family planning.pdf

FAMILY PLANNING
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS

Family Planning
Family planning is the planning of when to have
children.
Family planning allows individuals and couples to
anticipate and attain their desired number of children
and the spacing and timing of their birth. It is
achieved through use of contraceptive methods and
the treatment of involuntary infertility.
(WHO, Department of reproductive health and
research)
1/22/2023 Reena Bhagat 3

Contd..
• Family planning is the term given for pre-
pregnancy planning and action to delay, prevent or
actualize a pregnancy.
• Family planning is a way of thinking and living
that is adopted voluntarily, upon the bases of
knowledge, attitude and responsible decision by
individuals and couples in order to promote the
health and welfare of family group and thus
contribute effectively to the social development of
country -B T BASVANTHAPPA

Contd..
Family planning refers to practices that help
individuals or couples to attain certain objectives:
• To avoid unwanted births.
• To bring about wanted births.
• To regulate the intervals between pregnancies.
• To control the time which births occur in relation
to the age of parent.
• To determine the number of children in the family.

Family Planning as Basic Human Rights
Fifty years ago, at the 1968 International Conference
on Human Rights, family planning became a human
rights obligation of every country, government and
policymaker.
In 2015, all 192 members of the United Nations
committed to Sustainable Development Goal 3.7:
―ensure universal access to sexual and reproductive
health-care services, including for family planning,
information and education, and the integration of
reproductive health into national strategies and
programmes‖ by 2030.

Contd..
Earlier this year UNFPA and the World Health
Organization (WHO) recognized nine standards to uphold
the human right to family planning.
1. Non-discrimination
2. Availability
3. Accessibility
4. Acceptable
5. Good quality
6. Informed decision-making
7. Privacy and confidentiality
8. Participation
9. Accountability

Contd..
Family Planning has accepted as a basic human
right of an individual and couple. This is also
considered as basic for the overall development and
quality of life.
The Bucharest conference in its ‗plan of action‘
stated that ―all the couples and individuals have the
basic human right to decide freely & responsibly
the number and spacing of their children & to have
the information, education , & means to do so.‖

Family Planning program in Nepal
• Family Planning (FP) program is long withstanding
program in Nepal.
• The aim of National FP Program is to ensure individuals
and couples fulfill their reproductive needs and rights by
using quality FP methods voluntarily based on informed
choices.
• Government of Nepal (GoN) is committed to equitable
and right based access to voluntary, quality FP services
based for all individuals with special focus on hard to
reach communities such as adolescents, migrants, slum
dwellers, sexual minorities and other vulnerable groups
ensuring no one is left behind.

Contd..
• To achieve this, GoN is committed and striving to
strengthen policies and strategies related FP within the
new federal context, mobilize resources, improve
enabling environment to engage effectively with
supporting partners, promote public-private
partnerships, and involve non-health sectors.
• FP has been enshrined as a fundamental right in the
constitution, and included in the basic health service
package under the Public Health Act 2018, thus paving
a way towards universal health coverage.

Objectives, policies and strategies
The overall objective of Nepal‘s FP programme is to
improve the health status of all people through informed
choice on accessing and utilizing client-centred quality
voluntary FP. The specific objectives are as follows:
To increase access to and the use of quality FP services
that is safe, effective and acceptable to individuals and
couples. A special focus is on increasing access in rural
and remote places and to poor, Dalit and other
marginalized people with high unmet needs and to
postpartum and post-abortion women, wives of labour
migrants and adolescents.

Contd…
To increase and sustain contraceptive use, and reduce
unmet need for FP, unintended pregnancies and
contraception discontinuation.
To create an enabling environment for increasing
access to quality FP services to men and women
including adolescents.
To increase the demand for FP services by
implementing strategic behavior change
communication activities.

Contd..
The five policies and strategic areas to achieve the above
objectives are presented:
1. Enabling environment: Strengthen the enabling
environment for FP
2. Demand generation: Increase health care seeking
behavior among populations with high unmet need for
modern contraception
3. Service delivery: Enhance FP service delivery
including commodities to respond to the needs of
marginalized people, rural people, migrants,
adolescents and other special groups

Contd.
4. Capacity building: Strengthen the capacity of
service providers to expand FP service delivery
5. Research and innovation: Strengthen the evidence
base for programme implementation through
research and innovation

Target of Family Planning
• Selected FP targets and indicators to ensure
universal access to sexual and reproductive
health-care services, including for FP/SRH
program are as follows:

SDG targets and indicators
Targets and Indicators 2020
(Status)
2022 2025 2030 Sources
Proportion of women of reproductive
age (aged 15-49 years) who have their
need for family planning satisfied with
modern methods
61.9 74 76 80 NMICS,
2019
Contraceptive prevalence rate (CPR)
(modern methods) (%)
44.2 53 56 60 NMICS,
2019
Total Fertility Rate (TFR) (births per
women aged 15-49 years)
2.0 2.1 2.1 2.1 NMICS,
2019
Adolescent birth rate (aged 10-14
years; aged 15-19 years) per 1,000
women in that age group
63 51 43 30 NMICS,
2019

Major activities in 2077/78
FP program are implemented at various level (federal,
province and local level). Key activities carried out in
2077/78 are as follows:
Provision of long acting reversible services (LARCs-
IUCD and Implant)
Permanent FP Methods or Voluntary Surgical
Contraception (VSC)
Provision of regular comprehensive FP service including
post-partum and post abortion FP services.
Micro planning for addressing unmet need of FP in hard
to reach and underserved communities

Contd.
Provision of Roving ANM and Visiting Service
Provider service to increase FP service use
Integration of FP and immunization service
Satellite clinic services for long acting reversible
contraceptives
Contraceptive update for Obstetrician/Gynecologist,
nurses & concerned key players Family Welfare
Policy dialogue on introducing emergency
contraceptive pills (ECP) in all public health facilities.
Policy decision has been made to provide ECP through
public health facilities and FCHVs.

Contd..
Interaction with organization working in people with
disabilities to improve Sexual and Reproductive Health
(SRH) access.
Interaction program on FP and RH including ASRH
with pharmacist and marginalized communities
Conducted two studies entitled ―Status and
Determinants of the Utilization of Family Planning
Services among Hard-to-Reach Population (HTRPs)‖
and ―study on effectiveness of PHC ORC, satellite
clinics and micro-planning‖

Achievements
 FP Current users
Female sterilization (38%) occupies the greatest part of
the contraceptive method mix among all current users,
followed by Implant (18%), Depo (14%), male
sterilization (11%), pills (7%), condom (6%), and lastly
IUCD (6%) in Fiscal Year 2077/78.
 Although findings of the method mix from National level
survey such as Nepal Demographic Health Survey
(NDHS) and Nepal Multiple Indicator Cluster Survey
(NMICS) show the Depo as the second most preferred
method after female sterilization.

Contd..
Trend of Contraceptive method mix
The share of implant in contraceptive method is in
increasing trend while that of condom and male
sterilization are in decreasing trend. The share of IUCD,
Pills, female sterilization, depo in contraceptive method
mix is almost remained stagnant in last 4-5 years.
Total number of current users of permanent method
exceeds that of spacing method at national level and in
Madhesh Province which is almost four times (>4X) the
current users of temporary methods.

Contd..
Current users: Sterilization
Among total MWRA, Female sterilization (ML/LA)
contributes about 35% in contraceptive method mix in
Province 2.
It is evident that female sterilization (minilap under
local anaesthesia--ML/LA) is popular in Terai which
have contributed also in national average. Male
sterilization (NSV) on the other hand is more popular
in Mountain and Hill than Terai.

Contd..
New acceptors of spacing methods
Nationally , new acceptors of all temporary methods
( absolute numbers) have increased in 2075/76 than in
pervious years.
Highest number of new acceptors for spacing
(temporary) method in 2075/76 are reported in
Province 5.
Likewise , implant acceptors are higher than IUCD in
all ecological regions. .

Contd..
Contraceptive Prevalence Rate:
The modern contraceptive prevalence rate (mCPR) at
national level stands at 39% in FY 2077/78 as compared
to 37% in the previous FY. This confirms that the
family planning services has resumed after COVID 19
pandemic in FY 2076/77.
Madhesh Province has the highest mCPR with 43%
while Gandaki has the lowest (33%).

Contd..
New acceptors method mix
Depo (39.37%) occupies the greatest proportion of the
contraceptive method mix for all method among new
acceptors, followed by condom (22.25%), pills
(20.82%), implant (13.54%), IUCD (1.84%), Female
sterilization (1.7%) and Male sterilization (0.48%) in
2077/78.
Madhesh Province recorded the highest number of
VSCs/permanent methods while Karnali Province the
lowest.

Contd..
• Ecological wise, Female VSC new acceptors (ML)
were highest in Terai ecological region followed by
Hill. However the share of female VSC acceptors (ML)
is increasing in hill. This shows that ML is making its
road in hill and indicates the increasing female
participation in VSC services.
• Among the total new sterilization services, majority of
the services is utilized by female (78%) at national
level. Share of miniliap (ML) is highest in Madhesh
province (97%) and is lowest in the Karnali province
(24%).

Contd..
• However, compared to the previous year, share of
NSV increased at National level as well as in
Province 1, Lumbini and Karnali Provinces which
shows that male participation in sterilization services
is increasing.
• Share of ML is increasing trend in Madhesh,
Bagmati, Gandaki, and Sudurpaschim Provinces.

Contd..
New acceptors of spacing methods
Nationally, new acceptors of all temporary methods
have increased in 2077/78 compared to the previous
year. Highest numbers of new acceptors for spacing
(temporary) methods in 2077/78 are reported in
Lumbini Province and lowest in Gandaki Province.
The postpartum uptake as proportion of the total
facility delivery is highest in Bagamati province
(2.36%), followed by Province 1 (2.13%). The lowest
proportion of PPFP services is in Sudurpaschim
province (0.15%). Postpartum uptake of IUCD is in
decreasing since FY 2074/75

Contd..
• More than three-forth of women (77%) who have
received abortion service accepted contraceptives.
• At the national level, post abortion contraceptive
increased from 73% in 2076/77 to 77% in 2077/78.
Acceptance of SARC has increased in FY 2077/78
compared to previous year.
• Although different research have shown that majority of
women seeking abortion service have desire to limit the
fertility, but almost two-thirds (62%) have accepted less
effective method (e.g. SARC) following abortion services
indicating the mismatch between fertility intention and
post abortion contraceptive uptake.

Issues, constraints and recommendations
Issues and constraints Recommendations Responsibility
Low uptake of family
planning services by
underserved and
marginalized
communities
• Mapping service availability
and conduct microplanning to
explore the gap and develop
action plan to improve service
access and utilization
• Expand FP services in private
and NGO run facilities.
Local,
Province and
Federal
Government
Low uptake of
immediate postpartum
contraceptive uptake
• Integration of postpartum
family services and counseling
during antenatal care, delivery,
postpartum, immunization,
growth monitoring to increase
FP service uptake during
immediate and extended
postpartum period.
FWD, PHD,
Hospitals

Issues and
constraints
Recommendations Responsibility
Low and substandard
reporting from high
volume facilities
• Improve quality of
recording and reporting of
services. Conduct routine
data quality assessment of
family planning services
IHMIS, FWD,
PHD, Hospitals,
HO
Low uptake of
effective family
planning method
following abortion
services
• Improve post abortion
family services method
mix. Focus on the
counseling and services
of LARC method to
address the fertility
intention of women.
FWD, PHD,
Hospitals
Contd..

Contd..
Issues and
constraints
Recommendations Responsibility
Institutionalized
Family Planning
Service Centers are
not functional
• Redefine the roles and
responsibilities of IFPSC
in the federal context to
ensure FP service
delivery. Revive the
structure of IFPSC.
Federal,
Provincial
Government
All health facilities
are not providing all
temporary methods
• Strengthen and expand
the capacity of FP
training sites, increase
service providers training
• Explore LARC s coach-
mentorship initiative
Federal,
Provincial,
Local
Government

Family planning status: World
• Among the 1.9 billion Women of Reproductive Age
group (15-49 years) worldwide in 2019, 1.1 billion have
a need for family planning; of these, 842 million are
using contraceptive methods, and 270 million have an
unmet need for contraception.
• The proportion of the need for family planning satisfied
by modern methods, Sustainable Development Goals
(SDG) indicator 3.7.1, has stagnated globally at around
77% from 2015 to 2020 but increased from 55% to 58%
in the Africa region.

Contd..
• Only one contraceptive method, condoms, can prevent
both a pregnancy and the transmission of sexually
transmitted infections, including HIV.
• Use of contraception advances the human right of
people to determine the number and spacing of their
children.
- Key facts, WHO

Unmet Need of FP
Condition of wanting to avoid pregnancy or postpone child
birth but not using any method of contraception.
This concept is applied to married women, however can
also be applied to fecund women & men too. But, its
measurement has only been limited to married women.
Definition:
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 next child. The concept of unmet need
points to the gap between women's reproductive intentions
and their contraceptive behavior. - WHO

Contd..
Unmet need for family planning
= Women of reproductive age (15-49) who are married or in a
union and who have an unmet need for family planning x 100
Total number of women of reproductive age (15-49)
who are married or in a union

Contd..
The standard definition of unmet need for family planning
(UMN), included in the numerator:
 All pregnant women (married or in consensual union) whose
pregnancies were unwanted or mistimed at the time of
conception.
 All postpartum amenorrheic women (married or in consensual
union) who are not using family planning and whose last birth
was unwanted or mistimed.
 All fecund women (married or in consensual union) who are
neither pregnant nor postpartum amenorrheic, and who either
do not want any more children (limit), or who wish to postpone
the birth of a child for at least two years or do not know when
or if they want another child (spacing), but are not using any
contraceptive method.

Contd..
 Common Reasons for Unmet Need
1. Lack of access
2. Unsatisfactory services
3. Poor quality of services provided:
oChoice of method
oProvider competence
oInformation given to client
oProvider-client relationship
oRelated health care services
oFollow-up care
4. Health concerns
oActual side effects
oFear of side effects

Contd…
5. Lack of information or misinformation about:
oAvailable methods
oMode of action/how used
oSide effects
oSource/cost of methods
6. Family/community opposition
oConcerns about unfaithfulness
oFear of side effects
oObjections to male providers
oReligious objections
oLittle perceived risk of pregnancy
7. Ambivalence: uncertain or unable to decide about what course to
follow = ambivalent

Contd..
 Measures to reduce unmet needs:
Measures to reduce unmet needs:
1.Improve access
to good quality
services
 Offer choice of methods
 Eliminate medical barriers
 Expand service delivery points
o Home delivery
o Social marketing
 Provide confidentiality
2. Improve
communication
about:
 Source of FP information and supplies
 Misinformation and rumors regarding
effects/side-effects
 Risks of contraception
 Risks of pregnancy: legitimacy :lawfulness by
virtue of being authorized or in accordance
with law

Contd..
3. Overcomes
husband’s
opposition:
 Address men directly with Information
about the benefits and safety of family
planning.
 Recognizing men's often-dominant role
in decision-making but promoting the
equal participation of a women, too.
 Encourage better communication
between spouses about family planning
and reproductive health.
 Help women learn how they can talk
with their partners about family
planning, including how to start the
discussion.

Contd..
Prenatal care/
Post-partum care/
Breastfeeding/
Immunization
Link Family Planning to other
services
o Prenatal care
o Post-partum
care/breastfeeding
o Immunization
o Post-abortion care
o Child health services

Assessment and counseling( CoFP)
Family Planning Counseling :
Family planning counseling is the process whereby
counselor help clients and people to make informed
and voluntary choices about the number of children
and the spacing of the children within their family.

Contd..
• Counseling is one of the critical elements in the
provision of quality family planning services.
• Through counseling, providers help clients make
and carry out their own choices about reproductive
health and family planning.
• Good counseling leads to improved client
satisfaction.
• A satisfied client promotes family planning, returns
when s/he needs to and continues to use a chosen
method.

Contd..
Informed choice:
Informed choice is defined as a voluntary choice or
decision, based on the knowledge of all available
information relevant to the choice or decision.
In order to allow people to make an informed choice
about family planning, provider must make them
aware of all the available methods, and the advantages
and disadvantages of each. They should know how to
use the chosen method safely and effectively, as well
as understanding possible side-effects.
There are different ways of providing effective family
planning counseling.

Contd..
Individual Counseling:
• In most cases, individuals prefer privacy and
confidentiality during communication or counseling
with counselor.
• It is important to respect the needs and interests of a
client by finding a private room or place where
counselor can talk with them.

Contd..
Couple Counseling:
• Couple counseling is when you give a counseling
service to a couple or partners together.
• This is particularly common when they are thinking of
using irreversible family planning measures, such as
voluntary surgical methods.

Contd..
Group Counseling: Group information sharing:
Group information sharing is used when individual
counseling is not possible, or if there are people who are
more comfortable in a group .
In this situation, after greeting everyone in a friendly
manner, provider would explain to them the benefits of
family planning, discuss briefly common myths and
mistaken beliefs about family planning, and then inform
the group about how to obtain appropriate contraception.
It is a cost-effective way of information sharing and
answering general questions, but people are not likely to
share their more personal concerns in this setting.

Principles of Family Planning counseling
• Maintain Privacy
• Ensure Confidentiality
• Be non –judgmental
• Focus on the needs of the client
• Informed voluntary choice
• Empowerment: It is a process that enables a person to
identify his/her needs, make decisions and exercise their
rights.
• Use simple culturally appropriate and easy to understand
language
• Use good interpersonal communication skills

Contd.
• Consent: The counselor should inform the client that
consent in writing or by thumb print is required for
minilaparatomy, laparoscopy and vasectomy. This consent
indicates that the client has been full informed about the
surgical contraceptive procedure they have chosen.
• Be brief, simple and specific with key message
• Encourage the client to ask questions and express any
concern
• Use AV aids, anatomic models and contraceptive samples
• Provide feedback, repeat key information
• Always verify with client has understood by having the
client repeat the key messages.

Stages of counseling for family planning
1. General counseling:
 The first contact usually involves counseling on general
issues to address the client‘s needs and concerns.
 Provider will also give general information about methods,
and clear up any mistaken beliefs or myths about specific
family planning methods. All this will help the client in arrive
at an informed decision on the best contraceptive method to
use.
 During this session provider would also give information on
other sexual and reproductive health issues, like sexually
transmitted infections (STIs), human immunodeficiency virus
(HIV), acquired immunodeficiency syndrome (AIDS) and
infertility.

Contd..
2. Method-specific counseling:
In method-specific counseling, counselor gives more
information about the chosen method.
In this case, counselor can explain the examination for
fitness (screening), and instruct on how and when to
use the given method.
She/he also tell the client when to return for follow-up,
and ask them to repeat what you have said on key
information.

Family planning counseling
— the BRAIDED approach. It stands for:
B= Benefits of the method
R= Risks of the method, including consequences of method
failure
A = Alternatives to the method (including abstinence and
no method)
I = Inquiries about the method (individual‘s right and
responsibility to ask)
D= Decision to withdraw from using the method, without
penalty
E = Explanation of the method chosen
D = Documentation of the session for your own records.

Family planning counseling
— the GATHER approach
G =Greet the client respectfully.
A =Ask them about their family planning needs.
T= Tell them about different contraceptive options and
methods.
H= Help them to make decisions about choices of
methods.
E= Explain and demonstrate how to use the methods.
R =Return/refer; schedule and carry out a return visit and
follow up.

Contd..
 G — Greet the client:
In the first case, give full your attention to the your clients.
Greet them in a respectful manner and introduce yourself
after offering seats.
Ask them how you can help them.
Tell them that you will not tell others what they say.
If the counseling is in a health institution, you have to
explain what will happen during the visit, describing
physical examinations and laboratory tests if necessary.
Conduct counseling in a place where no-one can overhear
your conversation.

Contd..
A — Ask the clients about themselves
Help them to talk about their needs, doubts, concerns and
any questions they might have.
If they are new, use a standard checklist or form from
your Health Management Information system to write
down their name and age, marital status, number of
pregnancies, number of births, number of living children,
current and past family planning use, and basic medical
history.
Explain that you are asking for this information in order
to help you to provide appropriate information, so that
they can choose the family planning method which is the
best for them.

Contd..
• Keep questions simple and brief, and look at her/them
as you speak.
• Many people do not know the names of diseases or
medical conditions. Ask them specific questions. Say,
‗Have you had any headaches in the past two weeks?‘,
or ‗Have you had any genital itching?‘, or ‗Do you
experience any pain when urinating?‘ Do not say,
‗Have you had any diseases in the recent past‘.
• If you have seen the client(s) previously, ask if
anything has changed since the last.

Contd
T — Tell them all about family planning methods:
Tell them which methods are available.
Ask which methods interest them and what they know
about the methods.
Briefly describe each method of interest and explain
how it works, its advantages and disadvantages, and
possible side-effects.

Contd..
H — Help them to choose a method
To help them choose a method of contraception, ask them
about their plans and family situation. If they are uncertain
about the future, begin with the present situation.
Ask what the spouse/partner likes and wants to use.
Ask if there is anything they cannot understand, and repeat
information when necessary.
When the chosen method is not safe for them, explain
clearly why the method may not be appropriate and help
them choose another method.
Check whether they have made a clear decision and
specifically ask, ‗What method have you decided to use?‘

Contd..
E — Explain how to use a method
After a method has been chosen:
Give supplies if appropriate. If the method cannot be
given immediately, explain how, when and where it will
be provided.
For methods like voluntary sterilization the client will
have to sign a consent form. The form says that they want
the method, have been informed about it, and understand
this information. You must help the individual understand
the consent form.

Contd..
Explain how to use the method.
Ask the client to repeat the instructions.
Describe any possible side-effects and warning signs,
and tell them what to do if they occur.
Ask them to repeat this information back to you.
 Give them printed material about the method to take
home if it is available.
Tell them when to come back for a follow-up visit and
to come back sooner if they wish, or if side-effects or
warning signs occur.

Contd..
R — Appoint a return visit for follow-up:
At the follow-up visit:
ask the client if she is, or they are, still using the
method, and whether there have been any problems.
ask if there have been any side-effects.
reassure the client/s concerning minor side-effects.
Explain that the side effects are not dangerous and
suggest what can be done to relieve them.
refer for treatment in the case of severe side-effects.
ask the client if they have any questions.

Contd..

FPCounseling-ABHIBADAN approach
ABHIBADAN approach
A Abhibadan garne To greet
Bhi Bhinna nathani
sodhpuch garne
Asking without
discrimination
Ba Badhaa hataune to deal with problems
and concerns
Da Datta Chitta bhayi
sahayog garne
Help whole-heartedly
N Namaskar garne punha
aauna anurodh garne
Bid goodbye and
request to come back
again

FPCounseling-ABHIBADAN approach

Tips for Successful Counseling
 Show every client respect, and help each client feel at ease.
 Encourage the client to explain needs, express concerns, ask
questions.
 Let the client‘s wishes and needs guide the discussion.
 Be alert to related needs such as protection from sexually
transmitted infections including HIV, and support for condom
use.
 Talk with the client in a private place, where no one else can
hear.
 Assure the client of confidentiality —that you will not tell
others about your conversation or the client‘s decisions.

Contd..
Listen carefully. Listening is as important as giving
correct information.
Give just key information and instructions. Use words
the client knows.
Respect and support the client‘s informed decisions.
Bring up side effects, if any, and take the client‘s
concerns seriously.
Check the client‘s understanding.
Invite the client to come back any time for any reason

Contd..
Counseling has succeeded when:
Clients feel they got the help they wanted
Clients know what to do and feel confident that they
can do it
Clients feel respected and appreciated
Clients come back when they need to
And, most important, clients use their methods
effectively and with satisfaction.

Factors influencing FPcounseling outcomes
There are different factors that affect the quality and
effectiveness of communication in FP counseling.
• FP services provider , ability to engage in effective
communication,
• His/her technical knowledge, skills, attitudes and
behaviors, and
• Personal values and belief of service provider on
specific methods,

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