FAMILY PLANNING NOTES.ppt

1. FAMILY PLANNING

2. Definition • Allowing individuals and couples to decide on the number and spacing of their children achieved through use of contraception. • Voluntary action taken by individuals to prevent or delay a pregnancy

3. • Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. • A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy.

4. Birth spacing • Unintended pregnancies are often associated with short between-birth intervals, which can have deadly consequences for infants and children. • WHO recommendation – 2-3 years • After a miscarriage or induced abortion, the recommended minimum interval to next pregnancy is at least six months

5. Birth spacing • Women should wait at least two years after giving birth before getting pregnant again. • Family planning education, counselling, and contraceptive services can help in spacing births at intervals recommended for the health of the mother and the baby.

6. Risks of spacing pregnancies too close A pregnancy within 12 months of giving birth is associated with an increased risk of: • Placental abruption • Placenta previa in women who had a first birth by C-section • Autism in second-born children • An increased risk of uterine rupture in women who attempt vaginal birth after cesarean (VBAC) less than 18 months after a previous delivery. • Low birth weight • Small size for gestational age • Preterm birth

7. Risks associated with spacing pregnancies too far apart A pregnancy five years or more after giving birth is associated with an increased risk of: • Pre-eclampsia • Preterm birth • Low birth weight • Small size for gestational age

8. Kenya statistics • Kenya’s average total fertility in 2010 is between 4-5 children per woman (TFR- 4.6) • Contraceptive prevalence rate (CPR) is at 46% however it falls far below the national target for CPR of 56% by 2015. • Maternal mortality rate (MMR) of 488 per 100,000 live births has not improved. • Unmet need for FP is 24%.

9. Kenya statistics • Half of all pregnancies in Kenya occur less than 24 months after the preceding birth while 15% of these pregnancies occur within short intervals of less than 12 months and 35% occur within intervals of 12-23 months (KDHS, 2008-09). • Social and cultural beliefs and practices, gender dynamics, lack of male involvement, and weak health management systems continue to impede the demand for and utilization of reproductive health care.

10. Rights of FP client All clients have certain rights, including: • The right to decide whether to practice FP • The freedom to choose which method to use • The right to privacy and conﬁdentiality • The right to refuse any type of examination • The freedom to choose where to seek services

11. Family Planning clients have right to freely choose whether to: • Have children, and how many to have • Use FP or not • Be tested for STIs/ HIV • Use condoms • Have one or more sexual partners • Talk with partner about condoms or FP • Reveal their HIV status

12. Factors affecting access of FP • These factors include logistical, social, and behavioural barriers to meeting the contraceptive needs and wishes of individuals and couples, as well as obstacles that stem from the organization of the services. • The major restrictive barriers include distance, cost, religion, culture, provider bias, and legal and medical regulations.

13. UNMET NEED OF FP • Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of their next child. • Unmet need for contraception can lead to unintended pregnancies, which pose risks for women, their families, and societies. • In less developed countries, about one-fourth of pregnancies are unintended—that is, either unwanted or mistimed

14. Unmet need is especially high among groups such as: • Adolescents • Migrants • Urban slum dwellers • Refugees • Women in the postpartum period

15. WHO categories The WHO groups medical conditions into these four categories: 1. Conditions for which there is no restriction on the use of the contraceptive method. 2. Conditions for which the advantages of using the method generally outweigh the theoretical or proven risks. In most situations, the method can be used freely, but careful follow-up might be required.

16. WHO categories 3. Conditions for which the theoretical or proven risks usually outweigh the advantages of using the method. In this case, use of the method is not usually recommended unless other more appropriate alternative methods are not available or acceptable. 4. Conditions that present an unacceptable health risk if the contraceptive method is used, (i.e., the method should not be used).

17. WHO categories` Conditions represent either: • A physiological status (e.g. parity, breastfeeding), • A group with special needs (adolescents, perimenopausal women) • A health problem (e.g. headache, irregular bleeding) • A known pre-existing medical condition (e.g. hypertension, STI, diabetes)

18. Legal Issues related to Family Planning and Contraception • May vary from state to state concerning minors, sterilization, and abortions. • Informed consent-need to document information provided and understanding of client -the nurse should use (BRAIDED) when counseling client on contraceptive methods • decision about contraception should be made voluntarily with informed consent

19. Initiating a method Counseling is very important (GATHER) • GREET • ASK • TELL • HELP • EXPLAIN • RETURN/REFER

20. BRAIDED • B- Benefits/Advantages • R-Risks/Disadvantages • A- Alternatives/Other methods available • I-Inquiries/ Allow time for questions • D-Decisions/opportunity to decide or change mind • E-Explanation/about method/how to use • D-Documentation /everything taught

21. Stages of FP Counseling • Establish rapport and assess client’s needs and concerns • Provide information to address client’s needs and concerns • Help client make an informed decision or address a problem • Help carry out client’s decision

22. Assess Client’s Needs, Concerns • Greet client appropriately • Ensure privacy, confidentiality, and client comfort • Ask about reason for visit • Ask about partner(s), home life, family, health, sexual behavior, HIV status • Ask about plans to have children, desire for FP • Explore STI risk and what client does to avoid STI’s

23. Provide Information to Address Client’s • Needs and Concerns • Inform client when needs or concerns are beyond health worker capability • Advise on how to prevent STIs • Advise on how to have a healthy pregnancy (if client wants to become pregnant) • Explain benefits of FP and healthy spacing • If client wants FP, help client identify methods suited to her needs • Give information on methods of interest • Respond to other client questions or concerns

24. Why clients choose a method • Effectiveness • How long client wants • protection from pregnancy • Ease of use • Health benefits and possible side effects • Safety

25. Help Client Make Informed Decision • Ask client if she or he has any questions about methods you discussed • Ask client to choose a method • Use pregnancy checklist or method • screening checklist to determine if client can use method • Agree on decision or plan in partnership with client

26. Help Carry Out Client’s Decision • Role-play or rehearse negotiation skills • Give FP method and condoms, if needed • Explain/ demonstrate correct use • Ask client to explain/ demonstrate, reinforce understanding or correct demonstration • Remind client about side effects, reasons to return • Arrange follow-up, resupply, or referral, as needed

27. Elements of good counseling • Focus on the woman's needs and knowledge • Assess the context of the problem with the woman • Actively listen and learn from her • Engage in interactive discussion • Utilize skilled ways of asking questions • Explore situations and beliefs • Do not be judgmental • Build trust • Explore options together • Facilitate problem-solving • Make a plan of action together • Encourage and reinforce actions • Evaluate together your plan of action

28. Counseling is Not … • Solving a client’s problems • Telling a client what to do or making decisions for client • Judging, blaming, or lecturing a client • Interrogating a client • Imposing your beliefs • Pressuring a client to use a specific method • Lying to or misleading a client

29. Counseling messages • Dual protection • Supermarket approach – wide range to choose from • Values and attitudes among the health worker • Infection prevention

30. Rumours and misconceptions about FP • injectable cause abortion • remain infertile after removal of implants • implant will move from my arm to other parts of the body • You might get cancer or go blind if you have an implant inserted

31. TYPES OF CONTRACEPTIVES

32. Methods of FP and contraceptive • Hormonal contraception • Mechanical methods • Fertility based awareness methods • Surgical contraception

33. Hormonal methods of family planning and contraceptive • This is the most common used method of family planning and contraceptive . • Hormonal contraceptives are highly effective (if used correctly), safe, and convenient. They can be taken in the form of oral pills, injectables, implants, skin patches, or hormone-releasing intrauterine systems. - Combined oral contraceptives • · Emergency pills • · Ordinary pills • -Progesterone only contraceptives • · Injectables • · Implants i.e. Jadelle®, Implanon® , Norplant®

34. Hormonal Contraceptives The following are the methods commonly available in Kenya: ■ Combined oral contraceptive pill (COC) ■ Progestin-only contraceptive pill (POP) ■ Progestin-only injectable contraceptives (DMPA, NET-EN) ■ Progestin-only contraceptive implants (Norplant, Jadelle)

35. Less common methods in Kenya • Combined injectable contraceptives • Combined contraceptive (skin) patch (Evra), • Combined vaginal contraceptive ring (NuvaRing), which releases a daily dose of hormone when the ring is placed high up in the vagina. • Hormone-Releasing Intrauterine Contraceptive Device (IUCDs) family planning and Contraceptive Device - made of plastic and work by releasing a progestin, levonorgestrel, during a period of five years. • Mirena and LNG-20 IUS are the most widely used hormone-releasing intrauterine system

36. Hormonal Contraceptives COCs are highly effective , they primarily prevent pregnancy by: ■ Suppressing ovulation ■ Thickening the cervical mucus, thereby preventing penetration of the sperm ■ Possibly changing the endometrial lining, making implantation less likely

37. COMBINED ORAL CONTRACEPTIVE PILL • Contains a combination of PROGESTOGEN and OESTROGEN the quantities of which may vary with the particular preparation. • The pill acts by: inhibiting ovulation and thickening cervical mucus, thus providing a physical barrier to spermatozoa and making the endometrium too thin for implantation.

38. Types Pills come in packets of 21 or 28 tablets. In the 28-pill packet only the first 21 are active pills (they contain hormones); the remaining 7 are not active and usually contain iron. The low-dose pill comes in three types: ■ Monophasic– each active pill contains the same amount of oestrogen and progestin. Examples are Microgynon, Lo- Femenal, Nordette, Marvelon. ■ Biphasic– the active pills in the packet contain two different dose-combinations of oestrogen and progestin. For example in a cycle of 21 active pills, 10 may contain one combination while 11 contain another. Examples are Biphasil, Ovanon, Normovlar.

39. Types ■ Triphasic– the active pills contain three different dose combinations of oestrogen and progestin. Out of a cycle of 21 active pills, 6 may contain one combination, 5 another combination, while 10 pills contain other combinations of the same two hormones. Examples are Logynon and Trinordial.

40. Advantages of COCs Contraceptive Benefits As a method of contraception, COCs have many benefits: • COCs are highly effective and are effective immediately when started within the first five days of the menstrual cycle. • COCs are safe for the majority of women. • COCs are easy to use. • COCs can be provided by trained non-clinical service providers. • A pelvic exam is not required to initiate use if COCs.

41. Non-contraceptive Benefits • Reduce menstrual flow (lighter, shorter periods) • Decrease dysmenorrhoea. • Protect against ovarian and endometrial cancer • Decrease benign breast disease • Prevent ectopic pregnancy. • Improvement and prevention of anaemia • Possible protection from symptomatic pelvic inﬂammatory disease • Treatment for acne and hirsutism

42. Eligibility for Using COCs Women Who Can Use COCs without Restrictions (Category 1) • Women of any parity, including women who have never given birth • Women who want highly effective protection against pregnancy and who feel they can follow a daily routine of pill taking • Post-abortion women (should begin within ﬁve days of abortion for immediate effectiveness) • Women with severe dysmenorrhoea • Women with a history of ectopic pregnancy • Women who suffer from headaches (can initiate pill use [category 1]; but if headaches continue, eligibility changes to category 2)

43. Eligibility for Using COCs • Women on antibiotics that do not affect effectiveness of COCs • Women with AIDS but not on antiretroviral (ARV) therapy, or those receiving ARVs that do not interfere with effectiveness of COCs • Women at increased risk of STIs, or with a very high individual risk of exposure to STIs • Women at high risk of HIV, or those already infected with HIV

44. Eligibility for Using COCs • Women with any of the following conditions: – Malaria – Non-pelvic TB – Thyroid disease – Iron-deﬁciency anaemia – Benign breast disease – Endometrial or ovarian cancer – Cervical ectropion, uterine ﬁbroids without cavity distortion or endometriosis – Abnormal vaginal bleeding patterns: irregular, heavy, or prolonged bleeding – Chronic hepatitis, carrier state or mild cirrhosis – Vaginitis, current purulent cervicitis, chlamydia or gonorrhoea or current PID – Other STIs excluding HIV and hepatitis B

45. Side effects Some women experience: • irregular menstrual bleeding, • Nausea, • weight gain, • Headaches, • Skin colour changes, and • Other side effects that may go away after several months or continue as long as oral contraceptives are taken.

46. Limitations ■ Use may be associated with minor and major side effects Minor Side Effects - Nausea (common in first 3 months) - Spotting or bleeding in between menstrual periods, especially if a woman forgets to take her pills or takes them late (common in first 3 months) - Mild headaches - Breast tenderness - Slight weight gain - Amenorrhoea (some women see amenorrhoea as an advantage

47. Limitations Major Side Effects - Serious major side effects and complications, though rare, are possible. They include myocardial infarction, stroke, and venous thrombosis/embolism. ■ Their effectiveness may be lowered when certain drugs are taken concurrently (e.g., certain anti- tuberculosis, anti-epileptic, and anti-retroviral drugs). ■ Effectiveness may also be lowered in the presence of gastroenteritis, vomiting and diarrhoea. ■ The combined pills offer no protection against STls

48. Client Education • Requires strict compliance in taking the daily regime • Highly protective against pregnancy • Pregnancy rate increases if pill not taken regularly • May cause MINOR complaints; nausea, headache, weight gain, gastrointestinal upsets • Unsuitable to breastfeeding mothers due to a relative reduction of milk output. • If you forget to take one pill, take it as soon as you remember. Take the next pill at the regular time, even if this means you take 2 pills on the same day.

49. Client Education Return to the clinic if you experience: • - suspected pregnancy • - swelling or pain in legs • - yellowing of skin or eyes • - pain in abdomen, chest, or arms; shortness of breath • - severe headaches, depression, vision difficulties.

50. Complications • Increased risk of cardiovascular disease in women over 35 years of age who smoke and increased risk of hypertension; • users exposed to STIs may be at risk of serious diseases, including PID and possibly cervical cancer.

51. PROGESTOGEN-ONLY PILL (Minipill) • This is a pill that is taken daily and contains a progestogen only. They act by altering cervical mucus making it thicker/denser, thus preventing sperm transport. Also suppresses ovulation and inhibits implantation of fertilised ovum. • contain only one hormone—progestin; they do not contain any oestrogen. •

52. Progestin-Only Pills (POPs) • Therefore they do not cause many of the side effects associated with COC use. Progestins do not suppress production of breast milk, which makes POPs an ideal contraceptive method for breastfeeding women. • POPs prevent pregnancy by thickening the cervical mucus, which prevents the passage of sperm, and suppressing ovulation in about 50 percent of cycles.

53. Types of POPs • The brands commonly available include Microlut, Micronor, Microval, Ovrette, Norgeston, and Noriday.

54. Advantages of POPs • They are effective. • They are safe (POPs have no known health risks). • Women return to fertility immediately upon discontinuation. • A pelvic exam is not required to initiate use. • They can be given to a woman at any time to start later. • Taking POPs does not affect milk production or breastfeeding. • POPs add to the contraceptive effect of breastfeeding. • Taking POPs does not increase blood clotting.

55. Non-contraceptive Benefits • Does not affect lactation • Lighter shorter periods • Decreased breast tenderness • Do not increase blood clotting • Decrease dysmenorrhoea • Protect against endometrial cancer.

56. Limitations of POPs • They provide a slightly lower level of contraceptive protection than COCs. • They require strict daily pill-taking, preferably at the same time each day. • They do not protect against STIs, including hepatitis B and HIV/AIDS. • They may lower effectiveness when certain drugs are taken concurrently (e.g., certain anti- tuberculosis, anti-retroviral and anti-epileptic drugs).

57. Side Effects of POPs • • Irregular spotting or bleeding, frequent or infrequent bleeding, prolonged bleeding, amenorrhea (less common). Bleeding changes are common, but not harmful. • • Headaches, dizziness, nausea. • • Mood changes. • • Breast tenderness (although less common than with COCs).

58. Eligibility for Using POPs Women Who Can Use This Method without Restrictions (Includes MEC Category 1) • Women of any parity, including women who have never given birth (nulliparous women) • Women immediately postpartum, if they are not breastfeeding • Breastfeeding mothers from four weeks postpartum • Women of any age who are cigarette smokers • Women who cannot use COCs as a result of oestrogen- related contraindications • Post-abortion clients

59. Eligibility for Using POPs • • Women with any of the following conditions: • – Hypertension • – Sickle cell disease • – Benign breast disease • – Viral hepatitis, acute or chronic, or mild (compensated) cirrhosis • – Gestational trophoblastic disease (GTD) • – Migraine without aura • • Obese women and girls (individuals whose BMI is greater than 30 kg/m2) • • Women with a family history (ﬁrst-degree relatives) of DVT or PE, and those who have had minor or major surgery without prolonged immobilization

60. Women Who Should Not Use POPs (Includes MEC Categories 3 and 4) • Conditions that require extra care when taking POPS • Women with diabetes (including those with vascular complications) and hypertension (BP higher than 160/100). • Undiagnosed breast lumps

61. Women Who Should Not Use POPs (Includes MEC Categories 3 and 4) • Initiate method and evaluate the lump or refer as appropriate as soon as possible. • After evaluation, women with benign breast disease fall into category 1; women with breast cancer fall into category 4 and POPs should be discontinued. • Allow it if these three criteria are met: no other method is available or acceptable, clinical judgement is possible, and careful follow-up can be assured (category 3)

62. Women Who Should Not Use POPs (Includes MEC Categories 3 and 4) These circumstances include the following: • Breastfeeding women less than four weeks postpartum • Women who have breast cancer or a history of breast cancer • Women with severe (decompensated) cirrhosis, and liver tumours (benign hepatocellular adenoma and malignancy hepatoma) • Women with acute DVT or PE • Women on any of the following: – ARV regimen with ritonavir or ritonavir-boosted protease inhibitors – Anticonvulsants, such as phenytoin, carbamazepine,barbiturates, primidone, and oxcarbazepine – Rifampicin or rifabutin therapy for TB • Women with SLE with positive or unknown antiphospholipid antibodies

63. Method Prescription and Use • POPs can be given to a woman at any time to start later. • Clients should take one pill every day. • POPs must be taken at the same time every day (+/- two hours) to avoid pregnancy and minimize side effects. • When one pack is ﬁnished, client should begin the next pack with no break in between packs. • An estimated 48 hours of POP use is usually required to achieve the contraceptive effects on cervical mucus.

64. Client Education • • Used in breastfeeding mothers because it does not interfere with lactation • • Has a high level of pregnancy protection • • There is need for compliance on a daily regimen • • Unrelated to sexual intercourse • • May cause menstrual irregularities • • If you forget to take one pill, take it as soon as you remember (see combined pills) • • Return to the clinic immediately for a pregnancy check if 45 days have passed since your last menstrual period.

65. EMERGENCY CONTRACEPTIVES • Emergency contraception (EC) refers to the use of certain contraceptive methods by women to prevent pregnancy after unprotected sexual intercourse. • Hormonal ECPs must be taken within 120 hours of intercourse, however, the sooner they are taken, the more effective they are. • Emergency contraceptives reduce the occurrence of pregnancy in unprotected intercourse from 8% to 2% (75% protection).

66. EMERGENCY CONTRACEPTIVES Indications ECPs provide a second chance or preventing pregnancy after: • unprotected sex, either accidental or coerced sex, or rape. • • Condom leakage • • Condom breakage/slippage. • An IUCD has come out of place. • A woman has run out of oral contraceptives, has missed two or more POPs, or is more than four weeks late for her DMPA injection, and has had unprotected intercourse.

67. EMERGENCY CONTRACEPTIVES Types Combined Oral Contraceptives • Two tablets of a 50 mcg pill e.g. eugynon to be taken within 72 hours of unprotected intercourse. Repeat same after in 12 hours. Requires total of 4 tablets of 50 mcg pill. OR • Four tablets of a 30 mcg pill (e.g. microgynon or nordette) to be taken within 72 hours of unprotected intercourse. Repeat same dose 12 hours later. OR Progestin-only Oral Contraceptives • one tablet of 75 mcg levonorgestrel e.g postinor 2, Pregnon, Smart lady, ECee2, and Truston2 and repeat same dose 12 hours later all within 72 hours of exposure. They are more effective than the combined pills, preventing up to 95 percent of expected pregnancies.

68. EMERGENCY CONTRACEPTIVES ECPs prevent pregnancy by: • Preventing or delaying ovulation • Inhibiting or slowing down transportation of the egg and sperm through the fallopian tubes, which prevents fertilization and implantation

69. Beneﬁts of ECP • • It is safe, effective, and easy to use. • • No medical examination or pregnancy tests are necessary or required. • • It can be used at any time during the menstrual cycle. • ECPs are available in government, private, and NGO health facilities; and over the counter at pharmacies.

70. Limitations and Side Effects of ECPs • • ECPs are only effective if used within 120 hours of unprotected intercourse. • • They are not to be used as a regular method. • • ECPs do not protect against STls, HIV/AIDS. • • They can cause nausea (more common for the COC regimen).

71. Women Who Can Use ECPs • Any woman can use ECPs, however emergency oral contraception should not be used in place of regular FP methods. • It should be emphasised that ECPs contain a much higher dose of hormones compared to the regular hormonal contraceptive methods.

72. Women Who Should Not Use ECPs • Includes MEC Categories 3 and 4 • EC is not to be used as a regular method. • Recurrent demand for ECPs is an indication that the woman requires further counselling to use other contraceptive options.

73. INJECTABLE CONTRACEPTIVES • These are either progesterone only or combined progesterone + oestrogen. • They comprise of long acting progestogen usually administered as deep intramuscular injections. They act by: suppressing ovulation, inducing a thin atrophic endometrium, producing a thick cervical mucus difficult for sperm penetration.

74. INJECTABLE CONTRACEPTIVES It is available in three forms: Depot-medroxyprogesterone acetate (DMPA): Depo-ProveraR, Megestron 150mg is given every three months (13 weeks), but it can be given as much as two weeks (14 days) earlier or four weeks (28 days) later.

75. The dosages for the different injectables • • Norethisterone enanthate (NET-EN): NoristeratR 200mg is given every two months, but it can be given as much as two weeks (14 days) earlier or two weeks (14 days) later. • • Depo-subQ provera 104 (also called DMPA-SC) is a new, lower-dose formulation of DMPA that is injected sub-cutaneously instead of intramuscularly. It contains 104 mg of DMPA instead of the 150 mg in the IM formulation. DMPA-SC is given at three-month intervals.

76. INJECTABLE CONTRACEPTIVES Client Education • May be associated with heavy menses, amenorrhoea or spotting • Regular administration as required • Return to the clinic as scheduled to continue using this method • Return to the clinic if you suspect pregnancy, dizziness, heavy bleeding. Side effects: Users may experience menstrual irregularity (amenorrhoea, spotting, and rarely, heavy bleeding). Complications Studies to date have shown no long term complications.

77. COMBINED INJECTABLE CONTRACEPTIVES • Cyclofem (DMPA 25 mg + oestradiol cypionate 5 mg) • Mesiyna/Norigynon (NET EN 50 mg + oestradiol valerate 5 mg) They give effective protection for 30 days hence the name monthly injectable. Advantages: They contain natural oestrogens and hence have a protective effect on CVS and CNS and give a better cycle control.

78. Category 2 conditions: • Women who are younger than 18 or older than 45. • Decreased bone density • Heavy or irregular vaginal bleeding patterns. Consider evaluating for an underlying condition, such as cervical cancer, after method initiation. • CIN or cervical cancer awaiting treatment. The treatment might render the woman sterile. • Migraine without aura. • History of DVT or PE, current DVT or PE and established on anticoagulant therapy, known thrombogenic mutations and hyperlipidaemias, or major surgery with prolonged immobilization. • SLE with negative antiphospholipid antibodies, on immunosuppressive treatment and those without severe thrombocytopenia. If a woman has positive or unknown antiphospholipid antibodies, she would fall into category 3.

79. Category 2 conditions: • History of hypertension, adequately controlled BP, or BP between 140/90 and 159/99. • Diagnosis of AIDS and under treatment with ARVs, including ritonavir. This applies to NET-EN only; DMPA is category 1. • Rifampicin or rifabutin for TB. This applies to NET-EN only; DMPA is category 1. • Anticonvulsants such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine. This applies to NET-EN only; DMPA is category 1. • Gall bladder disease, symptomatic or asymptomatic. • Uncomplicated diabetes. • Focal nodular hyperplasia (benign liver tumour).

80. Contraceptive implants • Are small rods that are inserted under the skin of a woman’s upper arm to release the hormone progestin slowly and prevent pregnancy. Contraceptive implants, which are also called sub-dermal implants, do not contain oestrogen; therefore, they are free from the side effects associated with that hormone. • Contraceptive implants prevent pregnancy primarily by making cervical mucus too thick for sperm to pass through it, and they also suppress ovulation in many cycles.

81. Types Device Design Hormone Duration of effectiveness Jadelle 2 rods Levonorgestrel 75 mg/rod 5 years Implanon 1 rod Etonogestrel 68 mg/rod 3 years Sino-implant [ZARIN] 2 Rods Levonorgestrel 75 mg/rod 4 years (possibly 5)

82. Advantages and Benefits of Using Contraceptive Implants Contraceptive Benefits • As a method of contraception, contraceptive implants are highly effective and safe, and they have significant benefits: • Contraception is immediate if inserted within the first seven days of menstrual cycle, or within the first five days for Implanon. • There is no delay in return to fertility. • They offer continuous, long-term protection

83. • Contraception is immediate if inserted within the first seven days of menstrual cycle, or within the first five days for Implanon. • There is no delay in return to fertility. • They offer continuous, long-term protection

84. Non-contraceptive Health Benefits • Implants do not affect breastfeeding. • They reduce menstrual flow. • They help prevent ectopic pregnancy (but do not eliminate the risk altogether). • They protect against iron-deficiency anaemia. • They help protect from symptomatic PID.

85. Benefits • • Highly effective • • Immediate return to fertility • • Offer continuous, long-term protection • • Reduce menstrual flow • • Protect against endometrial cancer and ectopic pregnancy • • Do not affect lactation.

86. Limitations of Contraceptive Implants • • Contraceptive implants must be inserted and removed by trained providers. • This requires a minor surgical procedure with appropriate infection prevention practices.

87. Side Effects of Contraceptive Implants • Common side effects of using implants include menstrual changes, such as irregular light spotting or bleeding, prolonged bleeding, infrequent bleeding, and amenorrhea. • • Non-menstrual side effects include headache, dizziness, nausea, breast tenderness, mood changes, weight change, and mild abdominal pain.

88. SUB-DERMAL IMPLANTS (Norplant) • A silastic system comprises of 6 small capsules which contain a progestogen and are inserted under the skin of the arm slowly releasing progestogen for up to 5 years. They act by: Thickening cervical mucus. Suppression of ovulation. Causing atrophic endometrium which is unsuitable for zygote implantation.

89. Women Who Can Use Contraceptive Implants without Restrictions (includes MEC Category 1) • Breastfeeding mothers after four weeks postpartum, or immediate postpartum if not breastfeeding • Women who prefer not to use or have contraindications to contraceptives that contain oestrogen or have developed oestrogen-related complications while taking COCs • Women with STIs and PID • Women with HIV and AIDS, unless they are on ARV therapy

90. Women Who Can Use Contraceptive Implants without Restrictions (includes MEC Category 1) • Women with adequately controlled or moderate hypertension (BP is less than 160/100) and those with history of hypertension during pregnancy • Women who have had major and minor surgery without prolonged immobilisation, or varicose veins • Women who take broad-spectrum antibiotics, anitfungals or antiparasitics

91. Women Who Can Use Contraceptive Implants with Extra Precautions (Includes MEC Category 2) • • Irregular, prolonged or heavy bleeding patterns • • Diabetes without or with vascular complications • • Woman with multiple risk factors for cardiovascular disease (e.g., more than 35 years of age, cigarette smoking, diabetes, and hypertension) • • Women with ischemic heart disease or stroke (can initiate implants, but will have to discontinue if they develop these conditions while using the method)

92. Women Who Can Use Contraceptive Implants with Extra Precautions (Includes MEC Category 2) • • History of hypertension where BP cannot be measured • • Severe hypertension (BP of 160/100 or higher); or with vasculopathy • • Migraine with or without aura • • History of DVT/PE or DVT/PE and established on anticoagulant therapy; major surgery with prolonged immobilisation; known thrombogenic mutations • • Gall bladder disease, symptomatic or asymptomatic • • Diagnosed CIN or cervical cancer (risk of sterility)

93. MEC 3&4 • Breastfeeding women less than four weeks postpartum • Women who have severe cirrhosis or liver tumours (hepatocellular adenoma or hepatoma) • Women who have unexplained vaginal bleeding suspicious for serious underlying condition • Women who have breast cancer or women with a history of breast cancer • Women who currently have DVT, 3 (Note: DVT is category 3 for both or who developed ischaemic heart initiation and continuation; disease or stroke while using implants ischaemic heart disease or stroke is category 3 for continuation only) • Women whose migraine with aura became worse while using implants

94. Timing for implant insertion • Insert implant within 7 days after the start of her menstrual bleeding (within the first 5 days for Implanon). No additional contraceptive protection is needed. • Insert implant any time if it is reasonably certain that she is not pregnant. • Between 4 weeks and 6 months postpartum and she is amenorrhoeic • The woman is switching from another hormonal method.

95. Instructions to Women After Insertion • Keep insertion area dry for four to five days. • Remove the gauze bandage after one or two days, but leave the adhesive plaster in place for an additional five days. • Return to the clinic if the rods come out or if soreness develops after the removal of the adhesive plaster. • Return to the clinic if she experiences pain, heat, pus, or redness at the insertion site, or if she sees a rod come out.

96. Instructions for Clients Following Removal of Implants • Keep removal area dry for four to five days. • Remove the gauze bandage after one or two days, but leave the adhesive plaster in place for an additional five days. • Return to the clinic if swelling and pain develops after the removal of the adhesive plaster.

97. Client Education • May be associated with prolonged menses, sporting or amenorrhoea • Requires a minor surgical procedure for insertion and removal • If possible return to the same clinic if you desire implant or removal • Return for removal any time you desire, but it can be kept in place for 5 years

98. Client Education Return to the clinic if: • - suspect pregnancy • - experience pain, swelling or pus at the implant site • - experience dizziness, headache. • - experience heavy bleeding

99. Side effects: Users may experience infection at insertion site, irregular menstrual bleeding (longer bleeding episodes, amenorrhoea, or spotting). Complications • Studies to date have shown no serious long- term complications.

100. Skin Patch • adhesive skin patch, about 2¾ inch square, applied once a week to one of four places. Contraceptive material in patch enters blood stream to protect user against pregnancy. • EFFECTIVENESS: If used correctly patch is as effective as the contraceptive pill, 95%-99%. • SIDE EFFECTS: - Positive- Regular periods, less anemia, less cramping, less benign breast disease. May protect against some forms of cancer. - Negative- (Normally disappear within 3 months) May include nausea, spotting, missed periods, headaches, mood changes, dark skin areas. Major but rare: blood clots, high blood pressure, gall bladder disease, heart attacks, liver tumors.

103. Vaginal ring • A soft, flexible vaginal ring, which is about 2 inches in diameter, delivers low doses of estrogen and progestin into the body. • This helps prevent pregnancy by suppressing ovulation and thickening the cervical mucus, which helps block sperm from entering the uterus. The ring is inserted into the vagina and left for 3 weeks. It is then removed for 1 week, during which a woman menstruates, and a new ring is inserted after the 1-week "break."

104. Nuva ring • The vaginal ring is a small, flexible ring a woman inserts into her vagina once a month to prevent pregnancy. • It is left in place for three weeks and taken out for the remaining week each month. The hormones that are released work by keeping a woman’s ovaries from releasing eggs.

105. Nuva ring

107. Pregnancy after hormonal contraceptives • Women who use combination estrogen-progestin methods usually begin to ovulate regularly 1-3 months after stopping. In one study, the median time for a woman to have a menstrual period after stopping the continuous pill was 32 days, and 185 of 187 women (98.9 percent) had a menstrual period or became pregnant within 90 days. • Women who use contraceptive implants (eg, Implanon) usually begin to ovulate again within one month after the device is removed.

108. Pregnancy after hormonal contraceptives • With injectable depot medroxyprogesterone acetate (DMPA or Depo-Provera), return of fertility can be delayed. Fifty percent of women will become pregnant within 10 months of the last injection. In a small number of women, however, it may take up to 18 months after the last injection to conceive. Women with lower body weights tend to become pregnant sooner than women with higher body weights after discontinuing DMPA.

109. Mechanical methods of FP

110. Mechanical methods of family planning and contraceptive This type of family planning method involves use of devices which may sometime have some form of drug(hormone ) attached to it ,there mode of function is by placing a barrier so that sperm does not get into the fallopian tube to fertilize the woman’s egg. The following are the available mechanical methods of family planning • · Intrauterine contraceptive Devices(IUCD,LOOP,COIL) • · Condoms • · Diaphragm

111. Mechanical Methods of Family Planning • Intrauterine contraceptive device is a small device (sometimes medicated) coil which is placed inside the uterus through the vagina, after the device has been inserted there are two strings which hang down high up in the vagina, woman check to feeling this string be sure her coil is still in place.

113. Mechanical Methods of Family Planning • The best time of insertion of IUCD is between 4-6 weeks after delivery when woman is still passionate about family planning and the cervix is still soft. • Another good time is just after menstruation by this time the cervix is slightly more expanded. After insertion the IUCD shall be checked at clinic at third month of insertion followed by checking at sixth month after insertion then one yearly Kenyan style.

114. Intrauterine Contraceptive Devices (IUCDS) • A widely used family planning method. A plastic device usually bound with copper wire and placed in the uterus through the cervix. Lippes's loop has no copper. • The IUCDs act by preventing implantation of fertilised ovum, inhibiting sperm mobility, and inhibiting fertilization.

115. Types Duration of effectiveness Copper T 380A 10 yrs Nova T 5 yrs Multiload-375 5 yrs Multiload-250 3 yrs Copper T 220 3 yrs

116. Insertion • Use non-touch technique • After insertion, it is advisable to cut the strings short, to about 3cm long from the cervical’s external os, or coil the strings around the fornix (postpartum insertion).

117. When? • Trans-caesarean (i.e., following a caesarean delivery): • Post-placental: The IUCD can be inserted within 10 minutes after expulsion of the placenta following a vaginal delivery. • Immediate postpartum: The IUCD can be inserted after the post-placental window, but within 48 hours of delivery. • Four weeks after delivery. • Postabortion where there are no complications. • Within the first 12 days after the start of menstrual bleeding or any other time of woman’s menstrual cycle if provider is reasonably sure she is not pregnant.

118. Contraindications of postpartum IUCD • • Prolonged rupture of membranes • • Prolonged labour • • Puerperal genital infection • • Puerperal sepsis

119. IUCD shall NOT be used by a woman with any of the following condition · Irregular vaginal bleeding of unknown cause · Heavy or painful menstruation · Cancer of uterus · Infection of the vaginal or uterus until it has completely been cured

120. Advantages • It is acceptable because it does not interfere with intercourse in any way • Available at all government hospitals • Highly and immediately effective • Long-term protection with immediate return to fertility upon removal • Do not interfere with intercourse • Can be used in women who are breastfeeding

121. Disadvantages • Inserted by a trained worker at the MCH clinic in hospital. • IUCDs do not protect against STIs or HIV/AIDS. • An IUCD could be expelled or translocated. • Perforation of the uterus could occur, but this is rare.

122. Side effects • Users may experience pain on insertion and increased menstrual bleeding and abdominal cramps. • Slight bleeding at any time of the circle otherwise known as spotting may occur. • Very rarely perforations occur during insertion. • · There is risk of infection. • · Expulsion Special comment • IUCD does not interfere with sexual intercourse.

123. Client Education • Check regularly to ensure IUD is in place • Return for removal any time, but can be worn for 3-10 years and the Lippes Loop R for an indefinite period of time • May cause dysmenorrhea and menorrhagia • Return to the clinic if client experiences: - signs of pregnancy, heavy bleeding or spotting - abnormal sexual pain or vaginal discharge - chills or fever.

124. DISPLACED IUCDs • When threads not visible at cervix and pregnancy ruled out then: • attempt removal with a simple artery forceps. If it fails then localization by ultrasound, plain X-ray with tracer IUCD and removal • If one conceives with IUCD remove it if possible, otherwise leave alone (ultrasound if possible) and counsel client accordingly.

125. BARRIER METHODS

126. THE MALE CONDOM • Offer physical barrier to sperm deposition into the vagina. • Condoms also offer some protection against STIs including HIV/AIDS, HBV and carcinoma of the cervix. • Effectively prevent pregnancy if used every time of intercourse • Perfect effectiveness rate = 97% • Typical effectiveness rate = 88% • Combining condoms with spermicides raises effectiveness levels to 99%

127. Condoms • · Some people argue that it reduces sexual intercourse pleasure • · Available over the counter in shops and free distribution in some places • · On side effect rarely allergic reaction to rubber

128. How to use a condom

129. Disposal • • After ejaculation and before completely losing his erection, the man should hold the rim of the condom to the base of the penis so it will not slip off when he is pulling his penis out of the woman’s vagina. • • He should take the condom off his penis without spilling the semen on the vaginal opening. • • The used condom can be thrown into a pit latrine, burned, or buried. It should be kept away from children. Condoms must not be reused.

130. THE MALE CONDOM Client Education • Before every intercourse, place condom on erect penis, leaving tip empty to collect semen • Withdraw the penis from the vagina after each ejaculation while the penis is still erect • Remove condom after use • Do not re-use condoms • Discard used condom immediately in toilet or pit latrine • Using spermicides with condoms increases the effectiveness • Complications may include local irritation if allergic to latex/lubricants • May interfere with sexual pleasure for some people. • Store in a cool dry place (not in the wallet)

131. THE MALE CONDOM Benefits • Fairly effective if used properly • Immediately effective • Highly effective protection against STIs/HIV/AIDS • May prevent premature ejaculation Side effects: Some users experience sensitivity to rubber or lubricants.

133. THE FEMALE CONDOM • The female condom is a thin (0.05 mm) polyurethane sheath, 7.8 cm in diameter and 17 cm long. • It is soft, loose fitting and has two flexible rings. One ring is inserted into the vagina and acts as an internal anchor. The other ring forms the open edge of the device and remains outside the vagina after insertion.

134. • The female condom provides protection for one act of intercourse. It can be inserted (up to 8 hours) before intercourse but must be removed immediately after. • EFFECTIVENESS: 79%-95% effective if used perfectly

137. SPERMICIDES • Spermicidal creams, jellies and/or foaming tablets are inserted into vagina before sexual intercourse and act by inactivating the spermatozoa and physically preventing entry into uterus. • Only 76% effective (used alone), should be used in combination with another method i.e., condoms

138. SPERMICIDES Client Education • • Interferes with natural spontaneity of sexual act • • May cause local irritation • • May be difficult to insert by client • • Low effectiveness as a contraceptive. Side effects: Some users experience sensitivity to spermicide. Complications • None.

139. Diaphgram • A diaphram is a shallow silicon or rubber cup made of about three inches in diameter, inserted before intercourse and act by creating a barrier of sperm at entrance of at the cervix, after intercourse diaphragm is left 6-8 hours sometime up to 16 hours before removal should intercourse be desired again. Additional spermicidal cream may be added with the diaphragm.

140. Diaphragm

141. Diaphram • Diaphragm is moderately effective (moderately reliable “effective” for a woman, who is motivated,) this means that it is not particularly reliable for average women. • Perfect Effectiveness Rate = 94% • Typical Effectiveness Rate = 80% • Diaphragm is not widely acceptable because of difficulty to use without adequate privacy and standard hygiene has to be maintained.

142. Diaphram • Diaphragm because of its reduced effectiveness , infection and dislodging it is not widely available in Kenya and can in most cases be found at larger clinics • On side effect rarely allergy to rubber • Diaphragm does not protect from sexually transmitted diseases • Once the woman has stopped using the diaphragm she has equal chance of conceiving like any ordinary normal woman • There is risk of infection

144. Diaphram Client Education - by a provider and refitted after marked weight change (5kg gained or lost, or after child birth) - must be kept clean and stored properly - must be used with spermicide - can be inserted up to 6 hours before intercourse - can remain in place for 6 hours (not longer than 24 hours)

145. Diaphram • Contraceptive sponge must be moistened with water to activate its spermicide; contraceptive sponge must never be re-used and must not be used during menstruation. Side effects: Some users experience sensitivity to rubber or lubricants/spermicides; some diaphragm users experience increased frequency of urinary tract infection. Complications • None.

146. 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%

148. Difference between diaphragm and cervical cap Cervical cap Diaphragm Made of one piece of silicone that heats and cools uniformly, allowing for autoclave sterilization. Made of silicone and a steel wire in the rim, that heats differently. •Is soft and conforms to the anatomy of the cervix and vagina and adapts to physiological changes during intercourse. •Does not cause any pressure on the vagina, cervix, or urethra. •Is designed with unique delivery system facing the vaginal opening that stores the spermicide and trap sperm, bacteria, and viruses as soon as they are deposited into the vagina. The Diaphragm is a large cup-shaped device with metal wire in the rim. It does not adapt to physiological changes during intercourse. The metal rim causes pressure on the vaginal walls and the urethra. Spermicide placed in the bowl of the cup disrupts cervical cells, and can leak outside of the vagina. Lower risk, of urinary tract infection UTI. Higher risk UTI. Provides continuous protection for 48 hours. Recommended for only 24-hour use.

149. Natural Family Planning • Avoidance of sexual intercourse during ovulation and for a safety margin before and after ovulation. Various methods may be used to determine the fertile period: cervical mucus, basal body temperature, rhythm. Benefits • No physical side effects it is cheap • No need for prescriptions by medical person • Improved knowledge of reproductive system and possible closer relationship between couples.

150. Fertility awareness based (FAM)/Natural It is called natural because it does not involve use of drug or device and it require abstention from intercourse during the fertile time of a woman’s menstrual cycle, thereby avoiding conception.

151. Fertility awareness based (FAM)/Natural The following are the available methods: • Withdrawal method (coitus interruptus) • Safe period (rhythm method) • Lactational amenorrhea method (LAM) • Cervical mucus membrane • Basal body temperature (BBT) method • Sympto thermal method

152. Fertility awareness based (Natural) Methods of FP and contraceptive • Newer FAM options, such as the Standard Days Method® (SDM) and TwoDay Method® (TDM), require less reliance on the provider, as they are offered and learned in one client- provider contact. • Effectiveness of FAMs is enhanced by use of multiple techniques to identify the fertile time.

153. Facts of FAM • Based on understanding ovulatory cycle • Require periods of abstinence & careful recording of events throughout cycle • Cooperation very important • Free, safe, and acceptable to all spiritual beliefs • Require extensive initial counseling • 25% of women will experience unintended pregnancy in first year (typical use; 3-5% in perfect use) • Some women combine with barrier methods (use during fertile periods) and/or combine types of FAM • More difficult when breastfeeding (masks some signs)

154. Periodic Abstinence (Natural Family Planning) Client Education • Requires high motivation • Has a high failure rate • Assumes a regular, perfect menstrual cycle • Requires proper record-keeping • Has no health risks, except for pregnancy. Side effects: None. Complications None.

155. Phases of the Menstrual Cycle Pre-Ovulatory Infertile Phase Fertile Phase Post-Ovulatory Infertile Phase Ovulation

156. Variability of the Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

157. Estrogen - secreted by the ovary’s follicle • Stimulates cervical mucus production LH - secreted by the pituitary • Stimulates ovulation Progesterone - secreted by the corpus luteum • Raises basal body temperature • Dries cervical mucus

158. Markers of peak fertility • Cervical mucus – clear, stretchy, slippery • Rise in basal body temperature • LH hormone peaks

159. Calendar-Based Methods • In the calendar-based methods, the couple keeps track of the days in the menstrual cycle to identify the start and end of the fertile time.

160. Standard Days Method® (SDM) • The SDM is based on the fact that there is a fertile window during the woman’s menstrual cycle when she can become pregnant. • Typically, this window occurs several days before ovulation and a few hours after. To prevent pregnancy, couples avoid unprotected sex or abstain between days 8-19 of the menstrual cycle.

161. Standard Days Method® (SDM) • The SDM makes use of CycleBeads, a color-coded string of beads used with the SDM that represent the days of a woman’s fertility cycle. • CycleBeads help the woman track her cycle days, know on which days she is fertile, and monitor her cycle length. • The woman and her partner must avoid unprotected intercourse or abstain on the 12 fertile days identiﬁed by the white colour beads.

162. Symptoms-Based Methods • Symptoms-based methods depend on observation of signs of fertility, such as the presence or absence of cervical mucus, changes in the amounts and characteristics of the cervical mucus, changes in body temperature, a combination of the latter two, or use of speciﬁc ovulation detection kits.

163. TwoDay Method (TDM) • The TwoDay method® (TDM) is a simple, symptom-based method by which women check for the presence or absence of cervical secretions as the sign of fertility. • The TDM does not require interpretation of the quality or quantity of secretions. • A woman who uses the TDM asks herself two questions: (1) “Did I note secretions today?” and (2) “Did I note secretions yesterday?”

164. TwoDay Method (TDM) • She should consider herself fertile today if she notices cervical secretions of any type today, or if she noticed them yesterday. Women who use the TDM are instructed to avoid unprotected intercourse on these days to prevent pregnancy.

165. Cervical Mucus, or Billings Ovulation Method • In this method, the days of infertility, possible fertility, and maximum fertility of the menstrual cycle are deﬁned by observation of changes in the cervical mucus. The woman identiﬁes the fertile time by observing the characteristics of the cervical mucus.

166. Cervical Mucus Cycle Peak Fertility Beginning End

167. Cervical Mucus, or Billings Ovulation Method To use this method correctly, the woman should: • • Avoid sex on days of monthly bleeding. In cases when ovulation occurs early in the cycle, bleeding could make it hard to observe cervical mucus • • Avoid sex as soon as she notices any secretions. The fertile phase of the menstrual cycle begins with the appearance of a mucus secretion, which changes as the days go by, becoming more stretchy and slippery. • • Recognise evidence of ovulation (peak day), when the mucus is • very clear, stretchy (Spinnberkeit’s sign), and slippery. • • Continue to avoid sex for three more days after peak day, even if secretions completely disappear before three days have expired.

168. Basal Body Temperature (BBT) • With this method, the woman is instructed to take her body temperature either orally, rectally, or vaginally at the same time each morning before getting out of bed and before eating anything. • The routine for taking the temperature must be the same for the entire cycle.

169. Basal Body Temperature (BBT) • The temperature readings are recorded on a special graph paper, which makes it easy to identify small changes in temperature readings. • The woman’s temperature rises by 0.20C - 0.50 C, around the time of ovulation (about midway through the menstrual cycle for many women). The couple avoids sex from the ﬁrst day of monthly bleeding until three days after the woman’s temperature has risen above her regular temperature.

170. Sympto-thermal Method (Cervical Mucus + BBT) • In this method, the pre-ovulatory and post- ovulatory infertile phases of the menstrual cycle are identiﬁed by a combination of the above two techniques (the cervical mucus and BBT shift), as well as other signs and symptoms around ovulation.

171. Sympto-thermal Method (Cervical Mucus + BBT) The signs and symptoms used in the sympto- thermal method include: • Thermal shift (BBT) • Cervical mucus changes (BILLINGS) Involves careful assessment of cervical mucus changes throughout cycle – Ovulation mucus clearer, more stretchable (spinnbarkeit), more permeable to sperm – Also ferns when dried on glass slide – Luteal phase mucus thick, sticky, traps sperm (progesterone influence)

172. Sympto-thermal Method (Cervical Mucus + BBT) • Cervical changes (consistency, position, openness, or closure) • Other appropriate signs and symptoms, such as sharp lower abdominal pain (mittelschmerz), breast tenderness, increased libido, or intermenstrual bleeding

173. Coitus interruptus • 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’

174. Lactation Amenorrhoea Method • A temporary method of FP based on the lack of ovulation that results from exclusive breastfeeding. Criteria • • The woman’s menstrual periods have not resumed. • • The baby is exclusively or nearly exclusively breastfed. • • The baby is less than six months old.

175. Advantages and Benefits of LAM • • LAM does not interfere with sexual activity. • • It has no known health risks. • • Return to fertility is immediate.

176. Limitations • Breastfeeding can transmit HIV from a mother to her baby. • A woman might not breastfeed because she is taking certain drugs (e.g., radioactive drugs, lithium, or certain anticoagulants). • Exclusive breastfeeding might be inconvenient or difficult for some women, especially working mothers. • LAM does not protect a woman against STIs, including hepatitis B, HIV, and AIDS.

177. Surgical method The following are the available surgical family planning methods • Tubal ligation • vasectomy

178. Surgical Contraception • Many factors have contributed to improved safety of Voluntary Surgical Contraceptive in the last 20 years: • These include improved anaesthetic methods, better surgical techniques, asepsis, improved training of personnel and better selection and monitoring of clients.

179. Sterilization

180. Classification of criteria for medical eligibility for surgical contraception methods (adapted for use in Kenya from WHO, 2008) • Accept (Category A) No medical reason prevents performing the procedure in a routine setting. • Caution (Category C) The procedure can be performed in a routine setting, but with extra preparation and precautions.

181. Classification of criteria for medical eligibility for surgical contraception methods (adapted for use in Kenya from WHO, 2008) • Delay (Category D) Delay the procedure. Condition must be treated and resolved before the procedure can be performed. Provide temporary methods in meantime. • Special—Refer (Category S) Special facilities and equipment are needed for surgical procedure, including experienced surgeon and staff, general or regional (spinal) anaesthesia and specialist medical support. Otherwise Refer. Provide temporary methods in meantime.

182. TUBAL LIGATION • A voluntary irreversible procedure for fallopian tubal occlusion which can be done under general or local anaesthesia by minilaparotomy and laparoscopy. It is one of the most widely used methods in Kenya.

183. Types of TL • There are several ways to perform a TL: • • Minilaparotomy (postpartum, postabortion) • • Laparoscopic tubal ligation (interval) • • In conjunction with a caesarean section or other abdominal surgery

184. Benefits of TL • Highly effective, immediate, and safe form of contraception. Failure rates vary by procedure, from 0.8%-3.7% • TL does not change sexual function and does not interfere with intercourse. • TL is permanent. • TL has few known side effects • TL does not affect breastfeeding.

185. Limitations and Side Effects of TL • TL is irreversible Side effects include: • – Minimal risks and side effects of anaesthesia • – Risks associated with surgical procedures • – Some pain for several days after the procedure • In rare cases when pregnancy occurs, it is more likely to be ectopic • TL is not provided at all SDPs. • Only a trained provider can perform the procedure. • TL does not protect against STIs, including HIV/AIDS and hepatitis B

186. Surgical Contraception Client Education • IRREVERSIBLE (permanent) • Failure very rare when done by trained professional • Counselling absolutely necessary • No loss of libido or vigour or health Return to the clinic if: - post-operative fever, pus or pain at the surgical site - weakness or rapid pulse - vomiting or persistent abdominal pain.

187. Surgical Contraception Benefits • Permanent, highly and immediately effective • No change in sexual function • Good for client if pregnancy would be a serious health risk • Does not affect lactation Side effects: Some users experience minor pain and bleeding and wound infection following procedure. Complications Injury to other organs (e.g. gut, bladder) and rarely death; risk of complications increased if general anaesthesia is used. Haemorrhage.

188. Surgical Contraception • VASECTOMY • A voluntary surgical procedure done to cut and ligate the vas deferens so that spermatozoa cannot be ejaculated. Done under local anaesthesia. Now gradually becoming accepted in Kenya.

189. Advantages and Benefits of Vasectomy • Contraceptive benefits of vasectomies include the following: • The procedure is highly effective and safe. Failure rate = 0.1%, more effective than female sterilization. • There is no change in sexual function—the procedure does not interfere with sexual intercourse. • It is permanent.

190. Limitations and Risks • The procedure is virtually irreversible (i.e., success of reversal surgery cannot be guaranteed). • There are minimal risks and side effects of local anaesthesia. • There are risks associated with surgical procedures. • A vasectomy does not protect against STIs, including HIV/AIDS. • Only a trained provider can offer a vasectomy. • There is a delay in effectiveness after the procedure has been performed.

191. Men Who Should Not Have Vasectomies • Clients who are uncertain of their desire for future fertility • Clients who cannot withstand surgery • Clients who do not or cannot give voluntary informed consent

192. Client Education • Counselling necessary, permanent and irreversible • Use condom for at least 15 ejaculations • Return to the clinic if you experience: - post-operative fever - excessive swelling, pus or pain at the surgical site. Side effects: Some users experience minor swelling, pain, infection, and bruising following procedure. • Complications • Risk of serious complications or death extremely low.

193. Future contraceptives Nestorone- Estrogen and progestin(low dose) • Gel • Spray • Using the skin helps bypass the liver thus prevent toxicity http://www.popcouncil.org/research/nestorone -estradiol-transdermal-gel-contraception

195. Future contraceptives • Male hormonal contraceptive: monthly testosterone injection • Reversible Inhibition of Sperm Under Guidance - The vas is extracted through the scrotum and injected with a polymer made from styrene maleic anhydride (SMA) and dimethyl sulfoxide (DMSO). On the market, this non-toxic polymer is known as Vasalgel. The process is then repeated on the other side with the second vas deferens.

196. Future contraceptives • The highly charged polymer attaches to the inner walls of the vas deferens, and when it comes in contact with the negatively charged sperm, ruptures their tails so that they are incapable of fertilizing eggs. • The gel blocks the tube, meaning sperm cannot be released Read more: http://www.dailymail.co.uk/health/article- 2750650/First-male-contraceptive-injection-available- THREE-years.html#ixzz3PxVBlZ43

197. Future contraceptives ‘clean sheets’ or ‘dry orgasm’ pill. • This is a drug that could be taken before sex which leads to a semen-free orgasm. • Male contraceptive pill research (KOMO report, 2009, 2:10, YouTube)

198. Future contraceptives • The Intra Vas Device (IVD) is a set of tiny implants that block the flow of sperm. • http://malecontraceptives.org/methods/shug. php

199. • Nifedipine: the sperm of men taking nifedipine have low levels of mannose lectin on the sperm cell membranes. Mannose lectin is a molecule which is critical for binding with an egg’s zona pellucida (outermost layer). Nifedipine treatment may physically prevent mannose lectins from moving to the surface of the cell membrane by stiffening the membrane with excess cholesterol (Goodwin 1997, Benoff 1998a).

200. Others Neem extracts (Azadirachta indica) • The injection of minute quantities of neem oil into the vas deferens has been successfully tested as an alternative to surgical vasectomy Papaya seed extracts (Carica papaya) • When the crude extract of papaya seeds was fed to male rats, the quantity and quality of the sperm they produced deteriorated. At higher doses, this provided 100% effective contraception, but it also resulted in weight loss, possibly due to toxicity (Udoh 1999, Kusemiju 2002, Lohiya 2005).

201. Summary METHOD RECOMMENDED FOR: NOT RECOMMENDED FOR WOMEN/COUPLES: Combined Pill • Women under 40 years, of any parity • Women who want highly effective contraception • Breast-feeding mothers after 6 months post-partum • Younger women/adolescents who are sexually active and have been adequately counselled • with suspected pregnancy • who are over 35 years and a smoker • with history of blood clotting disorders or heart disease • with lump in either breast, liver disease • with unexplained abnormal vaginal bleeding • with BP over 140/90 mm/Hg confirmed on revisit Progestin Only Pill • Women of reproductive age, of any parity • Breast-feeding mothers after 4-6 weeks post-partum • with suspected pregnancy • with history of blood clotting disorders or heart disease • with lump in either breast, liver disease • with unexplained abnormal vaginal bleeding

202. Summary Injectable Methods • Women of proven fertility • Breast-feeding mothers after 6 weeks post partum • Women who want long-term contraception • Women who want at least 2 years between pregnancies (SAME AS PROGESTIN ONLY PILL) Implants • Women with 2+ children needing long- term protection • Breast-feeding mothers after 6 weeks post partum • (Long term highly effective contraception) • Women who have their desired family size but do not want permanent surgical contraception (SAME AS PROGESTIN ONLY PILL)

203. Summary Intrauterine Devices • Women who have delivered 1 or more times • Breast-feeding mothers • Women who want long-term contraception • Women in a stable monogamous sexual relationship • Women after 6 weeks post-partum; before 6 weeks if provider has specialised IUD insertion training. • with suspected pregnancy, history of PID or ectopic pregnancy • with anaemia or heavy menstrual bleeding • having no menses after 6 weeks postpartum • with history of heart disease • with abnormalities or cancer of pelvic organs • having unexplained vaginal bleeding or severe menstrual pains • at risk of exposure to STDs

204. Summary Diaphragm, Cervical Cap, Spermicides, Sponge NOT RECOMMENDED FOR WOMEN/COUPLES: • Women needing an immediately effective method • Breast-feeding mothers • Women who do not want hormonal methods or IUCDs • Women waiting to rule out a suspected pregnancy • Women needing a back-up method (forgotten pill) • Women desiring some protection against AIDS, STDs • who are unable or unwilling to feel their own cervix • who desire more effective contraception • who do not want the inconvenience of the method • who themselves or their partners are either allergic to the spermicide or device • with frequent urinary tract infections, vaginal abnormalities • with poor vaginal muscle tone (for diaphragm only)

205. Summary Condom • Men who desire to take contraceptive initiative • Couples needing an immediately effective method • Couples waiting to rule out a suspected pregnancy • Couples at risk of exposure to AIDS, STDs • who desire or require highly effective protection against pregnancy

206. Summary Natural Family Planning • Couples willing to learn about the woman's cycle and to practise abstinence from 1-2 weeks each cycle • Couples who, for religious or any other reasons, desire to practise periodic abstinence • who need/want more effective contraception • with irregular menstrual cycle is irregular • who are breast-feeding • who must not become pregnant for health or any other reasons • who are unwilling to abstain during fertile period

207. Summary Tubal Ligation or Vasectomy • Couples or individuals who have been fully counselled, understand and have voluntarily signed consent form. • Couples with desired family size? • Women for whom age or health problems might cause an unsafe pregnancy? • Couples certain they want no more children regardless of accidental death of a child or children • who do not fully understand VSC or are unwilling to agree to items on the consent form NOTE: Men or women whose spouses oppose VSC should be considered on a case by case basis for the procedure.

208. Guide to Family Planning Methods Pregnancy Rate = percentage accidental pregnancies in first year, typical rate and (rate when used perfectly). METHOD PREGNANCY RATE? USED AT INTERCOURS E? EFFECT ON STD RISK? COMPATIBLE WITH BREASTFEEDI NG? RETURN TO FERTILITY AFTER STOPPING? Male sterilization 0.15 (0.1) No None Yes Permanent method Female sterilization 0.4 (0.2) No None Yes Permanent method Implants 0.2 (0.04) No Probably none Yes, but not preferred method. Wait 6 weeks post-partum Immediate on removal

209. Guide to Family Planning Methods Pregnancy Rate = percentage accidental pregnancies in first year, typical rate and (rate when used perfectly). Progestin- only minipill 3-10 (0.5-3) No None Yes, but not preferred method. Wait 6 weeks post-partum Immediate to short delay Injectables 0.3-0.4 No Unknown Yes, but not preferred method. Wait 6 weeks post-partum Delayed 4 to 12 months Intrauterine devices (IUCD) 3 (0.3-2) No Increase risk of PID in women at risk of STDs Yes Immediate after removal by trained provider

210. Guide to Family Planning Methods Pregnancy Rate = percentage accidental pregnancies in first year, typical rate and (rate when used perfectly). Combined oral contraceptiv es 1-8 (0.1-3) No May protect against some forms of PID, but increase risk of infection with some STDs After 6 months postpartum, but not preferred method if breastfeedin g Immediate to short delay (average 2-3 months) Condoms 12 (2) Yes Protective (70% against AIDS) Yes Immediate

211. Guide to Family Planning Methods Pregnancy Rate = percentage accidental pregnancies in first year, typical rate and (rate when used perfectly). Vaginal spermicides 21 (3) Yes May have some protective effect Yes Immediate Diaphragm, cervical cap, other vaginal barrier methods 18-28 (6-9) Yes May have some protective effect Yes Immediate Natural family planning 20 (1-9) No None No, method not reliable Immediate

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