2Benefits of Family Planning Objectives At the end of this session, participants will be able toDefine contraception and family planning (FP)Describe the risks of pregnancy and delivery among women with various characteristics and conditionsDescribe how FP improves the lives of women, children, families, and communitiesList the benefits of FP for all women, for children, for families and communities.Discuss FP in the context of human rightsExplain how FP contributes to the Millennium Development GoalsSuggested script:The objectives for this session were developed based on input from various types of stakeholders who provided input: participants, supervisors, health officials.The objectives of this session are as follows: By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud >.
3Defining Contraception and Family Planning What is the definition of contraception?Contraception is the intentional prevention of pregnancy by artificial or natural means.What is the definition of family planning?Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility.– World Health Organization, Department of Reproductive Health and ResearchInstructions for facilitator:Show the questions to the participants without showing the definition. Ask participants to construct a definition of contraception and then family planning. Record participant suggestions on a flip chart—each response can build on previous responses until participants have cited the primary features of family planning and the group collectively arrives at comprehensive definition. Ask the group- What is the difference between contraception and family planning?After the group has crafted their definition, show the definition from WHO as an example. Ask the participants to compare the features included in their definition with the WHO definition.
4Family Planning Saves Lives Region/countryNumber of maternal deathsLifetime risk of maternal death 1 in:Sub-Saharan Africa162,00039Southern Asia83,000160These 2 regions account for 85% of maternal deaths worldwideDeveloped regions1,7004,300Suggested script: One of most important benefits of family planning is the potential to save lives. Each minute of every day, a woman dies from pregnancy or childbirth-related causes. The middle column of the table, shows the number of women who die each year in pregnancy or childbirth. Notice that most of the deaths occur in developing countries in Africa and Asia. The column on the right shows the lifetime risk of maternal death for each of these regions, which is the probability of dying from a pregnancy or childbirth-related cause during a woman’s reproductive lifespan. It is influenced by both the risks associated with an average pregnancy and the number of times the average woman gives birth.Over 287,000 women per year die from pregnancy or childbirth. Nearly 47,000 women die each year due to the complications of unsafe abortion. Complications of pregnancy and childbirth are the leading cause of death in young women aged between 15 and 19 years. Promoting policies and implementing programs that help young women delay their first pregnancy until the age of 18 can have a significant impact on girls’ health, education and life prospects.Approximately 94,000 maternal deaths could be avoided each year if all women who said they want to avoid pregnancy were able to stop childbearing either temporarily or permanently that is one of the ways that family planning saves lives. Unfortunately, the benefits from family planning are not realized in many locations around the world where the unmet need for family planning remains substantial.As described on the next series of slides, family planning has substantial benefits, especially for those women more likely to experience problems during pregnancy and delivery.Note to facilitator:Present and discuss country-specific or district/local data regarding maternal deaths. For example, see the following:Country profiles produced by UNFPA and PRB atDemographic and Health Surveys (DHS) from Measure atGuttmacher International Data Center atOver 287,000 women per year die in pregnancy or childbirth47,000 women per year die from complications of unsafe abortionComplications of pregnancy and childbirth are the leading cause of death in young women94,000 maternal deaths could be prevented if all women who said they want to avoid pregnancy were able to stop childbearing.Sources: WHO, UNICEF, UNFPA and The World Bank, 2010; WHO 2009; Guttmacher Institute, 2010.
5Women with an Increased Risk of Having Problems During Pregnancy and Delivery Women who:Are under the age of 18, or over age 35Become pregnant less than 2 years after a previous live birthBecome pregnant less than six months post-abortion or post-miscarriageHave too many children (high parity)Have certain existing health problemsDo not have access to skilled health careSuggested script:Research shows that women in these categories are at greater risk for problems during pregnancy and delivery, making access to family planning even more critical. <pause to allow participants to review the list and compare it with their responses from the brainstorming exercise on the previous slide> is there a brainstorming exercise on the previous page?On the next several slides, we’ll examine these risks in more detail. Compare your experiences and observations with the issues described on the slides, and raise any issues that you would like to discuss in further detail.Problems are more likely in those with multiple risk factors.
6Pregnancy Is Greater Risk for Adolescents Over 70,000 maternal deaths occur among adolescents aged 15–19 each yearGirls below the age of 15 are five times more likely to die in childbirth than women in their twentiesAdolescents are more likely to:Have pregnancy related complicationsDeliver prematurelyHave babies that die before their first birthdayAbout 2.5 million young women aged have an unsafe abortion in the developing world each yearSuggested script:Maternal deaths related to pregnancy and childbirth are a significant cause of mortality for adolescents. Over 70,000 maternal deaths occur among year olds annually. Adolescents this age are twice as likely to die as women in their twenties.The younger a girl is when she becomes pregnant, the greater the health risks. Girls who become pregnant before the age of 15 are five times more likely to die in childbirth than women in their twenties.Adolescents are more likely to have pregnancy related complications such as preeclampsia and vaginal fistula, to deliver prematurely, and to have babies that die before their first birthday.Adolescents aged 15–19 are estimated to have 2.5 million of the approximately 19 million unsafe abortions that occur annually in the developing world.Sources: Advocates for Youth, 2007; UNICEF, 2008; Guttmacher, 2009.
7Pregnancy Is Greater Risk for Women with Pregnancies Spaced Too Closely Women who become pregnant less than 2 years after a previous live birth are more likely to:Become sick or die from pregnancy and delivery complicationsHave babies at risk of prematurity, low birth weight, small size for gestational age, fetal and neonatal deathWomen who become pregnant less than 6 months postabortion or miscarriage may be at increased risk of complications for mother and childSuggested script:Research has shown that women who become pregnant less than two years after the birth of their last child are more likely to experience adverse maternal, perinatal, newborn, and infant outcomes. For example, 35 percent of deaths among children younger than age five in developing countries could have been avoided if births had been spaced at least 36 months apart. Thirty-six months approximates the recommended two-year delay following a birth combined with the nine-month gestation period of the next pregnancy.Women who do not wait six months after an abortion or miscarriage and become pregnant again may experience adverse maternal and perinatal outcomes such as elevated risks of premature rupturing of membranes, anemia and bleeding, pre-term birth, and low birth weight, compared with longer intervals.Source: WHO, 2006; Conde-Agudelo, 2006; Rutstein , 2005; Conde-Agudelo, 2005.
8Pregnancy Is Greater Risk for Women Over the Age of 35 Women over age 35 are:At least twice as likely to die in pregnancy or childbirth than women aged 20–24More likely to have problems during pregnancy such as miscarriage, hypertension, or diabetesMore likely to give birth to small babies, babies with disabilities, or stillborn babiesPregnancy for women over 35 is associated with certain risks that are less common with younger women. In many instances, older women are more likely to have more children and experience the additional risks associated with high parity. Older women are at least twice as likely to die in pregnancy and childbirth as younger women and in some data sets the risk rises to 4.5–8 times higher. Bleeding is the most common reason that women over age 35 die during childbirth. The chance of having twins increases with age. The risk of developing gestational diabetes or high blood pressure is greater in women over 35. Older mothers have a higher risk of pregnancy-related complications that might lead to a C-section delivery, such as placenta previa. The risk of miscarriage or giving birth to a low birth weight baby or a baby with a disability also increases in older women.Source: Stover, 2010; WHO, 1995.
9Pregnancy Is Greater Risk for Women of High Parity Women with more than four children who have an additional pregnancy are more likely to:Die during pregnancy or childbirthHave anemia, experience blood loss (post partum hemorrhage), and need transfusionsDevelop complications such as uterine relaxation (during and after delivery) and uterine ruptureSuggested script:If no other risk factors are involved, the risk of dying continues to increase with each additional pregnancy after the fourth pregnancy. The risk of dying is 1.5 to 3 times higher for women with five or more children than for women with two or three children.Pregnancy and delivery is riskier for these women because they are more likely to have anemia, require blood transfusions during delivery, or experience unexpected uterine relaxation which refers to the situation that the uterus does not contract as it should thus bleeding after delivery does not stop. They also are at high risk of uterine rupture. Both of these cause massive bleeding. In many instances, women with many children are older and experience the additional risks associated with births to women over 35.Long-acting and permanent family planning methods that limit childbearing—such as IUDs, implants, tubal ligation, or vasectomy for a partner—can help these women avoid a dangerous pregnancy. If a woman wishes to continue childbearing, she should be encouraged to wait at least two years after the birth of the last child before becoming pregnant, and use antenatal care.Source: WHO, 1995.
10Pregnancy Is Greater Risk for Women with Certain Existing Health Problems Health risks associated with pregnancy make effective contraception especially important for women with these conditions:Reproductive tract cancers and some infectionsSerious cardiovascular problemsDiabetes with vascular complicationsSickle cell anemiaSerious liver conditionsInfections such as schistosomiasis, TB, and HIVSuggested script:Some medical conditions may make pregnancy riskier for women. The effectiveness of a contraceptive method has special importance if a woman has one of the following conditions:reproductive tract infections and disorders such as breast, endometrial, and ovarian cancer; some sexually transmitted infections including gonorrhea and chlamydia; some vaginal infections such as bacterial vaginosis; anomalies among women who have undergone female genital cuttingcardiovascular disease such as high blood pressure, complicated valvular heart disease, ischemic heart disease, or stroke.insulin-dependent diabetes that damaged the arteries, kidneys, eyes, or nervous system or lasted more than 20 years.sickle cell anemia.severe cirrhosis of the liver, and cancerous liver tumors.other infections such as schistosomiasis with fibrosis of the liver, tuberculosis, and HIV AIDS; although HIV/AIDS is not made worse by pregnancy, HIV disease may increase some health risks of pregnancy and may also affect the health of the infant.Source: Global Handbook, updated 2011.
11Benefits of FP for All Women Lower risk of maternal deathLower risk of anemia, poor pregnancy outcomes and complications, and complications related to miscarriage or unsafe abortionNon-contraceptive benefits from some methods such as protection from:Disease transmission/acquisitionCertain cancers and other gynecological problemsImproved educational and economic opportunitiesSuggested script:Women who use family planning experience many benefits, including:A lower risk of maternal death.A lower risk of anemia; poor pregnancy outcomes including stillbirth, low-birth weight, preterm birth, miscarriage, and complications such as hemorrhage, infection, vaginal fistula, pre-eclampsia, and eclampsia; and a lower risk of complications related to miscarriage or unsafe abortion.Additional benefits provided by some contraceptive methods. For example, barrier methods such as male and female condoms provide protection from STI/HIV transmission between partners. Hormonal contraceptives may protect from acquiring symptomatic pelvic inflammatory disease (PID). In addition, various hormonal methods offer protection from endometrial and ovarian cancer and other gynecological problems such as symptoms of endometriosis and dysmenorrhea.When given control over their fertility, girls are more likely to stay in school and women to be employed.It is important to educate all women about the benefits of family planning. Targeted messages should be tailored to certain groups. For example, for nulliparous adolescents the message about delaying first pregnancy until at least age 18 should be emphasized to achieve greater benefits. For women who are pregnant, have just given birth, or experienced an abortion, messages about the benefits of healthy timing and spacing of pregnancies are key. For women with several children, messages about limiting are relevant and for people with mulitple partners….condoms!It may be important to involve a woman’s husband or partner, her mother-in-law, or other key family members in counseling and education about the benefits of family planning.Tailor messages to best serve needs of clients.Source: Lloyd, 2008; Wilcher, 2008.
12Benefits of FP for Children Longer breastfeeding:Provides nutritionProtects from childhood diseasesImproves mother/child bondingReduces child illness and deathAllows more time and resources for parents to meet the needs of each childSuggested script:When women and couples use family planning to space, time, and limit their pregnancies, their children also benefit. Better spaced pregnancies allow for longer periods of breastfeeding which give infants and young children the chance to derive the maximum benefits from the practice of breastfeeding including better nutrition, protection from childhood diseases, and opportunities for mother and child bonding. Children who are exclusively breastfed are at lower risk of disease, especially diarrhea and respiratory infections.Children born to women who use family planning to space, time, and limit births are more likely to survive and less likely to be sick. Research has shown that babies born less than two years after the next oldest sibling are more than twice as likely to die in the first year as those born after an interval of three years. Spacing births could save the lives of more than two million infants and children each year.Family planning gives parents the option to have the number of children they want when they want them which allows them to meet the varied needs of each individual child.Note to facilitator:Present and discuss country-specific or district/local data regarding infant and child deaths.Source: Rutstein, 2005; Demographic and Health Surveys, various years.
13Benefits of FP for Families and Communities Families can devote more resources to providing for each childReduced maternal and child illness reduces economic strain on familyReduced maternal deaths strengthen families and communitiesRelieves economic, social, and environmental pressuresEnhances women’s status and promotes equality between men and womenSuggested script:Family planning allows families to devote more resources to providing their children with food, clothing, housing, and education.The reduced risk of death and illnesses among mothers, newborns, infants, and children achieved by healthy timing, spacing, and limiting of pregnancies contributes to reducing the economic strain on a family and helps to ensure family health.Reductions in maternal mortality mean that more women are able to care for their children and families thus improving the quality of life for the entire community.When entire communities carefully plan their families, better space their pregnancies and limit the number of overall births, family planning may relieve the economic, social and environmental pressures from rapidly growing populations.1 Healthier families and communities may enhance opportunities for better planning and development and facilitate preservation of natural resources like forests, water, and land. Family planning has the potential to enhance women’s status in the community and promote equality between men and women.
14Benefits of FP for People Living with HIV Experience same benefits as othersAdditional benefits include:Reduction in number of children born HIV-positive (by reducing number of unintended pregnancies)Reduction in number of childrenborn who could become orphans_ Couples can use family planning until they are ready to get pregnantSuggested script:Integrated reproductive health services, that include family planning counselling and access to contraception, along with HIV testing, care and treatment, can improve the lives of women and couples with HIV and the lives of their families.When FP services are easy to access, clients with HIV experience the same health benefits as others in their communities. Couples can limit the size of their families to the number of children they desire and are able to care for. Women can better space their children and reduce the risks associated with too many pregnancies or pregnancies spaced too closely.What are some additional benefits that FP affords people with HIV? <accept suggestions from several participants without addressing whether the responses are correct, then click the mouse to reveal the first bullet>The impact of antiretroviral therapy may encourage clients with HIV to reconsider decisions about sex, relationships, and childbearing as ARVs improve their health and longevity and reduce mother-to-child HIV transmission. For clients with HIV:Family planning can also reduce HIV infections among children by helping women with HIV who do not want to have children avoid pregnancy.Parents with HIV who are concerned that they may eventually die of AIDS may decide to use contraception to avoid having children who may some day become orphans.Knowing about family planning means that couples can use family planning until they are ready to get pregnant. In our resource constrained environments this usually means making sure the HIV positive partner(s) are on ART and that CD4 counts are above 350.
15Key Timing, Spacing, and Limiting Messages to Share with Clients Women and infants may get sick or die if a pregnancy happens:Too early among adolescents delay first pregnancy until 18 yearsToo soon after giving birth wait at least 24 months before trying to become pregnantToo soon after an abortion or miscarriage delay trying to become pregnant at least 6 monthsToo late in a woman’s life plan prior to age 35After having four children risks increase with each pregnancySuggested script:As we have discussed, family planning allows clients to time, space, and limit births in healthy ways, and thereby avoid the risks of illness or death that are associated with pregnancies that occur too often, too early or late in life, or too soon after a previous pregnancy, miscarriage, or abortion.For clients to make an informed choice about family planning, they should understand the health benefits for themselves and their children. Providers should explain risks that are related to maternal age, high parity, and certain spacing practices. Providers should target messages for specific groups of clients.1, 2For adolescents, the key messages are:For the health of the mother and baby, women should wait until they are at least 18 years of age before trying to become pregnant. If and when adolescents become sexually active, they should consider using a family planning method of their choice until they are 18 years old, or older if they don't want to get pregnant.For couples who desire another pregnancy after a live birth, the messages are:For the health of the mother and the baby, after a birth wait at least 24 months, before trying to become pregnant again. Women should consider using a family planning method of their choice during that time.For couples who decide to have a child after a miscarriage or abortion, the messages are:For the health of the mother and the baby, wait at least six months before trying to become pregnant again. Women should consider using a family planning method of their choice during that time.For women over 35 years of age, the messages are:For the health of the mother and the baby, consider avoiding additional pregnancies. Women over the age of 35 should consider using a family planning method of their choice―particularly long-acting or permanent methods―if they want to avoid additional pregnancies. If women over the age of 35 want to become pregnant, they should space their pregnancies and be sure to use antenatal care and skilled birth attendants at delivery.For couples who have four or more children, the messages are:There are health risks for the mother and the baby when women have more than four children. Women should consider using a family planning method of their choice―particularly long-acting or permanent methods―if they want to avoid additional pregnancies.In addition to communicating these messages to clients, providers should screen all women for existing health conditions that would put them at risk for health complications associated with pregnancy and childbirth.Source: WHO 1995; ESD, 2008.
16Family Planning and Human Rights All individuals and couples have the right:“…to decide freely and responsibly the number, spacing and timing of their children and to have the information, education, and means to do so, and the right to attain the highest standard of sexual and reproductive health...”– ICPD Programme of ActionSuggested script:• Explain that the 1994 International Conference on Population and Development (ICPD) in Cairo was a milestone in the history of population and development, as well as in the history of women's rights. At the conference the world agreed that population is not just about counting people, but about making sure that every person counts.• Ask participants to explain what the quotation means. Note their responses on a flip chart.• Ask participants to generate ideas about how they can help ensure the ICPD Program of Action. Answers should include basic principles such as providing full access to information on contraceptive choices and to counseling, services, and supplies that allow a client to choose freely and allowing clients to make decisions independently, without the influence of any special incentives or forms of coercion.Explain that:• Providing family planning services allows women and couples to delay and space pregnancies and limit the size of their families to the number of children they desire and are able to care for.• When women and couples reduce the risks associated with pregnancies that occur too early or late in life, having too many pregnancies, and pregnancies spaced too closely, they reap the benefits of healthier outcomes for all members of the family.• Healthier families are a benefit to the larger community. Access to FP also helps ensure that the human right to reproductive health is protected and upheld.• FP services are most effective when clients are free to make informed contraceptive choices that take into account fertility intentions and desired family size.Source: United Nations, 1995.
17Benefits of Providing FP Services Improves well-being of families and communitiesHelps achieve the healthiest outcomes for women and their childrenAllow women and couples to delay, space, and limit pregnanciesSuggested script:Providing family planning services allows women and couples to delay and space pregnancies and limit the size of their families to the number of children they desire and are able to care for.When women and couples reduce the risks associated with pregnancies that occur too early or late in life, having too many pregnancies, and pregnancies spaced too closely, they reap the benefits of healthier outcomes for all members of the family.Healthier families are a benefit to the larger community. Access to FP also helps ensure that the human right to reproductive health is protected and upheld.FP services are most effective when clients are free to make informed contraceptive choices that take into account fertility intentions and desired family size.Note to facilitator:For participants who desire more information about the Benefits of FP and healthy timing and spacing of pregnancy, distribute copies of the optional handoutFamily Planning Saves Lives Backgrounder, Population Reference Bureau, 2009FP services are most effective when clients are free to make informed choices.
18Family Planning and the Millennium Development Goals (MDGs) End Hungerand PovertyIncreaseEducationSupportPartnershipsFamily PlanningSuggested script:FP is a cost-effective intervention that can substantially improve health and development. Universal, equitable access to reproductive health, including FP, is designated as Millennium Development Goal 5B. Indicators being used to track progress include contraceptive prevalence rates, unmet need for family planning, and adolescent birth rates.How do you think FP might affect the MDGs? <accept responses from several participants without confirming whether the response is correct; continue with the explanation below>FP affects all eight of the UN’s MDGs, specifically: MDG 1: Eradicate poverty and hunger—Family planning can help improve the economic status of families and countries, and reduce demand for scarce food resources.MDG 2: Universal primary education—FP can help girls stay in school. Girls often leave school because of unintended pregnancies or to take care of younger siblings.MDG 3: Gender equality—Access to FP can empower women and change gender norms.MDGs 4 and 5: Maternal and child health—As we’ve discussed, when families can use FP to time, space and limit their births, the health of children and mothers improves.MDG 6: Combat HIV/AIDS—As we’ve discussed, when HIV-positive women have access to FP to avoid unintended pregnancies, the number of infant HIV infections is reduced. Also, FP allows HIV positive couples to time conception when HIV transmission risk is lowest.MDG 7: Environmental sustainability—When individuals and couples use FP to avoid unwanted pregnancies, pressure on ecological resources—including land, water and food—is reduced.MDG 8: Global partnerships— From the local level to the international level, strong partnerships can increase access to FP.Save theEnvironmentEmpowerWomenDecreaseHIV/AIDSImproveInfantHealthImproveMaternalHealthSource: United Nations, 2000; Cates, 2010.