lecture 1 family planning

Birth Control & Birth Control & Family PlanningFamily Planning

Remember Remember The The total riskstotal risks of of birth control are birth control are

much much less thanless than the the total risks of a total risks of a pregnancy!!pregnancy!!

Types of Birth ControlTypes of Birth Control

HormonalHormonal BarrierBarrier IUDIUD Methods based on Methods based on

informationinformation Permanent sterilizationPermanent sterilization

Hormonal MethodsHormonal Methods

Oral Contraceptives Oral Contraceptives

(Birth Control Pill)(Birth Control Pill) Injections (Depo-Injections (Depo-

Provera)Provera) Implants (Norplant I & II)Implants (Norplant I & II)

Birth Control PillsBirth Control Pills

Pills can be taken to prevent Pills can be taken to prevent pregnancypregnancy

Pills are safe and effective when Pills are safe and effective when taken properlytaken properly

Pills are over 99% effectivePills are over 99% effective Women must have a pap smear to Women must have a pap smear to

get a prescription for birth control get a prescription for birth control pillspills

How does the pill work?How does the pill work?

Stops ovulationStops ovulation Thins uterine liningThins uterine lining Thickens cervical mucusThickens cervical mucus

Positive Benefits of Birth Control Positive Benefits of Birth Control PillsPills

Prevents Prevents pregnancypregnancy

Eases menstrual Eases menstrual crampscramps

Shortens periodShortens periodRegulates Regulates

periodperiod

Decreases Decreases incidence of incidence of ovarian cystsovarian cysts

Prevents Prevents ovarian and ovarian and uterine uterine cancercancer

Decreases Decreases acneacne

Side-effectsSide-effects

Breast Breast tendernesstenderness

NauseaNausea Increase in Increase in

headachesheadaches

MoodinessMoodiness Weight changeWeight change SpottingSpotting

Taking the PillTaking the Pill

Once a day at the Once a day at the same timesame time everydayeveryday

Use condoms for first monthUse condoms for first month Use condoms when on antibiotics Use condoms when on antibiotics Use condoms for 1 week if you miss Use condoms for 1 week if you miss

a pill or take one latea pill or take one late The pill offers The pill offers no protection from no protection from

STD’sSTD’s

Depo-ProveraDepo-Provera

Birth control shot given once every Birth control shot given once every three months to prevent pregnancythree months to prevent pregnancy

99.7% effective preventing pregnancy99.7% effective preventing pregnancy No daily pills to remember No daily pills to remember

How does the shot How does the shot work?work?

Stops ovulationStops ovulation Stops menstrual cycles!! Stops menstrual cycles!! Thickens cervical mucusThickens cervical mucus

SIDE EFFECTSSIDE EFFECTS

Extremely irregular menstrual bleeding Extremely irregular menstrual bleeding and spotting for 3-6 months!and spotting for 3-6 months!

NO PERIOD NO PERIOD after 3-6 months after 3-6 months Weight change Weight change Breast tendernessBreast tenderness Mood changeMood change

*NOT EVERY WOMAN HAS SIDE-EFFECTS!*NOT EVERY WOMAN HAS SIDE-EFFECTS!

IMPLANTSIMPLANTS

Implants are placed in the body Implants are placed in the body filled with hormone that prevents filled with hormone that prevents pregnancypregnancy

Physically inserted in simple 15 Physically inserted in simple 15 minute outpatient procedureminute outpatient procedure

Plastic capsules the size of paper Plastic capsules the size of paper matchsticks inserted under the skin matchsticks inserted under the skin in the armin the arm

99.95% effectiveness rate99.95% effectiveness rate

Norplant I Norplant I vs. vs. Norplant II Norplant II

Six capsulesSix capsules Five yearsFive years

Two capsulesTwo capsules Three yearsThree years

Norplant ImplantNorplant Implant

Norplant Norplant ConsiderationsConsiderations

Should be considered long Should be considered long term birth control term birth control

Requires no upkeep Requires no upkeep Extremely effective in Extremely effective in

pregnancy prevention > 99%pregnancy prevention > 99%

Emergency Emergency contraception pills can contraception pills can reduce the chance of a reduce the chance of a pregnancy pregnancy by 75%by 75% if if

taken taken within 72within 72 hours hours of unprotected sex!of unprotected sex!

Emergency ContraceptionEmergency Contraception

Emergency Contraception Emergency Contraception (ECP)(ECP)

Must be taken within 72 hours of Must be taken within 72 hours of the act of unprotected intercourse the act of unprotected intercourse or failure of contraception methodor failure of contraception method

Must receive ECP from a physicianMust receive ECP from a physician 75 – 84% effective in reducing 75 – 84% effective in reducing

pregnancypregnancy California pharmacies can prescribe California pharmacies can prescribe

without a doctor! (1/1/02)without a doctor! (1/1/02)

ECPECP

Floods the ovaries with high amount of Floods the ovaries with high amount of hormone and prevents ovulationhormone and prevents ovulation

Alters the environment of the uterus, Alters the environment of the uterus, making it disruptive to the egg and spermmaking it disruptive to the egg and sperm

Two sets of pills taken exactly 12 Two sets of pills taken exactly 12 hours aparthours apart

BARRIER METHODSBARRIER METHODS

SpermicidesSpermicides Male CondomMale Condom Female CondomFemale Condom DiaphragmDiaphragm Cervical CapCervical Cap

BARRIER METHODBARRIER METHOD

Prevents pregnancy blocks the Prevents pregnancy blocks the egg and sperm from meeting egg and sperm from meeting

Barrier methods have higher Barrier methods have higher failure rates than hormonal failure rates than hormonal methods due to design and methods due to design and human errorhuman error

SPERMICIDESSPERMICIDES Chemicals kill sperm in the vaginaChemicals kill sperm in the vagina Different forms:Different forms:

--JellyJelly -Film-Film

-Foam-Foam --SuppositorySuppository Some work instantly, others Some work instantly, others

require pre-insertionrequire pre-insertion Only 76% effective (used alone), Only 76% effective (used alone),

should be used in combination with should be used in combination with another method i.e., condomsanother method i.e., condoms

MALE CONDOMMALE CONDOM

• Most common and effective barrier Most common and effective barrier method when used properlymethod when used properly

• Latex and Polyurethane should Latex and Polyurethane should only be used in the prevention of only be used in the prevention of pregnancy and spread of STI’s pregnancy and spread of STI’s (including HIV)(including HIV)

MALE CONDOMMALE CONDOM

Perfect effectiveness rate = Perfect effectiveness rate = 97%97%

Typical effectiveness rate = Typical effectiveness rate = 88%88%

Latex and polyurethane Latex and polyurethane condoms are availablecondoms are available

Combining condoms with Combining condoms with spermicides raises effectiveness spermicides raises effectiveness levels to 99%levels to 99%

FEMALE CONDOMFEMALE CONDOM

Made as an alternative to male Made as an alternative to male condomscondoms

PolyurethanePolyurethane Physically inserted in the vaginaPhysically inserted in the vagina Perfect rate = 95%Perfect rate = 95% Typical rate = 79%Typical rate = 79% Woman can use female condom if Woman can use female condom if

partner refusespartner refuses

Reality Reality : The Female : The Female CondomCondom

DIAPRAGHMDIAPRAGHM

Perfect Effectiveness Rate = 94%Perfect Effectiveness Rate = 94% Typical Effectiveness Rate = 80%Typical Effectiveness Rate = 80% Latex barrier placed inside vagina Latex barrier placed inside vagina

during intercourseduring intercourse Fitted by physicianFitted by physician Spermicidal jelly before insertionSpermicidal jelly before insertion Inserted up to 18 hours before Inserted up to 18 hours before

intercourse and can be left in for a intercourse and can be left in for a total of 24 hourstotal of 24 hours

DIAPHRAGM DIAPHRAGM

CERVICAL CAPCERVICAL CAP

Latex barrier inserted in vagina before Latex barrier inserted in vagina before intercourseintercourse

““Caps” around cervix with suctionCaps” around cervix with suction Fill with spermicidal jelly prior to useFill with spermicidal jelly prior to use Can be left in body for up to a total of Can be left in body for up to a total of

48 hours 48 hours Must be left in place six hours after Must be left in place six hours after

sexual intercoursesexual intercourse Perfect effectiveness rate = 91%Perfect effectiveness rate = 91% Typical effectiveness rate = 80%Typical effectiveness rate = 80%

INTRAUTERINE DEVICES INTRAUTERINE DEVICES (IUD)(IUD)

T-shaped object placed in the T-shaped object placed in the uterus to prevent pregnancyuterus to prevent pregnancy

Must be on period during insertionMust be on period during insertion A Natural childbirth required to useA Natural childbirth required to use

IUD IUD Extremely effective without using Extremely effective without using

hormones > 97 %hormones > 97 % Must be in monogamous Must be in monogamous

relationshiprelationship

Copper T Copper T vs.. vs..

ProgestasertProgestasert 10 years10 years 99.2 % effective99.2 % effective Copper on IUD acts Copper on IUD acts

as spermicide, IUD as spermicide, IUD blocks egg from blocks egg from implantingimplanting

Must check string Must check string before sex and before sex and after shedding of after shedding of uterine lining.uterine lining.

1 year1 year 98% effective98% effective T shaped plastic T shaped plastic

that releases that releases hormones over a hormones over a one year time frameone year time frame

Thickens mucus, Thickens mucus, blocking eggblocking egg

Check string before Check string before sex & after sex & after shedding of uterine shedding of uterine lining.lining.

STERILIZATIONSTERILIZATION

Procedure performed on a man Procedure performed on a man or a woman or a woman permanentlypermanently sterilizessterilizes

Female = Tubal LigationFemale = Tubal Ligation Male = VasectomyMale = Vasectomy

TUBAL LIGATIONTUBAL LIGATION

Surgical procedure performed on a Surgical procedure performed on a womanwoman

Fallopian tubes are cut, tied, Fallopian tubes are cut, tied, cauterized, prevents eggs from cauterized, prevents eggs from reaching spermreaching sperm

Failure rates vary by procedure, Failure rates vary by procedure, from 0.8%-3.7%from 0.8%-3.7%

May experience heavier periodsMay experience heavier periods

LAPAROSCOPY-’BAND-AID’ LAPAROSCOPY-’BAND-AID’ STERILIZATIONSTERILIZATION

VASECTOMYVASECTOMY

Male sterilization procedureMale sterilization procedure Ligation of Vas Deferens tubeLigation of Vas Deferens tube No-scalpel technique availableNo-scalpel technique available Faster and easier recovery Faster and easier recovery

than a tubal ligationthan a tubal ligation Failure rate = 0.1%, more Failure rate = 0.1%, more

effectiveeffective than female than female sterilizationsterilization

VASECTOMYVASECTOMY

METHODS BASED ON METHODS BASED ON INFORMATIONINFORMATION

WithdrawalWithdrawal Natural Family PlanningNatural Family Planning Fertility Awareness MethodFertility Awareness Method AbstinenceAbstinence

WITHDRAWALWITHDRAWAL

Removal of penis from the vagina Removal of penis from the vagina beforebefore ejaculation occurs ejaculation occurs

NOTNOT a sufficient method of birth a sufficient method of birth control by itselfcontrol by itself

Effectiveness rate is 80% (very Effectiveness rate is 80% (very unpredictable in teens, wide variation)unpredictable in teens, wide variation)

1 of 51 of 5 women practicing withdrawal women practicing withdrawal become pregnantbecome pregnant

Very difficult for a male to ‘control’ Very difficult for a male to ‘control’

Natural Family Planning & Natural Family Planning & Fertility Awareness MethodFertility Awareness Method Women take a class on the menstrual cycle Women take a class on the menstrual cycle

to calculate to calculate moremore fertilefertile times times Requires special equipment and cannot be Requires special equipment and cannot be

self-taughtself-taught NFP abstains from sex during the NFP abstains from sex during the

calculated fertile timecalculated fertile time FAM uses barrier methods during fertile FAM uses barrier methods during fertile

timetime Perfect effectiveness rate = 91%Perfect effectiveness rate = 91% Typical effectiveness rate = 75%Typical effectiveness rate = 75% No 100% safe dayNo 100% safe day-irregular periods -irregular periods

AbstinenceAbstinence

Only 100% method of birth Only 100% method of birth control control

Abstinence is when partners do Abstinence is when partners do not engage in sexual intercoursenot engage in sexual intercourse

Communication between Communication between partners is important for those partners is important for those practicing abstinence to be practicing abstinence to be successfulsuccessful

Reasons for abstainingReasons for abstaining

Moral or religious valuesMoral or religious values Personal beliefsPersonal beliefs Medical reasonsMedical reasons Not feeling ready for an Not feeling ready for an

emotional, intimate emotional, intimate relationshiprelationship

Future plansFuture plans

SOMETHING TO THINK ABOUT…SOMETHING TO THINK ABOUT…

Couples who use no birth Couples who use no birth control have a 85% control have a 85% chance of a pregnancy chance of a pregnancy within the first year.within the first year.

EXCELLENT REFERENCE EXCELLENT REFERENCE SEE:SEE:

www.plannedparenthood.org/www.plannedparenthood.org/bc bc Hatcher, Robert, MD Hatcher, Robert, MD

Contraceptive TechnologyContraceptive Technology ,17ed. (2001) ,17ed. (2001)

Quality in Family PlanningQuality in Family Planning

QualityQualityQuality 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 & ObjectivesAims & ObjectivesIn 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.

Elements of ‘Quality of Care’ Elements of ‘Quality of Care’ in in

family planningfamily planning

Choice of method Interpersonal communication (verbal &

non verbal) Technical Competence Information Follow-up Appropriate constellation of services

By Judith Bruce, 1990

Choice of methodChoice 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 Good interpersonal communication (verbal & non verbal)(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 CompetenceTechnical 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.

InformationInformation

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-upFollow-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 Appropriate constellation of servicesservices

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.

IndicatorsIndicatorsQUALITY OF CAREQUALITY 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 GATHER Approach to CounselingApproach 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 ClientsRights 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 Rights of Clients (cont.)(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 needsProvider’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 Provider’s needs (cont.)(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.

Knowledge & AttitudesKnowledge & Attitudes

Use of Family PlanningUse of Family Planning

Exposure to Family Planning Exposure to Family Planning MessagesMessages

Family Planning

Knowledge of contraceptive Knowledge of contraceptive methodsmethods

96 95

33

92 92

24

Any method Any modern method Any traditional

Currently married women All women

Percent of women age 15-49

Which modern methods are Which modern methods are mostmost

familiar to married women?familiar to married women?

90

90

83

79

77

64

54

47

Injectables

Daily pill

IUD

Condom

Monthly pill

Female sterilization

Implants

Male sterilization

Percent of currently married women age 15-49

Does knowledge of any modern Does knowledge of any modern methodmethod

vary by residence, region and vary by residence, region and education?education?

• Women with no education (91%) know slightly less about modern methods than educated women (98%)

• No urban-rural difference

Do married women discuss Do married women discuss family planning with their husbands?family planning with their husbands?

34

53

12

Never Once or twice Three or +Percent of currently married women age 15-49 in the past year

What are couples’ attitudes What are couples’ attitudes toward toward

family planningfamily planning??

9

11

6

6

68

Respondent unsure

Husband's attitude unknown

One approves, other dissaproves

Both disapprove

Both approve

Percent of women who report that they and their husband approve or not of family planning




Family Planning

Use of contraception Use of contraception amongamong

married women married women

24

19

5

Any method

Modernmethods

Traditionalmethods


Does use of contraception Does use of contraception vary vary

by a woman’s level of by a woman’s level of education?education?


1916

2319

35

23

Any method Any modern method

No education Primary Secondary and +

Contraceptive use also Contraceptive use also varies by residencevaries by residence

33% of urban women use any 33% of urban women use any method of family planning method of family planning

compared to…compared to…

22% for their rural 22% for their rural counterpartscounterparts..

Other modern methods

1%

Female sterilisation

8%

Male condom5%

Injectables40%

IUD7%

Monthly pill15%

Daily pill24%

Women’s current use of modern contraceptive methods

Source of supply forSource of supply forcontraceptive methodscontraceptive methods

38

13

57

27

44

18 17

37

5

4744

70

5

65

9

Daily pill Monthly pill Injectables Condom IUD*

Public sector Private medical Other private

Percent

*First source, limited to women who started using IUD since 1995

Intention to use Intention to use contraceptioncontraceptionin the futurein the future

4245

13

Intends to use Does not intend Unsure

Percent of currently married women who are not using a contraceptive method

Preferred method of ContraceptionPreferred method of Contraceptionfor future usefor future use

34

26

15

4 2 2

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

Some reasons cited by Some reasons cited by women for not women for not

intending to use intending to use contraceptioncontraception

Health concernsHealth concerns

Difficult to get pregnantDifficult to get pregnant

Wants more childrenWants more children

Opposed to family Opposed to family

planningplanning

Infrequent sex/no sexInfrequent sex/no sex

Fear side effectsFear side effects

26%

24%

10%

9%

8%

6%

Currently married women who are not using a contraceptive method




Family Planning

From what source do From what source do women hear family women hear family planning messages?planning messages?

From radio onlyFrom radio only

From television From television onlyonly

From bothFrom both

NO MESSAGENO MESSAGEFor all women who heard a message about family planning

in the last few months preceding the interview

10%

5%

64%

21%

ResidenceUrbanUrban 86%86%RuralRural 78%78%

EducationNoneNone 70%70%PrimaryPrimary 80%80%Secondary+Secondary+ 92%92%

Does exposure to family Does exposure to family planning messages vary by planning messages vary by residence and residence and

education?education?

ResidenceUrbanUrban 59%59%RuralRural 36%36%

EducationNoneNone 28%28%PrimaryPrimary 39%39%Secondary+Secondary+ 62%62%

Does exposure to family planning messages in the print media

vary by residence and education?

Main findingsMain 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 findingsMain 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

lecture 1 family planning

Science