Family planning

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

Introduction to Primary Care

a course of the Center of Post Graduate Studies in FM

Objectives of this session

1. Aim of family planning

2. Islamic view of family planning

3. Methods of family planning

4. Modern contraceptive methods indications, C.I., & side effects

5. Family planning counseling

6. Obstacles to family planning.

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Aim of family planning1. Essential intervention of safe motherhood

2. Pregnancy/ birth spacing

3. Promote women reproductive health.

4. Decreased maternal mortality rate

5. Promote women health.

6. Decrease neonatal death rate

7. Benefit couples, family & community.

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Definition of family planning• Use of contraceptive (CC) methods by a

husband or wife with agreement between them to regulate their fertility.

• It compromises children spacing to allow breastfeeding (bf) & safeguard mother’s & child’s heath; timing pregnancies at a safe age & adjusting children no. to family’s need & to physical, financial, educational & child raising capabilities.

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History of family planning•Fertility control: thousands of years in different forms

•Withdrawal & bf oldest methods.•Many CC recipes & instructions prescribed by Greeks, Egyptian & Islamic physicians.

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The terms family planning, CC and birth control are used interchangeably

Islamic view• Sterilization prohibited unless medical need• Allow temporary CCs use. • Prophet Mohammed “peace be upon him”:

did not object to withdrawal use. • The Qur'an : no prohibiting text

Supports child spacing - bf for 2 years.

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باز ابن كان فتاوى إذا مؤقتا الحبوب بأخذ بأس ال الضرورة عند. عملية إجراء أو الوالدة بسبب للرحم تعب أو ضرر هناك

للتعقيم س : الرحم استئصال في الحكم منع- ما الحمل أيالطبية- الجهات تتوقعها لما ومستقبلية حاضرة طبية ألسباب

والعلمية؟ هناك ج : كان إذا لكن بأس فال ضرورة هناك كان إذا

الحمل منع أسباب تعاطي يجوز كما ، بأس فال ضرورةالشرعية للمصلحة .مؤقتا

Contraceptive (CC) Methods – Modern (supply)/ natural traditional / (non-supply) – Permanent/Temporary

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1. Hormonal:a. Combined oral CCb. Progestogen onlyc. Depot injectionsd. Implantse. Emergency oralf. Transdermal CC patch

2. IUD3. Barrier methodsa. Diaphragm

b. Cap

c. Condoms (♂ ,♀)

d. Spermicides

4. Fertility awareness-based (FAB) methods 5. Lactation amenorrhea method (LAM)6. Withdrawal7. Sterilizationa. Tubal ligation (♀)b. Vasectomy (♂)

•Worldwide use: >100 million women • last 4 decades: a dramatic increase in CC usage from 15% in 1960s to 54% in 2000.

•Contains both estrogen & progestogen hormones.

Mini-Pill/ Progestin-only pills (POP)The Mini-Pill

•Contains only progestogen..

The Pill The Pill

Combined Oral Contraceptives (COCs)..

Mechanism of Action : stop ovulation.

• Come only in 28-day packs. All pills are active, so patient must take all of them.

The Pill

The Mini-Pill

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1. Monophasic : active pills has same amount of estrogen & progestin,

2. Multiphasic / biphasic & triphasic- active pills : varied amounts of hormones -.

Ways of taking combination pills—for 21 days, 28 days, 91 days or continuously. 28-day pills: take a pill at same time daily for 28 days. Usually, 1st 21 pills contain hormones & last 7 pills placebo (reminder) pills – withdrawal bleed. 21-day pills: pack contains 21 pills, take one pill daily & then wait 7 days to start a new pack- withdrawal bleed.

Types of COC pills

The Pill

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Continuous use pills / extended-cycle / 91-day pills : • contain both estrogen and progesterone • 1st 84 pills contain hormones, & last 7are placebo pills- withdrawal bleed. Only get period 4x/year. •FDA approved Lybrel, 1st continuous-use pill in 2007 - Lybrel contains only active pills. It is a 28-day pack taken continuously, with no break in between pill packets- i.e. taken 365 days a year, which completely eliminates periods• They offer a choice for women who have painful periods or who just don't like the inconvenience of having a monthly period.

Types of combination pills

The Pill

Who can & cannot use the COC pill

But usually cannot use the pill if: • BP : ≥ 140/≥90• Smoke cigarettes & age ≥35•BF : ≤6 ms • May be pregnant

• Gave birth in last 3 weeks

Most women can safely use it.

• Serious health conditions

• No protection against STIs or HIV/AIDS• No protection against STIs or HIV/AIDS

The Pill

•Stroke, migraine , breast cancer. DM >20yrs•2 + risk factors for heart disease: HT,DM, smokes, or older age.

•Gallbladder disease, liver disease, surgery•Takes pills for TB, fungal infections, or epilepsy.

Side Effects

1. Changes in bleeding patterns – Spotting

The Pill

99 9 BP, risk 9 with age (few mm Hg), return to normal quickly after stop (3 ms).

11.Thrombotic or ischemic stroke: low riskCurrent COCs: 9 MI risk if have CV RF(DM, smoking, HT)12. Risk of breast cancer: low.

2. Headache 3. Dizziness4. Nausea5. Breast tenderness6. Wt gain - slight7. Mood changes8. Acne .

10. DVT: 3x risk if use <50 mcg estrogen –

Contributing RF: obesity & 9age

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Non-contraceptive health benefits

The Pill

Help protect against:Risks of pregnancyEndometrial cancerOvarian cancerSymptomatic PIDMay help protect:Ovarian cystsIron-def. anemia

Reduce:Menstrual cramps, bleeding problemsOvulation painExcess hair face/bodySymptoms of polycystic ovarianSyndrome Symptoms of endometriosis

They are 99% effective when taken every day. Typical failure rates: 3% to 8%.

Patient may be able to start today

• Client can start any day of the menstrual cycle if you can be sure she isn’t pregnant

The Pill

If switching from another method:• If switching from the mini-pill or implants, now is the best time to start. • If switching from injectable, should start pills at time she would have had repeat injection.• If switching from IUD, and menstruated >5 days ago, can start pills now but leave IUD in place

until the next period.

After childbirth, if breastfeeding:• Can start from 6 ms after childbirth. • If baby is <6 ms old: use condoms in the meantime. After childbirth, if NOT breastfeeding:• Can start from 3 weeks after childbirth.

After miscarriage or abortion:• Can start immediately after abortion. If in the first 7

days after abortion, no extra protection is needed.

If menstruated in past 5 days:

• She can start NOW. No extra protection needed.

If menstruated > 5 days ago or if amenorrhoeic :

• She can start NOW if reasonably certain she is not pregnant (No need to wait for next period to start pills.

• She should use condoms for 7 days after taking1st pill.

• Once daily.

How to take the pill

• If use the 28-pill pack: Once finish all pills in pack, start

new pack on the next day• If use the 21-pill pack: Once finish all pills in pack, wait 7

days before starting new pack

If miss pills ALWAYS take a pill as soon as remember & continue If miss 3/+ pills or start pack 3/+ days late: • use condoms

• If miss 3 or more pills in week 3:

Skip the reminder pills (or pill-free week) and go straight to the next pack

• Throw away the missed pill(s) & continue taking pills, one each day

Forgetting pills :can lead to pregnancy!

If miss a reminder pill (28-day packs only):

•Very effective when breastfeeding.•Easy to stop: A woman who stops pills can soon become pregnant.Compared with the combined pill:•Better if bf. Does not affect quality or amount of breast-milk.•Taking pills on time is even more important. For women not bf, taking a pill > a few hours late can increase pregnancy risk.

•Fewer side-effects except for bleeding changes.

The Mini-PillThe Mini-Pill

Who can and cannot use the mini-pill

But usually cannot use it if:Most women can safely use it.

• bf ≤ 6 wks • May be pregnant

• Some other serious health conditions

• Ever had breast cancer.• Liver disease.• Has DVT/PE. • Takes Rx for TB, fungal infections, or epilepsy (seizures/fits).

Possible side-effects

• Less common: headache, tender breasts, dizziness

• Common (when not breastfeeding): irregular bleeding, spotting, no monthly bleeding

The Mini-Pill

How to take the mini-pill• Take one pill each day at the same time

• Once finished all pills in pack, start a new pack following day

• Late taking a pill?

— Take it as soon as you remember

— may need to follow special instructions if more than 3 hours late.

How to take the mini-pill• Take one pill each day at the same time

• Once finished all pills in pack, start a new pack on following day

• Late taking a pill? — Take it as soon as you remember

If miss a pill by more than 3 hours and are:• Not bf OR bf but periods have returned: use condoms for next 2 days.• Bf & periods NOT returned: No special instructions. No extra protection needed.

May be able to start today

• If not bf : can start any day of menstrual cycle if you can be sure she isn’t pregnant

• Can start today if fully bf at least 6 weeks

After miscarriage or abortion:If switching from another method: Iike the pill.

Injectable

• Very effective, safe .

• Takes longer to get pregnant after stopping.

• Changes monthly bleeding

Long-acting Injectable

• Effective : 3, 2 or 1 month . • it’s use is rising : WHO - reassuring cancer risk data & USFDA - approval of 3-monthly injectable depo medroxy-progesterone acetate (DMPA/ Depo-Provera).

• Types : 1.3-monthly injectable : progestogen only. DMPA & estradiol cypionate & norethisterone enanthate (NET-EN)

2.Combined injectable CCs (CIC ): estrogen & progestin. Monthly injectables include Cyclofem and Mesigyna.

• No much information use existing information on use of COCs.

Monthly Injectable

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Safe & Suitable for Nearly All Women.

Who can use CICs

•Not bf &< 3 weeks post delivery•Primarily bf 6 wks to 6 ms post delivery•Smokes heavily & age 35 or older•High BP (140 to 159 / 90 to 99)•Gall bladder disease /Severe liver infection, or tumor•Migraine headaches •Had breast cancer >5 yrs ago it has not returned•DM >20 yrs or have complication•Multiple RFs for CVD - older age, smoke, DM, & HT

Who can not use CICs

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•Continuously release 2 hormone: progestin & estrogen•new, limited research on effectiveness, >COC ? Side EffectsSkin irritation or rash at patch siteChanges in monthly bleeding, Headachesvaginal discharge, Vaginitis

Combined Vaginal Ring

•Contain progestogen but not estrogen hormones- so use with bf•Provide long-term pregnancy protection.• Very effective (>99%) for 3-7 yrsSide Effects•Changes in monthly bleeding• Headaches, Nausea, Abdominal pain•Acne (can improve or worsen)•Weight change•Breast tenderness•Dizziness•Mood changes

Norplant Implants

Implants

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Intrauterine Device (IUD)

•> 99% effectiveness.Side Effects•Changes in bleeding patterns (esp. 1st 3-6 ms)•Acne ,Headaches, Nausea•Breast tenderness or pain , Ovarian cysts•Weight gain ,DizzinessMood changes–Complications : Rare:•Perforation of uterine wall. •Miscarriage, preterm birth, or• Infection if woman becomes pregnant with IUD.

Copper IUD

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Safe & Suitable for Nearly All Women:

Who can use IUD

Who can not use IUD•Less than 4 weeks since giving birth•Current DVT or PE•Had breast cancer > 5 yrs ago, and not returned•Severe liver disease, infection, or tumor•Benign gestational trophoblast disease•Current ovarian cancer• A very high risk for gonorrhea or chlamydia at time of insertion•Has AIDS not on antiretroviral therapy & clinically well

Copper IUD

•Natural methods •FAB methods : attempt to determine days in a woman’s menstrual cycle when she is fertile,. •Most useful when a woman has regular and predictable menstrual cycles.• On days when fertility is greatest : a couple can use alternative barrier method - condoms or a diaphragm.

Fertility Awareness-Based Methods(FAB)

Fertility Awareness

•FAB advantages : safe & inexpensive. Religious convictions make FAB only acceptable method of birth control.

Failure causes1. Do not keep careful records , not trained2. Women have irregular cycles3. Couples may find intervals of abstinence during fertile days too

long. FAB require both partners have a strong commitment to use the techniques correctly & consistently.

Methods: :- 1.Standard Days Method: (SDM)2. Calendar Rhythm Method (CRM)3. Cervical Mucus Testing: a woman observes changes in her cervical mucus to tell her when she may be fertile.

Fertility Awareness-Based Methods(FAB)

Fertility Awareness

The SDM method: New - >95% effective if used correctly. •A woman is considered fertile between days 8 through 19 counting day 1 as 1st day of menstruation. Women can use SDM if have regular cycles never <26 days or >32 days.

The CRM method: At least 90% effective when used correctly• a woman keeps track of length of her menstrual cycles for 6-12 months to figure out the days when she is likely to get pregnant.

SDM & CRM Methods: involve counting days in menstrual cycle &woman must know which day of her menstrual cycle she is on.

Lactational Amenorrhea Method (LAM )

LAM

• It is based on physiologic effect of suckling to suppress ovulation. • bf women can start to use LAM as a CC after birth if meet all 3 conditions1.Fully or nearly fully bf, includes exclusive bf, almost exclusive bf, & nearly fully bf, day & night, on demand by infant.2.baby must be <6 months old 3.mother's menses not have returned.

• 98%-99% effective (perfect use).• Can support LAM with : Mini-pill , IUD , Condum/diapgragm.

LAM can be taught during prenatal, perinatal, or postnatal periods .

This chart shows how effective methods are as usually used. The top four methods are most effective; user has nothing to do.

The effectiveness of the other methods depends on the user’s behaviour. These other methods are more effective when used correctly .

Comparing effectiveness of methods

Least effective

Generally 2 or fewer pregnancies per 100 women in one year

About 15 pregnancies

per 100 women in one year

About 30 pregnancies

per 100 women in one year

IUDImplants

Need repeat injections every 1 to 3 months

Must take a pill each day

Must follow LAM instructions

How to make your method most effective

One-time procedures. Nothing to do or remember .

Injectables

Pills

LAM (up to 6 months postpartum)

Female Sterilization

Most effective

*This ranking is based on a simplified calendar method. Some other fertility awareness-based methods that more accurately identify the fertile period, including the Standard Days Method, are more effective.

Vasectomy

Must use every time you have sex; requires partner’s cooperation.

Must abstain or use condoms on fertiledays; requires partner’s cooperation.

Must use every time you have sex

Must use every time you have sex

Must use every time you have sex; requires partner’s cooperation.

Male Condoms

Female Condom

Diaphragm

Spermicides

Fertility Awareness-Based

Methods*

Emergency Contraception (EC)

Emergency CC pills: • Take pills as soon as possible. ideally : within 72 hrs (3 days).• Can be up to 120 hrs (5 days) after - less effective each day passes.

• Consider EC if: — no method was used — a method was used incorrectly - missed pills, late for injection— method failed - broken condom, expelled IUD

EmergencyContraception

Levonorgestrel-only ECPs •Less nausea &vomiting than combined ECPs.•Dosage: 1.5 mg levonorgestrel in a single dose. Combined estrogen-progestogen ECPs•Use if levonorgestrel-only pills are unavailable.•Dosage: 2 doses of 100 mcg of ethinylestradiol + 0.5 mg of levonorgestrel, 12 hours apart.

Emergency copper IUD: •More effective than pills. Can also be used up to 5 days. •Good choice for women who want to keep using an IUD.

The Medical eligibility criteria wheel for CC use - WHO, 2007

WHO Medical Eligibility Criteria for Starting Contraceptive Methods

WHO Category

With Clinical Judgement

With Limited Clinical Judgement

1Use method in any circumstances

Use the method

2Generally use the method

Use the method

3

Use of method not usually recommended unless other, appropriate methods not available or acceptable

Do not use the method

4Method not to be used

Do not use the method

WHO Categories for Temporary Methods

CONDITIONCOCsPOCsDMPANPFSVasConIUDSpermDia/CCFAMBLAM

PregnantN/AN/AN/AN/ADelay—1411——

Age

Less than 18 (< 20 for IUD)

1121Caution3 —a12111b , c1

18 to 391111Accepta—a1 11111

40 to 452111Accepta—a11111b , c1

over 45 2121Accepta—a11111b , c1

Smoking

Less than age 35

2111Accepta—a111111

Age 35 and over

High blood pressure (hypertension)Systolic 140-

159 or diastolic 90-99

3121Caution—111111f

Systolic 160 and over or

diastolic 100 and over

4232Refer—1f11f1f1f1

Adequately conntrolled

hypertension where blood

pressure can be monitored

3121Caution—1 11 111f

Past hypertension where blood

pressure cannot be evaluated

3222Caution—111111

DiabetesPast elevated

blood sugar levels during

pregnancy

1111Accept—111111

Diabetes without vascular disease

Part of the table of WHO Medical Eligibility Criteria for Starting Contraceptive Methods

Family Planning Counseling

•As many as 50% of pregnancies are unplanned & 25% are unwanted. •Millions use family planning but fail why? :- 1.Not e received clear use instructions\2.Could not get a method better suited them, 3.Not prepared for side effects. Moreover, family planning job will never finishGeneration after generation, always needing family planning & other health care.

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Family Planning Counseling

•Helps patients to make choices about their reproductive options & CC methods. •Helps use chosen method safely &effectively •Most important step: uncover patient fears• Clarification of CC type wanted can help bridge gap between service availability & patient’ needs • should provide correct & updated information• It improve patient continuation & compliance.

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“Choice” is key word in today’s family planning

Family Planning obstacles1. Unmeet needs of women:• Services & supplies not yet available everywhere• Choices are limited. • Fear of social or partner’s disapproval. • Worries of side effects & health concerns • lack knowledge about CC options & their use.2. Poor compliance3. Ineffective health education to women & family4. Insufficient training of health providers5. Counseling services not available.

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تم بحمد تم بحمد Thankاللهاللهyou

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