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- 1. Family planning |Contraception PREPARED BY MARYAMA ISMAIL ELMI SUPERVISED BY DR EMMANUEL 1
- 2. Outline ◦ Introduction ◦ Epidemiology ◦Classifications ◦ Mechanisms of action ◦ Advantages and disadvantages ◦ Counsel patients and couples on family planning 2
- 3. I. Introduction oContraception alsoknown as birth control ,refers to the methods and techniques used to prevent pregnancy by interfering with the process of fertilization . oFamily planning is defined as the ability of individuals and couples to anticipate and attain their desired number of children and the spacing/timing of their births. oContraceptive methods vary widely , from oral contraceptive pills ,implants, injectables ,patches , vaginal rings intra uterine devices, condoms , male and female sterilization , lactational amenorrhea ,withdrawal and fertility awareness-based 3
- 4. According to WorldHealth organization oFamily planning/contraception reduces the need for abortion, especially unsafe abortion oFamily planning reinforces people’ s rights to determine the number and spacing of their children oBy preventing unintended pregnancy, family planning/contraception prevents deaths of women and children. Deciding which method is right for you involves considering a number of issues, including convenience, cost, potential side effects, and future pregnancy plans. 4
- 5. II. Epidemiology oContraceptive effectivenessis determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation. oLow and middle-income countries (LMICs) have the highest unmet need for modern contraception as over 200 million women who do not want to conceive are not using a contraceptive method . oAnnually, 111 million unintended pregnancies and 35 million unsafe abortions occur in LMICs (Kawuki et Al. 2022) oAccess to modern contraception and adequate care for all women could reduce unintended pregnancies by 68%, unplanned births by 71%, unsafe abortions by 72% and maternal mortality by 62 (Kawuki et Al. 2022) oUse of long-acting methods, such as intrauterine devices and subdermal implants, has increased substantially, from 6% of all contraceptive users in 2008 to 17.8% in 2016; these methods have failure rates of less than 1% per year. 5
- 6. Epidemiology cont; oIn Rwanda, thecontraceptive prevalence rate (CPR) is 64% among currently married women age (NISR, 2020) Most currently married women using contraception use a modern method (58%), while 6% use a traditional method. Fifty percent of sexually active unmarried women use a contraceptive method, with 48% using a modern method and 2% using a traditional method 6 The most used methods by women in Rwanda
- 7. III. Classification Natural contraceptivemethods: rhythm Modern contraceptive methods: •Barriers, •Hormonal , •Intrauterine devices •Permanent sterilization (men and women) •Lactational amenorrhea method 7
- 8. 1. Natural familyplanning Method that uses the body’s natural physiological changes and symptoms to identify the fertile and infertile phases of the menstrual cycle. Types of natural family planning methods ◦ Fertility awareness-based methods: involves tracking woman<s natural fertility cycle to determine when she is most and least likely to conceive . ◦ Coitus interrupts (withdrawal or pulling out) method 8
- 9. 2.Modern family planningmethods Short acting ◦ Barrier methods • Condoms (male, female) • Diaphragm • Cervical cap • Spermicidal ◦ Oral Contraceptive Pills • POP • COC ◦ Combined estrogen/progestin patch and ring ◦ Injectables ◦ Lactational Amenorrhea Long acting reversible contraception • Implants • Intra-uterine systems Permanent FP methods • Bilateral tubal ligation • Vasectomy Emergency contraception • Emergency contraceptive pills • IUCD 9
- 10. Barrier methods Male andfemale condoms ◦ Most are made from latex rubber ◦ Male condoms 85% effective ◦ Female condoms 79% effective in preventing pregnancy. Advantage ◦ Protection against STDs ◦ Easily accessible ◦ Few side effects Disadvantage ◦ Must be used with each act of intercourse ◦ Requires cooperation of both partners Possible health risks include: o Increased risk of toxic shock syndrome among cervical cap users if the cap is improperly used. o Other barrier methods pose no serious health risks. 10
- 11. Barrier methods cont’d Diaphragm ◦92-96% effective ◦ Need to be fitted and woman needs to be taught how to insert ◦ Must be inserted prior to intercourse ◦ Recommended to use with spermicide to increase effectiveness ◦ Slightly increased risk of UTI ◦ Leave in for minimum 6 hrs after intercourse, then remove ◦ and clean Cervical cap ◦ 71% effective ◦ Tighter fitting ◦ Use with spermicide ◦ Leave in 6 hours after intercourse, then remove and clean 11
- 12. Implants oHormonal implants alsocalled Nexplanon is a small rod that contains the hormone progestin ,are surgically placed beneath the skin of the client’s upper arm . oIs one of the most effective methods of birth control(????/%). o It provides at least three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues Types oJadelle® (levonorgestrel, a two-rod system effective for, 5 years). oImplanon NXT or Nexplanon 1 rod containing etonogestrel (for 3yrs) oTrust Implant(II)® or Sino-Implant (II)® levonorgestrel, a two-rod system, effective for 4 years). 12
- 13. Advantages of contraceptiveimplants include •It is the most effective reversible birth control method . •Insertion and removal is quick and easy. •It is safe for women who cannot use estrogen. • Have no effect on quality or quantity of breast milk, therefore can be used while breastfeeding •Fertility returns rapidly after the rod is removed. 13 Possible disadvantages: o Irregular bleeding is the most bothersome side effect. o Women who have liver disease , breast cancer or a history of breast cancer need to avoid this method. o Insertion problems, such as infection, are very rare, but possible. Implants is the most effective reversible contraception available.
- 14. Mechanism of action Implantscontinually release a small amount of progestin steadily into the blood. The contraceptive effect of implants is achieved through a combination of mechanisms. The primary mechanisms are: ◦ Increased viscosity of the cervical mucus making it harder for sperm to swim through (effect starts within 48-72 hours after insertion of implants) ◦ Inhibition of ovulation in about 50% of menstrual cycles The secondary mechanism: ◦ Suppression of endometrial growth so that it is less receptive to implantation 14
- 15. Lactational amenorrhea To beused effectively three criteria must be fulfilled 1. Work only for 6 months or until baby not exclusively breastfeeding 2. Woman must remain amenorrhoeic 3. Breast feed baby exclusively Mechanism of action Suckling induces a reduction in gonadotropin releasing hormone, luteinizing hormone and follicle stimulating hormone release, resulting in amenorrhea. 15
- 16. Oral contraceptive pills Theycontain either one or two female sex hormones Include combined oral contraceptive pills (COCs)-both estrogen and progestin and progestin only pills (POPs) The hormones are synthetic estrogens and synthetic progesterone . Up to 99.9% effective preventing pregnancy if taken correctly . 16
- 17. Combined oral contraceptivepills(COCP) Pills that contain low doses of 2 hormones (estrogen and progestin) High-dose >50 micrograms of estrogen; Mid-dose 30-35 mcg of estrogen; Low-dose < 20 micrograms of estrogen The three forms of low-dose COCs: Monophasic, Biphasic, Triphasic Forgotten pill(s): take as soon as they remember; if 2 days forgotten, take 2 pills for 2 days to catch up; if misses more than 2 pills, not covered and needs to use backup method 17
- 18. COC Mechanism of action oPrimarilyby preventing ovulation oPrevent synthesis of gonadotropins from the pituitary (negative feedback, prevents development of dominant follicle and LH surge). oHence, ovarian follicles do not mature and ovulation does not occur. 18
- 19. COC Advantages oThe pillmakes menstrual bleeding more regular, with fewer days of flow and overall lighter flow. Other benefits of the pill include a reduction in: oMenstrual cramps or pain oRisk of ovarian cancer or cancer of the endometrium (uterine lining) oAcne oIron-deficiency anemia 19 COC Side effects: Potential complications are DVT& PE Lighter bleeding and fewer days of bleeding, irregular and infrequent bleeding Amenorrhea Dizziness, headache Nausea, abdominal pain, weight changes Breast tenderness Acne Mood changes Slight increases in blood pressure (improves with discontinuation) All are less with lower doses of estrogen Contraindicated in women with uncontrolled HTN
- 20. Other Combined Estrogen andProgestin Birth control oPatch (one patch per week for 3 weeks of month) oRing (place one per month) oMechanism of action same as for combined oral contraceptive pills oSlightly fewer side effects due to topical and not oral route of administration 20
- 21. Progestin-only pills (POPs) ocontainvery low doses of a progestin (0.025 mg – 0.030 mg progesterone ) ocan be used throughout breastfeeding oPOPs are safe and suitable for nearly all women POP Mechanism of action oThickening cervical mucus oDisrupting the menstrual cycle, including preventing ovulation 21 oPOP lengthen the period of amenorrhea of breastfeeding women ofrequent or irregular bleeding for the first several months-if not breastfeeding oHeadaches, dizziness, breast tenderness oRare Contraindications: women with progestin + cancer (i.e. breast) or women with a hx of progesterone allergy POP Side effects
- 22. INJECTABLE BIRTH CONTROL oTheinjectable contraceptive currently available is depot medroxyprogesterone acetate or DMPA (brand name: Depo-Provera). oDMPA is injected deep into a muscle, such as in the buttock or upper arm, or injected subcutaneously (under the skin). oWith either type of injection, this contraceptive is given once every three months. 22
- 23. Injectable birth control Containsprogestogen or combination of estrogen and progestogen. Types ◦ Medroxyprogesterone acetate(DMPA) ◦ 150 mg IM every 3 months ◦ Norethisterone enanthate(NET-EN) ◦ 200 mg every 2 months Mechanism of action ◦ Inhibits Ovulation ◦ Thickens the Cervical Mucus ◦ Thins the Endometrial Lining 23 Advantages o Effective for 12 weeks o Independent of sexual intercourse o Safe for use during breast feeding Disadvantages oNo protection against STD oIrregular bleeding and spotting oWeight gain in certain population oProlonged return of fertility after discontinuation. Median time is 8.5 months oDepression in some women
- 24. Injectable Progestins Timing ofthe First Injection ◦ Anytime when it is reasonably certain the woman is not pregnant: ◦ During the first seven days after the start of menses. ◦ Immediately or within 7 days following a spontaneous or induced abortion. ◦ Immediately postpartum or up to 28 days after delivery if the woman is not breastfeeding. ◦ Repeat injections usually 3 months but depends on dose 24
- 25. Intra uterine contraceptivedevice (IUCD) oConsists of a small, flexible plastic device inserted into a woman’s uterus and is left in place for long periods of time. o≥ 99% effective in preventing pregnancy Types ◦ copper-bearing IUCDs ◦ Hormone-releasing IUCDs (progestin) ◦ Inert or unmedicated IUCDs 25
- 26. IUCD Mechanism: ◦ Prevention offertilization ◦ Intense local endometrial inflammatory response especially copper containing devices. ◦ Copper levels increase in the cervical mucus of users and decrease sperm motility and viability ◦ With LNG-IUS, endometrial atrophy which hinders normal implantation. 26
- 27. IUCD Advantages: ◦ Highly cost-effectivelong-acting ◦ Appropriate for lactating mothers ◦ Do not interact with any medication ◦ Best choice for women unable to use hormonal methods ◦ LNG IUD’s can help treat menorrhagia 27 Complications o Uterine infection near time of insertion o Do not place if PID or other infection o Do not place copper IUD in someone with copper storage disease (Wilson’s disease) o Menstrual irregularity o Expulsion o Perforation o Risk of ectopic if pregnancy occur with IUCD in place
- 28. IUCD Initiation ◦ Any timewithin 12 days after start of menses ◦ Anytime if she has been using reliable method of contraception ◦ Postpartum ◦ Post abortion ◦ Lactating mother 28
- 29. Permanent contraceptive methods Tubal ligation ◦Postpartum Vasectomy ◦ Needs backup contraceptive for two months with a negative semen analysis. 29
- 30. Emergency contraception Refers to theuse of drugs or a device as an emergency measure to prevent pregnancy. Situations to use emergency contraception-Should be taken as soon as possible if:- Sex was forced (rape) or coerced Any unprotected sex Contraceptive mistakes such as: ◦ Condom was used incorrectly (slipped or broke) ◦ Couple incorrectly used a fertility awareness method ◦ Missed 3 or more COC pills or has started a new pack 3 or more days late ◦ Woman is more than 2 weeks late for her repeat progestin-only injection. 30
- 31. 31 Also called “morningafter” pills or postcoital contraceptives. Progestin-only pills with levonorgestrel or norgestrel Combined oral contraceptive pills (COCs) with estrogen and a progestin- levonorgestrel, norgestrel, or norethindrone (norethisterone). Examples; 1. Emergency contraceptive pills (ECPs)
- 32. Emergency contraception Mechanism of action-preventor delay ovulation. They do not work if a woman is already pregnant (and do not abort an existing pregnancy). Prevents pregnancy only from acts of sex that took place in the 5 days before, Side effects include change in bleeding pattern, nausea and vomiting, headache, breast tenderness and dizziness. 32
- 33. Copper-bearing intrauterine devices (IUDs)emergency contraception Cause a chemical change in sperm and egg before they meet to prevent fertilization . The effectiveness of copper-bearing IUDs in preventing pregnancy is > 99% when inserted within 5 days of unprotected intercourse. N:B “Emergency contraception DOES NOT interrupt an established pregnancy and DOES NOT harm a developing embryo.” 33
- 34. Options for emergencycontraception 34
- 35.
- 36. V. Family PlanningCounseling •Counseling is a type of patient-provider interaction that involves two-way communication between a health care staff member and a patient for the purpose of confirming or facilitating a decision by the patient or helping the patient address problems or concerns. •Ask open ended questions when they seem hesitant about any method; (what do you know about IUCD’s or ocp’s or whichever method you think might suit them best) •Be non-judgemental, everyone’s life and circumstances are different •Be a source of reliable information 36
- 37. Counseling Principles The keyprinciples for cultivating good patient- provider interaction also apply to counseling. In addition, providers should follow these guidelines when counseling clients: Create an atmosphere of privacy, respect, and trust. Engage in two-way communication with the patient or couple. Ensure confidentiality. Remain nonjudgmental about values, behaviors, and decisions that differ from your own. 37
- 38. Principles oShow empathy forthe patient’s needs. oDemonstrate comfort in addressing sexual and gender issues. oTake time during the interaction and express interest. oProvide reliable and factual information tailored to the needs of the client. oProvide information to the patient that is understandable (written, pictures, …) oSupport the patient’s sexual and reproductive rights 38
- 39. CHOOSING A BIRTHCONTROL METHOD 39 Factors to consider include: ●Efficacy (how well it works to prevent pregnancy) ●Convenience ●How long the drug or device can be used ●Whether and how it affects your monthly period ●Type and frequency of side effects ●Affordability ●Whether or not it also protects against sexually transmitted diseases ●How quickly fertility will return if you stop taking it N:B No birth control is perfect; balance the advantages and disadvantages of the different options and decide which method is best . (Kaunitz, 2022)
- 40. Take home message Oral contraceptivepills are the most commonly used reversible contraceptives, Intrauterine devices and subdermal implants have the highest effectiveness, And progestin-only and nonhormonal methods have the lowest risks. Any reproductive-aged person-male or female, regardless of marital status is eligible for FP services, including information, education, and counseling. FP has health, economic and social benefits at individual, national and global levels. Implants and IUCD are effective LARC methods and can be used during breast feeding Emergency contraception are safe for all women due to their short term nature. 40
- 41. References 1. Kawuki, J.,Gatasi, G., Sserwanja, Q. et al. Utilisation of modern contraceptives by sexually active adolescent girls in Rwanda: a nationwide cross-sectional study. BMC Women's Health 22, 369 (2022). https://doi.org/10.1186/s12905-022-01956-y 2. Kaunitz, A. M. (2022). Patient education: Hormonal methods of birth control (Beyond the Basics). uptodate. 3. Family planning ,a global hand book for providers 2022 edition . 4. Stephanie Teal et, A. E. (2021). Contraception Selection, Effectiveness, and Adverse Effects. PubMed. 5. National Institute of Statistics of Rwanda, (2021). Rwanda Demographic and Health Survey 2019-20 Final Report. 41
- 42.
Editor's Notes
- #4 It has significant social , cultural and medical implications ,impacting reproductive health ,and population control . The choice of contraception is highly personal and can depend on factors like effectiveness, convenience, and individual preferences .
- #20 Taking birth control pills does not cause weight gain.
- #22 People with breast cancer may wish to avoid using birth control pills or hormonal intrauterine devices (IUDs). This is because these methods can affect the growth of tumor cells in people with hormone-sensitive cancers, such as breast cancer Women with breast cancer and other hormonally sensitive cancers are a unique group, with COCP contraindicated and progestin-only contraceptives also not indicated, limiting their options to non-hormonal methods. The Society of Family Planning clinical guideline recommends the copper intrauterine device (c-IUD) as the first-line contraceptive option for women with breast cancer
- #24 Progesterone-only contraceptives, including progesterone-only injectables (POIs), prevent pregnancy in the following ways: Inhibition of ovulation (the primary mechanism of action) Thickening of cervical mucus to stop sperm penetration Thinning of the endometrium of the uterus to make it unfavourable for implantation of the fertilised egg Slowing of sperm and ovum transport through reduced fallopian tube peristalsis (wave-like muscular contractions of the fallopian tube by which contents are forced onward towards the uterus).
- #26 they are available in two forms: nonhormonal copper-containing devices and plastic devices with progestogen hormone Types Copper intrauterine device “Intrauterine device” in “Nonhormonal contraception Progestin intrauterine device: a progestin-releasing (e.g., levonorgestrel-releasing) contraceptive device that is placed into the uterus Mechanisms [6] Produces local inflammatory reaction → prevents fertilization and implantation Interferes with sperm function and transport Characteristics ≥ 99% effective in preventing pregnancy [7] Provides long-term, reversible contraception: contraceptive activity lasts up to 5 years if kept in place after insertion. Less menstrual bleeding or amenorrhea compared to copper IUDs Adverse effects Abnormal uterine bleeding and/or menstrual changes Dysmenorrhea Pelvic pain following insertion Uterine perforation Contraindications Active PID )
- #28 LNG IUD : levonorgestrel intrauterine device .( release small amount of levonorgestel , a form of progesterone ,into uterus each , Reduces cramping and heavy menstrual bleeding
- #41 LARC long acting reversible contraception