1. Family planning Introduction to Primary Care
a course of the Center of Post Graduate Studies in FM
PO Box – Riyadh 11417
Tel: – Fax:

2. Objectives of this session
Aim of family planning
Islamic view of family planning
Methods of family planning
Modern contraceptive methods indications, C.I., & side effects
Family planning counseling
Obstacles to family planning.

3. Aim of family planning Essential intervention of safe motherhood
Pregnancy/ birth spacing
Promote women reproductive health.
Decreased maternal mortality rate
Promote women health.
Decrease neonatal death rate
Benefit 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 forms
Withdrawal & 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 text
Supports 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.

7. Contraceptive (CC) Methods – Modern (supply)/ natural traditional / (non-supply) – Permanent/Temporary
Hormonal:
Combined oral CC
Progestogen only
Depot injections
Implants
Emergency oral
Transdermal CC patch
IUD
Barrier methods
Diaphragm
Cap
Condoms (♂ ,♀)
Spermicides
Fertility awareness-based (FAB) methods
Lactation amenorrhea method (LAM)
Withdrawal
Sterilization
Tubal ligation (♀)
Vasectomy (♂)

8. The Pill Mini-Pill/ Progestin-only pills (POP)
The Mini-Pill
Mechanism of Action : stop ovulation.
Combined Oral Contraceptives (COCs)..
The Pill
Contains both estrogen & progestogen hormones.
Worldwide use: >100 million women
last 4 decades: a dramatic increase in CC usage from 15% in 1960s to 54% in 2000.
Minipill (Progestin-Only) : Brand names include:
Micronor
Nor-QD
Ovrette
Mini-Pill/ Progestin-only pills (POP)
The Mini-Pill
Contains only progestogen..
Come only in 28-day packs. All pills are active, so patient must take all of them.

9. The Pill
Types of COC pills
Monophasic : 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:
Alesse
Brevicon
Demulen
Desogen
Levlen
Loestrin
Norinyl
Ortho-Cept
Ortho-Cyclen
Ortho-Novum
Yasmin
Yaz (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-28
Mircette
Necon 10/11
Ortho-Novum 10/11
Triphasic: The 21 active pills contain three different doses of hormones. The dose changes every seven days. Brand names include:
Ortho-Novum 7/7/7
Ortho Tri-Cyclen
Tri-Levlen
Tri-Norinyl
Triphasil

10. Continuous use pills / extended-cycle / 91-day pills :
Types of combination pills
The Pill
Continuous use pills / extended-cycle / 91-day pills :
contain both estrogen and progesterone
1st 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 periods
They 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:
Lybrel
Seasonale
Seasonique
Seasonale 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 Pill
Most women can safely use it.
No protection against STIs or HIV/AIDS
But usually cannot use the pill if:
BP : ≥ 140/≥90
Smoke cigarettes & age ≥35
BF : ≤6 ms
Gave birth in last 3 weeks
Serious health conditions 
May be pregnant
Stroke, migraine , breast cancer. DM >20yrs
2 + risk factors for heart disease: HT,DM, smokes, or older age.
Gallbladder disease, liver disease, surgery
Takes pills for TB, fungal infections, or epilepsy.

12. DVT: 3x risk if use <50 mcg estrogen –
Side Effects
The Pill
Changes in bleeding patterns – Spotting
 BP, risk  with age (few mm Hg), return to normal quickly after stop (3 ms).
Headache
Dizziness
Nausea
Breast tenderness
Wt gain - slight
Mood changes
Acne .
DVT: 3x risk if use <50 mcg estrogen –
Contributing RF: obesity & age
Thrombotic or ischemic stroke: low risk
Current 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 Pill
Non-contraceptive health benefits
Help protect against:
Risks of pregnancy
Endometrial cancer
Ovarian cancer
Symptomatic PID
May help protect:
Ovarian cysts
Iron-def. anemia
Reduce:
Menstrual cramps, bleeding problems
Ovulation pain
Excess hair face/body
Symptoms of polycystic ovarian
Syndrome Symptoms of endometriosis

14. Patient may be able to start today
The Pill
If 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 pregnant
After 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 day
If use the 21-pill pack:
Once finish all pills in pack, wait 7 days before starting new pack
If miss pills
ALWAYS take a pill as soon as remember & continue
If miss 3/+ pills or start pack 3/+ days late:
use condoms
To 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 pack
If 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-pill
DVT : deep vein thrombosis
PE: pulmonary embolism
Most women can safely use it.
But usually cannot use it if:
bf ≤ 6 wks
May be pregnant
Ever 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-Pill
Common (when not breastfeeding): irregular bleeding, spotting, no monthly bleeding
Less common: headache, tender breasts, dizziness
How to take the mini-pill
Take one pill each day at the same time
Once finished all pills in pack, start a new pack following day
Late 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 time
Once finished all pills in pack, start a new pack on following day
Late taking a pill? — Take it as soon as you remember
If 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 today
Can start today if fully bf at least 6 weeks
If not bf : can start any day of menstrual cycle if you can be sure she isn’t pregnant
After miscarriage or abortion:
If switching from another method: Iike the pill.

19. Injectable Effective : 3, 2 or 1 month .
Long-acting Injectable
Monthly Injectable
Effective : 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 CICs
Not bf &< 3 weeks post delivery
Primarily bf 6 wks to 6 ms post delivery
Smokes heavily & age 35 or older
High BP (140 to 159 / 90 to 99)
Gall bladder disease /Severe liver infection, or tumor
Migraine headaches
Had breast cancer >5 yrs ago it has not returned
DM >20 yrs or have complication
Multiple RFs for CVD - older age, smoke, DM, & HT 20

21. Norplant Implants Combined Vaginal Ring
Continuously release 2 hormone: progestin & estrogen
new, limited research on effectiveness, >COC ?
Side Effects
Skin irritation or rash at patch site
Changes in monthly bleeding, Headaches
vaginal discharge, Vaginitis
Contain progestogen but not estrogen hormones- so use with bf
Provide long-term pregnancy protection.
Very effective (>99%) for 3-7 yrs
Side Effects
Changes in monthly bleeding
Headaches, Nausea, Abdominal pain
Acne (can improve or worsen)
Weight change
Breast tenderness
Dizziness
Mood changes

22. Intrauterine Device (IUD)
Copper IUD
> 99% effectiveness.
Side Effects
Changes in bleeding patterns (esp. 1st 3-6 ms)
Acne ,Headaches, Nausea
Breast tenderness or pain , Ovarian cysts
Weight gain ,Dizziness
Mood changes
–Complications : Rare:
Perforation of uterine wall.
Miscarriage, preterm birth, or
Infection if woman becomes pregnant with IUD.

23. Who can use IUD Who can not use IUD
Copper IUD
Safe & Suitable for Nearly All Women:
Who can not use IUD
Less than 4 weeks since giving birth
Current DVT or PE
Had breast cancer > 5 yrs ago, and not returned
Severe liver disease, infection, or tumor
Benign gestational trophoblast disease
Current ovarian cancer
A very high risk for gonorrhea or chlamydia at time of insertion
Has AIDS not on antiretroviral therapy & clinically well

24. Fertility Awareness-Based Methods
(FAB)
Fertility Awareness
Natural methods
FAB 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 causes
Do not keep careful records , not trained
Women have irregular cycles
Couples 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 Awareness
Methods: :-
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 correctly
a 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 conditions
Fully or nearly fully bf, includes exclusive bf, almost exclusive bf, & nearly fully bf, day & night, on demand by infant.
baby must be <6 months old
mother'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 year
Most effective
Implants
Vasectomy
Female Sterilization
IUD
How to make your method most effective
One-time procedures. Nothing to do or remember.
Need repeat injections every 1 to 3 months
Injectables
Must take a pill each day
Pills
Must follow LAM instructions
LAM (up to 6 months postpartum)
About 15 pregnancies per 100 women in one year
Must use every time you have sex; requires partner’s cooperation.
Male Condoms
Must use every time you have sex
Diaphragm
Must 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 year
Fertility Awareness-Based Methods*
Must abstain or use condoms on fertile days; requires partner’s cooperation.
Must use every time you have sex
Least effective
Spermicides

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 IUD
Emergency 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 ECPs
Less nausea &vomiting than combined ECPs.
Dosage: 1.5 mg levonorgestrel in a single dose.
Combined estrogen-progestogen ECPs
Use 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 Methods
WHO Category
With Clinical Judgement
With Limited Clinical Judgement 1
Use method in any circumstances
Use the method 2
Generally use the method 3
Use of method not usually recommended unless other, appropriate methods not available or acceptable
Do not use the method 4
Method not to be used
The Medical eligibility criteria wheel for CC use - WHO, 2007

30. Part of the table of WHO Medical Eligibility Criteria for Starting Contraceptive Methods
CONDITION
COCs
POCs
DMPA NP FS
Vas
Con
IUD
Sperm
Dia/CC
FAMB
LAM
Pregnant
N/A
Delay — 1 4
Age
Less than 18 (< 20 for IUD) 2
Caution3 —a
1b , c
18 to 39
Accepta
40 to 45
over 45
Smoking
Less than age 35
Age 35 and over
High blood pressure (hypertension)
Systolic or diastolic 90-99 3 1 2
Caution — 1f
Systolic 160 and over or diastolic 100 and over 4
Refer
Adequately conntrolled hypertension where blood pressure can be monitored
Past hypertension where blood pressure cannot be evaluated
Diabetes
Past elevated blood sugar levels during pregnancy
Accept
Diabetes 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 finish
Generation after generation, always needing family planning & other health care.

32. Family Planning Counseling
“Choice” is key word in today’s family planning
Helps patients to make choices about their reproductive options & CC methods.
Helps use chosen method safely &effectively
Most important step: uncover patient fears
Clarification of CC type wanted can help bridge gap between service availability & patient’ needs
should provide correct & updated information
It improve patient continuation & compliance.

33. Family Planning obstacles
Unmeet needs of women:
Services & supplies not yet available everywhere
Choices are limited.
Fear of social or partner’s disapproval.
Worries of side effects & health concerns
lack knowledge about CC options & their use.
Poor compliance
Ineffective health education to women & family
Insufficient training of health providers
Counseling services not available.

34. تم بحمد الله
Thank you