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-groupUnmet need for contraception 20%Only 44 % of 168 million eligible couples are currently protectedRole of Health sectorHigh wanted fertility 20%insurance against multiple infant and child deaths in a familyEarly age of marriage
6 Unmet NeedUnmet 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 activityPost-partum amenorrhoeaSub-fecundityOpposition to use a contraceptive methodReasons related to knowledge, access or side effectsLack of awarenessCost and access to good quality ServicesSide effects, health concerns
9 Characteristics of ideal contraceptive Safe100% effectiveFree of side effectsEasily obtainableAffordableAcceptable to the user and sexual partnerFree of effects on future pregnancies
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 methodInterpersonal communication (verbal & non verbal)Technical CompetenceInformationFollow-upAppropriate 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 inusing 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 competenceGood interpersonal communication (verbal & non verbal)
15 Other tenets of quality of carre Right informationFollow-upAppropriate 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 methodsPercentage of client visits during which provider demonstrates skill at clinical procedures, including asepsisPercentage of clients reporting “sufficient time” with providerPercentage of clients informed of timing and sources for re- supply/revisitPercentage of clients who perceive that hours/days are convenient and the range of services provided is adequate.
18 GATHER Approach to Counseling Greet the client in a friendly and respectful mannerAsk the client about FP/RH needsTell the client about different methods/servicesHelp the client to make her own decision about which method/service to useExplain to the client how to use the method/service she has chosenReturn visit and follow-ups of client scheduled
19 Rights of Clients Information Knowledge of not only the benefits but also the risks / side effectsOutlets 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.PrivacyContinuity
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 itCondoms, foam, diaphragm, can all be combined w/other methods for extra protectionWhen a backup method might be a good idea:If on the pill:During first cycle of the pillAfter forgetting 2 or more pills, or after several days of diarrhea or vomiting when on the pillFirst month after switching pill typeWhen taking medications that can reduce effectiveness of the pillDuring first 1-3 months after IUD insertionWhen first learning how to use a new methodTo increase overall effectiveness of contraception
22 Methods of Contraception Natural methodsBarrier methodsHormonal methodsIUDSterilization
23 Effectiveness of birth control methods w/o spermicideFDA, 1997
24 Natural Family planning methods They include:Calendar (Rhythm) methodStandard Day MethodBasal body temperatureCervical mucous methodSymptothermal methodOvulation awareness methodLactational amenorrhea methodWithdrawal ( Coitus interruption )
25 Fertility Awareness Methods Standard days methodFor women w/cycles b/w 26 & 32 daysCouples avoid unprotected intercourse b/w days 8-19 of each menstrual cycleHighest rate of effectiveness of natural family planning methodsCalendar method: self- knowledge of fertilityAfter charting cycles for some time (preferably 1 year), a woman estimates the time she is ovulating based on the calendarMucus method: based on cyclical changesVaginal secretions change throughout cycle; woman learns to “read” these changes and keeps a daily chartBasal body-temperatureBased on changes in body temperature around ovulationCombination 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.1Also, mark this date on your calendar2If 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 MethodThe 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 MucusTransitional MucusHighly Fertile MucusCervical Mucous MethodThis 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 amountThickWhiteStickyHolds its shapeIncreasing amountsThinnerCloudySlightly stretchyProfuseThinTransparentStretchy
28 Calendar or Rhythm Method Low-risk DaysEgg may still be presentOvulation14131615171211These days may be unsafe if 28-day cycle varies as much as 8-9 days between shortest and longest cycles.410Intercourse on these days may leave live sperm to fertilize egg.321987652827262524232221201918Calendar or Rhythm MethodThe 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 wakingSlight drop immediately before ovulationAfter ovulation, release of progesterone causes slight increase in temperatureBasal Body Temperature MethodBasal 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 freeNo medical side effectsDoes not interrupt sexual activityWoman gains awareness about her body and natural cycles, which can increase comfort w/sexualityAcceptable to Catholic ChurchCons:No STI protectionRequires 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 eggCondoms provide protection against STIs
32 Condoms (male) Sheath that fits over the erect penis The only temporary method of birth control for menOnly form of contraception that effectively reduces STI transmissionMade of thin latex, polyurethane, or natural membraneMany varietiesDifferent features, shapes, textures, colors, flavorsLubricated or nonlubricatedNote: 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 breakingUnroll condom over erect penis before any contact between the penis and vulva occursUse 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 condomConsists of two flexible polyurethane rings and a soft, loose-fitting polyurethane sheathOne ring at closed end fits loosely against cervix; other ring at open end encircles the labial areaCan 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 eachFemale condoms, about $3 eachAdvantagesSTI protection!Available w/o prescription or medical interventionDisadvantagesCan reduce sensationPolyurethane transmits heat well, so some say that the female condom has less reduction in sensationInterruption 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 applicationAdvantage: no prescription necessaryDisadvantages:Interruption of sexual experience (except for the sponge)Skin irritation (which can increase susceptibility to STI infection)No protection from STIsNot effective enough to be used w/o a condom or other method
37 Cervical barrier devices Cerv capdiaphragmCervical cap: covers cervix onlyDiaphragm: covers upper vaginal wall behind cervix underneath pubic boneFemCap & Lea’s shield have removal strapsLea’s Shield allows a one-way flow of fluid from cervix to vaginaMethod is usually combined w/spermicideFemCapLea’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) progesteroneSmall plastic objects inserted into uterus3 generationsInertCopper-releasingHormone-releasing (progesterone)Have fine plastic threads attached that hang slightly out of cervix into vagina for removalVery 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 fertilizationThickens cervical mucousInhibits sperm functionThins and suppresses the endometriumCopper-Releasing IUD(ParaGard® T380A)Inhibits fertilizationReleases copper ions (Cu2+) that reduce sperm motilityMay disrupt the normal division of oocytes and the formation of fertilizable ovaIntrauterine 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 AdvantagesVery effective (essentially no “user error”)Long-term protectionNo interruption of sexual activityDon’t have to remember to useCan be used during breast-feedingDisadvantagesNo STI protectionRisk of PID (usually within first 1-2 months following insertion)Rare incidence of perforating uterine wall
44 How hormonal contraceptives work Gonadotropin releasing hormone (GnRH) triggers release of gonadotropins FSH & LHFSH & LH triggerovulationEstrogen & progesterone inhormonal contraceptivesinhibit LH, FSH, and GnRHsecretion, preventing ovulationProgesterone also:•thickens cervical mucus to preventPassage of sperm into the uterus•changes uterine lining to inhibit implantation
45 Types of oral contraceptives Constant-dose combination pillContains both estrogen and progestinDose of each is constant throughout cycleAmount of estrogen in pills has decreased from approx. 175 micrograms in 1960 to avg. of 25 micrograms todayTriphasic pillLevels of hormones (estrogen & progestin) fluctuate during cycleSeasonaleReduces the # of menstrual periods to 4 instead of 13 per yearHas lower dose of estrogen and progestinProgestin-only pillLow dose of progestin and no estrogenFor 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 practitionerDon’t skip pills, regardless of whether or not you are having sexTake pill at the same time each dayIf you miss 1 pill: take missed pill as soon as you remember, and then take next pill at the regular timeIf 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 diseaseWomen considered risky for taking OCs:Women who smoke, have migraines, depression, high b.p., epilepsy, diabetes/prediabetes, asthma, varicose veinsSide effects of OCs can include:Weight gain, decreased sexual interest, headaches, mood changes, nausea, bleeding between periodsMay 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 ASAP10.3
49 Other hormonal methods (contain both estrogen and progestin) Vaginal ring (Nuvaring)2” ring inserted into the vagina during periodWorn for 3 weeks, removed for 1 week, then replaced with new ringPros: no daily pill; spontaneityCons: no STD protection, not effective for obese women.Transdermal patch (Ortho Evra)Patch is placed on buttock, abdomen, outer upper arm, or upper torsoReplaced weekly for 3 weeks, then a patch-free weekCons: no STD protection, skin irritation
50 Other hormonal methods (cont.) Injected ContraceptivesDepo-Provera (prog.); Lunelle (prog.+est.)Injections: D-P every 12 weeks; Lunelle monthlyPros: no daily pill; spontaneityCons: no STD protection, weight gain, bleeding, mood change, frequent clinic visitsD-P: takes up to 10 months for a woman to get pregnant after stopping injectionsContraceptive Implants1.5” rod is inserted under skin of upper armProgestin-onlyEffective for up to 3 yearsCost not yet knownCons: no STD protection, weight gain, bleeding, mood change, surgical procedure
51 SterilizationEssentially permanent, although vasectomies are sometimes reversibleDoes not affect hormones, desire, sexual functioningFemale sterilizationTubal sterilization: fallopian tubes are severed to block passage of sperm & eggsTranscervical sterilization: tiny coil inserted through cervix into fallopian tubesCoil promotes tissue growth that, after 3 months, blocks fallopian tubesMale sterilization (vasectomy)Safer, less expensive, fewer complications than female sterilizationCutting 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