Birth Control & Family Planning

Remember The total risks of birth control are much less than the total risks of a pregnancy!!

Types of Birth Control Hormonal Barrier IUD Methods based on information Permanent sterilization

Hormonal Methods Oral Contraceptives (Birth Control Pill) Injections (Depo-Provera) Implants (Norplant I & II)

Birth Control Pills Pills can be taken to prevent pregnancy Pills are safe and effective when taken properly Pills are over 99% effective Women must have a pap smear to get a prescription for birth control pills

How does the pill work? Stops ovulation Thins uterine lining Thickens cervical mucus

Positive Benefits of Birth Control Pills Prevents pregnancy Eases menstrual cramps Shortens period Regulates period Decreases incidence of ovarian cysts Prevents ovarian and uterine cancer Decreases acne

Side-effects Breast tenderness Nausea Increase in headaches Moodiness Weight change Spotting

Taking the Pill Once a day at the same time everyday Use condoms for first month Use condoms when on antibiotics Use condoms for 1 week if you miss a pill or take one late The pill offers no protection from STD’s

Depo-Provera Birth control shot given once every three months to prevent pregnancy 99.7% effective preventing pregnancy No daily pills to remember

How does the shot work? Stops ovulation Stops menstrual cycles!! Thickens cervical mucus

SIDE EFFECTS NO PERIOD  after 3-6 months Extremely irregular menstrual bleeding and spotting for 3-6 months! NO PERIOD  after 3-6 months Weight change Breast tenderness Mood change *NOT EVERY WOMAN HAS SIDE-EFFECTS!

IMPLANTS Implants are placed in the body filled with hormone that prevents pregnancy Physically inserted in simple 15 minute outpatient procedure Plastic capsules the size of paper matchsticks inserted under the skin in the arm 99.95% effectiveness rate

Norplant I vs. Norplant II Six capsules Five years Two capsules Three years

Norplant Implant

Norplant Considerations Should be considered long term birth control Requires no upkeep  Extremely effective in pregnancy prevention > 99%

Emergency Contraception Emergency contraception pills can reduce the chance of a pregnancy by 75% if taken within 72 hours of unprotected sex!

Emergency Contraception (ECP) Must be taken within 72 hours of the act of unprotected intercourse or failure of contraception method Must receive ECP from a physician 75 – 84% effective in reducing pregnancy California pharmacies can prescribe without a doctor! (1/1/02)

ECP Floods the ovaries with high amount of hormone and prevents ovulation Alters the environment of the uterus, making it disruptive to the egg and sperm Two sets of pills taken exactly 12 hours apart

BARRIER METHODS Spermicides Male Condom Female Condom Diaphragm Cervical Cap

BARRIER METHOD Prevents pregnancy blocks the egg and sperm from meeting Barrier methods have higher failure rates than hormonal methods due to design and human error

SPERMICIDES Chemicals kill sperm in the vagina Different forms: -Jelly -Film -Foam -Suppository Some work instantly, others require pre-insertion Only 76% effective (used alone), should be used in combination with another method i.e., condoms

MALE CONDOM Most common and effective barrier method when used properly Latex and Polyurethane should only be used in the prevention of pregnancy and spread of STI’s (including HIV)

MALE CONDOM Perfect effectiveness rate = 97% Typical effectiveness rate = 88% Latex and polyurethane condoms are available Combining condoms with spermicides raises effectiveness levels to 99%

FEMALE CONDOM Made as an alternative to male condoms Polyurethane Physically inserted in the vagina Perfect rate = 95% Typical rate = 79% Woman can use female condom if partner refuses

Reality  : The Female Condom

DIAPRAGHM Perfect Effectiveness Rate = 94% Typical Effectiveness Rate = 80% Latex barrier placed inside vagina during intercourse Fitted by physician Spermicidal jelly before insertion Inserted up to 18 hours before intercourse and can be left in for a total of 24 hours

DIAPHRAGM

CERVICAL CAP Latex barrier inserted in vagina before intercourse “Caps” around cervix with suction Fill with spermicidal jelly prior to use Can be left in body for up to a total of 48 hours Must be left in place six hours after sexual intercourse Perfect effectiveness rate = 91% Typical effectiveness rate = 80%

INTRAUTERINE DEVICES (IUD) T-shaped object placed in the uterus to prevent pregnancy Must be on period during insertion A Natural childbirth required to use IUD Extremely effective without using hormones > 97 % Must be in monogamous relationship

Copper T vs.. Progestasert 10 years 99.2 % effective Copper on IUD acts as spermicide, IUD blocks egg from implanting Must check string before sex and after shedding of uterine lining. 1 year 98% effective T shaped plastic that releases hormones over a one year time frame Thickens mucus, blocking egg Check string before sex & after shedding of uterine lining.

STERILIZATION Procedure performed on a man or a woman permanently sterilizes Female = Tubal Ligation Male = Vasectomy

TUBAL LIGATION Surgical procedure performed on a woman Fallopian tubes are cut, tied, cauterized, prevents eggs from reaching sperm Failure rates vary by procedure, from 0.8%-3.7% May experience heavier periods

LAPAROSCOPY-’BAND-AID’ STERILIZATION

VASECTOMY Male sterilization procedure Ligation of Vas Deferens tube No-scalpel technique available Faster and easier recovery than a tubal ligation Failure rate = 0.1%, more effective than female sterilization

VASECTOMY

METHODS BASED ON INFORMATION Withdrawal Natural Family Planning Fertility Awareness Method Abstinence

WITHDRAWAL Removal of penis from the vagina before ejaculation occurs NOT a sufficient method of birth control by itself Effectiveness rate is 80% (very unpredictable in teens, wide variation) 1 of 5 women practicing withdrawal become pregnant Very difficult for a male to ‘control’

Natural Family Planning & Fertility Awareness Method Women take a class on the menstrual cycle to calculate more fertile times Requires special equipment and cannot be self-taught NFP abstains from sex during the calculated fertile time FAM uses barrier methods during fertile time Perfect effectiveness rate = 91% Typical effectiveness rate = 75% No 100% safe day-irregular periods

Abstinence Only 100% method of birth control Abstinence is when partners do not engage in sexual intercourse Communication between partners is important for those practicing abstinence to be successful

Reasons for abstaining Moral or religious values Personal beliefs Medical reasons Not feeling ready for an emotional, intimate relationship Future plans

SOMETHING TO THINK ABOUT… Couples who use no birth control have a 85% chance of a pregnancy within the first year.

EXCELLENT REFERENCE SEE: www.plannedparenthood.org/bc Hatcher, Robert, MD Contraceptive Technology ,17ed. (2001)

Quality in Family Planning

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.

Aims & Objectives In 1994, the International Conference on Population and Development (ICPD) set a broader agenda for incorporating elements of quality in FP/RH services. to provide more and improved services to new groups of clients and to larger numbers of clients than ever before; to increase client satisfaction and client use of services; to have a positive impact on reproductive & overall health; and to increase efficiency and savings. The early family planning initiatives in the 1950s and 1960s were motivated by demographic concerns; the vanguard countries developed family planning programs in an effort to control rapid population growth. As such, the ultimate objective of these programs (and the majority that have followed) was to reduce fertility. This translated to a strong emphasis on the quantitative aspects of service delivery. How many acceptors entered the program each year? What volume of contraception was distributed? What percentage of the population at risk used a contraceptive method?

Elements of ‘Quality of Care’ in family planning By Judith Bruce, 1990 Choice of method Interpersonal communication (verbal & non verbal) Technical Competence Information Follow-up Appropriate constellation of services

Choice of method 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.

Good interpersonal communication (verbal & non verbal) It helps in conveying the right message and to build a rapport with the client. The language should be simple enough, without any technical terms so to put him/her at ease. It is a tool to get acquainted to the client’s knowledge, attitude, perceptions and feelings about the subject.

Technical Competence Quality needs command on the subject. It is inevitable to acquire all the essential knowledge and to polish one’s technical competence regarding family planning services.

Information Providing all the necessary information to the client helps him/her in using the selected method correctly, without any fear. Right information will certainly clear the myths and rumors about the subject and will improve the adopting rate among the potential clients.

Follow-up Correct and continuous follow up of the users is indispensable to monitor the possible complications with the use of contraceptives. It ensures eventually an improved continuation rate among the users.

Appropriate constellation of services Adding family planning services along with the routine ones under the same roof may attract more clientele. The clients do not have to go to some other service specialized in family planning only. Clients discuss their problems with more openness with their own physician in a friendly ambiance.

Indicators QUALITY OF CARE Number of contraceptive methods available at a specific outlet 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.

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

Rights of Clients Information about all the methods / services available. Knowledge of not only the benefits but also the risks / side effects of all the contraceptive methods / RH services to make an independent decision. Outlets providing FP/ RH services should carry a logo / indicative sign on a prominent place. They should also provide a comfortable clean environment to the clients where they will be treated with respect, attention and courtesy. 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.

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.

Provider’s needs Training will certainly help the provider to do a better counseling. It is needed to polish one’s skills to pass the right information, to help the client in decision making, to explain the use of a specific method, to screen the client etc. Information about all the FP methods/RH services.Moreover, other information about the local community like social, cultural and religious beliefs is always helpful in dealing with the FP clients. Update about the FP methods and about the new developments in the reproductive health. Outlet adequately equipped for a trained provider is an essential requirement for the FP/RH services. There should be a logo / sign to show the availability of FP services in that particular outlet.

Provider’s needs (cont.) Supplies continuous & adequate - needed at the provider’s outlet to ensure an all time good service for the users and other potential clients. Backup & referral for the complicated cases should be there, where and when needed. Feedback about the services provided in a certain outlet helps the provider to amend and ameliorate his/her services. Acknowledgement in the shape of certification or some incentives to be encouraged to continue with the same motivation and involvement.

Family Planning Knowledge & Attitudes Use of Family Planning Exposure to Family Planning Messages

Knowledge of contraceptive methods Percent of women age 15-49

Which modern methods are most familiar to married women? Percent of currently married women age 15-49

Does knowledge of any modern method vary by residence, region and education? No urban-rural difference Women with no education (91%) know slightly less about modern methods than educated women (98%)

Do married women discuss family planning with their husbands? Percent of currently married women age 15-49 in the past year

What are couples’ attitudes toward family planning? Percent of women who report that they and their husband approve or not of family planning

Family Planning Knowledge & Attitudes Use of Family Planning Exposure to Family Planning Messages

Use of contraception among married women Percent of currently married women age 15-49

Does use of contraception vary by a woman’s level of education? Percent of currently married women age 15-49

Contraceptive use also varies by residence 33% of urban women use any method of family planning compared to… 22% for their rural counterparts.

Women’s current use of modern contraceptive methods In India, only 55 percent of children under four months of age are exclusively breastfed

Source of supply for contraceptive methods Percent *First source, limited to women who started using IUD since 1995

Intention to use contraception in the future Percent of currently married women who are not using a contraceptive method

Preferred method of Contraception for future use Percent of currently married women who are not using a contraceptive method, but who intend to use

Some reasons cited by women for not intending to use contraception Health concerns Difficult to get pregnant Wants more children Opposed to family planning Infrequent sex/no sex Fear side effects 26% 24% 10% 9% 8% 6% Currently married women who are not using a contraceptive method

Family Planning Knowledge & Attitudes Use of Family Planning Exposure to Family Planning Messages

From what source do women hear family planning messages? From radio only From television only From both NO MESSAGE 10% 5% 64% 21% For all women who heard a message about family planning in the last few months preceding the interview

Does exposure to family planning messages vary by residence and education? Urban 86% Rural 78% Education None 70% Primary 80% Secondary+ 92%

Does exposure to family planning messages in the print media vary by residence and education? Urban 59% Rural 36% Education None 28% Primary 39% Secondary+ 62%

Main findings Knowledge of family planning is very high, except in two areas (56%) 19% of women use a modern method of contraception (24% use any method) Use of any contraceptive method has been increasing since 1995 (13%) to 24% in 2000 Use varies greatly by residence, region and level of education

Main findings Injectables and the daily and monthly pills are the 3 methods most used by women Slightly more than 2 women in 5 intend to use family planning in the future 4 women in 5 have heard of a family planning message in the media