day pills : Types of combination pillsThe PillContinuous use pills / extended-cycle / 91-day pills :contain both estrogen and progesterone1st 84 pills contain hormones, & last 7are placebo pills- withdrawal bleed. Only get period 4x/year.FDA approved Lybrel, 1st continuous-use pill in Lybrel contains only active pills. It is a 28-day pack taken continuously, with no break in between pill packets- i.e. taken 365 days a year, which completely eliminates periodsThey offer a choice for women who have painful periods or who just don't like the inconvenience of having a monthly period.Brands of extended-cycle pills include:LybrelSeasonaleSeasoniqueSeasonale contains 81 days of active pills. That's followed by seven days of inactive pills. That means pt get a period about once every three months.Seasonique contains 84 days of active pills. They're followed by seven days of low-dose estrogen pills. The pt have about four periods a year.Lybrel contains only active pills. It's taken 365 days a year, which completely eliminates your periods.
11 Who can & cannot use the COC pill The PillMost women can safely use it.No protection against STIs or HIV/AIDSBut usually cannot use the pill if:BP : ≥ 140/≥90Smoke cigarettes & age ≥35BF : ≤6 msGave birth in last 3 weeksSerious health conditions May be pregnantStroke, migraine , breast cancer. DM >20yrs2 + risk factors for heart disease: HT,DM, smokes, or older age.Gallbladder disease, liver disease, surgeryTakes pills for TB, fungal infections, or epilepsy.
12 DVT: 3x risk if use <50 mcg estrogen – Side EffectsThe PillChanges in bleeding patterns – Spotting BP, risk with age (few mm Hg), return to normal quickly after stop (3 ms).HeadacheDizzinessNauseaBreast tendernessWt gain - slightMood changesAcne .DVT: 3x risk if use <50 mcg estrogen –Contributing RF: obesity & ageThrombotic or ischemic stroke: low riskCurrent COCs: MI risk if have CV RF(DM, smoking, HT)12. Risk of breast cancer: low.
13 Non-contraceptive health benefits They are 99% effective when taken every day.Typical failure rates: 3% to 8%.The PillNon-contraceptive health benefitsHelp protect against:Risks of pregnancyEndometrial cancerOvarian cancerSymptomatic PIDMay help protect:Ovarian cystsIron-def. anemiaReduce:Menstrual cramps, bleeding problemsOvulation painExcess hair face/bodySymptoms of polycystic ovarianSyndrome Symptoms of endometriosis
14 Patient may be able to start today The PillIf menstruated in past 5 days:She can start NOW. No extra protection needed.If menstruated > 5 days ago or if amenorrhoeic :She can start NOW if reasonably certain she is not pregnant (No need to wait for next period to start pills.She should use condoms for 7 days after taking1st pill.Client can start any day of the menstrual cycle if you can be sure she isn’t pregnantAfter childbirth, if breastfeeding:Can start from 6 ms after childbirth.If baby is <6 ms old: use condoms in the meantime.After childbirth, if NOT breastfeeding:Can start from 3 weeks after childbirth.After miscarriage or abortion:Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed.If switching from another method:If switching from the mini-pill or implants, now is the best time to start.If switching from injectable, should start pills at time she would have had repeat injection.If switching from IUD, and menstruated >5 days ago, can start pills now but leave IUD in place until the next period.
15 How to take the pill If miss pills Once daily. Forgetting pills : can lead to pregnancy!Once daily.If use the 28-pill pack:Once finish all pills in pack, start new pack on the next dayIf use the 21-pill pack:Once finish all pills in pack, wait 7 days before starting new packIf miss pillsALWAYS take a pill as soon as remember & continueIf miss 3/+ pills or start pack 3/+ days late:use condomsTo take the birth control pill, follow the instructions on the package.If miss 3 or more pills in week 3:Skip the reminder pills (or pill-free week) and go straight to the next packIf miss a reminder pill (28-day packs only):Throw away the missed pill(s) & continue taking pills, one each day
16 The Mini-Pill Who can and cannot use the mini-pill Very effective when breastfeeding.Easy to stop: A woman who stops pills can soon become pregnant.Compared with the combined pill:Better if bf. Does not affect quality or amount of breast-milk.Taking pills on time is even more important. For women not bf, taking a pill > a few hours late can increase pregnancy risk.Fewer side-effects except for bleeding changes.Who can and cannot use the mini-pillDVT : deep vein thrombosisPE: pulmonary embolismMost women can safely use it.But usually cannot use it if:bf ≤ 6 wksMay be pregnantEver had breast cancer.Liver disease.Has DVT/PE.Takes Rx for TB, fungal infections, or epilepsy (seizures/fits).Some other serious health conditions
17 Possible side-effects The Mini-PillCommon (when not breastfeeding): irregular bleeding, spotting, no monthly bleedingLess common: headache, tender breasts, dizzinessHow to take the mini-pillTake one pill each day at the same timeOnce finished all pills in pack, start a new pack following dayLate taking a pill?— Take it as soon as you remember— may need to follow special instructions if more than 3 hours late.
18 How to take the mini-pill Take one pill each day at the same timeOnce finished all pills in pack, start a new pack on following dayLate taking a pill? — Take it as soon as you rememberIf miss a pill by more than 3 hours and are:Not bf OR bf but periods have returned: use condoms for next 2 days.Bf & periods NOT returned: No special instructions. No extra protection needed.May be able to start todayCan start today if fully bf at least 6 weeksIf not bf : can start any day of menstrual cycle if you can be sure she isn’t pregnantAfter miscarriage or abortion:If switching from another method: Iike the pill.
19 Injectable Effective : 3, 2 or 1 month . Long-acting InjectableMonthly InjectableEffective : 3, 2 or 1 month .it’s use is rising : WHO - reassuring cancer risk data & USFDA - approval of 3-monthly injectable depo medroxy-progesterone acetate (DMPA/ Depo-Provera).Types :3-monthly injectable : progestogen only.DMPA & estradiol cypionate & norethisterone enanthate (NET-EN)Combined injectable CCs (CIC ): estrogen & progestin. Monthly injectables include Cyclofem and Mesigyna.No much information use existing information on use of COCs.US Federal Drug Administration (USFDA).Very effective, safe .Takes longer to get pregnant after stopping.Changes monthly bleeding
20 Who can use CICs Who can not use CICs Safe & Suitable for Nearly All Women.Who can not use CICsNot bf &< 3 weeks post deliveryPrimarily bf 6 wks to 6 ms post deliverySmokes heavily & age 35 or olderHigh BP (140 to 159 / 90 to 99)Gall bladder disease /Severe liver infection, or tumorMigraine headachesHad breast cancer >5 yrs ago it has not returnedDM >20 yrs or have complicationMultiple RFs for CVD - older age, smoke, DM, & HT20
21 Norplant Implants Combined Vaginal Ring Continuously release 2 hormone: progestin & estrogennew, limited research on effectiveness, >COC ?Side EffectsSkin irritation or rash at patch siteChanges in monthly bleeding, Headachesvaginal discharge, VaginitisContain progestogen but not estrogen hormones- so use with bfProvide long-term pregnancy protection.Very effective (>99%) for 3-7 yrsSide EffectsChanges in monthly bleedingHeadaches, Nausea, Abdominal painAcne (can improve or worsen)Weight changeBreast tendernessDizzinessMood changes
22 Intrauterine Device (IUD) Copper IUD> 99% effectiveness.Side EffectsChanges in bleeding patterns (esp. 1st 3-6 ms)Acne ,Headaches, NauseaBreast tenderness or pain , Ovarian cystsWeight gain ,DizzinessMood changes–Complications : Rare:Perforation of uterine wall.Miscarriage, preterm birth, orInfection if woman becomes pregnant with IUD.
23 Who can use IUD Who can not use IUD Copper IUDSafe & Suitable for Nearly All Women:Who can not use IUDLess than 4 weeks since giving birthCurrent DVT or PEHad breast cancer > 5 yrs ago, and not returnedSevere liver disease, infection, or tumorBenign gestational trophoblast diseaseCurrent ovarian cancerA very high risk for gonorrhea or chlamydia at time of insertionHas AIDS not on antiretroviral therapy & clinically well
24 Fertility Awareness-Based Methods (FAB)Fertility AwarenessNatural methodsFAB methods : attempt to determine days in a woman’s menstrual cycle when she is fertile,.Most useful when a woman has regular and predictable menstrual cycles.On days when fertility is greatest : a couple can use alternative barrier method - condoms or a diaphragm.FAB advantages : safe & inexpensive. Religious convictions make FAB only acceptable method of birth control.Failure causesDo not keep careful records , not trainedWomen have irregular cyclesCouples may find intervals of abstinence during fertile days too long. FAB require both partners have a strong commitment to use the techniques correctly & consistently.
25 Fertility Awareness-Based Methods (FAB)Fertility AwarenessMethods: :-1.Standard Days Method: (SDM)2. Calendar Rhythm Method (CRM)3. Cervical Mucus Testing: a woman observes changes in her cervical mucus to tell her when she may be fertile.SDM & CRM Methods: involve counting days in menstrual cycle &woman must know which day of her menstrual cycle she is on.The SDM method: New - >95% effective if used correctly.A woman is considered fertile between days 8 through 19 counting day 1 as 1st day of menstruation. Women can use SDM if have regular cycles never <26 days or >32 days.The CRM method: At least 90% effective when used correctlya woman keeps track of length of her menstrual cycles for 6-12 months to figure out the days when she is likely to get pregnant.
26 Lactational Amenorrhea Method (LAM ) It is based on physiologic effect of suckling to suppress ovulation.bf women can start to use LAM as a CC after birth if meet all 3 conditionsFully or nearly fully bf, includes exclusive bf, almost exclusive bf, & nearly fully bf, day & night, on demand by infant.baby must be <6 months oldmother's menses not have returned.Amenorrhea, defined as the absence of the menses.Menses return is defined as the first two sequential days of bleeding or spotting which may occur after two months postpartum.98%-99% effective (perfect use).Can support LAM with : Mini-pill , IUD , Condum/diapgragm.LAM can be taught during prenatal, perinatal, or postnatal periods.
27 Comparing effectiveness of methods This chart shows how effective methods are as usually used. The top four methods are most effective; user has nothing to do. The effectiveness of the other methods depends on the user’s behaviour. These other methods are more effective when used correctly.Generally 2 or fewer pregnancies per 100 women in one yearMost effectiveImplantsVasectomyFemale SterilizationIUDHow to make your method most effectiveOne-time procedures. Nothing to do or remember.Need repeat injections every 1 to 3 monthsInjectablesMust take a pill each dayPillsMust follow LAM instructionsLAM (up to 6 months postpartum)About 15 pregnancies per 100 women in one yearMust use every time you have sex; requires partner’s cooperation.Male CondomsMust use every time you have sexDiaphragmMust use every time you have sex; requires partner’s cooperation.Female Condom*This ranking is based on a simplified calendar method. Some other fertility awareness-based methods that more accurately identify the fertile period, including the Standard Days Method, are more effective.About 30 pregnancies per 100 women in one yearFertility Awareness-Based Methods*Must abstain or use condoms on fertile days; requires partner’s cooperation.Must use every time you have sexLeast effectiveSpermicides
28 Emergency Contraception (EC) Consider EC if: — no method was used— a method was used incorrectly - missed pills, late for injection— method failed - broken condom, expelled IUDEmergency CC pills:Take pills as soon as possible. ideally : within 72 hrs (3 days).Can be up to 120 hrs (5 days) after - less effective each day passes.Levonorgestrel-only ECPsLess nausea &vomiting than combined ECPs.Dosage: 1.5 mg levonorgestrel in a single dose.Combined estrogen-progestogen ECPsUse if levonorgestrel-only pills are unavailable.Dosage: 2 doses of 100 mcg of ethinylestradiol mg of levonorgestrel, 12 hours apart.Emergency copper IUD:More effective than pills. Can also be used up to 5 days.Good choice for women who want to keep using an IUD.
29 WHO Medical Eligibility Criteria for Starting Contraceptive Methods WHO Categories for Temporary MethodsWHO CategoryWith Clinical JudgementWith Limited Clinical Judgement1Use method in any circumstancesUse the method2Generally use the method3Use of method not usually recommended unless other, appropriate methods not available or acceptableDo not use the method4Method not to be usedThe Medical eligibility criteria wheel for CC use - WHO, 2007
30 Part of the table of WHO Medical Eligibility Criteria for Starting Contraceptive Methods CONDITIONCOCsPOCsDMPANPFSVasConIUDSpermDia/CCFAMBLAMPregnantN/ADelay—14AgeLess than 18 (< 20 for IUD)2Caution3—a1b , c18 to 39Accepta40 to 45over 45SmokingLess than age 35Age 35 and overHigh blood pressure (hypertension)Systolic or diastolic 90-99312Caution—1fSystolic 160 and over or diastolic 100 and over4ReferAdequately conntrolled hypertension where blood pressure can be monitoredPast hypertension where blood pressure cannot be evaluatedDiabetesPast elevated blood sugar levels during pregnancyAcceptDiabetes without vascular disease
31 Family Planning Counseling As many as 50% of pregnancies are unplanned & 25% are unwanted.Millions use family planning but fail why? :-Not e received clear use instructions\Could not get a method better suited them,Not prepared for side effects.Moreover, family planning job will never finishGeneration after generation, always needing family planning & other health care.
32 Family Planning Counseling “Choice” is key word in today’s family planningHelps patients to make choices about their reproductive options & CC methods.Helps use chosen method safely &effectivelyMost important step: uncover patient fearsClarification of CC type wanted can help bridge gap between service availability & patient’ needsshould provide correct & updated informationIt improve patient continuation & compliance.
33 Family Planning obstacles Unmeet needs of women:Services & supplies not yet available everywhereChoices are limited.Fear of social or partner’s disapproval.Worries of side effects & health concernslack knowledge about CC options & their use.Poor complianceIneffective health education to women & familyInsufficient training of health providersCounseling services not available.