Family planning

1. Introduction to Primary Care a course of the Center of Post Graduate Studies in FM Family planning PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

2. Objectives of this session Aim of family planning Islamic view of family planning Methods of family planning Modern contraceptive methods indications, C.I., & side effects Family planning counseling Obstacles to family planning.

3. Aim of family planning Essential intervention of safe motherhood Pregnancy/ birth spacing Promote women reproductivehealth. Decreased maternal mortality rate Promote women health. Decrease neonatal death rate Benefit couples, family & community.

4. Definition of family planning • Use of contraceptive (CC) methods by a husband or wife with agreement between them to regulate their fertility. • It compromises children spacing to allow breastfeeding (bf) & safeguard mother’s & child’s heath; timing pregnancies at a safe age & adjusting children no. to family’s need & to physical, financial, educational & child raising capabilities.

5. History of family planning • Fertility control: thousands of years in different forms • Withdrawal & bf oldest methods. • Many CC recipes & instructions prescribed by Greeks, Egyptian & Islamic physicians. The terms family planning, CC and birth control are used interchangeably

6. Islamic view • Sterilization prohibited unless medical need • Allow temporary CCs use. • Prophet Mohammed “peace be upon him”: • did not object to withdrawal use. • The Qur'an : no prohibiting text • Supports child spacing - bf for 2 years. فتاوى ابن باز عند الضرورة لا بأس بأخذ الحبوب مؤقتا إذا كان هناك ضرر أو تعب للرحم بسبب الولادة أو إجراء عملية. س : ما الحكم في استئصال الرحم للتعقيم - أي منع الحمل - لأسباب طبية حاضرة ومستقبلية لما تتوقعها الجهات الطبية والعلمية؟ ج : إذا كان هناك ضرورة فلا بأس لكن إذا كان هناك ضرورة فلا بأس ، كما يجوز تعاطي أسباب منع الحمل مؤقتا للمصلحة الشرعية.

7. Contraceptive (CC) Methods –Modern (supply)/ natural traditional / (non-supply) – Permanent/Temporary Hormonal: Combined oral CC Progestogen only Depot injections Implants Emergency oral Transdermal CC patch IUD Barrier methods Diaphragm Cap Condoms (♂ ,♀) Spermicides Fertility awareness-based (FAB) methods Lactation amenorrhea method (LAM) Withdrawal Sterilization Tubal ligation (♀) Vasectomy(♂)

8. The Pill The Pill The Pill The Mini-Pill The Mini-Pill Mechanism of Action : stop ovulation. Combined Oral Contraceptives (COCs).. • Contains both estrogen & progestogen hormones. • Worldwide use: >100 million women • last 4 decades: a dramatic increase in CC usage from 15% in 1960s to 54% in 2000. Mini-Pill/ Progestin-only pills (POP) • Contains only progestogen.. • Come only in 28-day packs. All pills are active, so patient must take all of them.

9. The Pill Types of COC pills Monophasic : active pills has same amount of estrogen & progestin, Multiphasic / biphasic & triphasic- active pills : varied amounts of hormones -. Ways of taking combination pills— for 21 days, 28 days, 91 days or continuously. 28-day pills: take a pill at same time daily for 28 days. Usually, 1st 21 pills contain hormones & last 7 pills placebo (reminder) pills – withdrawal bleed. 21-day pills: pack contains 21 pills, take one pill daily & then wait 7 days to start a new pack- withdrawal bleed.

10. The Pill Types of combination pills • Continuous use pills / extended-cycle / 91-day pills : • contain both estrogen and progesterone • 1st 84 pills contain hormones, & last 7are placebo pills- withdrawal bleed. Only get period 4x/year. • FDA approved Lybrel, 1st continuous-use pill in 2007 - Lybrel contains only active pills. It is a 28-day pack taken continuously, with no break in between pill packets- i.e. taken 365 days a year, which completely eliminates periods • They offer a choice for women who have painful periods or who just don't like the inconvenience of having a monthly period.

11. Who can & cannot use the COC pill The Pill Most women can safely use it. • No protection against STIs or HIV/AIDS But usually cannot use the pill if: • BP : ≥ 140/≥90 • Smoke cigarettes & age ≥35 • BF : ≤6 ms • Gave birth in last 3 weeks • Serious health conditions  • May be pregnant • Stroke, migraine , breast cancer. DM >20yrs • 2 + risk factors for heart disease: HT,DM, smokes, or older age. • Gallbladder disease, liver disease, surgery • Takes pills for TB, fungal infections, or epilepsy.

12. The Pill Side Effects Changes in bleeding patterns – Spotting  BP, risk  with age (few mm Hg), return to normal quickly after stop (3 ms). Headache Dizziness Nausea Breast tenderness Wt gain - slight Mood changes Acne . DVT: 3x risk if use <50 mcg estrogen – Contributing RF: obesity & age Thrombotic or ischemic stroke: low risk Current COCs:  MI risk if have CV RF(DM, smoking, HT) 12. Risk of breast cancer: low.

13. They are 99% effective when taken every day. Typical failure rates: 3% to 8%. The Pill Non-contraceptive health benefits Help protect against: Risks of pregnancy Endometrial cancer Ovarian cancer Symptomatic PID May help protect: Ovarian cysts Iron-def. anemia • Reduce: • Menstrual cramps, bleeding problems • Ovulation pain • Excess hair face/body • Symptoms of polycystic ovarian • Syndrome Symptoms of endometriosis

14. Patient may be able to start today The Pill • If menstruated in past 5 days: • She can start NOW. No extra protection needed. • If menstruated > 5 days ago or if amenorrhoeic : • She can start NOW if reasonably certain she is not pregnant (No need to wait for next period to start pills. • She should use condoms for 7 days after taking1st pill. • Client can start any day of the menstrual cycle if you can be sure she isn’t pregnant • After childbirth, if breastfeeding: • Can start from 6 ms after childbirth. • If baby is <6 ms old: use condoms in the meantime. • After childbirth, if NOT breastfeeding: • Can start from 3 weeks after childbirth. • After miscarriage or abortion: • Can start immediately after abortion. If in the first 7 days after abortion, no extra protection is needed. • If switching from another method: • If switching from the mini-pill or implants, now is the best time to start. • If switching from injectable, should start pills at time she would have had repeat injection. • If switching from IUD, and menstruated >5 days ago, can start pills now but leave IUD in place until the next period.

15. Forgetting pills :can lead to pregnancy! How to take the pill • Once daily. • If use the 28-pill pack: • Once finish all pills in pack, start new pack on the next day • If use the 21-pill pack: • Once finish all pills in pack, wait 7 days before starting new pack If miss pills ALWAYS take a pill as soon as remember & continue If miss 3/+ pills or start pack 3/+ days late: • use condoms • If miss 3 or more pills in week 3: Skip the reminder pills (or pill-free week) and go straight to the next pack If miss a reminder pill (28-day packs only): • Throw away the missed pill(s) & continue taking pills, one each day

16. The Mini-Pill The Mini-Pill • Very effective when breastfeeding. • Easy to stop:A woman who stops pills can soon become pregnant. • Compared with the combined pill: • Better if bf. Does not affect quality or amount of breast-milk. • Taking pills on time is even more important. For women not bf, taking a pill > a few hours late can increase pregnancy risk. • Fewer side-effects except for bleeding changes. Who can and cannot use the mini-pill Most women can safely use it. But usually cannot use it if: • bf ≤ 6 wks • May be pregnant • Ever had breast cancer. • Liver disease. • Has DVT/PE. • Takes Rx for TB, fungal infections, or epilepsy (seizures/fits). • Some other serious health conditions 

17. The Mini-Pill Possible side-effects • Common (when not breastfeeding): irregular bleeding, spotting, no monthly bleeding • Less common: headache, tender breasts, dizziness How to take the mini-pill • Take one pill each day at the same time • Once finished all pills in pack, start a new pack following day • Late taking a pill? • — Take it as soon as you remember • — may need to follow special instructions if more than 3 hours late.

18. How to take the mini-pill • Take one pill each day at the same time • Once finished all pills in pack, start a new pack on following day • Late taking a pill? — Take it as soon as you remember • If miss a pill by more than 3 hours and are: • Not bf OR bf but periods have returned: use condoms for next 2 days. • Bf & periods NOT returned: No special instructions. No extra protection needed. May be able to start today • Can start today if fully bf at least 6 weeks • If not bf : can start any day of menstrual cycle if you can be sure she isn’t pregnant After miscarriage or abortion: If switching from another method: Iike the pill.

19. Monthly Injectable Long-acting Injectable Injectable • Effective : 3, 2 or 1 month . • it’s use is rising : WHO - reassuring cancer risk data & USFDA - approval of 3-monthly injectable depomedroxy-progesterone acetate (DMPA/ Depo-Provera). • Types : • 3-monthly injectable : progestogen only. • DMPA & estradiolcypionate & norethisteroneenanthate (NET-EN) • Combined injectable CCs (CIC ): estrogen & progestin. Monthly injectables include Cyclofem and Mesigyna. • No much information  use existing information on use of COCs. • Very effective, safe . • Takes longer to get pregnant after stopping. • Changes monthly bleeding

20. Who can use CICs Safe & Suitable for Nearly All Women. Who can not use CICs • Not bf &< 3 weeks post delivery • Primarily bf 6 wks to 6 ms post delivery • Smokes heavily & age 35 or older • High BP (140 to 159 / 90 to 99) • Gall bladder disease /Severe liver infection, or tumor • Migraine headaches • Had breast cancer >5 yrs ago it has not returned • DM >20 yrs or have complication • Multiple RFs for CVD - older age, smoke, DM, & HT 20

21. Implants Combined Vaginal Ring Norplant Implants • Continuously release 2 hormone: progestin & estrogen • new, limited research on effectiveness, >COC ? • Side Effects • Skin irritation or rash at patch site • Changes in monthly bleeding, Headaches • vaginal discharge, Vaginitis • Contain progestogen but not estrogen hormones- so use with bf • Provide long-term pregnancy protection. • Very effective (>99%) for 3-7 yrs • Side Effects • Changes in monthly bleeding • Headaches, Nausea, Abdominal pain • Acne (can improve or worsen) • Weight change • Breast tenderness • Dizziness • Mood changes

22. Copper IUD Intrauterine Device (IUD) • > 99% effectiveness. • Side Effects • Changes in bleeding patterns (esp. 1st 3-6 ms) • Acne ,Headaches, Nausea • Breast tenderness or pain ,Ovarian cysts • Weight gain ,Dizziness • Mood changes • –Complications :Rare: • Perforation of uterine wall. • Miscarriage, preterm birth, or • Infection if woman becomes pregnant with IUD.

23. Copper IUD Who can use IUD Safe & Suitable for Nearly All Women: Who can not use IUD • Less than 4 weeks since giving birth • Current DVT or PE • Had breast cancer > 5 yrs ago, and not returned • Severe liver disease, infection, or tumor • Benign gestational trophoblast disease • Current ovarian cancer • A very high risk for gonorrhea or chlamydia at time of insertion • Has AIDS not on antiretroviral therapy & clinically well

24. Fertility Awareness Fertility Awareness-Based Methods (FAB) • Natural methods • FAB methods : attempt to determine days in a woman’s menstrual cycle when she is fertile,. • Most useful when a woman has regular and predictable menstrual cycles. • On days when fertility is greatest : a couple can use alternative barrier method - condoms or a diaphragm. • FAB advantages : safe & inexpensive. Religious convictions make FAB only acceptable method of birth control. Failure causes Do not keep careful records , not trained Women have irregular cycles Couples may find intervals of abstinence during fertile days too long. FAB require both partners have a strong commitment to use the techniques correctly & consistently.

25. Fertility Awareness-Based Methods (FAB) Fertility Awareness Methods: :- 1.Standard Days Method: (SDM) 2.Calendar Rhythm Method (CRM) 3.Cervical Mucus Testing: a woman observes changes in her cervical mucus to tell her when she may be fertile. SDM & CRM Methods: involve counting days in menstrual cycle &woman must know which day of her menstrual cycle she is on. • The SDM method: New - >95% effective if used correctly. • A woman is considered fertile between days 8 through 19 counting day 1 as 1st day of menstruation. Women can use SDM if have regular cycles never <26 days or >32 days. • The CRM method:At least 90% effective when used correctly • a woman keeps track of length of her menstrual cycles for 6-12 months to figure out the days when she is likely to get pregnant.

26. LAM Lactational Amenorrhea Method (LAM ) • It is based on physiologic effect of suckling to suppress ovulation. • bf women can start to use LAM as a CC after birth if meet all 3 conditions • Fully or nearly fully bf, includes exclusive bf, almost exclusive bf, & nearly fully bf, day & night, on demand by infant. • baby must be <6 months old • mother's menses not have returned. • 98%-99% effective (perfect use). • Can support LAM with : Mini-pill , IUD , Condum/diapgragm. LAM can be taught during prenatal, perinatal, or postnatal periods.

27. Comparing effectiveness of methods Female Sterilization Vasectomy IUD Implants This chart shows how effective methods are as usually used. The top four methods are most effective; user has nothing to do. The effectiveness of the other methods depends on the user’s behaviour. These other methods are more effective when used correctly. How to make your method most effective Most effective Generally 2 or fewer pregnancies per 100 women in one year One-time procedures. Nothing to do or remember. Need repeat injections every 1 to 3 months Injectables Must take a pill each day Pills Must follow LAM instructions LAM (up to 6 months postpartum) About 15 pregnancies per 100 women in one year Must use every time you have sex; requires partner’s cooperation. Male Condoms Must use every time you have sex Diaphragm Must use every time you have sex; requires partner’s cooperation. Female Condom *This ranking is based on a simplified calendar method. Some other fertility awareness-based methods that more accurately identify the fertile period, including the Standard Days Method, are more effective. Fertility Awareness-Based Methods* Must abstain or use condoms on fertiledays; requires partner’s cooperation. About 30 pregnancies per 100 women in one year Must use every time you have sex Spermicides Least effective

28. EmergencyContraception Emergency Contraception (EC) • Consider EC if:— no method was used • — a method was used incorrectly - missed pills, late for injection • — method failed - broken condom, expelled IUD • Emergency CC pills: • Take pillsas soon as possible. ideally : within 72 hrs (3 days). • Can be up to 120 hrs (5 days) after - less effective each day passes. • Levonorgestrel-only ECPs • Less nausea &vomiting than combined ECPs. • Dosage: 1.5 mg levonorgestrel in a single dose. • Combined estrogen-progestogen ECPs • Use if levonorgestrel-only pills are unavailable. • Dosage: 2 doses of 100 mcg of ethinylestradiol + 0.5 mg of levonorgestrel, 12 hours apart. • Emergency copper IUD: • More effective than pills. Can also be used up to 5 days. • Good choice for women who want to keep using an IUD.

29. WHO Medical Eligibility Criteria for Starting Contraceptive Methods WHO Categories for Temporary Methods The Medical eligibility criteria wheel for CC use - WHO, 2007

30. Part of the table of WHO Medical Eligibility Criteria for Starting Contraceptive Methods

31. Family Planning Counseling • As many as 50% of pregnancies are unplanned & 25% are unwanted. • Millions use family planning but fail why? :- • Not e received clear use instructions\ • Could not get a method better suited them, • Not prepared for side effects. • Moreover, family planning job will never finish • Generation after generation, always needing family planning & other health care.

32. Family Planning Counseling “Choice” is key word in today’s family planning • Helps patients to make choices about their reproductive options & CC methods. • Helps use chosen method safely &effectively • Most important step: uncover patient fears • Clarification of CC type wanted can help bridge gap between service availability & patient’ needs • should provide correct & updated information • It improve patient continuation & compliance.

33. Family Planning obstacles • Unmeet needs of women: • Services & supplies not yet available everywhere • Choices are limited. • Fear of social or partner’s disapproval. • Worries of side effects & health concerns • lack knowledge about CC options & their use. • Poor compliance • Ineffective health education to women & family • Insufficient training of health providers • Counseling services not available.

34. تم بحمد الله Thank you