Fp

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 post-
partum
• 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 post-
partum, 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