Progesterone Vaginal Ring Session 2: Who Can and Cannot Use the PVR Photo credits: © 2006 David Alexander/CCP, Courtesy of Photoshare Session II, Slide 1

PVR: Session 2 Learning Objective In this session, the learner will be able to demonstrate how to screen women for medical eligibility to use the PVR. In the previous session, you learnt about the PVR, its mechanism of action, advantages and disadvantages and who can benefit from its use. In this session, you will learn how to screen women so that they are eligible to use the PVR. Session II, Slide 2

Who Can Use the PVR? Women who can use the PVR are… Breastfeeding at least 4 times a day 4–12 weeks postpartum and NOT pregnant The PVR is a contraceptive that women who are postpartum and breastfeeding can use. Therefore, as the first picture indicates a woman has to be breastfeeding at least four times/day for the PVR to be effective. Second, the woman should have delivered her baby between 4 and 12 weeks ago. If she had delivered within the past 4 weeks or she is beyond 12 weeks postpartum, she cannot use the PVR. Also, she should not be pregnant at the time she is going to start. In summary, she should be within the window of 4-12 weeks after birth and not be pregnant. Two other items to pay attention to are: The client does not have any medical condition that will contraindicate her using the PVR. Her menses should not have returned after having delivered. If all these conditions are met, the PVR will be a good option for the woman to consider. Do NOT have a serious health condition Menses have NOT returned Session II, Slide 3

Who Cannot Use the PVR? Women who cannot use the PVR are… Less than 4 weeks postpartum Ask her to come back when baby is 4 weeks old. Over 12 weeks postpartum Ask her to choose a different method. Breastfeeding less than 4 times a day Urge her to keep breastfeeding and to return for the PVR when she is breastfeeding at least 4 times a day. May be pregnant If in doubt, use pregnancy checklist or perform pregnancy test if available at your facility. Some other serious health conditions Currently have genital or urinary tract infection (can start PVR after remedied or treatment started). Pelvic Inflammatory Disease or Salpingitis since delivery. History of: uterine disease (endometrial or cervical), uterine abnormalities, migraine with symptoms, recurrent urinary tract infections, ectopic pregnancy, pelvic surgery, breast cancer, deep venous thrombosis, thromboembolic disorders, incomplete involution of the uterus after birth, pulmonary edema, liver damage or illness, presence of an IUD, STI, sensitivity to silicone. Women who cannot use the PVR are… In the earlier slide, we learnt about who can use the PVR. Now, let us review which type of women who cannot use the PVR. The first column lists who cannot use the PVR and the second column provides advice or information that can be provided. If the woman is less than 4 weeks postpartum: Advise the woman to come back when the baby is 4 weeks old. If the woman is breastfeeding less than 4/times a day: Advise the woman to keep breastfeeding for her baby’s health and when she breastfeeds at least 4 times to return for the PVR. She may be pregnant: Use the pregnancy checklist or perform a pregnancy test to rule out pregnancy. If she has some other serious health condition: Treat her for genital or urinary tract infections; refer her to care for other health conditions. Session II, Slide 4

The PVR is Safe for Nearly All Women Almost all women can use the PVR safely, including women who: Smoke cigarettes Have anemia now or have had it in the past Have varicose veins Are not married Are of any age, including adolescents and women over 40 years old Are infected with HIV (on antiretroviral therapy or not) The PVR is safe for nearly all women. Once you have determined that the woman is between 4 and 12 weeks postpartum and not menstruating, that she breastfeeding and intends to breastfeed at least four times, and is healthy you can proceed. Most women can use the PVR safely and effectively: Their marital status (if they are married or not) does not matter They can be of any age from adolescents to over 40 Women with HIV can use the PVR whether or not they are on Antiretroviral therapy Whether they smoke cigarettes or not Whether they have anemia now or had it in the past or If they have varicose veins Most health conditions do not affect safe and effective use of the PVR Finally, women who cannot use contraceptives that have estrogen in them can safely use the PVR because it contains only natural progesterone. Most health conditions do not affect safe and effective use of the PVR. Many women who cannot use methods that contain estrogen can safely use the PVR. Session II, Slide 5

Why might these women prefer or avoid using the PVR? Breastfeeding mother Infected with HIV Has little to no access to a health care facility Desires no more children Adolescent Now, let us use what we have learnt so far and see if the PVR would be a good match for these women. Breastfeeding mother It is a good method for her if she is breastfeeding and intends to breastfeed at least 4 times a day 2. Woman with HIV Women with HIV can use the PVR However, since the PVR does not protect against HIV transmission, she/her partner will have to use female/male condoms during sex 3. Little or no access to health care facility The PVR will be a good method but she will need to return to a health facility at the end of three months to get a new PVR. 4. Desires no more children The PVR is good for the first year postpartum. Hence at the end of the first year she will have to get a different contraceptive. For women who wish to have no more children, this method may not be the best option. 5. Adolescent Adolescents can use the PVR safely and effectively as long as they are breastfeeding The PVR has few side-effects It will help space pregnancies, especially for first time parents. The PVR has the potential to reduce access barriers while providing a safe alternative to young and perhaps new contraceptors. Session II, Slide 6

This set of questions identifies women who should not use the PVR. Understanding the PVR Checklist This set of questions identifies women who are not pregnant. Explain: Once you have led a client through an informed decision-making process to identify the contraceptive method she wishes to use, and she has selected the PVR as the method she prefers, use the PVR Eligibility Checklist (pictured here) to help determine whether she is medically eligible to use that method. Explain: that you do not expect providers to be able to read the text of the Checklist on the slide, but you want them to focus on the two balloons, which describe the parts of the Checklist. Invite: a volunteer to read the blue balloon. Comment: You will use this part of the checklist to help ensure that the client is not pregnant. Invite: a volunteer to read the second balloon. Comment: You will use this part of the checklist to determine whether the client is medically eligible to use the PVR. Ask: providers whether they have ever used a checklist like this as part of screening a woman for using a contraceptive method. Listen: to their responses. Explain: that they are going to have an opportunity to practice using the PVR Checklist during the next activity. This set of questions identifies women who should not use the PVR. Session II, Slide 7

When to Start the PVR? When a provider is reasonably certain a woman is not pregnant. Pregnancy can be ruled out if any of these situations apply: Is fully breastfeeding, has no menses, and baby is between 4 weeks and 6 months old Abstained from intercourse since last menses or delivery Pregnancy checklist from the MEC and FP Handbook indicates she is not pregnant Negative pregnancy test if a pregnancy test is available If the woman is between 4–12 weeks postpartum Consistently breastfeeding at least 4 times a day Ask: If a woman is medically eligible and wants to use the PVR, when can she start? Listen: to the providers’ answers. Click: one time to show the first bullet and review: “When a provider is reasonably certain a woman is not pregnant.” Click: again to show how the provider can be reasonably certain a woman is not pregnant. Click: again to reveal the statement: “If the woman is between 4–12 weeks postpartum” and review. Click: one more time and review: “Consistently breastfeeding at least 4 times a day.” Invite: one provider to read aloud the statement on the slide: “If all the above are true, the woman can start immediately!” If all the above are true, the woman can start immediately! Source: WHO, 2004 (updated 2008). Session II, Slide 8