Family planning

FITSUM ASHEBIR
Family planning or fertility control include both
Fertility inhibition (contraceptive)
Fertility stimulation

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why
•The rapid population growth in Ethiopia is a serious challenge to the
development efforts of the nation.
•Ethiopia has one of the highest rates of population growth in the world
and is the second most populous country is Sub-Saharan Africa
•Ethiopia’s population is expanding at more than 2 million people a year.
•If the current rate of growth remains unchanged, Ethiopia's population of
78 million will double in less than 25 years and reach 350 million by the
year 2050.

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The unmet need for family planning remains high.

Two out of three married women want to space or limit the

number of children they have but are not using a family planning
method.
While 1 million married women in Ethiopia are using family planning, 3.5
million have an unmet need.

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Population: 75,015,684
Annual Growth Rate: 2.7%:
Crude Birth Rate: 39.9/1,000
Crude Death Rate: 12.6/1,000
Total Fertility Rate: 5.9
Maternal Mortality Rate: 673/100,000
Infant Mortality Rate: 77/1,000
Under-five Mortality Rate: 123.1/1,000

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Overview of Female
Reproductive Physiology

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Pearl index
The number of pregnancies which would occur if 100 women use specific
method for one year.

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Factors to consider in choosing
method
Counseling in FP •Efficacy
◦ Informed choice
◦ Confidentiality •Convenience
◦ privacy •Duration of action
GATHER approach •Reversibility and time to return of
fertility
G- greet
A- asses knowledge
•Effect on uterine bleeding
T- tell z client about all the methods •Frequency of side effects and adverse
events
H- help the client approach to make
choice •Affordability
E- explain about the chosen method •Protection against sexually
transmitted diseases
R- return visit

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Methods
• Non hormonal • Hormonal
• Coitus interuptus • Pills- COC, progesterone only,
• Breastfeeding • Injectable – DMPA (Depomedroxy
• Fertility Awareness Progesterone Acetate)
• Calendar method • Implants
• Symptothermal
• Cervical mucous (Billings) • IUCD
• Barriers • PERMANENT BTL AND
• Condoms VASECTOMY
• Diaphrams
• Cervical caps
• Spermicides

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Non hormonal
Coitus interrupts
Breastfeeding- for the 1st 6 month
Fertility Awareness
◦ Calendar method
◦ Symptothermal -
◦ Combination of calendar & T0 method
◦ i.e. 1st day by calendar and last day
by T0
◦ Cervical mucous (Billings)
◦ Abstinence from the onset of menses
to 4 day after maximum secretion of Basal Body
the cervical mucous
Temperature
Chart
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The Standard Days Method
Barriers
Condoms - M and F has 6- 30/100 effectiveness
◦ Advantage – effective, protect from STI/ AIDS
◦ Disadvantage – breaking, slippage, allergy, claim of dulling sexual
sensation

Diaphragms - has 10-20/ 100 effectiveness

◦ Advantage - for those who practice sex infrequently
◦ Disadvantage – inappropriate of the method, increased incidence of
UTI, vaginal laceration

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Barriers
Cervical caps –
◦ Fits only the cervical external os
◦ Provide continuous protection for 48 hrs. Spermicide

Spermicides- 2- 40 / 100 effectiveness

◦ Placed 10 -15 min prior to intercourse
◦ Various preparations
◦ Cream, foaming, Tablet and aerosol foams
◦ Advantage – protect from STI, AIDS
◦ Disadvantage - inappropriateness, allergy, presumed risk of congenital
malformation

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Hormonal
Oral contraceptives
◦ inhibition of the midcycle surge of gonadotropin secretion, so that
ovulation does not occur.

Combined (estrogen-progestin)
◦ COCs are a reliable form of contraception and
◦ Non contraceptive benefits i.e. reductions in
◦ Dysmenorrhea,
◦ Menorrhagia,
◦ Acne,
◦ Ovarian cancer,
◦ Endometrial cancer due to the progestin component.

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 Monophasic, Biphasic,  That include
Triphasic  Personal characteristics
 Cardiovascular disease
 Based on amount of estrogen  Headache and epilepsy
& progesterone  Depression
 High dose Vs. low dose for  Reproductive tract/ breast
abnormalities, cancer, infections
monophasic  HIV/ Gastrointestinal disease
 Thalassemia and sickle cell anemia
 Preparation - tabs of 28  Diabetes and thyroid disease
 Indication and  Drug interactions
contraindications based on
WHO medical eligibility criteria

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WHO Eligibility Criteria

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WHO Eligibility Criteria
 Absolute contraindications

Relative contraindications

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Hormonal
How effective- 0.8 pregnancies per 100 women over first year.
Return of fertility – No delay
Protection against STD- None
Side effects
Nausea hyperpigmentation
Vomiting headache
Breast tenderness AUB .. Amenorrhea
Allergy….

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Combined oral contraception
(COC)
1950’s - first COC - trials in Puerto Rico: ENOVID - mestranol and norethynodel
1969 - first cardiovascular problems reported
Oestrogen + Progestogen

mestranol norethynodel
ethinylestradiol norethisterone
norgestrel
gestodene
desogestrel
norgestimate
drospirenone

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Types of COCs
Monophasic: All 21 active pills contain same
amount of Estrogen/Progestin (E/P)

Biphasic: 21 active pills contain 2 different E/P

combinations

Triphasic: 21 active pills contain 3 different E/P

combinations

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Pill Free Interval
Designed to induce withdrawal bleeding

Allows follicular growth

Prolonged PFI allows ovulation

Reduced to 4 days with pills < 20 mg estrogen

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 Missed pill
Missed 1 or 2 pills or started new pack 1 or 2 days late:
◦ Take a hormonal pill as soon as possible.
◦ Little or no risk of pregnancy.
Missed 3 or more pills in 1st / 2nd week? Started new pack 3 or more days late?
◦ Take a hormonal pill as soon as possible.
◦ Use a backup method for the next 7 days.
◦ Also, if she had sex in the past 5 days, use ECP
Missed 3 or more pills in the third week?
◦ As above AND
◦ After finish all hormonal pills in the pack start a new pack the next day without . Using
the 7 nonhormonal pills in the old pack
Missed any nonhormonal pills? (last 7 pills in 28-pill pack)
◦ Discard the missed nonhormonal pill(s) continue with the unmissed
◦ Start the new pack as usual.

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Extended and Continues Use
Extended use: Skip the last week of pills (without hormones)
in 3 packs in a row

Continues use no break at all

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Progestin only pills
are an option for women who want a contraceptive pill, but need to
avoid estrogen .
They are associated with more unscheduled (breakthrough) bleeding
and slightly higher failure rates than COCs.
The "minipill" has a dose of progestin that is close to the threshold of
contraceptive efficacy; therefore, these pills should be taken at the same
time each day and are taken every day without a pill-free interval

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Hormonal Contraception:
Mechanisms of Action

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Injectables

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Implants
Background
Contraceptive implants are matchstick-sized rods
that contain progestin.
Implanted beneath the skin of a woman’s upper
arm, the progestin is slowly released over 3 to 5
years.
Implants interrupt fertility by
◦ thickening cervical mucus (mechanically preventing the sperm from accessing
the ovum) and
◦ through hormonal effects that prevent ovulation in about half of menstrual
cycles.
Implant Systems
 Comparison
of Norplant®, Jadelle® and Implanon®
Implanon®
Jadelle ® Norplant®
 1 rod
 2 rods  6 capsules  Effective 3 years
 Effective 5 years  Effective 7 yrs.  Regulatory approval in 25
countries
 1-yr failure: 0.05% (1 in  1-yr failure: 0.05%  Insertion time: 1.1 min
20,000); 5-yr failure 1.1% (1 in 20,000); 5-yr. failure (0.03-5.0)
1.6%  Removal time:2.6 min (0.2
 Regulatory approval in – 20.0)
11 countries  Reg. approval in 62  Cost: comparable; AID
countries RFA out now
 Insertion time: 2 min  Insertion time: 4.3 min
 Removal time:4.9 min ± (0.8-18.0)
3.5 minutes  Removal time: 10.2 min
(1.3-50m)
 Cost: $29
 Cost: $27
[Sino-implant: $5]
 Features of Contraceptive
Implants
• Highly effective
• Not motivation dependent
• Can be used during lactation
• Discreet, virtually invisible
• Rapidly reversible
• Stable hormone levels
• Extended protection
• Contain no estrogen
• Safe

more…
Limitations of Contraceptive
Implants
Can cause irregular bleeding
Requires clinician visits for insertion and removal
Does not protect from STDs
IUCD
Intra uterine contraceptive devices, Intrauterine devices, Loop
Depending on the time 3 types
◦ Interval- in a non pregnant and after 6 month post partum or abortion
◦ Postabortal- immediately after abortion
◦ Postpartum- Immediately postpartum (from delivery of placenta to 48hrs)

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Types of IUCD
 Inert/ non medicated
 Lippes loop
 Dalkon shield
 Associated with higher risk of PID

 Medicated
 Progesterone
 Copper-bearing
 Copper coated/ Cu IUD

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Progesterone containing IUCD
1. Progestasert
◦ Contains 38mg of natural progesterone
◦ Supplies ~65µg/d into the uterine cavity for 1 yr.

2. Levonorgestrel (LNg 20-IUD)

◦ Also called Mirena®
◦ Contains 52mg of LNg
◦ Releases 20µg of LNg daily
◦ Serves for 5 yrs.

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Copper (Cu) containing IUCD
There are different types
Cu T 380A- place every 8-10 years
Multi-load 250
Multi-load 375
Nova T
Cu T 200 & 220
Cu 7, etc

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Cu T380A
Also called ParaGard®
Widely available
Used for 8-10 yrs.
Very effective, 0.8 pregnancy/100 women year
Coated with Cu bracelets = 33+33+314mm²
Polyethylene with barium sulfate for X-ray

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 Parts of IUCDs (Tcu 380A)

Arms (Rt./Lt.)
Copper sleeve
(33mm×2=66mm2 )
Stem

Copper wire
(314mm2 )
String/Thread

Main frame:- T shaped, flexible & containing barium sulfate

Long term contraceptives IUD 39

Cu T380A

Long term contraceptives IUD 40

 Effectiveness…

Source: CCP and WHO, 2007.

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Mechanism of action

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Progesterone releasing IUCDs:
Mechanisms of Action

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Advantages of IUCD
Highly effective and very safe
Does not interfere with intercourse
Easy to use
Long-acting
Easily reversible
Quick return to fertility
No systemic effects
Complications are rare

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Disadvantages of IUCD
 Side effects, including cramping and increased or
prolonged bleeding
 Rare complications include perforation and pelvic
inflammatory disease
 Method failure can lead to ectopic pregnancy
(extremely rare)
 Insertion and removal require trained provider
 No STI/HIV protection

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Indications/eligible for IUCD
Healthy reproductive tract – no infection, CA, or congenital anomaly
Mutually faithful sexual relationship
Women who have completed child bearing & do not want VSC
Who wants a long term reversible method
Who has precautions for other methods
Breast feeding women
Immediately postpartum (from delivery of placenta to 48hrs)
Who has successfully used IUD in the past
N.B. An IUD may be provided to young, nulliparous women
after thorough consideration

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 Contraindications
ABSOLUTE RELATIVE
Pregnancy or suspicions of pregnancy
Uterine abnormalities/anomalies –
Hx of dysmenorrhea or
 Myoma, Didelphic uterus
hypermenorrhea
Acute PID or Hx of PID in the past 3 months Valvular heart disease
Postpartum Endometritis/septic abortion Impaired immunity
Pelvic malignancies; Nulliparous
 cervical CA, endometrial CA, GTD
Previous ectopic
Undiagnosed AUB
Untreated acute cervicitis or vaginitis, including
Bacterial vaginosis, gonococcus, chlamydia
Wilson’s disease, allergic to Cu
Client or her partner has multiple sexual partners

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Emergency Contraception
Emergency contraception is a woman’s only reliable option for
preventing pregnancy after unprotected sexual intercourse has occurred,
or when another contraceptive method has failed or been used
incorrectly.
Emergency Contraception
Type
 Combined Oral Contraceptives (COC): COCPS (YUZPE’S regimen)
 Low-dose (30–35 µg EE and 150 µg LNG), or
 High-dose (50 µg EE and 250 µg LNG)
 Progestin-Only Pills (POP):
 750 µg LNG (preferred)X2
 30 µg LNG
 37.5 µg LNG
 75 µg norgestrel
 IUDs:
 TCu 380A, Multiload 375, Nova T
 Others

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Emergency contraceptive pills
Are hormonal methods
Sometimes called morning after pills or post coital pills
Can be used up to 72 hours
Should not be used as regular or on going basis only
emergency)
Two types-pills containing ethinylestradiol and
lovanolgestrol
Pills containing a progesterone only
Indications
Indications
Condom rupture,slipage,or misuse
Diaphragm or cup dislogment ,breakage,…
Failure coitus interuptus
Miscalculation of periodic abstinance
IUCD expulsion
rape
ECP Options
Two basic types of EC pills (ECPs) are:
(1) C-ECPs, ordinary combined hormonal contraceptive pills containing
estrogen and progestin (the Professor A. Albert Yuzpe regimen)
(2) P-ECPs, progestin-only pills, a newer
Both types of ECPs work by preventing ovulation, fertilization or
implantation.
Effectiveness

The overall protection provided by emergency

contraception (all methods) is to be approximately
75%(range 55 to 94 percent).
ECPs, both combined and progestin-only pills,
reduce rates of pregnancy by 75 to 88 % if taken
within 72 hours of unprotected intercourse.
IUD insertion can take place within five to seven
days of unprotected intercourse and can reduce a
woman’s chance of becoming pregnant by 99 %.
Surgical/permanent
Females Males
BTL vasectomy
Interval
Postabortal
Postpartum

Types
Effectiveness
Reversibility
contraindications

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Postpartum
Contraception
Counseling
FITSUM ASHEBIR
Goal of Presentation
What is different about contraception in postpartum period?
When should we counsel?
What are the options?
How do we use them?
Why do we recommend using them in this way?
What is different about contraception in
postpartum period?

•breastfeeding

•hypercoagulable state

different contraceptive needs

Breastfeeding Physiology
 Pregnancy
 Prolactin secretion in pregnancy -> breast growth, milk biosynthesis
 Progesterone (and estrogen) ->interferes with prolactin binding, inhibits
lactation
 Birth
 Rapid decline placental progesterone -> initiation of lactation
 Suckling -> oxytocin release -> contraction of the myoepithelial cells -> milk
ejection
 Day 2-4 postpartum,
 Steroid hormones cleared -> maintenance of milk production
 High serum prolactin -> inhibits pulsatile GnRH -> prevent ovulation ----->
maintained?
Breastfeeding
 Nutritional research 1970s-1980s – OCPs
 Sig changes in concentration of total protein, milk protein, and daily milk
volume (Lonnerdal 1980)
 Magnitude of changes w/in normal range, not of nutritional importance to
newborn (Kowetsawang 1987)

 WHO Task Force (1984)

 Prospective RCT of COC vs. POP vs. non-hormonal placebo.
 Milk volume: 41.9% decline in COC group vs. 12.0% in POP group vs. 6.1% in
non-hormonal controls.
 Comparable prevalence of complementary feeding and withdrawals due to
inadequate milk supply
 **No sig differences in growth of infants between treatment groups.
Postpartum Hypercoagulable
State
Physiology
◦ coagulation factors and fibrinogen, resistance to anti-coagulants protein C
and S

Risk of VTE (Gherman 1999)

◦ 22-84-fold high in first 6 weeks of postpartum period
◦ greatest in first 21 days, after which risk sharply drops off
Family planning needs?
Survey (Cwiak 2004) “extremely important qualities”
◦ ANTE-PARTUM: reliability, efficacy, and safety during breast-feeding
◦ POST-PARTUM SIG: ease of use, long-term protection, and no need for
monthly pharmacy trips

◦ > 80% using contraception prior to pregnancy, nearly 20% not satisfied with
the method used.
◦ > 40% thought IUC seemed ‘somewhat’ or ‘much better’ than their most
recent method, yet < 1% chose
When should we counsel?
Standard part of discharge discussion? (Glazer 2010)
◦ 77% (134) discussed contraception antepartum
◦ 87% (153) discussed postpartum.
◦ 1/3 discussing IUDs at any point.

Initiation of sexual activity? (Ford 1998, Barret 2000)

◦ 32-66% sexually active within first month,
◦ 62-88% within second month
How effective are we at
counseling?
Effectiveness of antenatal counseling (Smith 2002)
◦ Expert advice vs ‘routine standard advice’ in prenatal period
◦ Pregnancy rates at 1 year not significantly different, even when considering
intention
◦ Contraceptive practice differed significantly (only because those not intending
to get pregnant chose sterilization)

◦ Not many great studies out there…..

How effective are we at
counseling?
Cochrane Review of effects of postpartum interventions (Lopez 2002,
2010)

◦ Increased contraception use, decreased unplanned pregnancies in 2/4

interventional trials,
◦ More effective when interventions longer (beyond hospital stay period),
incorporating home visits
Part 2

What are the options? How do we use them?

Why do we recommend using them in this way?
Lactational Amenorrhea
◦ Ovulation within 3 months in exclusive breast feeders,
◦ As early as 3-6 weeks in women who are not exclusively breastfeeding
◦ May precede menstruation

Exclusively Breast feeding Mother

◦ < 2% “failure rate” in women exclusively or ‘mostly’ breastfeeding (DEF -
feeding both night and day, ammenorheic, infant less than 6 months old and
receiving >90% nutrition from breast milk) (WHO)
 LAM
ACOG WHO (AAFP)

NON- NOT recommended NOT recommended

Br Feed

Br Feed
LAM
Clinical Judgment
◦ Menstruation/ovulation is unpredictable
◦ Duration of breastfeeding
◦ Resumption of sexual activity
Combination contraceptives-
COCs, Nuvaring, Orthoevra
EBM
◦ In nonlactating women- risk of pregnancy related thrombosis reduced to
acceptable level after three weeks (Gherman 1999)
◦ Decreases median lactating period (WHO 1984)
◦ Effectiveness varies by method
Combination Contraceptives
ACOG WHO (AAFP) AAP

NON- > 4 weeks < 3 wks not rec unless No earlier than 3-6
Br Feed no other method avail weeks
> 3 wks use freely

Br Feed > 4 weeks, waiting < 6 wks do NOT use No earlier than 3 to
until br feeding well 6 wks- 6 mo not rec 6 wks, wait until
established unless no other infant not relying
method avail pred on br milk
> 6 mo use freely
Combination contraception
Clinical Judgment
◦ Acceptable reduction of risk of thrombosis
◦ Perceived effect on establishment of breastfeeding patterns
◦ Ease of use for mother
Progesterone only: Minipill, Depo-
Provera, Mirena IUD, Implanon
◦ Theoretical effect based on understanding of physiology
◦ Existing data of poor quality

EBM
◦ Progesterone little effect on coagulation factors, BP, lipids
◦ NOT been shown to effect milk quality sig, NO effect on infant growth and
development (Truitt 2003,WHO 1994,)
◦ Early initiation had NO effect on short-term breastfeeding patterns
(Halderman 2003)
Mirena-
Progesterone only IUD
Expulsion rates?
◦ Use: insert 20 minutes within delivery of placenta, using special technique OR
4-6 weeks postpartum, once uterus has involuted (24-48 hour interval not
recommended)
◦ 0.1%/0.1% one year failure rate (WHO)
◦ RCT of post-NVD insertion- Postplacental group 24% expulsion rate, Interval
group 4.4% expulsion rate (Chen 2010)
Depo-Provera-
Progesterone only injection
Breastfeeding (Hannon, 1997)
◦ NON-sig effect on duration or frequency of lactation
◦ NON-sig effect on timing of introduction of formula

Adolescents (Templeton 2000)

◦ 55% Depo vs 24% OC users continued method at 1 year.
◦ Total incidence of repeat pregnancy 10.6% at 1 year.
◦ 24% in OC users and 2.6% in Depo users pregnant at 1 year.
Progesterone only
Progesterone only
Clinical judgment
◦ Concerns for newborn – potential effects on newborn brain, liver unknown
(animal studies)
◦ Ease of use- timing of POPs
◦ Rate of expulsion of Mirena- timing of insertion?
◦ Complication rate for postplacental insertion- no quality data
◦ Prolonged/irregular bleeding
Copper IUD
EBM
◦ May insert 20 minutes within delivery of placenta, using manual insertion OR
4-6 weeks postpartum once uterus has involuted
◦ 0.6%/0.8% first year failure rate (WHO)
◦ No effect on breastmilk production, nutritional value
◦ Expulsion rate at six months 6.7 times more likely when placed postplacentaly
(7-15%) vs interval (Kapp 2009, Cochrane database 2010)
Copper IUD
Copper IUD
Clinical Judgment
◦ Review of safety of postpartum insertion based off of poor to fair quality trials
(Kapp 2009)
◦ Expulsion risks
Other methods
Sterilization (Tubal, Essure, Vasectomy)-
◦ Can be done at any immediatly after delivery/CS, within 24-48 hours or at an
interval of 4-6 weeks, effective immediately, no effect on breast milk, NOT
reversible

Condoms-
◦ Can be used at any time, effective immediately, no effect on breast milk,
protects against STIs, NOT always practical?
Plan B (and now ella….)
EBM
◦ No increased risk of VTEs for mom
◦ No effect on breastmilk

Clinical Judgment
◦ Availability
In summary
What is different about contraception in postpartum period?
When should we counsel?
What are the options?
How do we use them?
Why do we recommend using them in this way?
Thank you

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