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Family Planning and Contraception

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Presentation on theme: "Family Planning and Contraception"— Presentation transcript:

1 Family Planning and Contraception

2 Demographic Transition

3 Distribution of contraceptive methods: India

4 Distribution of contraceptive methods: Sri Lanka

5 Analyzing the population growth
Momentum of the population 58% Large size of population in the reproductive age-group Unmet need for contraception 20% Only 44 % of 168 million eligible couples are currently protected Role of Health sector High wanted fertility 20% insurance against multiple infant and child deaths in a family Early age of marriage

6 Unmet Need Unmet need for family planning is defined as the percentage of women of reproductive age, either married or in a union who are want to stop or delay childbearing but are not using any method of contraception.


8 Reasons for Unmet Need Perceived low risk of pregnancy
Infrequent sexual activity Post-partum amenorrhoea Sub-fecundity Opposition to use a contraceptive method Reasons related to knowledge, access or side effects Lack of awareness Cost and access to good quality Services Side effects, health concerns

9 Characteristics of ideal contraceptive
Safe 100% effective Free of side effects Easily obtainable Affordable Acceptable to the user and sexual partner Free of effects on future pregnancies

10 Quality in Family Planning

11 Quality Quality is often defined as ‘meeting the needs of clients’.
Programs that are customer focused consistently involve clients in defining their needs and in designing the services. Providing quality services is fundamental to sustainable services. Providing and subsequently maintaining quality services can only be accomplished through continuous problem solving and quality improvement.

12 Elements of ‘Quality of Care’ in family planning
Choice of method Interpersonal communication (verbal & non verbal) Technical Competence Information Follow-up Appropriate constellation of services

13 Choice of method Cafeteria approach/ Contraceptive method mix
Offering the right to the client to choose the method means giving confidence to the individual. He/she feels more comfortable in using the method for which he/she has been provided with clear, accurate and specific information and which is the best for his/her needs.

14 Competence of the provider
Technical competence Good interpersonal communication (verbal & non verbal)

15 Other tenets of quality of carre
Right information Follow-up Appropriate organization of services

16 Indicators QUALITY OF CARE
Number of contraceptive methods available at a specific outlet (basket of choice) Percentage of counseling sessions with new acceptors in which provider discusses all methods Percentage of client visits during which provider demonstrates skill at clinical procedures, including asepsis Percentage of clients reporting “sufficient time” with provider Percentage of clients informed of timing and sources for re- supply/revisit Percentage of clients who perceive that hours/days are convenient and the range of services provided is adequate.

17 Counselling

18 GATHER Approach to Counseling
Greet the client in a friendly and respectful manner Ask the client about FP/RH needs Tell the client about different methods/services Help the client to make her own decision about which method/service to use Explain to the client how to use the method/service she has chosen Return visit and follow-ups of client scheduled

19 Rights of Clients Information
Knowledge of not only the benefits but also the risks / side effects Outlets providing FP/ RH services should carry a sign on a prominent place. Access to get the FP/RH services regardless of his/her sex, race, religion, color and socio-economic status. FP services should be available to people in their closest vicinity. Privacy Continuity

20 Rights of Clients (cont.)
Choice to practice FP or RH service should be absolutely voluntary and free. A competent provider will help the client to make a decision and will not pressurize the client to make certain choice for a certain method/service. Privacy for FP/ RH counseling where the client would feel open and frank with the provider. Continuity to obtain the FP/RH services without any break or discontinuation to avoid the after effects and the give-ups of the service. Opinion about the subject, method used and the service provided. This feedback is always helpful for the provider to improve one’s service delivery.

21 Using backup methods to increase contraceptive effectiveness
Backup methods: contraceptive methods used simultaneously w/another method to support it Condoms, foam, diaphragm, can all be combined w/other methods for extra protection When a backup method might be a good idea: If on the pill: During first cycle of the pill After forgetting 2 or more pills, or after several days of diarrhea or vomiting when on the pill First month after switching pill type When taking medications that can reduce effectiveness of the pill During first 1-3 months after IUD insertion When first learning how to use a new method To increase overall effectiveness of contraception

22 Methods of Contraception
Natural methods Barrier methods Hormonal methods IUD Sterilization

23 Effectiveness of birth control methods
w/o spermicide FDA, 1997

24 Natural Family planning methods
They include: Calendar (Rhythm) method Standard Day Method Basal body temperature Cervical mucous method Symptothermal method Ovulation awareness method Lactational amenorrhea method Withdrawal ( Coitus interruption )

25 Fertility Awareness Methods
Standard days method For women w/cycles b/w 26 & 32 days Couples avoid unprotected intercourse b/w days 8-19 of each menstrual cycle Highest rate of effectiveness of natural family planning methods Calendar method: self- knowledge of fertility After charting cycles for some time (preferably 1 year), a woman estimates the time she is ovulating based on the calendar Mucus method: based on cyclical changes Vaginal secretions change throughout cycle; woman learns to “read” these changes and keeps a daily chart Basal body-temperature Based on changes in body temperature around ovulation Combination of these methods

26 Standard Days Method (w/Cyclebeads)
On the day you start your your period, move the ring to the RED bead. If you have not started your period by the day after you put the ring on the last brown bread, contact your provider. 1 Also, mark this date on your calendar 2 If you start your period before you put the ring on the darker brown bead, contact your provider. (may not be a good method for you) Every morning move the ring to the next bead. Always move the ring from the narrow to the wide end. On WHITE bead days you can get pregnant. Avoid unprotected intercourse to prevent a pregnancy. Standard DaysTM Method The Standard DaysTM method of contraception is based on a formula that accounts for natural variations in the length of the menstrual cycle and the occurrence of ovulation within the cycle (26 to 32 days). Accordingly, women are to abstain from unprotected intercourse between days 8 and 19 of their menstrual cycle. To use this method successfully, however, a woman must have no more than 2 cycles a year that are outside the 26- to 32-day range. This stipulation renders this method unfeasible for approximately 25% of women. With correct use during the first year, 5% of women who use this technique risk an unintended pregnancy. With typical use, the risk of unintended pregnancy during the first year of use increases to 12%. A set of color-coded set beads, called Cycle BeadsTM, help users track their menstrual cycle and the days they are likely to become pregnant. References: Arevalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception. 2002;65: Hatcher RA, Trussell JA, Stewart F, Cates W, Stewart GK, Guest F, Kowal D, eds. Contraceptive Technology. 18th rev. ed. New York: Bridging the Gap Communications; 2004. CycleBeads™ and Standard Days™ are trademarks of Georgetown University. CycleBeads are a patented product and are used by Cycle Technologies under license. Website located at Accessed September 11, 2006. On BROWN bead days you can have intercourse with very low probability of pregnancy. When you start your next period, move the ring directly to red bead and begin again. Arevalo M et al., Contraception, 2002;65:

27 Cervical Mucus Method Slight amount Thick White Sticky Holds its shape
Early Mucus Transitional Mucus Highly Fertile Mucus Cervical Mucous Method This method relies on the female becoming familiar with and tracking the changes in her cervical mucous. The amount of cervical mucous increases and becomes slipperier, stretchier, and clearer as the fertility window approaches during the course of the normal menstrual cycle. These changes are sufficiently predictable, and the quality of the mucous on the day before ovulation is directly related to the risk of conception. With correct use, it is estimated that 3% to 4% of women experience an unintended pregnancy during the first year of using this method. This method is not appropriate for patients who produce little or no cervical mucous or who cannot interpret its changes. Douching, spermicides, lubricants, and semen can interfere with recognizing the correct characteristics of cervical mucous. Reference: Stanford JB, Smith KR, Dunson DB. Vulvar mucous observations and the probability of pregnancy. Obstet Gynecol. 2003;101: Slight amount Thick White Sticky Holds its shape Increasing amounts Thinner Cloudy Slightly stretchy Profuse Thin Transparent Stretchy

28 Calendar or Rhythm Method
Low-risk Days Egg may still be present Ovulation 14 13 16 15 17 12 11 These days may be unsafe if 28-day cycle varies as much as 8-9 days between shortest and longest cycles. 4 10 Intercourse on these days may leave live sperm to fertilize egg. 3 2 1 9 8 7 6 5 28 27 26 25 24 23 22 21 20 19 18 Calendar or Rhythm Method The simplest and perhaps the least accurate method of determining the window of fertility in the menstrual cycle is the calendar or rhythm method, sometimes called the fixed days method. To use this method, a woman must first determine the length of her shortest and longest cycle by measuring it for 6 to 12 months. Then, to determine the first and last day of fertility in her average cycle, she subtracts 18 days from the shortest cycle and 11 days from the longest, respectively. To avoid becoming pregnant, she avoids unprotected intercourse from days 8 through 21 of her menstrual cycle. With perfect use during the first year, 9% of women using these techniques experience an unintended pregnancy. References: Billings JJ.  Natural family planning. Med J Aust. 1978;2:436. Hatcher RA, Trussell JA, Stewart F, Cates W, Stewart GK, Guest F, Kowal D, eds. Contraceptive Technology. 18th rev. ed. New York: Bridging the Gap Communications; 2004. Byer/Shainberg/Galliano. Dimensions of Human Sexuality, 5e. 1999, The McGraw-Hill Companies, Inc.

29 Basal Body Temperature Method
BBT=body temp in resting state on waking Slight drop immediately before ovulation After ovulation, release of progesterone causes slight increase in temperature Basal Body Temperature Method Basal body temperature, the body’s waking/resting temperature dips and then begins to rise approximately 3 days before ovulation during the course of the normal menstrual cycle. Women are considered to be fertile from the beginning of the temperature rise until 3 days after a sustained increase of at least 0.4 degrees Fahrenheit (0.2 degrees Celsius). However, this is not an accurate method of estimating the fertility window, since ovulation can only be identified in retrospect. Nonetheless, with perfect use, it is estimated that only 5% of women experience an unintended pregnancy during the first year with this method. Patients should be counseled to track their basal body temperature for 3 months before relying on this contraceptive method. Computerized devices that pool temperature data from several cycles have been developed to assist women who use this technique. References: 1. Frackelton B. Hormonal Forecaster. Available at: Accessed September 10, 2006. 2. Hatcher RA, Trussell JA, Stewart F, Cates W, Stewart GK, Guest F, Kowal D, eds. Contraceptive Technology. 18th rev. ed. New York: Bridging the Gap Communications; 2004.

30 Fertility Awareness Methods pros & cons
Essentially free No medical side effects Does not interrupt sexual activity Woman gains awareness about her body and natural cycles, which can increase comfort w/sexuality Acceptable to Catholic Church Cons: No STI protection Requires some degree of discipline in order to keep track of calendar/charts, etc. Need to abstain from intercourse or use a backup method during fertile days

31 Barrier & spermicide methods
Include: Condoms (male & female) Spermicides (foam, sponge) Cervical barriers (diaphragm & cervical cap) Work by preventing sperm from reaching an egg Condoms provide protection against STIs

32 Condoms (male) Sheath that fits over the erect penis
The only temporary method of birth control for men Only form of contraception that effectively reduces STI transmission Made of thin latex, polyurethane, or natural membrane Many varieties Different features, shapes, textures, colors, flavors Lubricated or nonlubricated Note: average shelf life of condoms is 5 years; don’t store latex condoms in hot places (glove compartment, back pocket) b/c heat can deteriorate the latex

33 How to use the (male) condom
Pinch reservoir tip or twist tip of nonreservoir tip condom before unrolling condom over the penis to leave room for ejaculate--reduces chance of condom breaking Unroll condom over erect penis before any contact between the penis and vulva occurs Use a water-based lubricant to reduce risk of condom breaking (oil-based lubricants deteriorate condom) Hold condom at the base of the penis before withdrawing from the vagina to avoid spilling semen inside vagina

34 Female condom Consists of two flexible polyurethane rings and a soft, loose-fitting polyurethane sheath One ring at closed end fits loosely against cervix; other ring at open end encircles the labial area Can be inserted before sexual activity; don’t need to remove it immediately following ejaculation

35 Costs, pros, & cons of condoms
Male condoms, about $0.75-$1 each Female condoms, about $3 each Advantages STI protection! Available w/o prescription or medical intervention Disadvantages Can reduce sensation Polyurethane transmits heat well, so some say that the female condom has less reduction in sensation Interruption of sexual experience (though some couples find sensual ways of incorporating condoms into foreplay) Note: female condom can be inserted several hours before intercourse

36 Vaginal spermicides Include: foam, sponge, suppositories, creams, film
Spermicide: chemical that kills sperm (nonoxynol-9) Cost: $0.85 per application Advantage: no prescription necessary Disadvantages: Interruption of sexual experience (except for the sponge) Skin irritation (which can increase susceptibility to STI infection) No protection from STIs Not effective enough to be used w/o a condom or other method

37 Cervical barrier devices
Cerv cap diaphragm Cervical cap: covers cervix only Diaphragm: covers upper vaginal wall behind cervix underneath pubic bone FemCap & Lea’s shield have removal straps Lea’s Shield allows a one-way flow of fluid from cervix to vagina Method is usually combined w/spermicide FemCap Lea’s shield

38 How to use cervical barrier devices
Diaphragm & cervical cap: need to be fitted (may need to be refitted w/weight gain or loss >10 lbs.) FemCap & Lea’s Shield do not have to be fitted, but still require a prescription in the U.S. Use diaphragm & cervical cap only with water-based lubricants b/c they are latex (FemCap & L.S. are silicone) Can insert up to 6-8 hr. before intercourse; should leave in at least 8 hr after

39 Placement of cervical barrier devices
(& FemCap)

40 Intrauterine Devices (IUDs)
progesterone Small plastic objects inserted into uterus 3 generations Inert Copper-releasing Hormone-releasing (progesterone) Have fine plastic threads attached that hang slightly out of cervix into vagina for removal Very high continuation rate (how many women are still using it one year after starting) compared w/other methods

41 IUD Mechanisms of Action
Levonorgestrel-Releasing IUD (LNG-IUS, Mirena®) Inhibits fertilization Thickens cervical mucous Inhibits sperm function Thins and suppresses the endometrium Copper-Releasing IUD (ParaGard® T380A) Inhibits fertilization Releases copper ions (Cu2+) that reduce sperm motility May disrupt the normal division of oocytes and the formation of fertilizable ova Intrauterine Contraceptives: Mechanisms of Action The primary method of action in intrauterine contraceptives (IUDs) is to prevent the fertilization of ova, which is supported by the low rate of ectopic pregnancies among users. The mechanisms of action of the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) are similar to that of levonorgestrel implants or levonorgestrel-containing mini-pills. The LNG-IUS has several different contraceptive actions: thickening of the cervical mucus; inhibition of sperm capacitation, survival, and motility; suppression of ovulation in some women; endometrial thinning; and stimulation of an inflammatory reaction that may impede sperm function and prevent implantation. A high concentration of levonorgestrel in the endometrium leads to increased endometrial atrophy that, in turn, results in a substantial reduction in menstrual flow or in amenorrhea in some users. The release of copper ions (Cu2+) from the ParaGard® IUD is believed to affect sperm motility and viability which impairs fertilization, and to disrupt the normal division of oocytes and the formation of fertilizable ova. Changes also occur in the endometrium that could interfere with the implantation of a fertilized ovum, which explains why this device is particularly effective as a method for emergency contraception. References: Jonsson B, Landgren BM, Eneroth P. Effects of various IUDs on the composition of cervical mucus. Contraception. 1991;43: Videla-Rivero L, Etchepareborda JJ, Kesseru E. Early chorionic activity in women bearing inert IUD, copper IUD and levonorgestrel-releasing IUD. Contraception. 1987;36: Kulier R, Helmerhorst FM, O'Brien P, Usher-Patel M, d'Arcangues C. Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev. 2006;3:CD

42 Costs, pros, & cons of IUDs
Advantages Very effective (essentially no “user error”) Long-term protection No interruption of sexual activity Don’t have to remember to use Can be used during breast-feeding Disadvantages No STI protection Risk of PID (usually within first 1-2 months following insertion) Rare incidence of perforating uterine wall

43 Hormone-based contraceptives
1) Oral contraceptives (pills) 2) Vaginal ring 3) Transdermal patch 4) Injected hormones 5) Hormonal IUDs

44 How hormonal contraceptives work
Gonadotropin releasing hormone (GnRH) triggers release of gonadotropins FSH & LH FSH & LH trigger ovulation Estrogen & progesterone in hormonal contraceptives inhibit LH, FSH, and GnRH secretion, preventing ovulation Progesterone also: •thickens cervical mucus to prevent Passage of sperm into the uterus •changes uterine lining to inhibit implantation

45 Types of oral contraceptives
Constant-dose combination pill Contains both estrogen and progestin Dose of each is constant throughout cycle Amount of estrogen in pills has decreased from approx. 175 micrograms in 1960 to avg. of 25 micrograms today Triphasic pill Levels of hormones (estrogen & progestin) fluctuate during cycle Seasonale Reduces the # of menstrual periods to 4 instead of 13 per year Has lower dose of estrogen and progestin Progestin-only pill Low dose of progestin and no estrogen For women who should not take estrogen (breastfeeding, high b.p., at risk for blood clots, smoke)

46 How to use oral contraceptives
Different types of OCs will differ in how to begin, and other instructions--read instructions carefully & talk w/health care practitioner Don’t skip pills, regardless of whether or not you are having sex Take pill at the same time each day If you miss 1 pill: take missed pill as soon as you remember, and then take next pill at the regular time If you miss >1 pill: consult health care practitioner for advice; use a backup method for remainder of your cycle

47 Oral contraceptives possible side effects & health issues
Women who should not take OCs: history of blood clots, strokes, heart/circulation problems, jaundice, breast or uterine cancer, liver disease Women considered risky for taking OCs: Women who smoke, have migraines, depression, high b.p., epilepsy, diabetes/prediabetes, asthma, varicose veins Side effects of OCs can include: Weight gain, decreased sexual interest, headaches, mood changes, nausea, bleeding between periods May clear up after 2-3 cycles on the pill

48 Oral contraceptives possible side effects & health issues
Rare but serious side effects of OCs--must be reported to a health care practioner ASAP 10.3

49 Other hormonal methods (contain both estrogen and progestin)
Vaginal ring (Nuvaring) 2” ring inserted into the vagina during period Worn for 3 weeks, removed for 1 week, then replaced with new ring Pros: no daily pill; spontaneity Cons: no STD protection, not effective for obese women. Transdermal patch (Ortho Evra) Patch is placed on buttock, abdomen, outer upper arm, or upper torso Replaced weekly for 3 weeks, then a patch-free week Cons: no STD protection, skin irritation

50 Other hormonal methods (cont.)
Injected Contraceptives Depo-Provera (prog.); Lunelle (prog.+est.) Injections: D-P every 12 weeks; Lunelle monthly Pros: no daily pill; spontaneity Cons: no STD protection, weight gain, bleeding, mood change, frequent clinic visits D-P: takes up to 10 months for a woman to get pregnant after stopping injections Contraceptive Implants 1.5” rod is inserted under skin of upper arm Progestin-only Effective for up to 3 years Cost not yet known Cons: no STD protection, weight gain, bleeding, mood change, surgical procedure

51 Sterilization Essentially permanent, although vasectomies are sometimes reversible Does not affect hormones, desire, sexual functioning Female sterilization Tubal sterilization: fallopian tubes are severed to block passage of sperm & eggs Transcervical sterilization: tiny coil inserted through cervix into fallopian tubes Coil promotes tissue growth that, after 3 months, blocks fallopian tubes Male sterilization (vasectomy) Safer, less expensive, fewer complications than female sterilization Cutting and closing vas deferens (ducts that carry sperm)

52 Ex. of female sterilization procedure
Laparoscope: narrow, lighted viewing instrument that is inserted into abdomen to locate the fallopian tubes

53 Ex. of male sterilization procedure
Vas deferens on each side is cut; small section is removed, and the ends are tied off or cauterized

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