1. Al Neelain University –Faculty of Medicine Department of Community Medicine Semester 7 Primary Health Care Course Family Planning Dr.Abeer Abuzeid Atta Elmannan ali

2. Session outlines : What is family planning? Who provides family planning? What are the commonly used contraceptive methods?

3. Definition Refers to practices that help couples to regulate the intervals between pregnancies Who provides family planning Nurses, Midwives Physicians, including gynecologists and obstetricians Physicians’ assistants Pharmacists, pharmacists’ assistants. Primary health care providers, community health care providers Specifically trained traditional birth attendants

4. Tips for Successful Counseling Show every client respect, and help each client feel at ease. Encourage the client to explain needs, express concerns, ask questions. Let the client’s wishes and needs guide the discussion. Be alert to related needs such as protection from sexually transmitted infections including HIV, and support for condom use. Listen carefully. Listening is as important as giving correct information. Give just key information and instructions. Use words the client knows. Respect and support the client’s informed decisions. Bring up side effects, if any, and take the client’s concerns seriously. Men are important for 2 reasons. First, they influence women, Second Men are also important as clients.

5. Contraceptive methods (Fertility regulating methods) Spacing methods Terminal methods

6. Spacing methods Barrier methods 1. Physical methods 2. Chemical methods 3. Combined methods Intra-Uterine Devices Hormonal methods Miscellaneous

7. Terminal methods Male sterilization Female sterilization

8. Barrier methods Aim: Prevent live sperms from meeting the ovum Advantages: 1. Absence of side effects associated with pill and IUCD 2. Protection from STD 3. Reduction of incidence of PID Disadvantages 1. Less effective than either the pill or the loop 2. Requires high degree of motivation on the part of the user.

9. I-Physical methods 1-Condom How Effective? Effectiveness depends on the user: Very few pregnancies or infections occur due to incorrect use, slips, or breaks.

10. 2- diaphragm What Is the Diaphragm? A soft latex cup that covers the cervix. Plastic diaphragms may also be available. The rim contains a firm, flexible spring that keeps the diaphragm in place. Used with spermicidal cream, jelly, or foam to improve effectiveness. Comes in different sizes and requires fitting by a specifically trained provider. Works by blocking sperm from entering the cervix.

11. 3- Cervical Caps What Is the Cervical Cap? A soft, deep, latex or plastic rubber cup that covers the cervix. Comes in different sizes; requires fitting by a specifically trained provider. The cervical cap works by blocking sperm from entering the cervix How Effective? Effectiveness depends on the user: Risk of pregnancy is greatest when the cervical cap with spermicide is not used with every act. More effective among women who have not given birth Side Effects, Health Benefits, and Health Risks Same as for diaphragms

12. II- Chemical methods Spermicides They comprise four categories: 1. Foams 2. Creams, jellies and pastes 3. Soluble films 4. suppositories

13. What Are Spermicides? Sperm-killing substances inserted deep in the vagina, near the cervix. Nonoxynol-9 is most widely used. Available in foaming tablets, melting or foaming suppositories, cans of pressurized foam, melting film, jelly, and cream Work by causing the membrane of sperm cells to break, killing them or slowing their movement.

14. IUDs (Intra uterine Devices) Types There are two basic types 1. Non medicated 2. Medicated Both are usually made of polyethylene or other polymers Medicated (bioactive) IUDs release either metal ions (copper) or hormones (progestrogens) Inert IUDs Lippe`s loop first generation Copper IUDs second generation Hormone-releasing IUDs third generation

15. Mechanism of action of IUDs endometrium IUDs causes a foreign-body reaction in the uterus causing cellular and biochemical changes in the endometrium and uterine fluids Copper affects enzymes in the uterus, alters cervical mucus,affects sperm motility and survival. Hormone-releasing devices increase viscosity of the cervical mucus, maintain high level of progestrone and low level of oestrogen.

16. Timing of insertion During menstruation or within 10 days of the beginning of a menstrual period Follow-up

17. Second generation Copper-Bearing Intrauterine Device What Is the Copper -Intrauterine Device? The copper-bearing intrauterine device (IUD) is a small, flexible plastic frame with copper sleeves or wire around it. A specifically trained health care provider inserts it into a woman’s uterus through cervix. Almost all types of IUDs have one or two strings, or threads, tied to them. The strings hang through the cervix into the vagina. Works primarily by causing a chemical change that damages sperm and ovum before they can meet.

18. Side Effects, Health Benefits, Health Risks, and Complications Side Effects Some users report the following: Changes in bleeding patterns (especially in the first 3 to 6 months) including: – Prolonged and heavy monthly bleeding – Irregular bleeding – More cramps and pain during monthly bleeding Known Health Risks Uncommon: May contribute to anemia if a woman already has low iron blood stores before insertion and the IUD causes heavier monthly bleeding Rare: Pelvic inflammatory disease (PID) may occur if the woman has Chlamydia or gonorrhea at the time of IUD insertion

19. Who Can and Cannot Use the Copper-Bearing IUD Safe and Suitable for Nearly All Women Most women can use IUDs safely and effectively, including women who: Have or have not had children Are of any age, including adolescents and women over 40 years old Have just had an abortion or miscarriage (if no evidence of infection) Are breastfeeding Do hard physical work Have had ectopic pregnancy Have had pelvic inflammatory disease (PID) Have vaginal infections Have anemia Are infected with HIV or on antiretroviral therapy and doing well

20. Removing the Intrauterine Device IMPORTANT: Providers must not refuse or delay when a woman asks to have her IUD removed, whatever her reason, whether it is personal or medical. All staff must understand and agree that she must not be pressured or forced to continue using the IUD

21. Hormonal (Levonorgestrel Intrauterine ) Device What Is the Levonorgestrel Intrauterine Device? The levonorgestrel intrauterine device (LNG-IUD) is a T-shaped plastic device that steadily releases small amounts of levonorgestrel each day. (Levonorgestrel is a progestin widely used in implants and oral contraceptive pills.) A specifically trained health care provider inserts it into a woman’s uterus through her vagina and cervix. Also called the hormonal IUD. Marketed under the brand name Mirena. Works primarily by suppressing the growth of the lining of uterus (endometrium).

22. Hormonal contraceptives I-Oral pills 1. Combined pill 2. Progestrone only pill POP 3. Post-coital contraception (morning after) 4. Once-a month long acting pill (ineffective) 5. Male pill II- Depot (slow releasing formulations) III- Injectables IV- Subcutaneous implants V- Vaginal rings

23. Hormonal contraceptives Combined Oral Contraceptives What Are Combined Oral Contraceptives? Pills that contain low doses of 2 hormones—a progestin and an estrogen—like the natural hormones progesterone and estrogen in a woman’s body. Combined oral contraceptives (COCs) are also called “the Pill,”low- dose combined pills, OCPs, and OCs. Work primarily by preventing the release of ova from the ovaries (ovulation). How Effective? Effectiveness depends on the user: Risk of pregnancy is greatest when a woman starts a new pill pack 3 or more days late, or misses 3 or more pills near the beginning or end of a pill pack

24. Combined Oral Contraceptives

25. Side Effects, Health Benefits, and Health Risks Side Effects Some users report the following :Changes in bleeding patterns including: – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Infrequent bleeding – No monthly bleeding Headaches Dizziness Nausea Breast tenderness Weight change Mood changes Acne (can improve or worsen, but usually improves) Other possible physical changes: Blood pressure increases a few points (mm Hg). When increase is due to COCs, blood pressure declines quickly after use of COCs stops.

26. Known Health Benefits Help protect against: Risks of pregnancy Cancer of the lining of the uterus (endometrial cancer) Cancer of the ovary Symptomatic pelvic inflammatory disease May help protect against: Ovarian cysts Iron-deficiency anemia Reduce: Menstrual cramps Menstrual bleeding problems Ovulation pain Excess hair on face or body Symptoms of polycystic ovarian syndrome (irregular bleeding,acne, excess hair on face or body) Symptoms of endometriosis (pelvic pain, irregular bleeding)

27. Known Health Risks Very rare: Blood clot in deep veins of legs or lungs (deep vein thrombosis or pulmonary embolism) Extremely rare: Stroke Heart attack

28. Who Can and Cannot Use Combined Oral Contraceptives Safe and Suitable for Nearly All Women Nearly all women can use COCs safely and effectively, including women who: Have or have not had children Are of any age, including adolescents and women over 40 years old Have just had an abortion or miscarriage Have anemia now or had in the past Have varicose veins Are infected with HIV, whether or not on antiretroviral therapy Women can begin using COCs even when a woman is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant.

29. Progestin-Only Pills (POP) Pills that contain very low doses of a progestin like the natural hormone progesterone in a woman’s body. Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen. Progestin-only pills (POPs) are also called “minipills” and progestin- only. Work primarily by: – Thickening cervical mucus (this blocks sperm from meeting an ovum) – Disrupting the menstrual cycle, including preventing the release of ova from the ovaries (ovulation)

30. Progestin-Only Pills (POP)

31. Others Morning after pill Once-a month pill Male pill

32. Progestin-Only Injectables What Are Progestin-Only Injectables? The injectable contraceptives each contain a progestin like the natural hormone progesterone in a woman’s body. (In contrast, monthly injectables contain both estrogen and progestin. Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen. DMPA, the most widely used progestin-only injectable, is also known as“the shot,” “the jab,” NET-EN is another type Given by injection into the muscle (intramuscular injection). The hormone is then released slowly into the bloodstream. A different formulation of DMPA can be injected just under the skin (subcutaneous injection). Work primarily by preventing the release of ova from the ovaries (ovulation).

33. Progestin-Only Injectables

34. Progestin-Only Injectables (New DMPA-SC)

35. Monthly Injectables What Are Monthly Injectables? Monthly injectables contain 2 hormones—a progestin and an estrogen—like the natural hormones progesterone and estrogen in a woman’s body. Work primarily by preventing the release of ova from the ovaries (ovulation).

36. Monthly Injectables

37. Combined Patch What Is the Combined Patch? A small, thin, square of flexible plastic worn on the body. Continuously releases 2 hormones—a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman’s body— directly through the skin into the bloodstream. A new patch is worn every week for 3 weeks, then no patch for the fourth week. During this fourth week the woman will have monthly bleeding. Works primarily by preventing the release of ova from the ovaries (ovulation).

38. Combined Vaginal Ring What Is the Combined Vaginal Ring? A flexible ring placed in the vagina. Continuously releases 2 hormones—a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman’s body—from inside the ring. Hormones are absorbed through the wall of the vagina directly into the bloodstream. The ring is kept in place for 3 weeks, then removed for the fourth week. During this fourth week the woman will have monthly bleeding.. Works primarily by preventing the release of ova from the ovaries (ovulation).

39. Implants What Are Implants? Small plastic rods or capsules, each about the size of a matchstick, that release a progestin like the natural hormone progesterone in a woman’s body. Provide long-term pregnancy protection. Very effective for 3 to 7 years, depending on the type of implant, immediately reversible. A specifically trained provider performs a minor surgical procedure to place the implants under the skin on the inside of a woman’s upper arm. Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen. Work primarily by: – Thickening cervical mucus (this blocks sperm from meeting an ovum) – Disrupting the menstrual cycle, including preventing the release of ova from the ovaries (ovulation)

40. Other methods Withdrawal (coitus interruptus) Breast feeding (Lactational Amenorrhea Method) Natural family planning methods (Fertility Awareness Methods) including the Safe period

41. Breast feeding (Lactational Amenorrhea Method) The lactational amenorrhea method (LAM) requires 3 conditions. All 3 must be met: 1. The mother’s monthly bleeding has not returned 2. The baby is fully or nearly fully breastfed and is fed often, day and night 3. The baby is less than 6 months old

42. What Are Fertility Awareness Methods? “Fertility awareness” means that a woman knows how to tell when the fertile time of her menstrual cycle starts and ends. (The fertile time is when she can become pregnant.) Sometimes called natural family planning.

43. Fertility Awareness Methods? A woman can use several ways, alone or in combination, to tell when her fertile time begins and ends. Calendar-based methods involve keeping track of days of the menstrual cycle to identify the start and end of the fertile time. Examples: Standard Days Method and calendar rhythm method. Symptoms-based methods depend on observing signs of fertility. – Cervical secretions: When a woman sees or feels cervical secretions, she may be fertile. She may feel just a little vaginal wetness. Basal body temperature (BBT): A woman’s resting body temperature goes up slightly after the release of an ovum (ovulation), when she could become pregnant. Her temperature stays higher until the beginning of her next monthly bleeding.

44. Female Sterilization What Is Female Sterilization? Permanent contraception for women The 2 surgical approaches most often used: −Minilaparotomy involves making a small incision in the abdomen. The fallopian tubes are brought to the incision to be cut or blocked. − Laparoscopy involves inserting a long thin tube with a lens in it into the abdomen through a small incision. Works because the fallopian tubes are blocked or cut. ova released from the ovaries cannot move down the tubes, and so they do not meet sperm.

45. Vasectomy What Is Vasectomy? Permanent contraception for men Through a puncture or small incision in the scrotum, Works by closing off each vas deferens, keeping sperm out of semen.

46. Planning Pregnancy A woman who wants to have a child can use advice about preparing for safe pregnancy and delivery and having a healthy child: It is best to wait at least 2 years after giving birth before stopping contraception to become pregnant. At least 3 months before stopping contraception to get pregnant, a woman should take care to eat a balanced diet and to continue doing so throughout pregnancy. Folic acid and iron are particularly important.

47. After Childbirth Coordinate family planning visits with an infant’s immunization schedule. Optimal breastfeeding offers triple value: 1- important improvements in child survival and health, 2- better health for mothers, and 3- temporary contraception.

48. Recommended Further Reading; 4 WHO handbooks: 1. Medical eligibility criteria for contraceptive use. 2. Selected practice recommendations for contraceptive use. 3. Family planning: a global handbook for providers. 4. Decision-making tool for family planning clients and providers.