Before we begin…

1. Before we begin… Say hello to three people you do not work with on a daily basis

2. Welcome, opening remarks and introductions of trainers

3. Community-based provision of Depo-Provera CBD Training in Mumbwa and Luangwa districts

4. Session 1 Introduction to pilot project: CBD provision of Depo and overview of week’s training agenda

5. By the end of this session, participants will have learned: • Basic background of CBD of Depo • Introduction to this pilot project • Training objectives • Overview of materials for this training • What to expect in the upcoming training (administrative, logistics, etc.)

6. Background on CBD of Depo

7. Why CBD of Depo? • Depo is most popular choice for family planning in Africa. • Family planning use in rural areas is low. CBDs live in rural areas, so they can provide family planning to women who have difficulty reaching a clinic. • CBDs are people the women already know and trust. Family planning can be provided in comfortable, private setting.

8. Experience with CBDs giving Depo elsewhere • Asia (1970s, 2000) • Latin America (1990s) • Uganda (2005) • Madagascar (2006) • Kenya, Nigeria (2009) Source: Population Council, Family Health International

9. Research and experience tells us… …with proper training and support, CBD provision of injectable contraception is: • Safe • Feasible • Acceptable

10. Pilot project in Mumbwa and Luangwa • Government of Zambia would like to know whether CBD of Depo works in Zambia. • Family Health International (FHI), Zambia Prevention, Care and Treatment (ZPCT) and ChildFund Zambia (CFZ) are working together to find out whether CBD of Depo works in Mumbwa and Luangwa. • After a year of research, we will know how CBD of Depo works in these two districts. • If it works well, the government may want to use CBD of Depo in more districts in Zambia.

11. Training objectives By the end of training, participants will have learned: • Definition of family planning • Benefits of family planning for the community and the country of Zambia • Four groups of women who are at high risk should they become pregnant • How to provide counseling on the full range of family planning (FP) methods • How to use screening checklists to decide if a woman can safely use her family planning method • When to initiate injectables (e.g., postpartum, breastfeeding or non-breastfeeding, switching from other methods). • Review of the parts and function of the male and female reproductive systems • Reviewed all of the family planning methods (what they are, how they work, how effective each one is, how each is used, advantages and disadvantages)

12. Training objectives – Cont’d • What is Depo and how does it work • What is the effectiveness of injectables • What are the common, non-harmful side effects of injectables • How to safely give a Depo injection • How to counsel the client about Depo (benefits and side effects, how it works in the body, etc.) • How to use the Counseling Flipbook with their clients • How to explain to client how to use injectables, including describing how the injection is administered and what to do post injection. • How to address common concerns, misconceptions, and myths clients may have • Prevent infection (washing hands and safely disposing of needles) • What to do in the event of a needle-stick injury or other unexpected event • How to locate the correct Depo injection site on the arm • Proper injection technique by having practiced on fruits or vegetables

13. Training objectives – cont’d • How to refer clients to health centers for any services they cannot provide • How to calculate a 13-week re-injection date and safe re-injection window. • How to make follow-up visits to their clients • How to track services they provide using the FP register and other forms • What are the roles of data retrievers and what to expect • When they should visit the district clinic and their supervisor • What their supervisor’s role will be in their work • How to order and store contraceptives and injection supplies How to dispose of their boxes at the district clinic • What to expect during the clinical practicum • About the supplies in the CBD kits they will receive after graduation

14. Which ones are you most excited about? • Pick five • Put colored dots next to your top five on flipcharts

15. Session 2: Benefits of Family Planning infants and children women families communities

16. Group Activity What is the definition of family planning? Family planning implies the ability of 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. – Working definition, WHO Department of Reproductive Health and Research

17. Questions to Consider • Brainstorm benefits of FP for: • women • children • men • communities

18. Health benefits of family planning for women • Lower risk of dying from pregnancy • Lower risk of poor pregnancy outcomes and complications • Lower risk of anemia • Lower risk of problems from miscarriage or unsafe abortion • Some contraceptive methods offer protection from • disease • certain cancers and other women’s health problems

19. Benefits for children • Longer breastfeeding: • provides nutrition • protects from childhood diseases • improves mother/child bonding • Reduces child illness and death • Allows more time for parents to meet the needs of each child

20. Family planning benefits for men • Allows men to decide when and if they become fathers • Allows men, in conjunction with their partners, to have the number of children they desire and can afford.

21. Benefits for Families and Communities • Families can devote more resources to providing for each child • Reduced maternal and child illness reduces economic strain on family • Reduced maternal deaths strengthen families and communities • Relieves economic, social, and environmental pressures

22. 4 groups of women at high risk for health problems if they become pregnant: • too young (younger than 18) • too old (more than 35) • too many (more than 5 births) • too close together (less than 2 years between births)

23. Group Activity • Are family planning services accessible to everyone in your community who may need them?

24. Session 3 Review of basics about the reproductive system

25. Parts on the outside of the man • Penis The organ that carries the man’s seeds into the vagina. At the end of the penis there are folds of skin called foreskin that covers uncircumcised penis. • Scrotum A sac where the testes are stored.

26. Parts on the outside of the man • Testes • Produces sperms which fertilize the eggs • Release the male hormone responsible for making a boy develop male characteristics such as • Beards • Deep voice • Broadened shoulders

27. Male reproductive parts

28. Female reproductive parts • Parts of the female that are involved in sexual activity, pregnancy and child bearing are called the female reproductive organs or parts • These consist of: • Parts on the outside (vulva, breast) • Parts on the inside (ovaries, fallopian tubes, uterus, vagina)

29. Female reproductive parts

31. Session 4 Overview of all family planning methods

32. Session 5: Overview of Depo learning objectives, Characteristics of Depo, and Why Women Like/Dislike Depo

33. Objectives • Describe the characteristics of Depo including common side effects. • Describe what makes women ineligible for Depo use and how the checklist is used to determine eligibility. • Describe when to initiate Depo. • Describe (and demonstrate) how to give an injection. • Describe key counseling topics. • Describe how to conduct initial and re-injection visits. • Identify clients in need of referral for Depo-related complications.

34. What is Depo? • Contraceptive method given by injection • Contains progestin (scientific name: Depo) • Similar to natural hormone made by woman’s body • Slowly released into blood from injection site

35. How is Depo Provided? (part 1) The injection is given in the upper arm:

36. How is Depo Provided? (part 2) • Every 13 weeks (3 months) • Can be up to 2 weeks early or 4 weeks late Injection Schedule: Schedule March April June September December

37. How does Depo work? Prevents eggs from getting ripe and leaving the ovaries

38. Questions to Consider • In your community, what do women believe about how injectables work? • Explain how injectables work.

39. Depo Is Popular Among Women Used: • by millions of women worldwide • in more than 175 countries • for almost 50 years

40. Depo Is Safe • Most women can use Depo safely • A few women with certain conditions should not use Depo • these women can be identified by asking a few simple questions • Depo does not cause any serious health problems, cancer, or infertility

41. Depo Is Very Effective • Women who have injections on time have very small risk of pregnancy (about one in 300 women)

42. Question to Consider • Why do women like Depo?

43. Easy to use Long acting Reversible Can be discontinuedwithout a provider’s help Does not interfere with sex Use can be private Has no effect on breastfeeding Eventually most women stop having monthly bleeding Why Women May Like Depo

44. Why Women May Not Like Depo • Causes side effects, particularly menstrual changes • Action cannot be stopped immediately • May take more time to become pregnant after stopping Depo • Provides no protection against STIs/HIV

45. Common Side Effects of Depo headaches and dizziness • prolonged or heavy bleeding • irregular bleeding or spotting • amenorrhea (no menses) abdominal bloating and discomfort weight gain changes in mood and sex drive

46. Questions to Consider • Which side effects do you think women in your community find most important when making a choice to use Depo? • Why do you think those are the most significant?

47. Session 6 Who Can Use and Who Should Not Use DMPA

48. Who Can Use Depo Any woman of reproductive age who desires an effective, reversible, and long-acting method who: • is breastfeeding a baby who is at least six weeks old • has or has not had children • cannot or does not want to use other methods (i.e., those containing estrogen) • has a sexually transmitted infection including HIV • is taking medications to treat AIDS or other diseases

49. My period is late… Hmm… that is high. Who Cannot Use Depo (part 1) have abnormal vaginal bleeding think they may be pregnant are pregnant are breastfeeding a baby less than six weeks old have very high blood pressure Source: WHO, 2004; updated 2008.

50. I cannot eat sweets. Who Cannot Use Depo (part 2) have diabetes have breast cancer have serious liver disease or lupus had a heart attack or stroke or have blood clots Source: WHO, 2004; updated 2008.